Nurs 327 study guide

The nurse is caring for a client with a suspected megacolon. The nurse anticipates that one of the findings of assessment will be Diarrhea Hemorrhoids Fecal incontinence Dark, tarry stools

fecal incontinence

A nurse is preparing to discharge a client newly diagnosed with peptic ulcer disease. The client's diagnostic test results were positive for H. pylori bacteria. The health care provider has ordered the "triple therapy" regimen. Which medications will the nurse educate the client on? H2-receptor antagonist and two antibiotics H2-receptor antagonist, proton-pump inhibitor, and an antibiotic Proton-pump inhibitor, an antibiotic, and bismuth salts Proton-pump inhibitor and two antibiotics

Proton-pump inhibitor and two antibiotics

The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length? A length of 50 cm (20 in) A point that equals the distance from the nose to the xiphoid process The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process The distance determined by measuring from the tragus of the ear to the xiphoid process

The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process

A nurse works in a bariatric clinic and cares for client with obesity who will or have undergone bariatric surgery. What is the nurse's understanding of how the procedure works? Restricts the client's ability to eat . Impairs caloric absorption. Restricts the client's ability to digest fat. Impairs gastric motility.

ability to eat

A middle-aged obese female presents to the ED with severe radiating right-sided flank pain, nausea, vomiting, and fever. A likely cause of these symptoms is: acute cholecystitis hepatitis A hepatitis B pancreatitis

acute

The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon return to the nursing unit, what does the nurse identify as the client goal? Recover from the general anesthesia Decrease nausea and vomiting Increase the amount of fluids Ambulate independently

increase fluids

The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly? Maintain intermittent or continuous suction at a rate greater than 120 mm Hg. Keep the vent lumen above the patient's waist to prevent gastric content reflux. Irrigate only through the vent lumen. Tape the tube to the head of the bed to avoid dislodgement.

keep vent above waist

A client has symptoms suggestive of peritonitis. Nursing management would not include: limiting analgesics to avoid the formation of paralytic ileus. accurate recording of input and output. inserting a nasogastric tube. inserting a urinary retention catheter.

limiting analgesics

The nurse should assess for an important early indicator of acute pancreatitis. What prolonged and elevated level would the nurse determine is an early indicator? Serum calcium Serum lipase Serum bilirubin Serum amylase

lipase

A nurse cares for a client who is postoperative bariatric surgery and has experienced frequent episodes of dumping syndrome. The client now reports anorexia. What is the primary reason for the client's report of anorexia? Fear of eating Taste of food Size of the stomach Absorption of food

fear of eating

A nurse cares for a client who is post op from bariatric surgery. Once able, the nurse encourages oral intake for what primary purpose? Stimulate GI peristalsis Assess for intact swallowing Assess for gastric perforation Stimulate digestive hormones

GI peristalisis

The nurse is caring for an older adult who reports xerostomia. The nurse evaluates for use of which medication? Steroids Antibiotics Antiemetics Diuretics

diuretics

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take? Remove the tape from the nose of the client. Withdraw the tube gently for 6 to 8 inches. Provide oral hygiene . Flush with 10 mL of water.

flush with 10ML

The nurse is admitting a client whose medication regimen includes regular injections of vitamin B12. The nurse should question the client about a history of: total gastrectomy. bariatric surgery. diverticulitis. gastroesophageal reflux disease (GERD).

gastrectomy

The nurse is conducting a community education program on peptic ulcer disease prevention. The nurse includes that the most common cause of peptic ulcers is: stress and anxiety. gram-negative bacteria. alcohol and tobacco. ibuprofen and aspirin.

gram neg bacteria

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. What would be the first activity performed by the nurse? Assess lung sounds bilaterally. Administer prescribed morphine intravenously. Obtain consent for the esophagogastroscopy. Suction the oral cavity of the client.

lung sounds bilat

After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching? "I'll have to wear an external collection pouch for the rest of my life." "I should eat foods from all the food groups." "I'll need to drink at least eight glasses of water a day." "I'll have to catheterize my pouch every 2 hours."

external collection pouch

A nurse is assessing the abdomen of a client just admitted to the unit with a suspected GI disease. Inspection reveals several diverse lesions on the client's abdomen. How should the nurse best interpret this assessment finding? Abdominal lesions are usually due to age-related skin changes. Integumentary diseases often cause GI disorders . GI diseases often produce skin changes. The client needs to be assessed for self-harm.

GI diseases often produce skin changes

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 Evaluate for masses in the large colon Administer nutritional substances

remove fluids, diagnose, flush, admin nutrional

The nurse cares for a client after an endoscopic examination and prepares the client for discharge. The nurse includes which instruction? Avoid driving for 24 hours. Continue a clear liquid diet. Resume regular diet. Increase fluid intake.

resume regular diet

The nurse observes the physician palpating the abdomen of a client that is suspected of having acute appendicitis. When the abdomen is pressed in the left lower quadrant the client complains of pain on the right side. What does the nurse understand this assessment technique is referred to? Referred pain Rebound pain Rovsing sign Cremasteric reflex

rovsing sign

When preparing to insert a nasogastric tube, the nurse determines the length of the tube to be inserted. The nurse nurse places the distal tip of the tube at which location? Tip of patient's nose Tragus of the ear Base of the neck Tip of the xiphoid process

tip of nose

An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom? Hiatal hernia Gastroesophageal reflux disease Gastritis Esophageal tumor

tumor

A nurse is creating a care plan for a client with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube? Auscultate the client's abdomen after injecting air through the tube. Assess the color and pH of aspirate. Locate the marking made after the initial x-ray confirming placement. Use a combination of at least two accepted methods for confirming placement.

use combo of 2

A client is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate? Administer antibiotics via the tube as prescribed. Wash the area around the tube with soap and water daily. Cleanse the skin within 2 cm of the insertion site with hydrogen peroxide once per shift. Irrigate the skin surrounding the insertion site with normal saline before each use.

wash area with soap and water daily

The client is receiving 50% dextrose parenteral nutrition with fat emulsion therapy through a peripherally inserted central catheter (PICC). The nurse has developed a care plan for the nursing diagnosis "Risk for infection related to contamination of the central catheter site or infusion line." The nurse includes the intervention Change the transparent dressing every 3 days. Wear a face mask during dressing changes. Assess the PICC insertion site daily . Use clean gloves when providing site care.

wear face mask

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? Slow the current infusion rate so that it will last until the new solution arrives. Hang a solution of dextrose 10% and water until the new solution is available. Have someone go to the pharmacy to obtain the new solution. Begin an infusion of normal saline in another site to maintain hydration.

10% dextrose and water

A client with peptic ulcer disease has been prescribed sucralfate. What health education should the nurse provide to this client? Take the medication 2 hours before or after other medications Blood levels will be evaluated after 1 week Take the medication at bedtime to accommodate sedative effects Ensure adequate potassium intake during therapy

2 hours before other meds

The nurse administers a tube feeding to a client via the intermittent gravity drip method. The nurse should administer the feeding over at least which period of time? 15 minutes 30 minutes 60 minutes 80 minutes

30 minutes

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? 5-mL 10-mL 20-mL 30-mL

30ML

After teaching a client who has had a Roux-en-Y gastric bypass, which client statement indicates the need for additional teaching? "I need to chew my food slowly and thoroughly." "I need to drink 8 oz of water before eating." "A total serving should amount to be less than 1 cup." "I should pick cereals with less than 2 g of fiber per serving."

8OZ of water

A client has been taking a 10-day course of antibiotics for pneumonia. The client has been having white patches that look like milk curds in the mouth. What treatment will the nurse educate the client about? Nystatin Cephalexin Fluocinolone acetonide oral base gel Acyclovir

nystatin

A client comes to the clinic reporting pain in the epigastric region. What statement by the client suggests the presence of a duodenal ulcer? "My pain resolves when I have something to eat." "The pain really interferes with my quality of life." "I know that my father and my grandfather both had ulcers." "I seem to have bowel movements more often than I usually do."

pain resolved when i eat

An elderly client comes into the emergency department reporting an earache. The client and has an oral temperature of 37.9° (100.2ºF) and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next? Palpate the client's parotid glands to detect swelling and tenderness. Assess the temporomandibular joint for evidence of a malocclusion. Test the integrity of cranial nerve XII by asking the client to protrude the tongue. Inspect the client's gums for bleeding and hyperpigmentation.

palpate parotid glands

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 nerve fibers of the intestinal lining are experiencing neuropathy . The pancreas secretes digestive enzymes. Elevated glucose levels cause bacteria overgrowth in the large intestine. Insulin has an adverse effect of constipation.

pancreas digestive enzymes

A patient reports an inflamed salivary gland below the right ear. The nurse documents probable inflammation of which gland? Buccal Parotid Sublingual Submandibular

parotid

A client is being treated for prolonged diarrhea. Which foods should the nurse encourage the client to consume? Protein-rich foods Potassium-rich foods High-fiber foods High-fat foods

potassium

A client who is postoperative from bariatric surgery reports foul-smelling, fatty stools. What is the nurse's understanding of the primary reason for this finding? Rapid gastric dumping Excessive fat intake Decreased motility Decreased gastric size

rapid dumping

The nurse inspects a client's tongue. Which finding would the nurse evaluate as an indication of potential oral cancer? V formation on dorsum of tongue thin, white coating on dorsum of tongue red plaque on undersurface of tongue large, vallate papillae on dorsum of tongue

red plauqe

Which nursing instruction is correct to provide the client following a barium enema? The client will maintain a low residue diet. The stools may be a white or clay colored. Sips of fluid may be increased if tolerated. An enema will be used to clear the bowel.

white or clay colored stools

A nurse is preparing to administer a client's scheduled parenteral nutrition (PN). Upon inspecting the bag, the nurse notices that small amounts of white precipitate are present in the bag. What is the nurse's best action? Recognize this as an expected finding. Place the bag in a warm environment for 30 minutes. Shake the bag vigorously for 10 to 20 seconds. Contact the pharmacy to obtain a new bag of PN.

contact pharm

A nurse is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply. Hypertension Diarrhea Decreased bowel sounds Tachycardia diaphoresis

diarrhea, tachycardia, diaphoresis

A nurse is assessing a client for GI dysfunction. What is the most common symptom in a client with GI dysfunction? Diffuse pain Dyspepsia Constipation Abdominal bleeding

dyspepsia

The nurse is conducting a community education session on the prevention of oral cancers. The nurse includes which cancer as being a type of premalignant squamous cell skin cancer? Herpes simplex 1 Actinic cheilitis Chancre Krythoplakia

Actinic cheilitis

The health care provider orders the insertion of a single lumen nasogastric tube. When gathering the equipment for the insertion, what will the nurse select? Salem sump tube Miller-Abbott tube Sengsten-Blakemore tube Levin tube

Levin

The nurse advises the patient who has just been diagnosed with acute gastritis to: Take an emetic to rid the stomach of the irritating products. Refrain from food until the GI symptoms subside. Restrict food and fluids for 12 hours. Restrict all food for 72 hours to rest the stomach.

Refrain from food until the GI symptoms subside.

The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease? Minimize intake of caffeine, beer, milk, and foods containing peppermint or spearmint. Avoid eating or drinking 2 hours before bedtime. Elevate the foot of the bed on 6- to 8-inch blocks. Eat a low-carbohydrate diet.

avoid eating and drinking

A patient is scheduled for a fiberoptic colonoscopy. What does the nurse know that fiberoptic colonoscopy is most frequently used to diagnose? Bowel disease of unknown origin Cancer Inflammatory bowel disease Occult bleeding

cancer

A positive Rovsing's sign is indicative of appendicitis. A nurse knows to assess for this indicator by palpating the: Right lower quadrant. Left lower quadrant. Right upper quadrant. Left upper quadrant.

lower left

A nurse is admitting a client diagnosed with late-stage gastric cancer. The client's family is distraught and angry that she was not diagnosed earlier in the course of her disease. What factor most likely contributed to the client's late diagnosis? Gastric cancer does not cause signs or symptoms until metastasis has occurred. Adherence to screening recommendations for gastric cancer is exceptionally low. Early symptoms of gastric cancer are usually attributed to constipation. The early symptoms of gastric cancer are usually not alarming or highly unusual.

not higly unusal

A client is treated for gastrointestinal problems related to chronic cholecystitis. What pathophysiological process related to cholecystitis does the nurse understand is the reason behind the client's GI problems? Contractile spasms of the gallbladder decreases appetite and leads to malnutrition. Inflammation of the gallbladder causes pain and impacts gastric motility. Reduced or absent bile as a result of obstruction impacts digestion. Increased bile as a result of inflammation leads to indigestion.

reduced or absent bile

A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms? A pattern of distinct exacerbations and remissions Severe diarrhea An absence of blood in stool Involvement of the rectal mucosa

absense of blood in stool

The client is postoperative following a graft reconstruction of the neck. It is most important for the nurse to Reinforce the neck dressing when blood is present on the dressing. Assess the graft for color and temperature. Administer prescribed intravenous vancomycin at the correct time. Cleanse around the drain using aseptic technique.

assess graft color and temp

A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond? "Your appendix doesn't play a major role, so you won't notice any difference after your recovery from surgery." "The surgeon will encourage you to limit your fat intake for a few weeks after the surgery, but your body will then begin to compensate." "Your body will absorb slightly fewer nutrients from the food you eat, but you won't be aware of this." "Your small intestine will adapt over time to the absence of your appendix."

appendix doesnt play a major role

The client has just had a central line inserted for parenteral nutrition. The client is awaiting transport to the Radiology Department for catheter placement verification. The client reports feeling anxious. Respirations are 28 breaths/minute. The first action of the nurse is Auscultate lung sounds. Position client flat in bed. Elevate the head of the bed. Consult with the healthcare provider.

auscultate lung sounds