Exam 3 PrepU
A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma?
"At first, the stoma may bleed slightly when touched."
A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing is:
"Has your partner had recent forceful vomiting?"
A home health nurse who sees a client with diverticulitis is evaluating teaching about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching?
"I should increase my intake of fresh fruits and vegetables during remissions."
The nurse is assessing a client following laparoscopy. The client states that his stomach looks bloated and asks if this is normal. How will the nurse respond?
"Yes, your abdomen may appear larger as a result of the injection of carbon dioxide for visualization."
A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. The first activity of the nurse is to:
Assess lung sounds bilaterally
A client who underwent abdominal surgery and has a nasogastric (NG) tube in place begins to complain of abdominal pain that he describes as "feeling full and uncomfortable." Which assessment should the nurse perform first?
Assess patency of the NG tube
When caring for a patient with cirrhosis, which of the following symptoms should the nurse report immediately?
Change in mental status
A client with a feeding tube is to receive medication. The medication supplied is an enteric-coated tablet. Which of the following would be most appropriate?
Check with pharmacist to see if liquid form is available
A client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement (select all options that apply):
Checks the pH of the gastric contents • Compares exposed tube length with original measurement • Visually assesses the color of the aspirate
A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
Drink liquids only between meals
Clients with Type O blood are at higher risk for which of the following GI disorders?
Duodenal ulcers
A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find?
Elevated urine amylase levels
A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test?
Encourage fluid intake
A physician suspects that a client has peptic ulcer disease. With which of the following diagnostic procedures would the nurse most likely prepare to assist?
Endoscopy
Which of the following would be most appropriate for a client who is experiencing biliary colic?
Ensure that the client rests.
A patient with an ileostomy should avoid which of the following?
Enteric coated tablets
Which of the following medications requires the nurse to contact the pharmacist in consultation when the patient receives all oral medications by feeding tube?
Enteric coated tablets
Cancer of the esophagus is most often diagnosed by which of the following?
Esophagogastroduodenoscopy (EGD) with biopsy and brushings
A patient underwent a continent ileostomy. Within which timeframe should the patient expect to empty the reservoir?
Every 4 to 6 hours
A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely?
Excess fluid volume
An elderly client states, "I don't understand why I have so many caries in my teeth." The nurse assesses the following as placing the client at risk:
Exhibiting hemoglobin A1C 8.2
A few hours after eating hot and spicy chicken wings, a client presents with lower chest pain. He wonders if he is having a heart attack. How should the nurse proceed first?
Further investigate the initial complaint
A client has a new order for metoclorpramide (Reglan). The nurse identifies that this medication can be safely administered for which conditon?
GERD
A nurse is preparing a client for surgery. During preoperative teaching, the client asks where is bile stored. The nurse knows that bile is stored in the:
Gallbladder
Which of the following surgical procedures for obesity utilizes a prosthetic device to restrict oral intake?
Gastric banding
A client has a gastrointestinal tube that enters the stomach through a surgically created opening in the abdominal wall. The nurse documents this as which of the following?
Gastrostomy tube
A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate?
Hang a solution of dextrose 10% and water until the new solution is available.
A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, and labored breathing; the client also appears to be confused. Which of the following complications has the client most likely developed?
Hemorrhage
A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations?
Hepatic encephalopathy
A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions?
Hepatic encephalopathy
When reviewing the history of a client with pancreatic cancer, the nurse would identify which of the following as a possible risk factor?
History of pancreatitis
After teaching a group of students about irritable bowel syndrome and antidiarrheal agents, the instructor determines that the teaching was effective when the students identify which of the following as an example of an opiate-related antidiarrheal agent?
Immodium
A student nurse is preparing a plan of care for a client with chronic pancreatitis. What nursing diagnosis related to the care of a client with chronic pancreatitis is the priority?
Impaired nutrition: less than body requirements
A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should the nurse include in her teaching plan?
Increase respiratory effectiveness
Which of the following laboratory test results would the nurse associate with obstructive jaundice?
Increased direct bilirubin
Which of the following is one of the first clinical manifestations of esophageal cancer?
Increasing difficulty is swallowing
A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is
Inserted into the lungs
Which of the following would be an intervention for a patient with a chemical burn to the esophagus?
Insertion of nasogastric tube
A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. The best nursing intervention is to
Instruct the client to swish prescribed nystatin (Mycostatin) solution for 1 minute.
A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?
Intrinsic factor
The nurse is caring for a client who underwent a subtotal gastrectomy 36 hours ago. The client has a nasogastric (NG) tube. The nurse knows to do the following with the NG:
Irrigate the NG tube with NS if ordered
When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function?
Irritability and drowsiness
A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?
Liver biopsy
A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?
Loss of 1 kg in 24 hours
A physician has ordered a liver biopsy for a client whose condition is deteriorating. Which of the following places the client at high risk due to her altered liver function during the biopsy?
Low platelet count
A critical care nurse is caring for a client with acute pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system?
Maintain patient in Semi-Fowlers position
A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and makes a recommendation when noting the following:
No land line; cell phone available and taken by family member during working hours
Which of the following venous access devices can be used for less than 6 weeks in patients requiring parenteral nutrition?
Non-tunneled catheter
Which of the following is caused by improper catheter placement and inadvertent puncture of the pleura?
Pneumothorax
The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also complains of unpleasant tastes and odors. Which of the following measures should be included in the client's plan of care?
Provide frequent mouth care
Which of the following would be the highest priority, immediate nursing intervention for a client just diagnosed with acute gastritis?
Provide physical and emotional support
A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk?
Reposition q 2hrs
A client with pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate?
Reserving an antecubital site for a peripherally inserted central catheter (PICC)
A nurse is providing postprocedure instructions for a client who had an esophagogastroduodenoscopy. The nurse should perform which action?
Review instructions with the person assisting the client home
A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake?
Six small meals daily with 120 mL fluid between meals
Gynecomastia is a common side effect of which of the following diuretics?
Spironolactone (Aldactone)
Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction?
Sudden, sustained abdominal pain
The nurse is preparing to examine the abdomen of a client complaining of a change in his bowel pattern. The nurse would place the client in which position?
Supine with knees flexed
A client with appendicitis is experiencing excruciating abdominal pain. An abdominal X-ray film reveals intraperitoneal air. The nurse should prepare the client for:
Surgery
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?
Take a stool softener such as docusate sodium (Colace) daily.
A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?
Take slow, deep breaths
Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery?
Vagus
A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. The nurse suspects:
Vasomotor symptoms associated with dumping syndrome
A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client?
Vasopressin
A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client?
Vasopressin (Pitressin)
The nurse knows that the client with cholelithiasis can have a nutritional deficiency. The obstruction of bile flow due to cholelitiasis can interfere with the absorption of
Vitamin A
Patients diagnosed with malabsorption syndrome may have vitamin and mineral deficiency. Patient who easily bleed have which of the following deficiencies?
Vitamin K
When assessing whether a patient is a candidate for home parenteral nutrition, which of the following would be important to address? Select all that apply.
• Health status • Family support • Motivation for learning • Telephone access
A mother brings her teenage son to the clinic, where tests show that he has hepatitis A virus (HAV). They ask the nurse how this could have happened. Which of the following explanations would the nurse correctly identify as possible causes? Select all that apply.
• Infection at school • Suboptimal sanitary habits • Consumption of sewage-contaminated water or shellfish • Sexual activity
Which of the following are functions of saliva? Select all that apply.
• Lubrication • Digestion • Protection against harmful bacteria
Which of the following the are early manifestations of liver cancer? Select all that apply.
• Pain • Continuous aching in the back
A 67-year-old client is returning for a follow-up appointment to the primary care group where you practice nursing. At his last appointment, he received the diagnosis of portal hypertension and the physician instituted interventions to begin treatment of this condition. What is the primary aim of portal hypertension treatment? Choose all correct options.
• Reduce fluid accumulation • Reduce venous pressure
A 67-year-old client is returning for a follow-up appointment to the primary care group where you practice nursing. At his last appointment, he received the diagnosis of portal hypertension and the physician instituted interventions to begin treatment of this condition. What is the primary aim of portal hypertension treatment? Choose all correct options.
• Reduce venous pressure • Reduce fluid accumulation
A client is prescribed tetracycline to treat peptic ulcer disease. Which of the following instructions would the nurse give the client?
"Be sure to wear sunscreen when taking this medication"
A client admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. Discharge teaching should include which instruction?
"Continue to take antacids even if your symptoms subside."
The nurse is caring for a man who has experienced a spinal cord injury. Throughout his recovery, the client expects to gain control of his bowels. The nurse's best response to this client would be which of the following?
"Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact."
The nurse determines that teaching for the client with peptic ulcer disease has been effective when the client states:
"I have learned some relaxation strategies that decrease my stress."
A nurse is performing discharge teaching with a client who had a total gastrectomy. Which statement indicates the need for further teaching?
"I will have to take vitamin B12 shots up to 1 year after surgery."
A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate?
"It is a vent that prevents backflow of the secretions."
A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct?
"Maintain a high-carbohydrate, low-fat diet."
A nurse is teaching a client who has experienced an episode of acute gastritis and knows further education is necessary when the client makes the following statement:
"My appetite should come back tomorrow"
A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The physician has ordered a visualization of the small intestine via a capsule endoscopy. Which of the following will the nurse include in the client education about this procedure?
"You will need to swallow a capsule."
A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The physician has ordered a visualization of the small intestine via a capsule endoscopy. Which of the following will the nurse include in the client education about this procedure?
"you will need to swallow a capsule"
A client with peptic ulcer disease must begin triple medication therapy. For how long will the client follow this regimen?
10-14 days
A nurse is preparing to administer a 500 mL bolus tube feeding to a patient. The nurse anticipates administering this feeding over which time frame?
10-15 minutes
Morbid obesity is defined as being how many pounds over the person's ideal body weight?
100 lbs
A nurse measures the residual gastric volume of a patient receiving intermittent tube feedings. The patient's last residual volume was 250 mL. Which finding would lead the nurse to notify the physician?
225 mL
A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use?
30 mL
As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach?
4
A client newly diagnosed with acute lymphocytic leukemia has a right subclavian central venous catheter in place. The nurse who's caring for the client is teaching a graduate nurse about central venous catheter care. The nurse should instruct the graduate nurse to change the central venous catheter dressing every:
48 hours
Pharmacologic therapy frequently is used to dissolve small gallstones. It takes about how many months of medication with UDCA or CDCA for stones to dissolve?
6-12 months
This example of cholesterol gallstones (left side of picture) is the result of decreased bile acid synthesis and increased cholesterol synthesis in the liver, which in turn, form stones. Cholesterol stones account for what percentage of cases of gallbladder disease in the United States?
75%
A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours?
80-120 mL
The nurse inserts a nasoduodenal tube for feeding of the client. To check best for placement, the nurse
Abdominal x-ray
A client reports to the clinic, stating that she rapidly developed headache, abdominal pain, nausea, hiccuping, and fatigue about 2 hours ago. For dinner, she ate buffalo chicken wings and beer. Which of the following medical conditions is most consistent with the client's presenting problems?
Acute gastritis
A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?
Acute pain related to biliary spasms
A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal?
Albumin
A nursing instructor is lecturing to a class about chronic pancreatitis. Which of the following does the instructor list as major causes?
Alcohol consumption and smokig
Which of the following medications would the nurse expect the physician to order for a client with cirrhosis who develops portal hypertension?
Aldactone
Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following?
Ammonia
The digestion of carbohydrates is aided by
Amylase
A longitudinal tear or ulceration in the lining of the anal canal is termed a (an)
Anal fissure
The client is postoperative following a graft reconstruction of the neck. It is most important for the nurse to
Assess the graft for color and temperature
A client with anorexia complains of constipation. Which of the following nursing measures would be most effective in helping the client reduce constipation?
Assist client to increase dietary fiber.
Which of the following terms describes the involuntary flapping movements of the hands associated with metabolic liver dysfunction?
Asterixis
A nurse assesses the abdomen of a newly admitted client. Which finding would necessitate further investigation?
Asymmetrical upper abdomen
A client has been receiving intermittent tube feedings for several days at home. The nurse notes the findings as shown in the accompanying documentation. The nurse reports the following as an adverse reaction to the tube feeding:
Blood glucose level
A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. The nurse instructs the client to
Brush and floss daily
The primary source of microorganisms for catheter-related infections are the skin and which of the following?
Catheter hub
The term for a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis is a
Chancre
When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as:
Chancre sore of the oral soft tissues
Which of the following is the most common presenting symptom of colon cancer?
Change in bowel habits
Which of the following is an accurate statement regarding cancer of the esophagus?
Chronic irritation of the esophagus is a known risk factor
A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:
Cirrhosis
If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?
Clamp the catheter
A client is scheduled for several diagnostic tests to evaluate her gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when she identifies which test as not requiring the use of a contrast medium?
Colonoscopy
A nurse administered a full strength feeding with an increased osmolality through a jejunostomy tube to a client. Immediately following the feeding, the client expelled a large amount of liquid brown stool and exhibited a blood pressure of 86/58 and pulse rate of 112 beats/min. The nurse
Consult physician regarding decreasing to half-strength
Which of the following ulcers is associated with extensive burn injury?
Curling's Ulcer
To ensure patency of central venous line ports, diluted heparin flushes are used in which of the following situations?
Daily, when not in use
Symptoms associated with pyloric obstruction include all of the following except:
Diarrhea
Which of the following is one of the primary symptoms of Irritable Bowel Syndrome (IBS)?
Diarrhea
Which of the following appears to be a significant factor in the development of gastric cancer?
Diet
Which of the following is the primary symptom of achalasia?
Difficulty swallowing
A client with cirrhosis has been referred to hospice care. Assessment data reveal a need to discuss nutrition with the client. What is the nurse's priority intervention?
Discuss meals that include low-fat high-carbohydrate content.
A patient is being treated for diverticulosis. Which of the following information should the nurse include in this patient's teaching plan?
Drink at least 8 to 10 large glasses of fluid every day
Which of the following is considered a stimulant laxative?
Dulcolax
A client has a new order for metoclorpramide (Reglan). The nurse identifies that this medication should not be used long term and only in cases where all other options have been exhausted. This is because this medication has what type of potential side effect?
Extrapyramidal
The mode of transmission of hepatitis A virus (HAV) includes which of the following?
Fecal-oral
Rebound hypoglycemia is a complication of parental nutrition caused by which of the following?
Feedings stopped too abruptly
The nurse is to discontinue a nasogastric tube that had been used for decompression. The first thing the nurse does is
Flush with 10 mL of water
Which type of deficiency results in macrocytic anemia?
Folic Acid
Postoperatively, a patient with a radical neck dissection should be placed in which position?
Fowler's
Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?
Hot roast beef sandwich with gravy
An elderly patient diagnosed with diarrhea is taking digoxin (Lanoxin). Which of the following electrolyte imbalances should the nurse be alert to?
Hypokalemia
Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia?
Hypotension
The nurse is caring for a patient diagnosed with abdominal perforation. Which of the following is a clinical manifestation of this disease process?
Hypotension
A nurse is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, blood pressure of 100/80 mm Hg, pulse rate of 88 beats/minute, respiratory rate of 20 breaths/minute, temperature 100° F (37.8° C). The nurse suspects the client will be diagnosed with:
IBD
A critical care nurse is caring for a client with pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system?
Maintain the client in a semi-Fowler's position.
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:
Maintaining patent airway
A client with cancer has a neck dissection and laryngectomy. An intervention that the nurse will do is:
Make a notation in the call light system that the patient cannot speak
When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?
Measure abdominal girth according to a set routine.
When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?
Measuring abdominal girth
Rebleeding may occur from a peptic ulcer and often warrants surgical interventions. Signs of bleeding include which of the following?
Mental confusion
Vomiting results in which of the following acid-base imbalances?
Metabolic alkalosis
A client presents to the emergency department, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances?
Metabolic alkalosis and hypokalemia
Which of the following is considered a bulk-forming laxative?
Metamucil
A client with cirrhosis is at risk for developing esophageal varices. Which of the following instructions should a nurse provide the client to minimize such risk?
Minimize alcohol use
Which of the following venous access devices can be used for less than 6 weeks in patients requiring parenteral nutrition?
Nontunneled catheter
When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are
Normal
A client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond?
Notify the physician
A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. It is best for the nurse to
Notify the surgeon about the tube's removal
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?
Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
A patient has undergone a liver biopsy. Which of the following postprocedure positions is appropriate?
On the right side
Which diagnostic produces images of the body by detecting the radiation emitted from radioactive substances?
PET Scan
A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should the nurse administer to the client before surgery?
Packed RBCs
Which of the following is the major cause of morbidity and mortality in patients with acute pancreatitis?
Pancreatic necrosis
A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered?
Permit the client to drink only clear liquids.
A client with a disorder of the oral cavity cannot tolerate tooth brushing or flossing. Which of the following strategies can the nurse employ to assist this client?
Provide the client with an irrigating solution of baking soda and warm water.
Which of the following is an enzyme that begins the digestion of starches?
Ptyalin
The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?
Purpura and petechiae
The nurse is caring for a client with hepatitis. Which of the following would lead the nurse to suspect that the client is in the prodromal phase?
Rash
When interviewing a client with internal hemorrhoids, which of the following would the nurse expect the client to report?
Rectal Bleeding
When interviewing a client with internal hemorrhoids, which of the following would the nurse expect the client to report?
Rectal bleeding
Which of the following is the most common symptom of a polyp?
Rectal bleeding
Following ingestion of carrots or beets, the nurse would expect which alteration in stool color?
Red
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?
Reglan
The nurse is assessing a client for constipation. Which of the following is the first review that the nurse should conduct in order to identify the cause of constipation? Choose the correct option.
Review the client's usual pattern of elimination
After undergoing a liver biopsy, a client should be placed in which position?
Right lateral decubitus position
Patients with chronic liver dysfunction have problems with insufficient vitamin intake. Which of the following may occur as a result of vitamin C deficiency?
Scurvy
The nurse should assess for an important early indicator of acute pancreatitis, which is a prolonged and elevated level of:
Serum lipase
The nursing student has just reviewed material in the course textbook regarding pancreatitis. The student knows that a major symptom of pancreatitis that causes the client to seek medical care is:
Severe abdominal pain
The patient is on a continuous tube feeding. The tube placement should be checked every
Shift
Which of the following terms is used to describe stone formation in a salivary gland, usually the submandibular gland?
Sialolithiasis
Which of the following would indicate to the nurse that a client who has received three cleansing enemas in preparation for a barium enema is experiencing dehydration?
Signs of dizziness and confusion
A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube.
Sit the client in an upright position Apply gloves to the nurse's hands Measure the length of the tube that will be inserted Apply water-soluble lubricant to the tip of the tube Tilt the client's nose upward Instruct the client to lower the head and swallow
The client has a chancre on his lips. The nurse instructs the client to
Take measures to prevent spreading to others
A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care?
Test for occult blood
Which outcome indicates effective client teaching to prevent constipation?
The client reports engaging in a regular exercise regimen.
A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?
The client's hepatic function is decreasing.
A client realizes that regular use of laxatives has greatly improved his bowel pattern. However, the nurse cautions this client against the prolonged use of laxatives for which reason?
The client's natural bowel function may become sluggish.
Which of the following is a true statement regarding regional enteritis (Crohn's disease)?
The clusters of ulcers take on a cobblestone appearance.
When describing the role of the pancreas to a client with a pancreatic dysfunction, the nurse would identify which substance as being acted on by pancreatic lipase?
Triglycerides
A nurse is caring for a client in the emergency department who is complaining of severe abdominal pain. The client is diagnosed with acute pancreatitis. Which laboratory value requires immediate intervention?
Troponin of 2.3 mcg/L
A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor?
Ultrasound before GI procedure
A client has a new order for metoclorpramide (Reglan). The nurse knows that this medication should not be used long term and only in cases where all other options have been exhausted. This is because this medication has the potential for extrapyramidal side effects. Extrapyramidal side effects include which of the following?
Uncontrollable movement of the face and limbs
A client with GERD develops espophagitis. Which diagnostic test would the nurse expect the physician to order to confirm the diagnosis?
Upper endoscopy with biopsy
Which type of positioning should be utilized for a patient undergoing a paracentesis?
Upright at the edge of the bed
The nurse would expect to observe which of the following when assessing a client with cholelithiasis?
Urine that appears dark brown
A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk?
Use incentive spirometry every hour.
The nurse is assessing a patient for constipation. Which of the following is the first review that the nurse should conduct in order to identify the cause of constipation?
Usual pattern of elimination
Which of the following is the most effective strategy to prevent hepatitis B infection?
Vaccine
Which of the following medications are used to decrease portal pressure, halting bleeding of esophageal varices?
Vasopressin
A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for:
diaphoresis, vomiting, and diarrhea.
Halitosis and a sour taste in the mouth are clinical manifestations associated most directly with
esophageal diverticula.
A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of:
increasing fluid intake to prevent dehydration.
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:
maintaining a patent airway
Regarding oral cancer, the nurse provides health teaching to inform the patient that
many oral cancers produce no symptoms in the early stages.
The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department for chest pain. The client was diagnosed as having gastroesophageal reflux disease. The nurse notes in the client's record that the client is taking carbidopa/levodopa (Sinemet). The nurse questions the physician's order for
metoclopramide
A patient has undergone a liver biopsy. Which of the following postprocedure positions is appropriate?
on the right side
Which client requires immediate nursing intervention? The client who:
presents with a rigid, boardlike abdomen.
A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is:
subnormal serum glucose and elevated serum ammonia levels.
Initially, which diagnostic should be completed following placement of a NG tube?
x-ray
A nurse is taking health history data from a client. Use of which of the following medications would especially alert the nurse to an increased risk of hepatic dysfunction and disease in this client? Select all that apply.
• Acetaminophen • Ketoconazole • Valproic acid
When caring for a client with cirrhosis, which of the following should a nurse notify immediately? Choose all correct options.
• Change in mental status • Signs of GI bleeding
A client is being treated for diverticulosis. Which of the following points should the nurse include in this client's teaching plan? Choose all correct options.
• Drink at least 8 to 10 large glasses of fluid every day. • Do not suppress the urge to defecate.
While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the possibility of liver problems? Select all that apply.
• Ecchymoses • Jaundice • Petechiae
A nursing student has learned about many collaborative interventions to achieve pain relief for clients with acute pancreatitis. Which of the following are appropriate? Choose all that apply.
• Encourage bed rest to decrease the client's metabolic rate. • Teach the client about the correlation between alcohol intake and pain. • Withhold oral feedings to limit the release of secretin.
A client is given a diagnosis of hepatic cirrhosis. The client asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? Select all that apply.
• Enlarged liver size • Ascites • Hemorrhoids
A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. The nurse does all of the following. Select all that apply.
• Ensures availability of an infusion pump • Ensures completion of baseline monitoring of the complete blood count (CBC) and chemistry panel • Places a 1.5-micron filter on the tubing
A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. She should:
turn the client on his left side and place the bed in Trendelenburg's position.
A client is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult?
"I didn't eat anything I shouldn't have; I just ate roast beef on rye bread."
A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment?
"I'll eat frequent, small, bland meals that are high in fiber."
A nursing instructor tells the class that review of oral hygiene is an important component during assessment of the gastrointestinal system. One of the students questions this statement. Which of the following explanations from the nurse educator is most appropriate?
"Injury to oral mucosa or tooth decay can lead to difficulty in chewing food."
A client with a peptic ulcer is diagnosed with Heliobacter pylori infection. The nurse is teaching the client about the medications prescribed, including metronidazole (Flagyl), omeprazole (Prilosec), and clarithromycin (Biaxin). Which statement by the client indicates the best understanding of the medication regimen?
"The medications will kill the bacteria and stop the acid production."
When gastric analysis testing reveals excess secretion of gastric acid, which of the following medical diagnoses is supported?
Duodenal ulcer
A nurse is preparing a presentation for a local community group of older adults about colon cancer. Which of the following would the nurse include as the primary characteristic associated with this disorder?
A change in bowel habits
A nurse is assessing a client with a family history of cancer. Which finding requires immediate follow-up?
A client states he feels a lump in his throat
A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?
A client's hepatic function is decreasing
Which of the following is the primary function of the small intestine?
Absorption
A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?
Acute pain r/t biliary spasms
When caring for a client with an acute exacerbation of a peptic ulcer, the nurse finds the client doubled up in bed with severe pain to his right shoulder. The intial appropriate action by the nurse is to
Assess abdomen and vitals
A client with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by
Assess lung sounds
Which of the following would the nurse expect to assess in a client with hepatic encephalopathy?
Asterixis
A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to
Auscultate lungs every 4 hours
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?
Avoid coffee and alcoholic beverages
Symptoms of progressive gastric cancer include which of the following?
Bloating after meals
In women, which of the following types of cancer exceeds colorectal cancer?
Breast
Which of the following is clinical manifestation of cholelithiasis?
Clay colored stools
What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
Deficient fluid volume
Which of the following is a nasoenteric feeding tube?
Dobhoff
Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes melitus. Which of the following explains the cause of this secondary diabetes?
Dysfunction of the pancreatic islet cells
The most common symptom of esophageal disease is
Dysphagia
A nurse has admitted a client suspected of having acute pancreatitis. The nurse knows that mild acute pancreatitis is characterized by:
Edema and inflammation
The following appears on the medical record of a male patient receiving parenteral nutrition: WBC: 6500/cu mm Potassium 4.3 mEq/L Magnesium 2.0 mg/dL Calcium 8.8 mg/dL Glucose 190 mg/dL Which finding would alert the nurse to a problem?
Glucose level
Which type of jaundice seen in adults is the result of increased destruction of red blood cells?
Hemolytic
Which of the following is a gerontological consideration associated with the pancreas?
Increase in fibrous material
The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, would the nurse question?
Indocin
Which of the following would be an intervention for a patient with a chemical burn to the esophagus?
Insert NG tube
Which of the following mouth conditions are associated with HIV infection?
Karposi's Sarcoma
A 68-year-old resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. She receives nutrition via a PEG tube. The client remains physically and socially active and has adapted well to the tube feedings. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. Which of the following is the most likely cause of this client's constipation?
Lack of free water intake
Which of the following enzymes aids in the digestion of fats?
Lipase
Celiac sprue is an example of which category of malabsorption?
Mucosal disorders causing generalized malabsorption
Which of the following diagnostics is used to identify malignant cells associated with esophageal cancer?
PET
A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?
Relieving abdominal pain
Which of the following is the most successful treatment for gastric cancer?
Removal of the tumor
When a central venous catheter dressing becomes moist or loose, what should a nurse do first?
Remove the dressing, clean the site, and apply a new dressing.
A client with a pilonidal sinus undergoes surgery. Which of the following would the nurse include in the client's postoperative plan of care?
Repacking the surgical wound
In what location would the nurse palpate for the liver?
Right upper quadrant
A client with diabetes begins to have digestive problems and is told by the physician that they are a complication of the diabetes. Which of the following explanations from the nurse is most accurate?
The pancreas secretes digestive enzymes
Hickman and Groshong are examples of which type of central venous access devices?
Tunneled central catheters
A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client?
Vitamin A
Why are antacids administered regularly, rather than as needed, in peptic ulcer disease?
To maintain gastric pH at 3.0-3.5
A nurse is providing discharge instructions for a client who fell from a bicycle, resulting in a fractured jaw. The client underwent surgical intervention with rigid fixation. The nurse includes in the instruction
Ways to obtain supplemental nutrition
Which of the following is an age-related change of the gastrointestinal system?
Weakened gag reflex
A client with complaints of right lower quadrant pain is admitted to the emergency department. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the physician immediately?
White blood cell (WBC) count 22.8/mm3
A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:
Yellow sclerae
A 72-year-old client seeks help for chronic constipation. Constipation is a common problem for elderly clients because of several factors related to aging, including:
decreased abdominal strength.
A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should:
wash her hands after touching the client.
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
Which of the following will the nurse observe as symptoms of perforation in a client with intestinal obstruction? Choose all that apply.
• Sudden, sustained abdominal pain • Abdominal distention
A nurse is monitoring a client with peptic ulcer disease. Which of the following assessment findings would most likely indicate perforation of the ulcer? Choose all that apply.
• Tachycardia • Hypotension • A rigid, board-like abdomen
A client with a nasogastric tube set to low intermittent suction is receiving D51/2NS at 100 mL/hr. The nurse has identified a nursing diagnosis of deficient fluid volume. Which of the following are data that support this diagnosis? Select all that apply.
• Urine output that decreased from 60 to 40 mL/hr • Heart rate that increased from 82 to 98 beats/min within 2 hours • Fluid output of 2150 mL and total fluid intake of 2000 mL for the past 24 hours
A nurse is teaching a client with gastritis about the need to avoid the intake of caffeinated beverages. The client asks why this is so important. Which of the following explanations from the nurse would be most accurate?
"Caffeine stimulates the central nervous system and thus gastric activity and secretions, which need to be minimized to promote recovery."
A nurse is performing health assessment with a client during an outpatient clinic visit. The most concerning client statement to the nurse is:
"Food seems to be getting stuck in my throat"
A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing is:
"Has he had any recent forceful vomiting?"
A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?
"I'll avoid eating or drinking anything 6 to 8 hours before the test."
A patient has a gastric sump tube inserted and attached to low intermittent suction. The physician has ordered the tube to be irrigated with 30 mL of normal saline every 6 hours. When reviewing the patient's intake and output record for the past 24 hours, the nurse would expect to note that the patient received how much fluid with the irrigation?
120 mL
The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance?
260 mL
A client with esophageal cancer has difficulty in swallowing. Which of the following would be appropriate to help the client achieve improved nutrition?
Give high-protein, semiliquid foods
A few hours after eating hot and spicy chicken wings, a client presents with lower chest pain. He wonders if he is having a heart attack. How should the nurse proceed first?
Investigate the initial complaint
For a patient with salivary calculi, which of the following procedures uses shock waves to disintegrate the stone?
Lithotripsy
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?
Metoclopramide (Reglan)
The nurse is talking with a client who is scheduled for a computed tomography (CT) colonography. Which client statement would indicate to the nurse that the client needs additional teaching about this procedure?
My doctor will be able to remove any polyps he finds
A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?
NPO
Which of the following is the most common symptom of gastrointestinal (GI) problems in general?
Nausea
Which of the following medications is classified as a proton pump inhibitor (PPI)?
Omeprazole
A client is scheduled for the following tests: barium enema, small bowel series, enteroclysis enema, and an oral cholecystogram. Which test would the nurse expect the client to undergo first?
Oral cholecystogram
A client is scheduled for an esophagogastroduodenoscopy (EGD) to detect lesions in the gastrointestinal tract. The nurse would observe for which of the following while assessing the client during the procedure?
Pain and discomfort tolerance
Which of the following is an enzyme secreted by the gastric mucosa?
Pepsin
A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered?
Permit to drink only clear liquids
A group of students is reviewing the medications that may be used to treat esophageal reflux. The students demonstrate understanding of the information when they identify which of the following as an example of a proton-pump inhibitor?
Prilosec
A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?
Take long, slow breaths
A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge?
The client is free from esophagitis and achalasia.
A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?
The client lying in a lateral position, with the head of bed flat
