GI

Three days after admission to the hospital for a brain attack (cerebrovascular accident [CVA]), a client has a nasogastric tube inserted and is receiving continuous tube feedings. What should the nurse do to best evaluate whether the feeding is being absorbed? 1.Aspirate for a residual volume. 2.Evaluate the intake in relation to the output. 3.Instill air into the client's stomach while auscultating. 4.Compare the client's body weight with the baseline data

1.Aspirate for a residual volume.

A client who has just been transferred to the inpatient unit following surgery for oral carcinoma indicates to the nurse that the client's spouse is the only person that is allowed to visit. To support the client at this time, the nurse should: 1.Comply with the client's wishes 2.Ask the client why other visitors should be restricted 3.Have the spouse explain to the client that everything will be okay 4.Promote communication to find out how the client really feels

1.Comply with the client's wishes

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? 1.Incontinence and inability to move independently. 2.Periodic diaphoresis and occasional sliding down in bed. 3.Reaction to just painful stimuli and receiving tube feedings. 4.Adequate nutritional intake and spending extensive time in a wheelchair.

1.Incontinence and inability to move independently.

A client who recently has had an abdominoperineal resection and colostomy accuses the nurse of being uncomfortable during a dressing change because the "wound looks terrible." The nurse identifies that the client is using the defense mechanism known as: 1.Projection 2.Sublimation 3.Compensation 4.Intellectualization

1.Projection

The nurse provides medication teaching to a client on diuretic therapy who receives a prescription for potassium supplements. The nurse concludes that the teaching was effective when the client states, "I should: 1.Report any abdominal distress." 2.Use salt substitutes to season food." 3.Take the drug on an empty stomach." 4.Increase the dosage if I have muscle cramps."

1.Report any abdominal distress."

Which recommendation is most important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet? 1.Use lemon juice to season meat 2.Put condiments on food to add flavor 3.Include canned vegetables in meal preparation 4.Drink carbonated beverages instead of decaffeinated coffee

1.Use lemon juice to season meat

A nurse educator of a college health course is discussing tattoos with the class. Which type of hepatitis associated with tattoos should the nurse include in the teaching plan? 1.A 2.C 3.D 4.E

2.C

A client has a paracentesis during which 1500 mL of fluid is removed. The nurse should monitor the client carefully for: 1.Hypertensive crisis 2.Hypovolemic shock 3.Abdominal distention 4.Tenting of the integument

2.Hypovolemic shock

On the third postoperative day after a subtotal gastrectomy, a client reports having severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. What should be the nurse's first action? 1.Assist the client to ambulate. 2.Obtain the client's vital signs. 3.Administer the prescribed analgesic. 4.Encourage using the incentive spirometer

2.Obtain the client's vital signs

A nurse obtains daily stool specimens for a client with chronic bowel inflammation. The nurse concludes that these stool examinations were prescribed to determine: 1.Fat content. 2.Occult blood. 3.Ova and parasites. 4.Culture and sensitivity

2.Occult blood.

A client with early-stage cancer of the esophagus is treated with laser therapy. What type of food should the nurse instruct the client to select when oral intake is permitted? 1.Cold 2.Pureed 3.Low in protein 4.Low in calories

2.Pureed

A client is admitted to the hospital with the diagnosis of intestinal obstruction and has an intestinal tube inserted. The plan of care includes a prescription to instill 30 mL of normal saline into the tube as needed to maintain patency. When considering the normal saline that is instilled, the nurse should: 1.Subtract the 30 mL from the gastric output 2.Record the 30 mL on the intake and output record 3.Understand that the amount instilled equals insensible losses 4.Consider the amount too small to document on the intake and output record

2.Record the 30 mL on the intake and output record

Morphine via an epidural catheter is prescribed for a client after abdominal surgery. The client asks the nurse why this medicine is necessary. What primary rationale does the nurse give for the administration of an opioid analgesic after abdominal surgery? 1.Facilitates oxygen use 2.Relieves abdominal pain 3.Decreases anxiety and restlessness 4.Dilates coronary and peripheral blood vessels

2.Relieves abdominal pain

A client is admitted to the hospital for a laparoscopic cholecystectomy. What should the nurse encourage the client to add to the diet to help normalize bowel function after surgery? 1.Vitamins 2.Whole bran 3.Cod liver oil 4.Amino acids

2.Whole bran

A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The client reports frequent nausea, pain that increases after meals, and black tarry stools. The client recently joined Alcoholics Anonymous. The nurse should give priority to which patient history item? 1.Pain that increases after meals 2.Frequent nausea 3.Black tarry stools 4.Joining Alcoholics Anonymous

3.Black tarry stools

Prednisone (Meticorten), an adrenal steroid, is prescribed for a client with an exacerbation of colitis. When administering the first dose of the medication, the nurse should inform the client that the medication: 1.Will protect the client from getting an infection 2.May cause weight loss by decreasing appetite 3.Is not curative but does cause a suppression of the inflammatory process 4.Is relatively slow in precipitating a response but is effective in reducing symptoms

3.Is not curative but does cause a suppression of the inflammatory process

A nurse is planning care for a client admitted to the hospital with abdominal spasms and pain associated with severe diarrhea. What primary serum blood level should the nurse monitor? 1.Urea 2.Chloride 3.Potassium 4.Creatinine

3.Potassium

An older adult is returned to the surgical unit after having a subtotal gastrectomy. Which dietary modification should the nurse anticipate that the health care provider will most likely prescribe? 1.Increase intake of dietary roughage slowly. 2.Avoid oral feedings for a prolonged period. 3.Resume small, easily digested feedings gradually. 4.Limit intake to self-selection of personally preferred foods

3.Resume small, easily digested feedings gradually.

A client had surgery for a ruptured appendix. Postoperatively, the health care provider prescribes an antibiotic to be administered intravenously twice a day. The nurse administers the prescribed antibiotic via a secondary line into the primary infusion of 0.9% sodium chloride. During the administration of the antibiotic, the client becomes restless and flushed, and begins to wheeze. What should the nurse do after stopping the antibiotic infusion? 1.Check the client's temperature 2.Take the client's blood pressure 3.Obtain the client's pulse oximetry 4.Assess the client's respiratory status

4.Assess the client's respiratory status

A client has a large open abdominal wound. The health care provider's prescription states to cleanse the wound with normal saline, pack the wound with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. What should the nurse do to maintain sterility when changing the dressing? 1.Use a separate square gauze to cleanse each half of the wound. 2.Apply new Montgomery straps each time the dressing is changed. 3.Hold the wet gauze with the tips of the forceps higher than the wrist. 4.Cleanse the wound with wet sterile gauze from the center of the wound outward

4.Cleanse the wound with wet sterile gauze from the center of the wound outward

A client tells the nurse about recent recurrent episodes of bleeding hemorrhoids. What should the nurse advise the client to do to help prevent future hemorrhoidal episodes? 1.Exercise to improve circulation 2.Eat bland foods and avoid spices 3.Use laxatives to avoid constipation 4.Consume a high-fiber diet and drink adequate water

4.Consume a high-fiber diet and drink adequate water

The nurse teaches the client with gastroesophageal reflux disease that after meals the client should: 1.Drink 8 ounces of water 2.Take a walk for 30 minutes 3.Lie down for at least 20 minutes 4.Rest in a sitting position for one hour

4.Rest in a sitting position for one hour

When teaching a client how to prevent constipation, the nurse evaluates that the dietary teaching is understood when the client states that the preferred breakfast cereal is: 1.Froot Loops 2.Corn Flakes 3.Cap'n Crunch 4.Shredded Wheat

4.Shredded Wheat