hesi GI - medsurg2
A client is recently diagnosed with a cancerous lesion of the mouth. Which question should the nurse ask when assessing the client's need for health education in relation to this condition? 1 "Are you having difficulty sleeping?" 2 "Do feel like your gums are inflamed?" 3 "How frequently are you seeing the dentist?" Correct 4 "Have you noticed any change in your appetite?" Problems involving the oral cavity often result in nutritional problems and weight loss, requiring the nurse to intervene. The question "Have you noticed any change in your appetite?" will elicit more information. The nurse needs to determine a client's past and current appetite and nutritional status. An inability to sleep usually is not a characteristic symptom of cancer of the oral cavity; it may occur after the diagnosis because of worry or fear. Gum infections usually are not an early problem after diagnosis of oral cancer. Although a dentist may be the first to identify oral cancer, medical treatment is needed. Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response. 13261983000 Confidence: Nailed It Stats 2. When inserting a catheter to irrigate a client's colostomy, the nurse meets some resistance. What should the nurse do? 1 Probe with the irrigating catheter to determine the contour of the bowel 2 Obtain a more rigid tip for the irrigating catheter to insert into the stoma 3 Apply pressure to the irrigating catheter to overcome the spasm of the bowel Correct 4 Instill a small amount of solution from the irrigating container into the stoma Instilling a small amount of solution from the irrigating container into the stoma helps distend the bowel ahead of the catheter and eases catheter insertion. Probing with the irrigating catheter can cause damage to the delicate mucous membrane of the intestinal tract and may perforate the bowel. Using a more rigid catheter tip can cause damage to the delicate mucous membrane of the intestinal tract and may perforate the bowel. Applying pressure to the irrigating catheter can cause damage to the delicate mucous membrane of the intestinal tract and may perforate the bowel. STUDY TIP: Enhance your organizational skills by developing a checklist and creating ways to improve your ability to retain information, such as using index cards with essential data, which are easy to carry and review whenever you have a spare moment. 13263181569 Confidence: Nailed It Stats 3. A client has a low hemoglobin level that is attributed to a nutritional deficiency. Which foods should the nurse teach the client to increase in the diet? Select all that apply. Correct 1 Liver 2 Apples 3 Carrots 4 Cheese Correct 5 Spinach Liver and spinach are high in iron. The client needs iron for red blood cell production and hemoglobin; a low hemoglobin indicates the client is anemic. Apples are high in fiber. Carrots are high in Vitamin A. Cheese is high in calcium. Apples, carrots, and cheese are low in iron. 13263099987 Confidence: Nailed It Stats 5. A client has 4 ounces (120 mL) of apple juice, 6 ounces (180 mL) of tea, and 8 ounces (240 mL) of chicken broth. How many mL of fluid will the nurse document the client ingested? Record your answer using a whole number. _____ mL 540 mL is a correct calculation. 4 ounces apple juice x 30 mL/ounce = 120 mL, 6 oz tea x 30 mL/ounce = 180 mL, and 8 oz chicken broth x 30 mL/ounce = 240 mL. 120 + 180 + 240 = 540 mL that the client has ingested. Test-Taking Tip: When taking the NCLEX exam, an on-screen calculator will be available for you to determine your response, which you will then type in the provided space. 13262148269 Confidence: Nailed It Stats 6. After surgery for cancer of the pancreas, the client's nutrition and fluid regimen are influenced by the remaining amount of functioning pancreatic tissue. The nurse considers both the exocrine and the endocrine functions of the pancreas and expects that, postoperatively, the client's dietary regimen will be focused on the management of what substances? 1 Alcohol and caffeine 2 Fluids and electrolytes 3 Vitamins and minerals Correct 4 Fats and carbohydrates Formation of lipase necessary for digestion of fats is an exocrine function; the endocrine function is to secrete insulin, which is a hormone essential in carbohydrate metabolism. Although it is necessary to avoid alcohol, this is not related to pancreatic exocrine functions; caffeine is unrelated to pancreatic function. Fluid and electrolyte problems are not related specifically to exocrine or endocrine pancreatic functioning. Deficiencies of vitamins and minerals may occur because of inadequate intake, but these deficiencies are not specifically related to exocrine or endocrine pancreatic functioning. Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late in the morning, take a high-powered snack with you to eat 20 minutes before the examination. The brain works best when it has the glucose necessary for cellular function. 13263194732 Confidence: Nailed It Stats 8. A nurse is caring for a client after surgical creation of an ostomy. The nurse observes that the stool is formed. In which part of the colon should the nurse assess the ostomy? 1 Ileum 2 Ascending 3 Transverse Correct 4 Descending As the effluent passes through the gastrointestinal system, water is absorbed, and the stool becomes more formed. The stool from an ostomy in the descending colon will be formed. The ileum is a component of the small intestines and produces very liquid stools. The stool from an ostomy in the ascending colon will be liquid because it is the first portion of the large intestine that the stool enters, and fluid has not yet been reabsorbed. The stool from an ostomy in the transverse colon will be soft and pasty because fluid still can be absorbed in the rest of the large intestine. 13261518880 Confidence: Nailed It Stats 10. A primary nurse is leaving the unit for lunch and gives a verbal report to another nurse on the unit. The primary nurse states that a client has a prescription for morphine 2 mg intravenously (IV) every 3 hours for abdominal pain because the client had major abdominal surgery that morning. While the primary nurse is still at lunch, the client complains of pain on a level 8 on a pain scale of 1 to 10. What is the first thing the covering nurse should do? 1 Determine when the pain medication was last given. Correct 2 Verify the pain medication prescription in the clinical record. 3 Employ nonpharmacological measures initially to relieve the pain. 4 Explain that the primary nurse will be back from lunch in a few minutes. Before administering any medication for the first time, the nurse must verify the accuracy of the prescription. The prescription as it appears in the medication administration record is verified against the prescription in the client's medical record. This ensures that the prescription was transcribed accurately. Checking when the pain medication was last given is done after the prescription is verified. Nonpharmacological measures are used for mild to moderate pain, not pain associated with recent major abdominal surgery. The client's pain must be immediately addressed. The covering nurse is capable of verifying the pain medication prescription and administering it safely at the correct time. 13262058846 Confidence: Nailed It Stats 12. A client who recently immigrated to the United States (Canada) has a chronic vitamin A deficiency. What information about vitamin A should the nurse consider when assessing this client for clinical indicators of this deficiency? 1 Vitamin A is an integral part of the retina's pigment called melanin. 2 It is a component of the rods and cones, which control color visualization. 3 Vitamin A is the material in the cornea that prevents the formation of cataracts. Correct 4 It is a necessary element of rhodopsin, which controls responses to light and dark environments. Vitamin A is used in the formation of retinol, a component of the light-sensitive rhodopsin (visual purple) molecule. Melanin is a pigment of the skin. Vitamin A does not influence color vision, which is centered in the cones. The cornea is a transparent part of the anterior portion of the sclera; a cataract is opacity of the usually transparent crystalline lens. Vitamin A does not prevent cataracts.
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Gastrointestinal EAQ - Due 7-9-17 @ 10pm Incorrect Answers: 4 13263220788 Confidence: Nailed It Stats 4. The nurse is caring for a client following a laparoscopic cholecystectomy. Which nursing action is priority? 1 Monitor the abdominal dressing for bleeding Incorrect 2 Instruct on using patient-controlled analgesia 3 Teach about six-week activity restriction Correct 4 Assess puncture sites for bleeding The one to four puncture sites used to perform the surgery laparoscopically should be monitored for any possible bleeding. There will not be an abdominal dressing unless a traditional cholecystectomy is performed. Patient-controlled analgesia is not necessary as there is no abdominal incision. Activity restriction is about one week with a laparoscopic cholecystectomy. 13262004008 Confidence: Nailed It Stats 7. A nurse is assessing different clients. Which female client has the greatest risk of developing gallbladder disease? Correct 1 Older than age 40 and obese 2 Older than age 40 with a low serum cholesterol level Incorrect 3 Less than 40 years of age with a history of high fat intake 4 Less than 40 years of age with a family history of gallstones These characteristics are well-established risk factors for gallbladder disease (4 Fs: female, fat, forty, and fertile). Gallbladder clients have an increase in serum cholesterol. A high fat intake does not predispose one to cholecystitis. Although there is an increased risk with a family history of gallstones, gallbladder clients usually are older than the age of 40. 13263220729 Confidence: Nailed It Stats 9. What information from a client's history should the nurse identify as risk factors for the development of colon cancer? Select all that apply. Incorrect 1 Hemorrhoids Correct 2 Increased age 3 High-fiber diet Correct 4 Ulcerative colitis 5 Low hemoglobin level A slower fecal transit time, which occurs with aging, may increase the risk for colon cancer. Chronic irritation of the intestinal mucosa, such as occurs in ulcerative colitis, increases the risk for colon cancer. Hemorrhoids are not a risk factor; they are associated with constipation. A high-fiber diet is linked to a decreased risk for colon cancer. Low hemoglobin level is not a risk factor for colon cancer; this may occur as a result of cancer and its therapies. 13261965846 Confidence: Nailed It Stats 11. After an acute episode of upper gastrointestinal (GI) bleeding, a client vomits undigested antacids and reports having severe epigastric pain. The nursing assessment reveals an absence of bowel sounds, a pulse rate of 134, and shallow respirations of 32 per minute. In addition to calling the healthcare provider, what is the priority nursing action? Correct 1 Prepare the client for surgery. Incorrect 2 Administer oxygen per nasal catheter. 3 Place in the supine position, with legs elevated. 4 Ask the client if there have been any black stools. These symptoms are classic indicators of a perforated ulcer, for which immediate surgery is indicated; this should be anticipated. Although oxygen may be helpful, it is not the priority. The symptoms are more indicative of perforation than of shock, so placing the patient in the supine position with legs elevated is not appropriate at this time. Black, tarry stools indicate bleeding, not perforation. STUDY TIP: A word of warning: do not expect to achieve the maximum benefits of this review tool by cramming a few days before the examination. It doesn't work! Instead, organize planned study sessions in an environment that you find relaxing, free of stress, and supportive of the learning process.
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