TEST 1

10. The nurse is caring for a client with peptic ulcer disease. Which assessment finding indicates to the nurse that the client most likely has an ulcer in the stomach rather than in the duodenum? a. Body mass index (BMI) is 16.6. b. Stool is positive for occult blood. c. Client has had four ulcers in the last 5 years. d. Hemoglobin is 13 g/dL and hematocrit is 42%.

ANS: A A BMI of 17.6 indicates that the client is underweight (<18.5 is underweight in adults). This finding is more commonly seen with gastric ulcers than with duodenal ulcers because the pain is made worse with food ingestion. Occult blood and low hemoglobin and hematocrit levels may be seen with both gastric and duodenal ulcers. Recurrence is more commonly seen with duodenal than with gastric ulcers. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment)

5. When performing an assessment, the nurse detects a fruity odor on the client's breath. What does the nurse do next? a. Assess the client's blood sugar level. b. Assess the client's stool for occult blood. c. Instruct the client in oral hygiene techniques. d. Assess the client for petechiae, itching, and jaundice.

ANS: A A fruity odor to the breath may indicate uncontrolled or undiagnosed diabetes mellitus. The client's blood sugar level should be checked immediately for hyperglycemia. The nurse may perform the other assessment tests for the client, but they will not be helpful in determining the cause of the fruity breath. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

2. Which question best assists the nurse in assessing a client with acute diarrhea? a. "Have you traveled outside the country recently?" b. "Have you had a colonoscopy lately?" c. "Do you have any trouble swallowing?" d. "Do you have any allergies?"

ANS: A A history of recent travel may help pinpoint an infectious source for the client's diarrhea. A colonoscopy will not cause acute diarrhea. Trouble swallowing is not related to diarrhea. Allergic reactions do not typically cause acute diarrhea. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

9. The nurse finds a positive Blumberg's sign in a client with abdominal pain. Which action does the nurse plan? a. Have the client be NPO in preparation for surgery. b. Document this normal finding in the client's record. c. Immediately auscultate the client's abdomen for bowel sounds. d. Repeat the maneuver with the client in a supine position, with the knees flexed.

ANS: A A positive Blumberg's sign (rebound tenderness), an abnormal sign, is indicative of peritoneal inflammation, which commonly accompanies appendicitis. The client should be made NPO in preparation for surgery to remove the appendix. The maneuver should not be repeated with the client in the supine position. The nurse should perform auscultation before percussion for the abdominal assessment. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

11. The nurse is caring for a client who has been brought to the emergency department with upper GI bleeding. The client is vomiting copious amounts of bright red blood. Which is the nurse's priority action? a. Ensure that the client has a patent airway. b. Start a normal saline IV infusion. c. Gather equipment to start a saline lavage. d. Assess the client for causative factors.

ANS: A Airway always comes first. The client must have a patent airway. The client does need an IV and a saline lavage via nasogastric (NG) tube, but these actions are not as important as maintaining the airway. Assessing for causative factors will be important after the client has stabilized. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

13. The nurse is preparing the client for a computed tomography (CT) scan of the abdomen with IV contrast. Which question does the nurse ask the client before the examination? a. "Are you allergic to shrimp, scallops, or shellfish?" b. "Have you had anything to eat or drink in the past 12 hours?" c. "Did you finish taking all the prescribed laxatives?" d. "Can you tolerate being tilted from side to side?"

ANS: A Allergies to iodine or seafood can cause a cross-allergic reaction to the contrast dye used for CT scans. Clients reporting such allergies should be scheduled for CT without contrast to avoid anaphylactic reactions. The client does not need to be NPO for this test and does need not to take laxatives. The client is not tilted during the CT scan. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Error Prevention) MSC: Integrated Process: Nursing Process (Assessment)

16. A client has been taking an antacid for several weeks without improvement in symptoms. Which response by the nurse is most helpful? a. "Tell me exactly how you take your antacid." b. "Would you be willing to try a more expensive medication?" c. "Are you sure you are taking this exactly as ordered?" d. "Let's ask the health care provider if the dose can be doubled."

ANS: A Antacids can be effective anywhere from 30 minutes to 3 hours after eating. Their neutralizing effect is eliminated when they are taken on an empty stomach. However some people take them before eating to prevent symptoms. The nurse should first discover how the client takes the medication before suggesting other medications or increasing the dose. Asking the client whether the medication is being taken exactly as ordered is a closed-ended question, which is not a good communication tool. Also, the way the statement is phrased is likely to place the client on the defensive. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation)

29. An older client is 1 day post-esophagectomy. The nurse finds the client short of breath with a heart rate of 120 beats/min. Which action by the nurse takes priority? a. Assess the client's lungs and oxygen saturation. b. Ask the client to rate pain, and treat if needed. c. Help the client change to a side-lying position. d. Increase the client's supplemental oxygen.

ANS: A Clients can have many complications from this operation, and older clients are especially vulnerable to fluid overload. The nurse should first assess lung sounds and oxygen saturation. Although pain can cause tachycardia, it usually does not cause shortness of breath. If the client has pain, it should be treated, but it is not the priority. The nurse needs to know the client's oxygen saturation before turning up the oxygen. Changing the client's position will not help. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

20. A client is admitted with progressive dysphagia. What intervention by the nurse takes priority? a. Weigh the client daily. b. Instruct the client on a high-protein diet. c. Assess and treat the client's pain. d. Administer antitussive medications.

ANS: A Clients with progressive dysphagia can lose weight as a result of their inability to take adequate nutrition. Weighing the client daily is an important intervention to gauge the effectiveness of interventions designed to meet nutritional needs. Increased protein in the diet is important, but if the client has trouble swallowing, this is not the best option. The other two interventions do not relate to dysphagia. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration) MSC: Integrated Process: Nursing Process (Assessment)

8. An older client is admitted to the hospital with acute gastritis. The health care provider orders magnesium hydroxide (Mylanta) 1 hour and 3 hours after meals and at bedtime. Which action by the nurse is most appropriate? a. Check the client's renal function studies before giving the drug. b. Call the health care provider and ask for a different antacid for the client. c. Assess the client's pain and treat pain if present. d. Assist the client in ordering bland food from the menu.

ANS: A Hypermagnesemia can develop if the client's kidneys are not functioning well because Mylanta contains magnesium, which is excreted via the kidneys. Kidney function declines as a normal age-related change, so the nurse should be cautious to check kidney function before administering this medication. The client may be able to take the medication; without further information, the nurse should not yet call the provider. Assessing and treating pain and helping the client choose appropriate foods are good interventions, but they are not specific to ensuring safety regarding the medication ordered. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Analysis)

31. A client is admitted with a chemical injury to the esophagus after ingestion of an alkaline substance. The client states, "I am having trouble breathing because of these air bubbles in my neck." Which action by the nurse is most appropriate? a. Continue assessing the client while another nurse calls the health care provider. b. Ask the client to rate the pain and prepare to administer pain medication. c. Have the client cough and deep breathe, then assess his or her lung sounds. d. Give the client small sips of water to see whether he or she has dysphagia.

ANS: A Ingestion of alkaline substances is dangerous because of their potential to fully penetrate the esophagus, leading to perforation. "Air bubbles" in the neck (subcutaneous emphysema) would lead the nurse to suspect this complication. The nurse needs to continue assessing the client and must stay with him or her, but because this is an emergency, someone else must notify the provider immediately. The nurse should not administer pain medication at this time. Coughing and deep-breathing exercises will not be beneficial to the client. If the client's esophagus has perforated, having the client drink can cause more problems. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Analysis)

7. The nurse is teaching a health promotion class about preventing cancer. Which statement by a student indicates understanding of gastric cancer development? a. "I should skip my morning bacon and egg sandwich to reduce my risk of gastric cancer." b. "I have been lactose intolerant for many years, so I should have a yearly test for gastric cancer." c. "I should switch from regular to decaffeinated coffee to reduce my risk of gastric cancer." d. "I am at low risk for developing gastric cancer because I am a vegetarian and I eat only organic produce."

ANS: A Regular consumption of processed foods with nitrates (including bacon) can increase risk for gastric cancer. Lactose intolerance, coffee intake, and vegetarian diet are not factors in gastric cancer development. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Evaluation)

9. The nurse is caring for a client with chronic gastritis. The client asks the nurse how to prevent another flare-up of gastritis. Which is the nurse's best response? a. "Join a support group to help you stop smoking." b. "Take a multivitamin with iron and folic acid every day." c. "Make sure to include plenty of fresh vegetables in your diet." d. "Make sure that your weight stays within normal limits."

ANS: A Smoking and stress contribute to the development of gastritis, so the client should join a support group to help him quit smoking. Multivitamins, fiber, and weight management do not help prevent gastritis development. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1221 TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

30. What does the nurse teach the client with esophageal diverticula about dietary needs? a. "Eat soft foods and smaller meals." b. "Only eat puréed foods." c. "Avoid drinking liquids with meals." d. "Avoid dairy products."

ANS: A Soft foods and smaller meals assist in reducing the symptoms of pressure and reflux that accompany diverticula. The client does not have to avoid liquids or dairy products because these do not cause symptoms. The client does not have to eat puréed foods because he or she does not have difficulty swallowing or chewing foods. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1218 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Teaching/Learning

5. The home care nurse is caring for a client who has recently undergone a subtotal gastrectomy. The nurse notes that the client's tongue is shiny and beefy red. Which assessment question does the nurse ask the client regarding this finding? a. "Have you been taking your multivitamin every day?" b. "How much weight have you lost since your surgery?" c. "Have you been experiencing heartburn or nausea after eating?" d. "What kind of mouthwash do you use after you brush your teeth?"

ANS: A Symptoms of atrophic glossitis are caused by a decrease in vitamin B12, which results from lack of intrinsic factor secondary to surgical resection of a portion of the stomach. The nurse should check to see whether the client has been taking the prescribed multivitamin every day. The other questions will not help the nurse discover the cause of this finding. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment)

10. The nurse is caring for a client who has just completed treatment for basal cell carcinoma on the lower lip. The client says to the nurse, "Cigarettes are ruining my life. I'll do anything to quit smoking." Which is the nurse's best response? a. "Here is some information about smoking cessation programs in the area. Let's discuss the options." b. "Here are some pamphlets that show the financial benefits of quitting smoking." c. "If you quit smoking, your risk for developing cancer again will decrease dramatically." d. "Your chest x-ray is still clear, so you could prevent permanent lung damage if you quit smoking now."

ANS: A The client has indicated a readiness to quit smoking; therefore, the nurse should help the client choose the best course of action by taking time to discuss the options. The other responses provide good rationales for why quitting smoking would be a positive outcome, but no help is being offered in preparing a plan to quit. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Behavioral Interventions) MSC: Integrated Process: Nursing Process (Planning)

11. The nurse is caring for a client who just completed an upper GI radiographic series with oral barium contrast. Which instructions does the nurse provide to the client? a. "Drink plenty of fluids over the next few days." b. "Do not eat or drink anything for 6 hours after the test." c. "You may not drive or operate heavy machinery today." d. "Do not take any blood thinners for 24 hours after the test."

ANS: A The client is encouraged to drink plenty of fluids after a barium swallow to help eliminate the barium from the colon. Limiting the diet as the barium is being cleared is not necessary. The test will not make the client drowsy, so driving should not be limited. Similarly, blood thinners will not affect the client. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1187 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Teaching/Learning

9. The nurse is teaching a client about self-management of gastroesophageal reflux. Which statement by the nurse is most appropriate? a. "Eat four to six small meals each day." b. "Eat a small evening snack 1 to 2 hours before bed." c. "No specific foods or spices need to be cut from your diet." d. "You may include orange or tomato juice with your breakfast."

ANS: A The client is instructed to eat four to six small meals daily rather than three larger meals to avoid pressure in the stomach and delayed gastric emptying, which can increase reflux. Evening snacks and acidic foods also should be avoided. The client should keep a diary to assess for foods or spices that increase symptoms, and those items need to be avoided. DIF: Cognitive Level: Comprehension/Understanding REF: Chart 57-2, p. 1206 TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

5. A client just experienced an episode of reflux with regurgitation. What assessment by the nurse is the priority? a. Auscultate the lungs for crackles. b. Inspect the oral cavity. c. Check the oxygen saturation. d. Teach the client to sleep sitting up.

ANS: A The client with regurgitation is at risk for aspiration, pneumonia, and bronchitis. The nurse should auscultate the lungs for crackles—an indication of aspiration. If abnormalities are found, the nurse can then check the oxygen saturation. The nurse should teach the client to sleep with the head of the bed elevated, however; this is not a priority action. Inspecting the oral cavity probably is not needed. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Assessment)

19. The nurse is caring for a client who recently has undergone a partial gastrectomy. Two hours after eating lunch, the client becomes dizzy, diaphoretic, and confused. Which is the nurse's priority action? a. Check the client's blood sugar level. b. Increase the client's IV infusion rate. c. Auscultate the client's bowel sounds. d. Place the client in high Fowler's position.

ANS: A The client's symptoms are consistent with late dumping syndrome, in which hypoglycemia is caused by increased insulin levels. The client's blood sugar level should be checked immediately. The other actions are not necessary. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

32. A client has been diagnosed with early esophageal cancer. The nurse plans care by implementing measures designed to address which priority concern? a. Nutritional support b. Pulmonary toileting c. Fluid and electrolyte balance d. Educational needs

ANS: A The major concern for a client with esophageal cancer is weight loss secondary to dysphasia. Therefore, nutritional support is required, with intake monitored and weight maintained. The other concerns are important, but they are not the priority. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Planning) MULTIPLE RESPONSE

6. The nurse is caring for a client who just had a radical jaw and neck resection. The nurse is developing a teaching plan for the client and spouse about care after discharge from the hospital. Which is an effective teaching objective for this client and spouse? a. The client's spouse will be able to change the client's tracheostomy ties correctly after three teaching sessions. b. The client and spouse will verbalize the signs of readiness for oral feedings following placement of the tracheostomy. c. The client's spouse will correctly administer the client's tube feedings twice daily. d. The client and spouse will understand incision care and the importance of infection prevention.

ANS: A The objective is action oriented, specific, achievable, and measurable. The other responses are not as clear and measurable. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning

15. The nurse is caring for a client with suspected upper GI bleeding. The nurse inserts a nasogastric (NG) tube for gastric lavage and checks placement of the tube in the stomach. When fluid is aspirated from the tube, the pH is found to be 6. Which is the priority action of the nurse? a. Obtain an order for a stat chest x-ray. b. Auscultate over the lung fields bilaterally. c. Assess whether the tube is coiled in the client's throat. d. Auscultate over the epigastric area while instilling air.

ANS: A The pH of gastric contents should be below 3.5. A stat chest x-ray should be obtained whenever any doubt arises regarding NG tube placement. The other methods are not appropriate for confirming placement. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of Equipment) MSC: Integrated Process: Nursing Process (Assessment)

16. The nurse is caring for a client who has just undergone a partial glossectomy and partial mandibulectomy for oral cancer. Which is the highest priority for this client? a. Maintenance of the airway b. Ability to communicate c. Adequate body image d. Pain management

ANS: A The priority problem for a client with oral cancer surgery is possible ineffective airway clearance. Airway obstruction can result from the presence of edema or secretions and could be life threatening. Communication is another problem postoperatively because of the tracheostomy tube, but a communication process should be established preoperatively. Emotional support should be given to help the client adjust to the new body image, and pain management should be maintained with IV medications. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Analysis)

2. Which interventions can the nurse delegate to unlicensed personnel when caring for a client with esophageal cancer? (Select all that apply.) a. Maintaining intake and output b. Maintaining calorie count c. Administering tube feeding d. Obtaining vital signs e. Teaching changes in daily activities f. Changing the incision dressing

ANS: A, B, D Unlicensed personnel can be responsible for charting fluid intake and output and food intake, keeping the calorie count, and taking/recording vital signs. They are not trained or allowed by law to assess, teach, or provide treatments. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Delegation) MSC: Integrated Process: Nursing Process (Planning)

3. The nurse is caring for a client with stomatitis. Which items reported during the history of the client may contribute to the reoccurrence of this condition? (Select all that apply.) a. Drinking two glasses of wine nightly b. Smoking three cigarettes each day c. Vitamin A deficiency d. Drinking four cups of coffee daily e. Fruits and nuts as the mainstay of the diet f. Vitamin C deficiency

ANS: A, B, D, E Stomatitis can result from irritants such as alcohol, smoking, caffeine, fruits, and nuts. Deficiencies in vitamin A or C do not seem to have any relationship to the development of stomatitis, but deficiency of vitamin B, folate, and iron has a relationship to stomatitis development. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Nursing Process (Assessment)

1. The nurse is obtaining the history of a client with a sliding hernia. Which symptoms does the nurse expect to see in this client? (Select all that apply.) a. Reflux b. Bleeding c. Dysphagia d. Belching e. Breathlessness f. Vomiting

ANS: A, C, D Clients with sliding hernias often experience symptoms of reflux, pain, dysphagia, and belching. Some clients may experience breathlessness or a feeling of suffocation. Breathlessness after eating is a symptom of paraesophageal hernias. Bleeding should not be seen. DIF: Cognitive Level: Knowledge/Remembering REF: Chart 57-5, p. 1209 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

3. A client has jaundice and ascites. Which laboratory values indicate hepatic disease? (Select all that apply.) a. Albumin, 2.0 g/dL b. Potassium, 3.0 mEq/L c. Alanine aminotransferase (ALT), 45 IU/L d. Aspartate aminotransferase (AST), 45 U/L e. Unconjugated (indirect) bilirubin, 1 mg/dL f. Ammonia, 120 mg/dL

ANS: A, C, D, E, F Decreased albumin and increased ALT, AST, unconjugated bilirubin, and ammonia all indicate hepatic disease. When the liver is damaged, albumin is not produced by the hepatic cells. ALT and AST liver enzymes increase with liver disease. Bilirubin, the primary component of bile, can be measured as direct or indirect and, if elevated, can indicate impaired secretion. Elevated levels of ammonia indicate severe hepatocellular damage. Decreased potassium does not indicate possible liver involvement but can be reduced by vomiting and diarrhea. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

1. The nurse performs percussion of a client's abdomen. Which findings may the nurse determine with this assessment technique? (Select all that apply.) a. Hepatomegaly b. Kidney stones c. Ascites d. Large mass below the liver e. Biliary colic f. Ileus

ANS: A, C, D, F Percussion allows the nurse to identify the presence of masses, fluid, enlarged organs, and air in the abdomen. The nurse would not be able to identify biliary colic or kidney stones with percussion. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

2. A client reports that he has been passing black stools for the last few days. Which findings from the client's health history does the nurse consider as possible causes? (Select all that apply.) a. Cirrhosis b. Cholecystitis c. Hemorrhoids d. Diverticulitis e. Long-term use of NSAIDs f. Use of iron supplements

ANS: A, E, F Cirrhosis may cause black stools when bleeding occurs from esophageal varices. Long-term NSAID use may lead to gastric ulcer development and bleeding. Iron supplements may turn the color of the stool black. Hemorrhoids or diverticulitis would result in stools that are streaked with red. Cholecystitis may result in pale-colored stools if bile flow is obstructed. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

12. The nurse is caring for a client who has just arrived in the emergency department reporting epigastric pain. The client says that emesis earlier in the day looked like coffee grounds. What does the nurse prepare to do for the client first? a. Check the client's stool for occult blood. b. Insert 18-gauge IV lines with normal saline infusions. c. Insert a nasogastric tube and prepare for gastric lavage. d. Determine whether the client has a history of ulcers.

ANS: B "Coffee ground" emesis is indicative of bleeding in which the blood has been partially digested by gastric acid. This client is at risk for hemorrhage and severe volume depletion and requires two large-bore IVs immediately. The client next will most likely need a saline lavage. Checking the stool and obtaining a history can be done later when the client is stable. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

17. A client who has undergone a fundoplication wrap for hernia repair has returned from the postanesthesia care unit with a nasogastric tube draining dark brown fluid. Which is the nurse's priority action? a. Assess the placement of the tube. b. Document the finding and continue to monitor. c. Clamp the nasogastric tube for 30 minutes. d. Irrigate the nasogastric tube with normal saline.

ANS: B After fundoplication, drainage from the nasogastric tube is initially dark brown with old blood. This finding is expected and requires only documentation. The drainage should become yellow-green within 8 hours after surgery. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)

14. An abdominal ultrasound is scheduled for the client. Which statement by the client indicates that the nurse's teaching about the procedure was effective? a. "The IV contrast may burn when it is injected." b. "I will drive myself home after the test is completed." c. "I will empty my bladder completely before the test." d. "I may have to take a laxative to pass the barium afterward."

ANS: B Because sedation is not used for this test, clients may drive themselves home after the abdominal ultrasound is completed. Barium and IV contrast are not needed. The client's bladder should be full for accurate visualization. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

23. A client with Zollinger-Ellison syndrome will be admitted to the medical unit. Which intervention does the nurse include in the client's nursing plan of care? a. Performing a urine test for ketones every morning before breakfast b. Performing perineal care and applying a moisture barrier twice daily c. Assessing the abdomen for fluid wave and shifting dullness every 8 hours d. Keeping 2 units of packed red blood cells on hold at all times

ANS: B Clients with Zollinger-Ellison syndrome often experience severe diarrhea and steatorrhea, so the nurse should include careful perineal care in the plan of care. Abdominal fluid wave testing and shifting dullness checks for ascites, which is not seen with Zollinger-Ellison syndrome. Ketones are not associated with this condition either. Blood transfusions are not part of the typical management plan for clients with Zollinger-Ellison syndrome, and blood would not be kept on hand unless the client was bleeding. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Personal Hygiene) MSC: Integrated Process: Nursing Process (Planning)

15. Which statement indicates that the client understands the management of his or her sliding hiatal hernia? a. "I will lie flat for 30 minutes after each meal." b. "I will remain upright for several hours after each meal." c. "I will have my blood count done in 2 weeks to check for anemia." d. "I will sleep at night while lying on my left side to prevent reflux."

ANS: B Clients with hiatal hernia experience gastroesophageal reflux disease (GERD). Positioning is an important intervention. The client should be taught to sleep with the head of the bed elevated, to remain upright after meals for 2 to 3 hours, and to avoid straining or restrictive clothing. The other actions are not consistent with managing a sliding hiatal hernia. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation)

4. The nurse is screening clients at a health fair. Which client is at highest risk for the development of colon cancer? a. Older white client with irritable bowel syndrome b. Middle-aged African-American client who smokes cigars c. Middle-aged Asian client who travels and eats out frequently d. Older American Indian client taking hormone replacement therapy

ANS: B Colon cancer is more prevalent among African Americans and smokers. Irritable bowel syndrome, travel, and hormone replacement therapy do not increase the risk for colon cancer. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1181 TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Nursing Process (Assessment)

8. The nurse assesses dullness at the left anterior axillary line. The nurse is concerned about which condition that the client may have? a. Cirrhosis b. Splenomegaly c. Bowel obstruction d. Abdominal aortic aneurysm

ANS: B Dullness in front of the tenth intercostal space, at the left anterior axillary line, is indicative of splenomegaly, which is commonly seen with mononucleosis. Cirrhosis would be noted with percussion in the client's left upper quadrant, indicating hepatomegaly. The nurse may note tympanic sounds with bowel obstruction. Percussion would not be used to assess abdominal aortic aneurysm. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1184 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

18. The nurse is caring for a client with stomatitis. Which statement does the nurse include in teaching about oral care for this client? a. "Rinse your mouth out twice a day with mouthwash." b. "Clean your mouth frequently during the day with a gentle foam sponge." c. "Use lemon-glycerin swabs to clean your mouth after meals and at bedtime." d. "Suck on ice cubes to minimize the discomfort."

ANS: B During painful, acute episodes of stomatitis, gentle mouth care using a gauze sponge dipped in warm normal saline or normal saline plus sodium bicarbonate is most appropriate. Commercial mouthwashes containing alcohol, acidic foods such as lemon-glycerin swabs, and techniques that may cause bleeding such as sucking on ice cubes should be avoided. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1194 TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning MULTIPLE RESPONSE

13. The nurse is caring for a client who presents with chronic epigastric pain, heartburn, and anorexia. The client asks the nurse how the doctor can best determine whether the symptoms are caused by gastritis. Which is the nurse's best response? a. "You will be asked to drink a barium solution while x-rays are taken of your stomach." b. "The doctor will take a look inside your stomach using a tube with a light on the end of it." c. "A CT scan of your abdomen will show whether inflammation is present in your stomach." d. "A blood sample will be sent to the laboratory to determine whether you have a stomach infection or bleeding."

ANS: B Endoscopy (esophagogastroduodenoscopy) with biopsy is the best method for diagnosing gastritis. Computed tomography (CT) scans, upper GI series, and blood samples are less accurate for making the diagnosis of gastritis. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1222 TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning

2. An obese client has reflux and asks how being overweight could cause this condition. Which response by the nurse is best? a. "You eat more food, more often, than nonobese people do." b. "The weight adds extra pressure, which helps push stomach contents up." c. "Obese people tend to eat more high-fat food, which presents a risk." d. "Obesity is not related to reflux, but losing weight would be healthy."

ANS: B Esophageal reflux can occur when intra-abdominal pressure is elevated, or when the sphincter tone of the lower esophageal sphincter (LES) is decreased. Obesity can increase intra-abdominal pressure. The other statements are not accurate explanations of the connection between obesity and reflux. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1204 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Teaching/Learning

26. A client with esophageal cancer is receiving radiation therapy. Which finding alerts the nurse to a possible complication in this client? a. Redness of the skin at the site of radiation b. Worsening of dysphagia or odynophagia c. Development of nausea or vomiting d. A profound feeling of tiredness

ANS: B Esophageal stricture is a complication of radiation therapy to the esophagus. This would manifest with worsening dysphagia or odynophagia. Redness is an expected result. Nausea and vomiting are common side effects, as is profound fatigue. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Assessment)

8. A client has Barrett's esophagus. Which client assessment by the nurse requires consultation with the health care provider? a. Sleeping with the head of the bed elevated b. Coughing when eating or drinking c. Wanting to eat several small meals during the day d. Chewing antacid tablets frequently during the day

ANS: B In Barrett's esophagus (a complication of gastroesophageal reflux disease [GERD]), fibrosis and scarring that accompany the healing process can cause esophageal stricture, leading to difficulty in swallowing. This can be manifested by coughing when the client eats or drinks and requires consultation with the health care team. The other assessments are typical of clients trying to control their GERD. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

3. A client has been taking naproxen (Naprosyn) for several months. Which assessment question is important for the nurse to ask? a. "Have you experienced any constipation?" b. "Have you had any stomach pain or indigestion?" c. "Have you had any difficulty swallowing?" d. "Have you noticed any weight loss lately?"

ANS: B Long-term use of NSAIDs for chronic pain can precipitate peptic ulcer formation through inhibition of prostaglandins, which normally protects the gastric mucosa. The client should be assessed for stomach pain or indigestion. This medication does not typically cause constipation or difficulty swallowing. Weight loss would not be related to this medication. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

15. The nurse is caring for a client who has just undergone surgery for oral cancer. What advice does the nurse give the client to assist in maintaining the airway? a. "Limit your fluids to 3 cups of water a day." b. "Take deep breaths, hold, then cough to mobilize any secretions." c. "Lying flat in bed will be more comfortable for breathing." d. "Usually suctioning is not needed after oral surgery."

ANS: B Maintaining an airway after oral surgery is a priority. The client must be taught to deep breathe and mobilize the secretions by coughing effectively. The other responses are incorrect. Fluids should be increased, a semi-Fowler's or high Fowler's position should be maintained, and the client should be taught how to suction the oral cavity. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1197 TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Implementation)

14. The nurse is caring for a client who will be undergoing a radical jaw and throat resection for oral cancer. Which statement by the client indicates that further teaching is needed? a. "I will have a temporary tracheostomy placed in my neck to help me breathe." b. "I will not be able to get out of bed for 3 days after surgery." c. "The doctor will put in a feeding tube for nutrition until I can swallow and eat." d. "My speech may be slurred for a long time after the surgery."

ANS: B Mobility should not be extensively limited. The client should not be on bedrest for 3 days. A temporary tracheostomy will be inserted to maintain a patent airway postoperatively. A nasogastric tube may be needed until oral nutrition can begin. Slurred speech is a common outcome if extensive resection has taken place and nerve damage has occurred. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Nursing Process (Evaluation)

11. A client with severe gastroesophageal reflux disease (GERD) is still having symptoms of reflux despite taking omeprazole, (Prilosec) 20 mg daily. What does the nurse do next? a. Document the finding in the client's chart. b. Obtain an order for omeprazole twice daily. c. Instruct the client to double the daily dose. d. Tell the client to take antacids with omeprazole.

ANS: B Omeprazole is a proton pump inhibitor that acts to reduce gastric acid secretion. If once-daily dosing fails to control the client's symptoms, the nurse should obtain an order for the client to take omeprazole twice daily for better symptom control. This finding should be documented, but the nurse should do more than merely record the client's symptoms. Doubling the daily dose and adding antacids will not be as effective as obtaining an order for twice-a-day dosing. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation)

18. A client had an open fundoplication 2 days ago. Which assessment by the nurse indicates that an important National Patient Safety Goal is being met for this client? a. The client uses the spirometer during the shift. b. The client's pain is monitored and treated. c. The client has vital signs taken routinely. d. The client verbalizes understanding of the discharge teaching.

ANS: B Pain must be monitored and aggressively treated after an open fundoplication because the high incision makes breathing very painful. If the client does not participate in deep-breathing exercises and will not use the spirometer, the chance of respiratory complications is quite high. National Patient Safety Goals include goals selected to reduce/prevent health care-related infection. Using the spirometer will help prevent pneumonia and atelectasis, but the client must use it hourly. Taking vital signs may help the nurse notice an infection but will not prevent the infection. Understanding discharge teaching is important, but preventing respiratory complications takes priority. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Evaluation)

20. The nurse is caring for a client with advanced gastric cancer who is scheduled for palliative surgery to relieve gastric outlet obstruction. The client asks the nurse why he should bother having the surgery, because he will not be cured. Which is the nurse's best response? a. "It will allow the doctors to determine more accurately how long you have to live." b. "It will relieve the obstruction so you will be more comfortable and able to eat again." c. "It will remove much of the tumor so that chemotherapy will be more effective." d. "It will help prevent the tumor from spreading to other parts of your body."

ANS: B Palliative surgery will relieve the gastric outlet obstruction and allow the client to eat again, thus improving quality of life. The surgery will not provide physicians with an accurate prognosis, make chemotherapy more effective, or prevent metastasis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communications) MSC: Integrated Process: Caring

16. A client has returned to the nursing unit after a sliding hernia repair. Which action by the nurse is most important in preventing complications? a. Range of motion to the lower extremities b. Elevating the head of the bed to 30 degrees c. Monitoring input and output d. Assessing for bowel sounds

ANS: B Prevention of respiratory complications is the primary focus of postoperative care. The high incision makes taking deep breaths extremely painful for this client. By elevating the head of the bed to at least 30 degrees, the nurse promotes lung expansion in the client. The other activities are important too but do not take priority over preventing respiratory complications. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

14. The nurse is caring for a client with a history of heart failure and chronic gastritis. The client tells the nurse about taking 2 teaspoons of sodium bicarbonate every night before going to bed to prevent heartburn. Which is the nurse's best response? a. "You should let the doctor know right away if you develop diarrhea." b. "I will let your doctor know so a safer antacid can be prescribed for you." c. "Do not take that with milk, because the combination can cause kidney stones." d. "Make sure that you mix the sodium bicarbonate with at least 8 ounces of water."

ANS: B Sodium bicarbonate can cause fluid retention and edema, which can be dangerous for clients with heart failure. The provider should be notified so that an alternative antacid can be prescribed. The other statements do not reflect an accurate concern with sodium bicarbonate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Implementation)

3. The nurse is caring for a client with a gastric ulcer who suddenly develops sharp mid-epigastric pain. The nurse notes that the client's abdomen is hard and very tender to light palpation. Which is the priority action of the nurse? a. Place the client in a knee-chest position. b. Prepare the client for emergency surgery. c. Insert a nasogastric (NG) tube to low intermittent suction. d. Assess the client's pain and administer analgesics.

ANS: B Sudden, sharp mid-epigastric pain is indicative of perforation, which is a surgical emergency. Pain medication should not be administered just now because the surgeon will need to assess the client's abdomen, and the client will need to sign an operative permit. The client may assume the knee-chest position in an attempt to relieve pain. The provider may order placement of an NG tube, but this would not take priority over getting the client ready for surgery. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

17. The nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD) completed. The client tells the nurse that her mouth is very dry after the procedure. Which is the nurse's best action? a. Keep the client NPO (nothing by mouth). b. Check the client's gag reflex. c. Offer the client sips of clear liquids. d. Provide the client with a few ice chips.

ANS: B The back of the throat is numbed for the EGD, impairing the gag reflex. Therefore the client is initially NPO postoperatively. The nurse should check the gag reflex before offering any type of liquid to the client. The client may be given ice chips or sips of fluids once the gag reflex has returned. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse is caring for a client who has just received a diagnosis of advanced oral cancer and has learned that a glossectomy with jaw resection will have to be scheduled. The client states to the nurse, "I would rather die than have half of my face removed. My life is over." Which is the best description of the client's response to the diagnosis? a. Refusal of any more treatment b. Grief over the diagnosis c. Acceptance of the diagnosis d. Denial about the diagnosis

ANS: B The client is grieving the loss of his health and present appearance. Because the client has just learned of the diagnosis and treatment, the client is reacting in a negative way. This behavior demonstrates grief, not necessarily refusal of treatment, nor denial or acceptance of the diagnosis. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1200 TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss) MSC: Integrated Process: Nursing Process (Assessment)

6. The nurse is preparing to perform an abdominal assessment on a client with suspected cholecystitis. In what sequence does the nurse palpate the client's abdomen? a. Palpate the lower quadrants only. b. Palpate the upper quadrants last. c. Palpate the upper quadrants only. d. Defer palpation and use percussion only.

ANS: B The client with cholecystitis will report pain in the right upper quadrant of the abdomen. Tender or painful areas should be palpated last to prevent the client from tensing his or her abdominal muscles because of pain, thereby making the examination more difficult. All quadrants should be palpated. Palpation is an important assessment tool that should not be deferred for this client. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

10. The nurse is in the room of a client who is sleeping in bed. The client experiences an episode of reflux with regurgitation. Which action does the nurse take first? a. Have the client roll to the side. b. Raise the head of the client's bed. c. Auscultate the client's lung sounds. d. Call the Rapid Response Team.

ANS: B The immediate danger for this client is aspiration. The nurse first should raise the head of the bed to reduce this risk. Asking the client to roll to the side will take too much time. The nurse can auscultate the client's lungs after raising the head of the bed. Calling the Rapid Response Team may or may not be necessary but would be done after the client is in a safer position. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

9. The spouse of a client has just completed tracheostomy care for the first time, with minimal assistance from the nurse. Which statement offers the most constructive feedback from the nurse? a. "I see that you had a tough time, but you will do better with practice." b. "You were able to clean the inner cannula well. Now, let's change the ties again." c. "You seem to have had a tough time because it was your first attempt." d. "You seem to understand what I said. Is there anything else I can help you with?"

ANS: B The statement that provides the most positive feedback concerns what the client's spouse did well and identifies a skill that needs more practice. The other responses by the nurse give negative overtones to the teaching environment and do not empower the spouse. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Nursing Process (Evaluation)

2. The nurse is assessing a client with a salivary gland tumor for facial nerve involvement. Which movements does the nurse ask the client to perform? (Select all that apply.) a. Open the mouth wide. b. Raise the eyebrows. c. Smile or frown. d. Pucker the lips. e. Blow the nose. f. Puff out the cheeks.

ANS: B, C, D, F With salivary gland tumors, close proximity to the facial nerve can cause damage to the nerve, which can be assessed by looking at the symmetric performance of certain movements such as raising the eyebrows, smiling, frowning, puckering the lips, and puffing out the cheeks. Opening the mouth widely or blowing the nose would not indicate any facial nerve involvement. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Nursing Process (Evaluation)

1. The nurse is performing oral health screenings at a local community center. Which clients are at higher risk for developing oral cancer? (Select all that apply.) a. Female who has taken oral contraceptives for the last 4 years b. Adult client with a history of alcoholism c. Adult client who regularly eats spicy foods d. Middle-aged male who smokes a pipe e. Adult client who goes to a tanning salon weekly f. Client who frequently chews gum

ANS: B, D, E Alcoholism (particularly with poor nutritional status), tobacco use, and exposure to the sun or tanning salons are all risk factors for the development of oral cancer. Oral contraceptives, spicy foods, and chewing gum are not high-risk activities for oral cancer. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1195 TOP: Client Needs Category: Health Promotion and Maintenance (High-Risk Behaviors) MSC: Integrated Process: Nursing Process (Assessment)

3. Which referrals does the nurse make for an older adult client who is being discharged with esophageal cancer? (Select all that apply.) a. IV infusionist b. Home health aide c. Medicare or Medicaid d. Meals on Wheels e. Housecleaning service f. Transportation to and from treatment

ANS: B, D, F The outcome is to keep the client as independent as possible. Providing a home health aide will help the client with normal self-care activities, shopping, and light housework, so the client can reserve energy for essential activities. Meals on Wheels will provide nutritious meals within the client's dietary restrictions. It is essential for the client to maintain adequate intake despite dysphagia. Transportation to treatments and the physician's office is essential for maintaining the client's health. The client may or may not need home infusion therapy or full housekeeping services. The client may or may not be eligible for Medicare or Medicaid. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Referrals) MSC: Integrated Process: Nursing Process (Planning)

14. Which symptom indicates a need for immediate intervention in a client with a rolling hernia? a. Reflux b. Crackles in the lungs c. Distended and firm abdomen d. Two episodes of diarrhea

ANS: C A rolling hernia causes the fundus and portions of the stomach's greater curvature to roll into the thorax next to the esophagus, predisposing the client to volvulus, obstruction, and strangulation. A firm, distended abdomen may indicate a bowel obstruction. This is a serious situation and the provider must be notified immediately. Crackles and diarrhea also warrant intervention, but not as a priority. Reports of reflux would be the lowest-level priority. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment)

7. The nurse is caring for a client who has just returned from abdominal surgery. When auscultating the client's abdomen, the nurse does not hear any bowel sounds. Which is the nurse's best action? a. Notify the health care provider. b. Percuss the abdomen. c. Document the finding. d. Insert a nasogastric tube.

ANS: C Absent bowel sounds are expected immediately following abdominal surgery. The finding should be noted in the client's record for later reference. The provider does not need to be notified at this time. The nurse should insert a nasogastric tube if ordered by the physician if the ileus persists. Percussion may be performed but may be uncomfortable for the client and will not reveal the cause of the ileus. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

24. A client has esophageal cancer. Which intervention by the nurse takes priority? a. Maintaining nutritional intake b. Allowing grieving c. Preventing aspiration d. Managing pain relief

ANS: C Although nutrition and pain are both high on the list of priorities, prevention of aspiration is the highest. When a client aspirates, his or her respiratory system is compromised, thereby causing further deterioration, which increases nutritional needs. Grieving, although also important, does not take priority over physical needs and safety. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Planning)

12. The client is scheduled for a colonoscopy. Which statement indicates that the client needs additional teaching about the procedure? a. "I may have gas and abdominal cramps after the test." b. "I will take strong laxatives the afternoon before the test." c. "I will take my Coumadin with a sip of water tomorrow morning." d. "I will take nothing by mouth after midnight on the day of the test."

ANS: C Blood thinners should not be taken before colonoscopy because bleeding may occur if polyps are removed. The client should stop taking warfarin (Coumadin) approximately 2 weeks before the colonoscopy. The other answers describe accurate complications of the colonoscopy and preparation for the procedure. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Assessment)

2. The nurse is caring for a female client who has just undergone excision of a parotid gland tumor. The client tells the nurse that she is experiencing facial weakness on the operative side. Which is the nurse's best response? a. "You may be experiencing a slight stroke, and I will notify the doctor." b. "This is a temporary condition that will resolve once radiation treatment is begun." c. "You are experiencing weakness because the facial nerve was irritated during the surgery." d. "You probably have a pinched nerve after lying on the operating room table for so long."

ANS: C Cranial nerve V involvement is a possible outcome of this type of surgery. The client presents with facial weakness and possibly with loss of sensation to the affected side. The other choices regarding facial weakness following this type of surgery are not accurate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

13. The nurse is caring for a client who has undergone a radical jaw and neck resection. The client tells the nurse that the area feels very swollen and painful. Which is the best intervention for the nurse to make this client more comfortable? a. Frequently suction the client's mouth and airway. b. Apply warm moist compresses to the area. c. Elevate the head of the client's bed to semi-Fowler's. d. Administer ibuprofen (Motrin) 600 mg every 6 hours around the clock.

ANS: C Elevating the head of the bed will help to reduce edema by using gravity. Ibuprofen can affect blood clotting, leading to bleeding from the incisions. Intravenous morphine is a better choice than ibuprofen. Suctioning should be completed only when necessary because this will be uncomfortable. Moist compresses are used with salivary gland inflammation, not with postoperative radical jaw and neck resection. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Integrity—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)

21. The nurse is caring for a client who will be discharged from the hospital following surgery for advanced gastric cancer. The client's daughter verbalizes the fear that she will not be able to manage her parent's symptoms adequately at home. Which is the nurse's best response? a. "The nurses have taught you everything you need to know to care for your parent." b. "Don't worry, the pain pills will keep your parent comfortable until the end." c. "I will ask the social worker to arrange for a hospice nurse to help you at home." d. "I will ask the health care provider to review the care instructions with you again."

ANS: C Hospice nurses can assist family members with caring for clients who are terminally ill. The nurse should not belittle the daughter's concerns, nor should she ask the provider to review the discharge instructions again. The hospice nurse can provide not only physical care, but support for the family as they care for a loved one at home. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communications) MSC: Integrated Process: Caring

22. Which factor places a client at risk for esophageal cancer? a. High-stress occupation b. Preference for high-fat foods c. 20-pack-year smoking history d. History of myocardial infarction

ANS: C In the United States, the two most important factors for the development of esophageal cancer are tobacco use and alcohol ingestion. The other factors do not increase the risk for developing esophageal cancer. DIF: Cognitive Level: Knowledge/Remembering REF: p. 1212 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

11. The nurse is leading a teaching session about methods to decrease the risk of mouth cancer. Which client statement indicates that the nurse was successful in teaching the information? a. "I will chew tobacco rather than smoke it." b. "I will use sugar rather than artificial sweeteners." c. "I will regularly use a lip balm that contains sunscreen." d. "I will use a tanning salon rather than sunbathing at the beach."

ANS: C Lip balms that contain sunscreen can help prevent the development of oral cancer. The rest of the client choices can promote cancer, such as chewing tobacco and tanning. Using sugar rather than artificial sweeteners is not applicable to the risk of mouth cancer. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Lifestyle Choices) MSC: Integrated Process: Nursing Process (Evaluation)

8. The nurse is caring for a client who will be going home after a radical jaw and neck resection. The client's spouse will be the primary caregiver at home and will need to care for the client's feeding tube and tracheostomy. Which skill is the highest priority for the nurse to teach the client's spouse before discharge from the hospital? a. Monitoring the incision lines for infection or leakage of saliva b. Assessing the client for readiness to resume oral feedings c. Cleaning the tracheostomy and suctioning as needed d. Administering tube feedings and cleaning the feeding tube site

ANS: C Maintaining a patent airway is the highest priority for this client and spouse. The other responses are next in importance because they reflect needed knowledge regarding infection control and knowledge of proper technique for nutritional support of the client. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning

2. The nurse is caring for a female client who has just received a prescription for misoprostol (Cytotec). Which instructions does the nurse provide to the client regarding this medication? a. "You may dissolve the contents of the capsule in warm water if it is difficult for you to swallow." b. "Take this medication on an empty stomach just before going to bed every evening." c. "You will need to stop taking your magnesium hydroxide (Mylanta) now that you are on this drug." d. "You should add extra fiber to your diet because this medication may cause constipation."

ANS: C Misoprostol is a prostaglandin analogue. Clients on this medication need to avoid magnesium-containing antacids; Mylanta contains magnesium. Clients should not dissolve the pill, should take misoprostol with food, and do not need to take precautions against constipation while on this drug. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Teaching/Learning

12. A client is admitted to the cardiac monitoring unit for a suspected myocardial infarction. The client reports long-standing nighttime reflux, and the health care provider orders nizatidine (Axid) 150 mg twice a day. Which action by the nurse is most appropriate? a. Consult with the health care provider because the dose is too high. b. Check the client's kidney function tests before administering the drug. c. Ask the pharmacist to recommend another histamine receptor agonist. d. Give the medication as ordered and monitor for effectiveness.

ANS: C Nizatidine, a histamine receptor agonist, can cause dysrhythmias. Because the client has a heart condition that may cause rhythm problems, the nurse should consult with the pharmacist for another drug in the same class to recommend to the provider. The dose is appropriate. Kidney function does not need to be monitored while on this drug. The nurse should monitor all drugs given for effectiveness, but this drug should not be given as prescribed. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Analysis)

4. A client with esophageal reflux who experiences regurgitation while lying flat is at risk for which complication? a. Erosion b. Bleeding c. Aspiration d. Odynophagia

ANS: C Regurgitation of stomach contents while the client is recumbent poses a risk of aspiration for the client. DIF: Cognitive Level: Knowledge/Remembering REF: p. 1205 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Planning)

1. The nurse is caring for a client who is receiving radiation treatment for oral cancer. Which problem does the nurse anticipate for this client? a. Failure to absorb nutrients from the stomach b. Inability to digest protein c. Impaired ability to soften and break down food d. Difficulty swallowing food

ANS: C Saliva is responsible for the softening of food in the mouth and contains an enzyme, salivary amylase (ptyalin), which assists in the breakdown of carbohydrates. Radiation to the oral cavity can result in reduction of saliva production. Radiation to the mouth will not impair swallowing, ability to digest protein, or ability to absorb nutrients from the stomach. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness) MSC: Integrated Process: Nursing Process (Planning)

4. The nurse is caring for a client with peptic ulcer disease. The client vomits a large amount of undigested food after breakfast. Which intervention does the nurse prepare to provide for the client? a. Administer a soap suds cleansing enema. b. Change the client's diet to clear liquids only. c. Insert a nasogastric (NG) tube to low intermittent suction. d. Administer prochlorperazine (Compazine) 10 mg IM.

ANS: C Symptoms of abdominal distention and nausea and vomiting of undigested food signal pyloric obstruction. Treatment is aimed at decompression of the stomach by an NG tube and restoration of fluid and electrolyte balance. The client should remain NPO, and a soap suds cleansing enema is not indicated. Decompressing the stomach should alleviate the nausea, but if antiemetics are ordered, they would not take priority over decompressing the stomach. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

18. A client has a family history of colon cancer. Which laboratory tests are ordered to rule out colon cancer? a. Cholesterol b. Serum lipase c. Carcinoembryonic antigen d. Xylose absorption

ANS: C The carcinoembryonic antigen can indicate colorectal, stomach, or pancreatic cancer if elevated. Elevated cholesterol and serum lipase may indicate pancreatitis. Decreased xylose absorption may indicate malabsorption in the small intestine. DIF: Cognitive Level: Comprehension/Understanding REF: Chart 55-3, p. 1186 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment) MULTIPLE RESPONSE

19. A client who has undergone an open fundoplication hernia repair is preparing for discharge. Which information is most important for the nurse to include in discharge instructions? a. "You can take laxatives for constipation." b. "Eat three normal-sized meals daily." c. "Notify your health care provider if you get a cough." d. "You can go back to work in about a week."

ANS: C The client is instructed to report cold or flu-like symptoms because persistent coughing associated with these conditions can cause dehiscence of the incision in the early postoperative stage. Constipation can be caused by narcotic medications, but the client should be instructed to use fiber, water, and stool softeners first before using laxatives. The client must continue eating six small meals a day. After the open procedure, activity restrictions continue for up to 6 weeks. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

7. A client is undergoing diagnostic testing for gastroesophageal reflux disease (GERD). Which test does the nurse tell the client is best for diagnosing this condition? a. Endoscopy b. Schilling test c. 24-Hour ambulatory pH monitoring d. Stool testing for occult blood

ANS: C The most accurate method of diagnosing gastroesophageal reflux disease is 24-hour ambulatory pH monitoring. DIF: Cognitive Level: Knowledge/Remembering REF: p. 1205 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Teaching/Learning

15. While a health history is obtained from a client with a new diagnosis of advanced pancreatic cancer, the client begins to cry. Which is the nurse's best response? a. "I am so sorry for making you cry!" b. "I will step out for a few minutes until you feel better." c. "I can see that you are upset about this. It is all right to cry." d. "I can see that I am upsetting you. Let's move on to something else."

ANS: C The nurse should recognize the client's feelings and should allow the client to cry. Moving on to another topic shows disregard for the client's feelings. The nurse should not leave the room but should stay to offer support. Apologizing to the client does not place the focus on the client or acknowledge the client's feelings and emotions in this situation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication) MSC: Integrated Process: Caring

17. The nurse is assessing a client during a routine physical examination. Which statement made by the client concerning the risk of oral cancer indicates that further teaching is needed? a. "I will brush my teeth and floss regularly." b. "I will begin a smoking cessation program." c. "I can still use chewing tobacco since I stopped smoking." d. "I will limit my intake of alcoholic beverages."

ANS: C Tobacco in any form increases the risk of oral cancer. The client should be educated to eliminate all tobacco products. The other statements concerning brushing the teeth, flossing, smoking cessation, and decreasing alcohol intake are healthy choices to maintain good oral health. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Nursing Process (Evaluation)

13. A client who has undergone Nissen fundoplication for gastroesophageal reflux disease (GERD) is ready for discharge home. Which statement made by the client indicates understanding of the disease? a. "I will no longer need any medication for my GERD." b. "I will avoid spicy foods because they can irritate the suture line." c. "I should take anti-reflux medications when I eat a large meal." d. "I will need to continue to watch my diet and may still need medication."

ANS: D A high percentage of recurrence of reflux has been noted after this type of surgery, so clients are encouraged to continue anti-reflux regimens of medication and diet control. These include taking medications, eating small meals, and avoiding spicy or acidic foods. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation)

3. Which client does the nurse assess most carefully for the development of gastroesophageal reflux disease? a. Client with atrial fibrillation who drinks decaffeinated coffee b. Client who has lost 20 pounds through diet and exercise c. Diabetic client taking oral hypoglycemic agents d. Postoperative client who has a nasogastric (NG) tube

ANS: D A nasogastric tube keeps the cardiac sphincter open, allowing acidic contents from the stomach to enter the esophagus. The other clients do not have increased risk for gastroesophageal reflux. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Assessment)

1. The nurse is caring for a client who is being discharged following surgery for oral cancer. Which sign is the client instructed to watch for that indicates possible metastasis of the cancer? a. Fragile gums that bleed easily b. White patches on the tongue and the back of the throat c. Painful ulcerated lesions on the gums or inside of the cheek d. Small hard lumps on the side of the neck or under the chin

ANS: D Cervical lymph nodes that become hardened, enlarged, and fixed in position are indications of metastatic disease. An older adult or a client with a dry mouth may develop fragile gums that bleed easily. White patches on the tongue and the back of throat could be leukoplakia—precancerous lesions that are normally benign. Stomatitis or inflammation of the oral cavity can lead to fragile gums, white patches (candidiasis), and painful open sores throughout the oral cavity, but these conditions are not cancerous. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Implementation)

10. Which laboratory finding does the nurse expect to find on assessment of a client with advanced cirrhosis? a. Amylase, 129 IU/L; alkaline phosphate, 45 U/L b. Reticulocyte count, 1%; magnesium, 1.5 mEq/L c. Hemoglobin, 14 g/dL; direct bilirubin, 0.2 mg/dL d. Prothrombin time (PT), 17.5 seconds; albumin, 1.6 g/dL

ANS: D Cirrhosis frequently results in impaired production of clotting factors, with increased PT and partial thromboplastin time (PTT). Serum albumin is decreased with cirrhosis because protein formation within the liver is impaired. The other laboratory values are within normal limits and would not be expected with advanced cirrhosis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse is caring for a client who is receiving radiation therapy for treatment of oral cancer. The client reports a constant dry mouth. Which is the nurse's best response? a. "Massage the area just over the lower jaw twice a day." b. "Use lemon and glycerin swabs to clean your mouth and help keep it moist." c. "Suck on lemon slices to help increase saliva production." d. "Rinse your mouth out often with warm saline or sodium bicarbonate solution."

ANS: D Clients should avoid agents that can irritate the oral mucosa and should keep their mouth moist with frequent rinses of warm saline or sodium bicarbonate solution. Massage is recommended only for acute sialadenitis—inflammation of a salivary gland. Lemon slices and lemon and glycerin swabs are acidic and can further dry the mucosa, causing a burning sensation. The use of lemon slices after radiation therapy is discontinued may promote saliva production. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1197 TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort Interventions) MSC: Integrated Process: Nursing Process (Implementation)

23. The nurse is performing an assessment of a client with suspected esophageal cancer. Which statement made by the client does the nurse correlate with advanced disease? a. "I have difficulty swallowing solids." b. "I usually have a sticking feeling in my throat." c. "I have difficulty swallowing soft foods." d. "I have difficulty swallowing liquids."

ANS: D Dysphagia is a common sign of esophageal cancer, but it often does not present until late in the disease. Clients first notice swallowing problems with solid foods, then liquids; they can even choke on saliva. Sometimes they have the feeling of food sticking in their throats. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

6. The nurse is providing discharge teaching for a client who has peptic ulcer disease caused by Helicobacter pylori infection. Which statement by the client indicates that additional teaching is needed? a. "I will avoid drinking coffee, even if it is decaffeinated." b. "I will take a multivitamin every morning with breakfast." c. "I will go to my tai chi class to wind down after a busy day." d. "I will take my medication every day until my heartburn is gone."

ANS: D Long-term medication compliance is crucial to eradicate Helicobacter pylori and prevent recurrence. The nurse stresses the importance of continuing medications for the entire time prescribed. Decaffeinated coffee is a better choice than caffeinated coffee for the client with peptic ulcer disease. Stress management should also be part of the treatment plan. Good nutrition is always important. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation)

1. The nurse is caring for a client who is at risk for developing gastritis. Which finding from the client's history leads the nurse to this conclusion? a. Client is lactose intolerant and cannot drink milk. b. Client recently traveled to Mexico and South America. c. Client works at least 60 hours per week in a stressful job. d. Client takes naproxen sodium (Naprosyn) 500 mg daily for arthritis pain.

ANS: D Motrin and other NSAIDs can cause gastritis, even if symptoms are not yet apparent. Stress, travel, and spicy foods do not increase the risk for gastritis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Analysis)

12. The nurse is caring for a client who will be taking nystatin (Mycostatin) for treatment of oral candidiasis. Which instructions does the nurse provide for the client before administering the medication? a. "Let the tablet dissolve slowly in your mouth." b. "Take the medicine with a snack or a light meal." c. "Swallow the pills whole, followed by a full glass of water." d. "Swish the liquid around your mouth before swallowing it."

ANS: D Mycostatin (nystatin) is a liquid medication that should be swished around the mouth for a minute before swallowing. The other responses do not reflect accurate administration of nystatin. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1195 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Teaching/Learning

17. The nurse is caring for a client with gastritis who will undergo a nuclear medicine GI bleeding study in the morning. What instruction for preparation does the nurse give the client? a. "You cannot eat anything after midnight." b. "You should drink several glasses of water in the morning." c. "You must make arrangements for transportation home." d. "No special preparations are required for this test."

ANS: D No special preparations are required for this test, so the client is not required to be NPO or to drink several glasses of water. Sedation is not used, so the client does not need to find transportation home. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1229 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Teaching/Learning

16. The nurse is performing an abdominal assessment on an older client. Which assessment finding does the nurse expect as a normal consequence of aging? a. Increased salivation and drooling b. Hyperactive bowel sounds and loose stools c. Increased gastric acid production and heartburn d. Impaired sensation to defecate and constipation

ANS: D Older adults may lose the sensation to defecate, resulting in constipation. Salivation decreases with aging, along with peristalsis and gastric acid production. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

21. A client 2 hours post-esophageal dilation develops increasing pain in the throat. Which is the best action of the nurse? a. Administer an analgesic. b. Document the finding. c. Reposition the client. d. Assess the client for perforation.

ANS: D Pain may be indicative of perforation, which is a known complication of dilation and requires immediate intervention. An analgesic should not be administered until the problem is diagnosed. Repositioning will not help the nurse determine what is wrong. Documentation should be done after the nurse finishes assessing the client. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Assessment)

22. The nurse is caring for a client who reports persistent epigastric pain, heartburn, and nausea, despite faithfully taking ranitidine (Zantac), aluminum hydroxide (Amphojel), and metronidazole (Flagyl) as prescribed. Which is the nurse's best response? a. "Is your pain better or worse after you eat?" b. "Have you tried elevating the head of your bed at night?" c. "Have you been taking the Amphojel and Flagyl together?" d. "Have you been experiencing foul-smelling diarrhea lately?"

ANS: D Peptic ulcer disease (PUD) symptoms that are not alleviated by medications may indicate Zollinger-Ellison syndrome, a similar condition that is often refractory to treatment. A hallmark of Zollinger-Ellison syndrome is diarrhea and steatorrhea, with frothy, foul-smelling diarrhea. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

27. A client has undergone an esophagogastrostomy for cancer of the esophagus. How will the nurse best support the client's respiratory status? a. Assessing the client's breath sounds every 4 hours b. Performing chest physiotherapy every 6 hours c. Maintaining the client in a supine position d. Administering analgesia regularly

ANS: D Respiratory care is the highest postoperative priority. Incisional support and adequate analgesia are crucial for effective coughing and deep breathing. As long as vital signs are stable, the nurse administers analgesia regularly to assist the client in performing deep breathing, turning, and coughing routines. Assessing breath sounds is a vital nursing assessment but will not help support respiratory function. The client may or may not need chest physiotherapy. The client should not be kept in a supine position, but rather sit up in the chair and ambulate as much as possible. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

5. The nurse is caring for a client who has just received a diagnosis of advanced oral cancer that will require extensive surgery. Which statement by the client indicates that the diagnosis is accepted? a. "The biopsy test results will be confirmed again next week." b. "Of all the bad things to happen to me, now I have cancer on top of it all." c. "If I can live long enough to see my son get married, everything will be alright." d. "I don't like it, but I have cancer and that's the way it is."

ANS: D The client has accepted the diagnosis. He is not happy about it but has acknowledged the reality of the situation. The other responses indicate denial, anger, or bargaining responses to the diagnosis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms) MSC: Integrated Process: Nursing Process (Assessment)

25. A client with esophageal cancer and dysphagia states that it has become more difficult to swallow, and the client has experienced several choking episodes during meals. Which strategy would the nurse recommend to assist this client in obtaining adequate nutrition? a. Monitor caloric intake and weigh the client daily. b. Instruct the client to drink only clear liquids. c. Tell the client that artificial feeding will now be required. d. Encourage the client to eat semisoft foods and thickened liquids.

ANS: D The client with dysphagia usually is able to tolerate swallowing semisoft foods and/or thickened liquids to obtain adequate intake. Monitoring caloric intake and weighing the client are good for monitoring response to therapy but will not help the client obtain nutrition. Clear liquids alone may not provide enough calories or nutrients. Efforts are made to preserve swallowing ability as long as possible, although in the case of complete obstruction, a feeding tube may be necessary. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration) MSC: Integrated Process: Nursing Process (Implementation)

18. The nurse is caring for a client who has recently undergone a partial gastrectomy. The client reports becoming dizzy and sweaty with heart palpitations about 2 hours after eating. The client is now afraid to eat anything. Which is the nurse's best response? a. "Drink at least 6 ounces of fluid before each meal." b. "Try a clear liquid diet for the next few days." c. "You probably should avoid dairy products." d. "Limit carbohydrate intake with meals."

ANS: D The client's symptoms are consistent with late dumping syndrome, which is caused by a rapid rise in insulin secretion in response to increased glucose levels after eating. Eliminating sugary foods and eating low to moderate carbohydrates with meals helps manage this problem. Liquids should be taken between meals. Clear liquids and limited dairy products are not needed. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1236 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Teaching/Learning

7. The nurse is caring for a client who just had a radical jaw and neck resection for oral cancer. The nurse has just completed teaching for the spouse and client about tracheostomy care. Which notation in the client's chart is the most accurate documentation of the teaching that occurred? a. "The client and spouse were instructed regarding management of mucous plugs and thick secretions." b. "Information about home oxygen therapy and equipment was provided for the client and spouse." c. "The client and spouse were shown how to suction the tracheostomy and change the ties." d. "Correct suctioning procedure was demonstrated, and the client's spouse verbalized two instances when suctioning needs to occur."

ANS: D The documentation should include teaching actions, as well as the spouse's response to the instructions. The other choices do not indicate the response by the client and spouse to the teaching. A return demonstration would be beneficial. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Nursing Process (Evaluation)

28. The nurse notes frank red blood in the drainage container from the nasogastric (NG) tube of a client who is 2 days post-esophagogastrostomy. Which is the nurse's priority intervention? a. Irrigate the NG tube with cold saline. b. Document the drainage in the chart. c. Reposition the tube in the opposite nostril. d. Assess the client's vital signs and abdomen.

ANS: D The initial nasogastric drainage appears bloody but should turn yellow-green by the end of the first postoperative day. If the bloody color continues, this may indicate bleeding at the suture line. The nurse should assess the client further, then should notify the provider. If the tube is draining, it is not necessary to irrigate it. Repositioning the tube will not change the drainage. In addition, repositioning the tube might cause more damage to the suture line. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment)

1. A client weighs 228 pounds (103.6 kg) and is 5'3" (160 cm) tall. What is this client's body mass index (BMI)? (Record your answer using a decimal rounded up to the nearest tenth.) _____

ANS: 40.4 Using the formula : , or 40.4 rounded up to the nearest tenth. DIF: Applying/Application REF: 1236 KEY: Nutritional assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

1. A client is to receive 12 mg/kg of 5-fluorouracil (5-FU) chemotherapy IV for treatment of colon cancer. The client weighs 132 lb. The client will receive ______ milligrams of 5-FU.

ANS: 720 132 lb = 60 kg 60 kg ´ 12 mg/kg = 720 mg DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Dosage Calculation) MSC: Integrated Process: Nursing Process (Implementation)

14. For which client would the nurse suggest the provider not prescribe misoprostol (Cytotec)? a. Client taking antacids b. Client taking antibiotics c. Client who is pregnant d. Client over 65 years of age

ANS: C Misoprostol can cause abortion, so pregnant women should not take this drug. The other clients have no contraindications to taking misoprostol. DIF: Remembering/Knowledge REF: 1129 KEY: Gastrointestinal disorders| prostaglandin analogues MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

2. A client wants to lose 1.5 pounds a week. After reviewing a diet history, the nurse determines the client typically eats 2450 calories a day. What should the client's calorie goal be to achieve this weight loss? (Record your answer using a whole number.) __ calories/day

ANS: 1700 calories/day To encourage a weight loss of 1 pound (2.2 kg) a week, 500 calories per day would be subtracted. To encourage a weight loss of 2 pounds (4.4 kg) a week, 1000 calories each day are subtracted. In this scenario, to lose 1.5 pounds a week the client needs to cut 750 calories per day from the diet: 2450 - 750 = 1700 calories. DIF: Applying/Application REF: 1249 KEY: Nutritional disorders| nutritional assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance

1. The nurse is to administer an infliximab (Remicade) infusion to a client who weighs 110 lb. The client is to receive 5 mg/kg of the drug, which is available as a 100-mg/10 mL solution. The nurse will draw up _____ milliliters of solution for the client's infusion.

ANS: 25 100 lb = 50 kg 50 kg ´ 5 mg/kg = 250 mg 250 mg ´ 10 mL/100 mg = 25 mL DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Dosage Calculation) MSC: Integrated Process: Nursing Process (Implementation)

1. A nurse cares for a client who is prescribed 5 mg/kg of infliximab (Remicade) intravenously. The client weighs 110 lbs and the pharmacy supplies infliximab 100 mg/10 mL solution. How many milliliters should the nurse administer to this client? (Record your answer using a whole number.) ____ mL

ANS: 25 mL 100 lb = 50 kg. 50 kg ´ 5 mg/kg = 250 mg. DIF: Applying/Application REF: 1176 KEY: Medication safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

3. A client is receiving continuous tube feeding at 70 mL/hr. When the bag is empty, how much formula does the nurse add? (Record your answer using a whole number.) _____ mL

ANS: 280 mL The nurse never adds more than 4 hours' worth of formula to a hanging bag of enteral feedings. 70 mL/hr ´ 4 hr = 280 mL. DIF: Applying/Application REF: 1242 KEY: Nutritional disorders| tube feedings MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

1. A nurse prepares to administer 12 mg/kg of 5-fluorouracil chemotherapy intravenously to a client who has colon cancer. The client weights 132 lb. How many milligrams should the nurse administer? (Record your answer using a whole number.) _____ mg

ANS: 720 mg 132 lb = 60 kg. 60 kg ´ 12 mg/kg = 720 mg. DIF: Applying/Application REF: 1152 KEY: Medication safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

7. To promote comfort after a colonoscopy, in what position does the nurse place the client? a. Left lateral b. Prone c. Right lateral d. Supine

ANS: A After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position. DIF: Remembering/Knowledge REF: 1096 KEY: Gastrointestinal system| positioning| nonpharmacologic comfort measures MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

2. A client has a large oral tumor. What assessment by the nurse takes priority? a. Airway b. Breathing c. Circulation d. Nutrition

ANS: A Airway always takes priority. Airway must be assessed first and any problems resolved if present. DIF: Applying/Application REF: 1104 KEY: Oral disorders| cancer| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

20. A facility is beginning to perform bariatric surgery on obese clients. Which action by the nursing manager is most important? a. Obtain appropriately sized equipment for these clients. b. Select a dedicated group of staff members for these clients. c. Send personnel to sensitivity training as part of orientation. d. Establish multidisciplinary rounding for clients in this program.

ANS: A All actions might be appropriate and helpful in the care of bariatric clients. However, staff and client safety is a unique priority when working with this group of clients. The manager must ensure appropriately sized equipment, so that neither staff nor clients injure themselves. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1354 TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention) MSC: Integrated Process: Communication and Documentation MULTIPLE RESPONSE

6. A client is having a temporary tracheostomy placed during surgery for oral cancer. What action by the nurse is best to relieve anxiety? a. Agree on a postoperative communication method. b. Explain that staff will answer the call light promptly. c. Give the client a Magic Slate to write on postoperatively. d. Reassure the client that you will take care of all of his or her needs.

ANS: A Before surgery that interrupts the client's ability to communicate, the nurse, client, and family (if possible) agree upon a method of communication in the postoperative period. The client may or may not prefer a slate and may not be able to communicate in writing. Reassuring the client and telling him or her you will take care of all of his or her needs does not help the client be an active participant in care. Ensuring that the staff will answer the call light promptly will not guarantee this will occur. DIF: Applying/Application REF: 1105 KEY: Oral disorders| communication MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

8. A client is prescribed cetuximab (Erbitux) for oral cancer and asks the nurse how it works. What response by the nurse is best? a. "It blocks epidermal growth factor." b. "It cuts off the tumor's blood supply." c. "It prevents tumor extension." d. "It targets rapidly dividing cells."

ANS: A Cetuximab (Erbitux) targets and blocks the epidermal growth factor, which contributes to the growth of oral cancers. The other explanations are not correct. DIF: Understanding/Comprehension REF: 1105 KEY: Oral disorders| cancer| patient education MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

8. A nurse and a registered dietitian are assessing clients for partial parenteral nutrition (PPN). For which client would the nurse suggest another route of providing nutrition? a. Client with congestive heart failure b. Older client with dementia c. Client who has multiorgan failure d. Client who is post gastric resection

ANS: A Clients receiving PPN typically get large amounts of fluid volume, making the client with heart failure a poor candidate. The other candidates are appropriate for this type of nutritional support. DIF: Analyzing/Analysis REF: 1244 KEY: Nutritional disorders| heart failure| parenteral nutrition| nursing assessment MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

10. A client who is malnourished has a total lymphocyte count of 1450/mm3. Which instruction does the nurse provide to the unlicensed assistive personnel helping to care for this client? a. "Wash your hands or use hand foam when you first enter the room." b. "Be sure to offer this client a glass of water each time you are with the client." c. "You may need to open cartons and packages on the client's food tray." d. "Record all of the client's food and drink intake for the shift."

ANS: A Clients who are malnourished often have a low total lymphocyte count, which puts them at higher risk for infection. The nurse should emphasize good hand hygiene. The other interventions may be appropriate depending on client needs, but good hand hygiene would be the priority. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Communication and Documentation

25. The nurse is caring for a client who has received multiple serious injuries in a motor vehicle accident. The client asks the nurse why ranitidine (Zantac) is prescribed because she does not have any abdominal pain. Which is the nurse's best response? a. "It will help prevent the development of a stomach ulcer from the stress of your injuries." b. "It will help prevent aspiration pneumonia when you are anesthetized during surgery tomorrow." c. "It will help your throat heal after it was irritated from the nasogastric tube." d. "It will help prevent nausea and vomiting from the narcotic pain medications that you are taking."

ANS: A Clients who have sustained traumatic injuries are at risk for development of stress ulcers during recovery. H2-antagonist medications may be prescribed to prevent stress ulcers. Zantac will not prevent aspiration pneumonia, esophageal healing after nasogastric intubation, or nausea from narcotic pain medications. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Teaching/Learning

22. A nurse cares for a client with ulcerative colitis. The client states, "I feel like I am tied to the toilet. This disease is controlling my life." How should the nurse respond? a. "Let's discuss potential factors that increase your symptoms." b. "If you take the prescribed medications, you will no longer have diarrhea." c. "To decrease distress, do not eat anything before you go out." d. "You must retake control of your life. I will consult a therapist to help."

ANS: A Clients with ulcerative colitis often express that the disorder is disruptive to their lives. Stress factors can increase symptoms. These factors should be identified so that the client will have more control over his or her condition. Prescription medications and anorexia will not eliminate exacerbations. Although a therapist may assist the client, this is not an appropriate response. DIF: Applying/Application REF: 1180 KEY: Ulcerative colitis| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity MULTIPLE RESPONSE

3.A client is scheduled to have a fundoplication. What statement by the client indicates a need to review preoperative teaching? a. "After the operation I can eat anything I want." b. "I will have to eat smaller, more frequent meals." c. "I will take stool softeners for several weeks." d. "This surgery may not totally control my symptoms."

ANS: A Nutritional and lifestyle changes need to continue after surgery as the procedure does not offer a lifetime cure. The other statements show good understanding. DIF:Evaluating/SynthesisREF:1117 KEY:Gastrointestinal disorders| patient education MSC:Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

15. A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider? a. White blood cell (WBC) count of 1500/mm3 b. Fatigue c. Nausea and diarrhea d. Mucositis and oral ulcers

ANS: A Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the client's WBC count is very low (normal range is 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately. DIF: Applying/Application REF: 1151 KEY: Colorectal cancer| medications| adverse effects MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

23. The nurse is caring for a client who is to receive 5-fluorouracil (5-FU) chemotherapy IV for the treatment of colon cancer. Which assessment finding leads the nurse to contact the health care provider? a. White blood cell (WBC) count of 1500/mm3 b. Presence of fatigue with a headache c. Presence of slight nausea and no appetite d. Two diarrhea stools yesterday

ANS: A Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the client's WBC count is very low (normal range, 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Analysis)

6. An older client has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? a. "Changes in your liver cause drugs to be metabolized differently." b. "Perhaps you don't need as high a dose of the drug as before." c. "Stomach muscles atrophy with age and you digest more slowly." d. "Your body probably can't tolerate as much medication anymore."

ANS: A Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugs—possibly to toxic levels. The other options do not accurately explain this age-related change. DIF: Understanding/Comprehension REF: 1088 KEY: Gastrointestinal system| older adult| patient education MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

14. The nurse is caring for an overweight client who gained 10 pounds during the previous 2 weeks. The client states that she is hungry all the time and doesn't understand why. Which assessment finding could explain the client's weight gain and hunger? a. The client started taking dexamethasone (Decadron) daily. b. The client started taking naproxen sodium (Naprosyn) daily. c. The client's glycosylated hemoglobin level is 6%. d. The client's thyroxine (T4) level is 8 mcg/dL.

ANS: A Dexamethasone is a corticosteroid. These drugs alter carbohydrate, protein, and lipid metabolism, predisposing the client to obesity when taken on a long-term basis. In addition, corticosteroids increase the client's appetite. Naprosyn is an NSAID, which can lead to gastric upset and ulceration and decreased appetite and weight loss. The client's glycosylated hemoglobin and thyroid levels are within normal limits and would not explain the hunger and weight gain. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Assessment)

13. A nurse reviews the chart of a client who has Crohn's disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions? a. Serum potassium of 2.6 mEq/L b. Client ate 20% of breakfast meal c. White blood cell count of 8200/mm3 d. Client's weight decreased by 3 pounds

ANS: A Fistulas place the client with Crohn's disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium level takes priority. DIF: Applying/Application REF: 1184 KEY: Crohn's disease| electrolyte imbalance MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

22. A client with Crohn's disease has a draining fistula. Which finding leads the nurse to intervene most rapidly? a. Serum potassium of 2.6 mEq/L b. The client not wanting to eat anything c. White blood cell count of 8200/mm3 d. The client losing 3 pounds in a week

ANS: A Fistulas place the client with Crohn's disease at risk for hypokalemia, which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium takes priority. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Analysis)

30. The nurse is caring for a client with Giardia lamblia infection. Which medication does the nurse anticipate teaching the client about? a. Metronidazole (Flagyl) b. Ciprofloxacin (Cipro) c. Sulfasalazine (Azulfidine) d. Ceftriaxone (Rocephin)

ANS: A Flagyl is the drug of choice for Giardia lamblia infection. Cipro and Rocephin are antibiotics used for bacterial infections. Azulfidine is used for ulcerative colitis and Crohn's disease. DIF: Cognitive Level: Knowledge/Remembering REF: p. 1289 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Planning)

5. The nurse is reviewing recent laboratory values for a client who is being treated for malnutrition. Which laboratory finding indicates that the client is not receiving adequate iron supplementation? a. Hematocrit, 31% b. Serum albumin, 3.5 g/dL c. Creatine phosphokinase (CPK), 55 U/mL d. Erythrocyte sedimentation rate (ESR), 15.8 mm/hr

ANS: A Hematocrit is an indicator of iron status. Low hematocrit may indicate that the client has not received enough iron supplementation and remains anemic. Serum albumin indicates protein intake and CPK is a measure of muscle injury. An elevated ESR indicates inflammation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse notes a bulge in a client's groin that is present when the client stands and disappears when the client lies down. Which conclusion does the nurse draw from these assessment findings? a. Reducible inguinal hernia b. Indirect umbilical hernia c. Strangulated ventral hernia d. Incarcerated femoral hernia

ANS: A In a reducible hernia, the contents of the hernial sac can be replaced into the abdominal cavity by gentle pressure or by lying flat. The contents of irreducible, strangulated, or incarcerated hernias may not be replaced into the abdomen when the client lies down. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis)

2. A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client? a. "Have you been experiencing any constipation?" b. "Are you eating a diet high in fiber and fluids?" c. "Do you have a history of high blood pressure?" d. "What vitamins and supplements are you taking?"

ANS: A Ischemic colitis is a life-threatening complication of alosetron. The nurse should assess the client for constipation. The other questions do not identify complications related to alosetron. DIF: Applying/Application REF: 1146 KEY: Medications| adverse effects MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

24. The nurse reviews a health teaching for a client with Crohn's disease. Which instruction does the nurse provide for the client? a. "You should have a colonoscopy every few years." b. "You should eat a diet that is high in protein and fiber." c. "You should avoid heavy lifting and tight-fitting clothes." d. "You should take the Asacol whenever you have loose stools."

ANS: A Long-term inflammatory bowel disease increases the risk of colon cancer, so regular colonoscopies are recommended. A high-fiber diet is not recommended for clients with Crohn's disease because fiber can further irritate the inner lining of the bowel. Asacol (mesalamine [5-aminosalicylic acid]) should be taken daily, not as needed. Avoiding heavy lifting and tight-fitting clothes is not necessary. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1284 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Teaching/Learning

3. The nurse is caring for a client who is a vegan and has developed B12 deficiency. Which foods does the nurse encourage the client to include in the diet? a. Fortified cereals and tofu b. Pumpkin seeds and blackstrap molasses c. Kale, spinach, and whole grain bread d. Strawberries and sweet red peppers

ANS: A Megaloblastic anemia is caused by lack of folic acid and vitamin B12 in the diet. Vegans are susceptible to this and need to include fortified cereals, soy beverages, or meat substitutes in their diets. The other foods listed are not good sources of folic acid and vitamin B12. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration) MSC: Integrated Process: Teaching/Learning

17. A nurse cares for a client who has a Giardia infection. Which medication should the nurse anticipate being prescribed for this client? a. Metronidazole (Flagyl) b. Ciprofloxacin (Cipro) c. Sulfasalazine (Azulfidine) d. Ceftriaxone (Rocephin)

ANS: A Metronidazole is the drug of choice for a Giardia infection. Ciprofloxacin and ceftriaxone are antibiotics used for bacterial infections. Sulfasalazine is used for ulcerative colitis and Crohn's disease. DIF: Remembering/Knowledge REF: 1190 KEY: Parasitic infection| medication MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

5. The nurse reads a client's chart and sees that the health care provider assessed mucosal erythroplasia. What should the nurse understand that this means for the client? a. Early sign of oral cancer b. Fungal mouth infection c. Inflammation of the gums d. Obvious oral tumor

ANS: A Mucosal erythroplasia is the earliest sign of oral cancer. It is not a fungal infection, inflammation of the gums, or an obvious tumor. DIF: Remembering/Knowledge REF: 1102 KEY: Oral disorders| cancer| pathophysiology MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

13. The postanesthesia care nurse is caring for a client who had gastric banding surgery and was extubated an hour ago. The client's blood gases are as follows: pH, 7.22; HCO3- 21 mEq/L; PCO2, 65 mm Hg; and PO2, 58 mm Hg. Which is the priority action by the nurse? a. Assess the client's airway. b. Increase the client's oxygen flow rate. c. Check the client's oxygen saturation level. d. Document findings in the client's chart.

ANS: A Obese clients are at higher risk for hypoventilation. The arterial blood gas values indicate acute respiratory acidosis with hypoxia. The client needs oxygen. However, if the airway is not patent, increasing the oxygen flow rate will be of minimal benefit. The first action is to ensure a patent airway and then apply oxygen, notify the physician, and document events. The client may need to be re-intubated and mechanically ventilated. Checking the client's oxygen saturation level will provide no additional information about the client's oxygenation status. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

26. The nurse is caring for a client who has undergone removal of a benign colonic polyp. The client asks the nurse why a follow-up colonoscopy is necessary. Which is the nurse's best response? a. "You are at risk for developing more polyps in the future." b. "You may have other cancerous lesions that could not be seen right now." c. "The doctor can remove only a few of the polyps during each colonoscopy." d. "This test will ensure that you have healed where the polyp was removed."

ANS: A Once a person has developed a polyp, risk for occurrence of multiple polyps is present. The physician usually can remove all visible polyps during the colonoscopy procedure. Follow-up colonoscopy is not done to ensure that healing occurred where a polyp was removed, or to check for cancerous lesions that were not visible during the first procedure. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1260 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Teaching/Learning MULTIPLE RESPONSE

2. A client scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best? a. Ask the client about shellfish allergies. b. Document this information on the chart. c. Ensure that the client has a ride home. d. Instruct the client on bowel preparation.

ANS: A PTC uses iodinated dye, so the client should be asked about seafood allergies, specifically to shellfish. Documentation should occur, but this is not the priority. The client will need a ride home afterward if the procedure is done on an outpatient basis. There is no bowel preparation for PTC. DIF: Applying/Application REF: 1093 KEY: Gastrointestinal system| gastrointestinal assessment| allergies| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

32. The nurse is caring for a client with a parasitic gastrointestinal infection. What statement by the client indicates a need for further teaching? a. "I will have my housekeeper keep my toilet very clean." b. "I need to shower or bathe every day." c. "I need to have my well water tested." d. "My sexual partner needs to have a stool test."

ANS: A Parasitic infections can be transmitted to other people. The client himself or herself should keep the toilet area clean instead of possibly exposing another person to the disease. The other statements are accurate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Evaluation) MULTIPLE RESPONSE

6. A nurse is caring for a client receiving enteral feedings through a Dobhoff tube. What action by the nurse is best to prevent hyperosmolarity? a. Administer free-water boluses. b. Change the client's formula. c. Dilute the client's formula. d. Slow the rate of infusion.

ANS: A Proteins and sugar molecules in the enteral feeding product contribute to dehydration due to increased osmolarity. The nurse can administer free-water boluses after consulting with the provider on the appropriate amount and timing of the boluses, or per protocol. The client may not be able to switch formulas. Diluting the formula is not appropriate. Slowing the rate of the infusion will not address the problem. DIF: Analyzing/Analysis REF: 1242 KEY: Nutritional disorders| tube feedings MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

1. The nurse conducts a physical assessment for a client with abdominal pain. Which finding leads the nurse to suspect appendicitis? a. Severe, steady right lower quadrant (RLQ) pain b. Abdominal pain that started a day after vomiting began c. Abdominal pain that increases with knee flexion d. Marked peristalsis and hyperactive bowel sounds

ANS: A Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has a gastroenteritis. Abdominal pain due to appendicitis decreases with knee flexion. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. DIF: Cognitive Level: Knowledge/Remembering REF: p. 1267 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

1. A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find? a. Severe, steady right lower quadrant pain b. Abdominal pain associated with nausea and vomiting c. Marked peristalsis and hyperactive bowel sounds d. Abdominal pain that increases with knee flexion

ANS: A Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion. DIF: Remembering/Knowledge REF: 1169 KEY: Inflammatory bowel disorder| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

18. The nurse is caring for a client who has been diagnosed with a bowel obstruction. Which assessment finding leads the nurse to conclude that the obstruction is in the small bowel? a. Potassium of 2.8 mEq/L, with a sodium value of 121 mEq/L b. Losing 15 pounds over the last month without dieting c. Reports of crampy abdominal pain across the lower quadrants d. High-pitched, hyperactive bowel sounds in all quadrants

ANS: A Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range, 3.5 to 5.0 mEq/L) and hyponatremic (normal range, 136 to 145 mEq/L). Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched, hyperactive bowel sounds may be noted with large and small bowel obstructions. Crampy abdominal pain across the lower quadrants is associated with large bowel obstruction. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis)

5. The nurse is teaching a client how to use a truss for a femoral hernia. Which statement by the client indicates the need for further teaching? a. "I will put on the truss before I go to bed each night." b. "I will put some powder under the truss to avoid skin irritation." c. "The truss will help my hernia because I can't have surgery." d. "If I have abdominal pain, I will let my health care provider know right away."

ANS: A The client is instructed to apply the truss before arising, not before going to bed at night. The other statements show accurate knowledge in using a truss. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Evaluation)

4. A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? a. "It's a good thing I love orange and cherry gelatin." b. "My spouse will be here to drive me home." c. "I should refrigerate the GoLYTELY before use." d. "I will buy a case of Gatorade before the prep."

ANS: A The client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show a good understanding of the preparation for the procedure. DIF: Evaluating/Synthesis REF: 1095 KEY: Gastrointestinal system| gastrointestinal assessment| patient education MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. After teaching a client who has a femoral hernia, the nurse assesses the client's understanding. Which statement indicates the client needs additional teaching related to the proper use of a truss? a. "I will put on the truss before I go to bed each night." b. "I'll put some powder under the truss to avoid skin irritation." c. "The truss will help my hernia because I can't have surgery." d. "If I have abdominal pain, I'll let my health care provider know right away."

ANS: A The client should be instructed to apply the truss before arising, not before going to bed at night. The other statements show an accurate understanding of using a truss. DIF: Applying/Application REF: 1147 KEY: Herniation MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

5. The nurse is caring for a client who has acute viral gastroenteritis. Which dietary instruction does the nurse provide to the client? a. "Drink plenty of fluids to prevent dehydration." b. "You can have only clear liquids to drink." c. "Milk products will give you extra protein." d. "You can have sips of cola or tea to relieve nausea."

ANS: A The client should drink plenty of fluids to prevent dehydration. Clients are not necessarily restricted to clear liquids. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Teaching/Learning

3. A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this client's teaching? a. "Drink plenty of fluids to prevent dehydration." b. "You should only drink 1 liter of fluids daily." c. "Increase your protein intake by drinking more milk." d. "Sips of cola or tea may help to relieve your nausea."

ANS: A The client should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided. DIF: Applying/Application REF: 1173 KEY: Inflammatory bowel disorder| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

4. The nurse is caring for a client with an umbilical hernia who reports increased abdominal pain, nausea, and vomiting. The nurse notes high-pitched bowel sounds. Which conclusion does the nurse draw from these assessment findings? a. Bowel obstruction; client should be placed on NPO status. b. Perforation of the bowel; client needs emergency surgery. c. Adhesions in the hernia; client needs elective surgery. d. Hernia is dangerously enlarged; client needs a nasogastric (NG) tube.

ANS: A The client with a hernia presenting with abdominal pain, fever, tachycardia, nausea and vomiting, and hypoactive bowel sounds should be suspected of having developed strangulation. Strangulation poses a risk of intestinal obstruction. The client should be placed on NPO status, and the health care provider should be notified. The symptoms are not suggestive of enlargement of the hernia, adhesion formation, or bowel perforation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Analysis)

15. A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would be most helpful? a. Arrange a dietary consult. b. Increase fluid intake. c. Limit the client's foods. d. Make the client NPO.

ANS: A The client with dumping syndrome after a gastrectomy has multiple dietary needs. A referral to the registered dietitian will be extremely helpful. Food and fluid intake is complicated and needs planning. The client should not be NPO. DIF: Applying/Application REF: 1140 KEY: Gastrointestinal disorders| referrals| nutrition MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

20. A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Pale and bluish stoma b. Liquid stool c. Ostomy pouch intact d. Blood-smeared output

ANS: A The nurse should assess the stoma for color and contact the health care provider if the stoma is pale, bluish, or dark. The nurse should expect the client to have an intact ostomy pouch with dark green liquid stool that may contain some blood. DIF: Applying/Application REF: 1177 KEY: Ostomy care| postoperative nursing MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

14. A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says "I didn't know it would be this hard to live like this." What response by the nurse is best? a. Assess the client's coping and support systems. b. Inform the client that things will get easier. c. Re-educate the client on needed dietary changes. d. Tell the client lifestyle changes are always hard.

ANS: A The nurse should assess this client's coping styles and support systems in order to provide holistic care. The other options do not address the client's distress. DIF: Applying/Application REF: 1252 KEY: Nutritional disorders| obesity| psychosocial response| coping MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Psychosocial Integrity

16. A client tells the nurse that her husband is repulsed by her colostomy and refuses to be intimate with her after surgery. Which is the nurse's best response? a. "Let's talk to the ostomy nurse to help you and your husband work through this." b. "You could try to wear longer lingerie that will better hide the ostomy appliance." c. "You should empty the pouch first so it will be less noticeable for your husband." d. "If you are not careful, you can hurt the stoma if you engage in sexual activity."

ANS: A The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the client's concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by becoming intimate with her husband. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication) MSC: Integrated Process: Caring

11. A nurse cares for a client who states, "My husband is repulsed by my colostomy and refuses to be intimate with me." How should the nurse respond? a. "Let's talk to the ostomy nurse to help you and your husband work through this." b. "You could try to wear longer lingerie that will better hide the ostomy appliance." c. "You should empty the pouch first so it will be less noticeable for your husband." d. "If you are not careful, you can hurt the stoma if you engage in sexual activity."

ANS: A The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the client's concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by engaging in sexual activity. DIF: Applying/Application REF: 1156 KEY: Ostomy care| support| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

20. A nurse cares for a client who has a new colostomy. Which action should the nurse take? a. Empty the pouch frequently to remove excess gas collection. b. Change the ostomy pouch and wafer every morning. c. Allow the pouch to completely fill with stool prior to emptying it. d. Use surgical tape to secure the pouch and prevent leakage.

ANS: A The nurse should empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy wafers with paste should be used to secure and seal the ostomy appliance; surgical tape should not be used. DIF: Applying/Application REF: 1154 KEY: Ostomy care MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

12. A nurse assesses a client with Crohn's disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Distended abdomen b. Temperature of 100.0° F (37.8° C) c. Loose and bloody stool d. Lower abdominal cramps

ANS: A The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the client's provider should be notified right away. Low-grade fever, bloody diarrhea, and abdominal cramps are common symptoms of Crohn's disease. DIF: Applying/Application REF: 1179 KEY: Crohn's disease| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

20. The nurse is caring for a client with Crohn's disease and colonic strictures. Which assessment finding requires the nurse to consult the health care provider immediately? a. Distended abdomen b. Temperature of 100.0° F (37.8° C) c. Traces of blood in the stool d. Crampy lower abdominal pain

ANS: A The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the client's provider should be notified right away. Low-grade fever, bloody diarrhea, and crampy abdominal pain are common symptoms of Crohn's disease. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Analysis)

8.A client is in the emergency department with an esophageal trauma. The nurse palpates subcutaneous emphysema in the mediastinal area and up into the lower part of the client's neck. What action by the nurse takes priority? a. Assess the client's oxygenation. b. Facilitate a STAT chest x-ray. c. Prepare for immediate surgery. d. Start two large-bore IVs.

ANS: A The priorities of care are airway, breathing, and circulation. The priority option is to assess oxygenation. This occurs before diagnostic or therapeutic procedures. The client needs two large-bore IVs as a trauma client, but oxygenation comes first. DIF:Applying/ApplicationREF:1123 KEY:Gastrointestinal disorders| trauma nursing| nursing assessment MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

25. A client has an anorectal abscess. Which teaching topic does the nurse address as the priority? a. Perineal hygiene b. Comfort measures c. Nutrition therapy d. Antibiotic use

ANS: A The priority intervention for a client with an anorectal abscess focuses on maintaining meticulous perineal hygiene to prevent infection. Comfort measures are also important, but are not as high a priority. Nutrition management and antibiotic teaching may or may not be needed. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Personal Hygiene) MSC: Integrated Process: Nursing Process (Planning)

24. A client who has had a colostomy placed in the ascending colon expresses concern that the effluent collected in the colostomy pouch has remained liquid for 2 weeks after surgery. Which is the nurse's best response? a. "This is normal for your type of colostomy." b. "I will let the health care provider know, so that it can be assessed." c. "You should add extra fiber to your diet to stop the diarrhea." d. "Your stool will become firmer over the next few weeks."

ANS: A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. The provider may be notified, but this is not the best response from the nurse. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet or with the passage of time. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Teaching/Learning

16. A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, "The stool in my pouch is still liquid." How should the nurse respond? a. "The stool will always be liquid with this type of colostomy." b. "Eating additional fiber will bulk up your stool and decrease diarrhea." c. "Your stool will become firmer over the next couple of weeks." d. "This is abnormal. I will contact your health care provider."

ANS: A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet or with the passage of time. DIF: Applying/Application REF: 1151 KEY: Ostomy care MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

9. A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes the client's pulse is 128 beats/min, blood pressure is 98/56 mm Hg, and skin turgor is dry. What action should the nurse perform next? a. Assess the 24-hour fluid balance. b. Assess the client's oral cavity. c. Prepare to hang a normal saline bolus. d. Turn up the infusion rate of the TPN.

ANS: A This client has clinical indicators of dehydration, so the nurse calculates the client's 24-hour intake, output, and fluid balance. This information is then reported to the provider. The client's oral cavity assessment may or may not be consistent with dehydration. The nurse may need to give the client a fluid bolus, but not as an independent action. The client's dehydration is most likely due to fluid shifts from the TPN, so turning up the infusion rate would make the problem worse, and is not done as an independent action. DIF: Analyzing/Analysis REF: 1245 KEY: Nutritional disorders| parenteral nutrition| intake and output MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

1. A client is in the family practice clinic. Today the client weighs 186.4 pounds (84.7 kg). Six months ago the client weighed 211.8 pounds (96.2 kg). What action by the nurse is best? a. Ask the client if the weight loss was intentional. b. Determine if there are food allergies or intolerances. c. Perform a comprehensive nutritional assessment. d. Perform a rapid bedside blood glucose test.

ANS: A This client has had a 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on risk factors and other findings, a blood glucose test may be warranted. DIF: Applying/Application REF: 1236 KEY: Nutrition| nutritional disorders| nutritional assessment| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

18. A severely malnourished client was started on enteral feedings. The following day, the client is confused, has a heart rate of 112 beats/min, and reports feeling weak. Which laboratory value does the nurse correlate with this condition? a. Serum phosphate, 1.8 mg/dL b. Serum potassium, 3.1 mEq/L c. Serum sodium, 143 mEq/L d. Serum glucose, 110 mg/dL

ANS: A This client has refeeding syndrome, which is caused primarily by hypophosphatemia. The serum phosphate level is low. The potassium is slightly low, but this is not related. The sodium is normal, and the glucose is not related. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Analysis)

15. A client has been prescribed lorcaserin (Belviq). What teaching is most appropriate? a. "Increase the fiber and water in your diet." b. "Reduce fat to less than 30% each day." c. "Report dry mouth and decreased sweating." d. "Lorcaserin may cause loose stools for a few days."

ANS: A This drug can cause constipation, so the client should increase fiber and water in the diet to prevent this from occurring. Reducing fat in the diet is important with orlistat. Lorcaserin can cause dry mouth but not decreased sweating. Loose stools are common with orlistat. DIF: Understanding/Comprehension REF: 1249 KEY: Nutritional disorders| obesity| patient education| anorectic drugs MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

2. The nurse is performing a physical examination on a client. Which assessment finding leads the nurse to check the client's abdomen for the presence of an acquired umbilical hernia? a. Body mass index (BMI) of 41.9 b. Cholecystectomy last year c. History of irritable bowel syndrome d. Daily dose of lansoprazole (Prevacid) 30 mg orally

ANS: A This type of hernia is associated with obesity. The other assessment findings do not place the client at increased risk for an acquired umbilical hernia. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common causes for which the nurse assesses in these clients? (Select all that apply.) a. Colon cancer b. Diverticulitis c. Inflammatory bowel disease d. Peptic ulcer disease e. Pernicious anemia

ANS: A, B, C, D In adults, the most common cause of anemia is GI bleeding. This is commonly associated with colon cancer, diverticulitis, inflammatory bowel disease, and peptic ulcer disease. Pernicious anemia is not associated with GI bleeding. DIF: Remembering/Knowledge REF: 1091 KEY: Gastrointestinal system| laboratory values| gastrointestinal assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

4.The nurse has taught a client about lifestyle modifications for gastroesophageal reflux disease (GERD). What statements by the client indicate good understanding of the teaching? (Select all that apply.) a. "I just joined a gym, so I hope that helps me lose weight." b. "I sure hate to give up my coffee, but I guess I have to." c. "I will eat three small meals and three small snacks a day." d. "Sitting upright and not lying down after meals will help." e. "Smoking a pipe is not a problem and I don't have to stop."

ANS: A, B, C, D Lifestyle modifications can help control GERD and include losing weight if needed; avoiding chocolate, caffeine, and carbonated beverages; eating frequent small meals or snacks; and remaining upright after meals. Tobacco is a risk factor for GERD and should be avoided in all forms. DIF:Understanding/ComprehensionREF:1113 KEY: Gastrointestinal disorders| lifestyle modifications| patient education MSC:Integrated Process: Nursing Process: Evaluation NOT:Client Needs Category: Health Promotion and Maintenance

3.A client has been discharged to an inpatient rehabilitation center after an esophagogastrectomy. What menu selections by the client at the rehabilitation center indicate a good understanding of dietary instructions? (Select all that apply.) a. Boost™ supplement b. Greek yogurt c. Scrambled eggs d. Whole milk shake e. Whole wheat toast

ANS: A, B, C, D Malnutrition is a serious problem after this procedure. The client needs high-protein, high-calorie foods that are easy to chew and swallow. The Boost supplement, Greek yogurt, scrambled eggs, and whole milk shake are all good choices. The whole wheat bread, while heart healthy, is not a good choice as it is dry and not easy to chew and swallow. DIF:Evaluating/SynthesisREF:1122 KEY:Gastrointestinal disorders| nutrition| patient education MSC:Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

1.The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply.) a. Delayed gastric emptying b. Eating large meals c. Hiatal hernia d. Obesity e. Viral infections

ANS: A, B, C, D Many factors predispose a person to GERD, including delayed gastric emptying, eating large meals, hiatal hernia, and obesity. Viral infections are not implicated in the development of GERD, although infection with Helicobacter pylori is. DIF:Remembering/KnowledgeREF:1111 KEY: Gastrointestinal disorders MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. The student nurse learns about risk factors for gastric cancer. Which factors does this include? (Select all that apply.) a. Achlorhydria b. Chronic atrophic gastritis c. Helicobacter pylori infection d. Iron deficiency anemia e. Pernicious anemia

ANS: A, B, C, E Achlorhydria, chronic atrophic gastritis, H. pylori infection, and pernicious anemia are all risk factors for developing gastric cancer. Iron deficiency anemia is not a risk factor. DIF: Remembering/Knowledge REF: 1138 KEY: Gastrointestinal disorders| gastrointestinal assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

5. When working with older adults to promote good nutrition, what actions by the nurse are most appropriate? (Select all that apply.) a. Allow uninterrupted time for eating. b. Assess dentures for appropriate fit. c. Ensure the client has glasses on when eating. d. Provide salty foods that the client can taste. e. Serve high-calorie, high-protein snacks.

ANS: A, B, C, E Older adults need unhurried and uninterrupted time for eating. Dentures should fit appropriately and glasses, if used, should be on. High-calorie, high-protein snacks are a good choice. Salty snacks are not recommended because all adults should limit sodium in their diets. DIF: Applying/Application REF: 1238 KEY: Nutritional disorders| older adult| nutrition MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Health Promotion and Maintenance SHORT ANSWER

2. A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse instructs the client and family about the signs of potential complications, which include what problems? (Select all that apply.) a. Cholangitis b. Pancreatitis c. Perforation d. Renal lithiasis e. Sepsis

ANS: A, B, C, E Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP. DIF: Understanding/Comprehension REF: 1095 KEY: Gastrointestinal system| diagnostic testing| patient education MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

1. The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (Select all that apply.) a. Alcohol b. Caffeine c. Corticosteroids d. Fruit juice e. Nonsteroidal anti-inflammatory drugs (NSAIDs)

ANS: A, B, C, E Risk factors for acute gastritis include alcohol, caffeine, corticosteroids, and chronic NSAID use. Fruit juice is not a risk factor, although in some people it does cause distress. DIF: Remembering/Knowledge REF: 1127 KEY: Gastrointestinal disorders MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.) a. Decreased hydrochloric acid production b. Diminished sensation that can lead to constipation c. Fat not digested as well in older adults d. Increased peristalsis in the large intestine e. Pancreatic vessels become calcified

ANS: A, B, C, E Several age-related changes occur in the gastrointestinal system. These include decreased hydrochloric acid production, diminished nerve function that leads to decreased sensation of the need to pass stool, decreased fat digestion, decreased peristalsis in the large intestine, and calcification of pancreatic vessels. DIF: Remembering/Knowledge REF: 1088 KEY: Gastrointestinal system| older adult MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

3. When reviewing an older client's medical record, which findings lead the nurse to perform a nutrition assessment? (Select all that apply.) a. Widow/widower status b. Chronic constipation c. History of depression d. Random blood sugar level of 198 mg/dL e. Cholecystectomy 4 years ago f. Inability to afford a new pair of glasses

ANS: A, B, C, F Many factors contribute to malnutrition in older clients. Depression and loneliness from the loss of a spouse; constipation; poor eyesight; chronic medical problems, including depression; and taking prescription and/or over-the-counter medications can contribute to malnutrition. Blood glucose levels and a previous cholecystectomy would not necessarily contribute. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration) MSC: Integrated Process: Nursing Process (Assessment)

5. After teaching a client with an anal fissure, a nurse assesses the client's understanding. Which client actions indicate that the client correctly understands the teaching? (Select all that apply.) a. Taking a warm sitz bath several times each day b. Utilizing a daily enema to prevent constipation c. Using bulk-producing agents to aid elimination d. Self-administering anti-inflammatory suppositories e. Taking a laxative each morning

ANS: A, C, D Taking warm sitz baths each day, using bulk-producing agents, and administering anti-inflammatory suppositories are all appropriate actions for the client with an anal fissure. The client should not use enemas or laxatives to promote elimination, but rather should rely on bulk-producing agents such as psyllium hydrophilic mucilloid (Metamucil). DIF: Applying/Application REF: 1189 KEY: Skin lesions/wounds| bowel care MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

7. A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding - Erosion of the bowel wall b. Abscess formation - Localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon - Transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction - Paralysis of colon resulting from colorectal cancer e. Fistula - Dilation and colonic ileus caused by paralysis of the colon

ANS: A, B, D Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon. DIF: Understanding/Comprehension REF: 1181 KEY: Ulcerative colitis MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation SHORT ANSWER

4. A nurse plans care for a client who is recovering from an inguinal hernia repair. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Encouraging ambulation three times a day b. Encouraging normal urination c. Encouraging deep breathing and coughing d. Providing ice bags and scrotal support e. Forcibly reducing the hernia

ANS: A, B, D Postoperative care for clients with an inguinal hernia includes all general postoperative care except coughing. The nurse should promote lung expansion by encouraging deep breathing and ambulation. The nurse should encourage normal urination, including allowing the client to stand, and should provide scrotal support and ice bags to prevent swelling. A hernia should never be forcibly reduced, and this procedure is not part of postoperative care. DIF: Applying/Application REF: 1148 KEY: Herniation| postoperative care MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2.The nurse is caring for a client who had an esophagectomy 3 days ago and was extubated yesterday. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assisting with position changes and getting out of bed b. Keeping the head of the bed elevated to at least 30 degrees c. Reminding the client to use the spirometer every 4 hours d. Taking and recording vital signs per hospital protocol e. Titrating oxygen based on the client's oxygen saturations

ANS: A, B, D The UAP can assist with mobility, keep the head of the bed elevated, and take and record vital signs. The client needs to use the spirometer every 1 to 2 hours. The nurse titrates oxygen. DIF:Applying/ApplicationREF:1122 KEY: Gastrointestinal disorders| postoperative nursing| delegation| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

7. A nurse plans care for a client who has chronic diarrhea. Which actions should the nurse include in this client's plan of care? (Select all that apply.) a. Using premoistened disposable wipes for perineal care b. Turning the client from right to left every 2 hours c. Using an antibacterial soap to clean after each stool d. Applying a barrier cream to the skin after cleaning e. Keeping broken skin areas open to air to promote healing

ANS: A, B, D The nurse should use premoistened disposable wipes instead of toilet paper for perineal care, or mild soap and warm water after each stool. Antibacterial soap would be too abrasive and damage good bacteria on the skin. The nurse should apply a thin layer of a medicated protective barrier after cleaning the skin. The client should be re-positioned frequently so that he or she is kept off the affected area, and open skin areas should be covered with DuoDerm or Tegaderm occlusive dressing to promote rapid healing. DIF: Remembering/Knowledge REF: 1166 KEY: Bowel care MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

2. A client has a gastrointestinal hemorrhage and is prescribed two units of packed red blood cells. What actions should the nurse perform prior to hanging the blood? (Select all that apply.) a. Ask a second nurse to double-check the blood. b. Prime the IV tubing with normal saline. c. Prime the IV tubing with dextrose in water. d. Take and record a set of vital signs. e. Teach the client about reaction manifestations.

ANS: A, B, D, E Prior to starting a blood transfusion, the nurse asks another nurse to double-check the blood (and client identity), primes the IV tubing with normal saline, takes and records a baseline set of vital signs, and teaches the client about manifestations to report. The IV tubing is not primed with dextrose in water. DIF: Applying/Application REF: 1136 KEY: Patient safety| blood transfusions MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

1. A client is malnourished and needs encouragement and assistance to eat. Which activities does the nurse delegate to the unlicensed assistive personnel (UAP) when giving this client a food tray? (Select all that apply.) a. Open food packages and cut food if needed. b. Remove the urinal from the bedside table. c. Assess the client's ability to swallow. d. Report to the nurse pain described by the client. e. Sit with the client and do not rush the feeding.

ANS: A, B, D, E When assisting or encouraging a client to eat, appropriate activities include opening food packages and cutting food if needed; removing urinals and bedpans, or other offensive objects, from the immediate area; reporting complaints of pain so it can be treated; and sitting with the client without rushing the client to finish the meal. Only the nurse can assess for swallowing, although the UAP should report choking episodes or coughing. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration) MSC: Integrated Process: Communication and Documentation

6. A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Distended abdomen b. Inability to pass flatus c. Bradycardia d. Hyperactive bowel sounds e. Decreased urine output

ANS: A, B, E A client with peritonitis may present with a distended abdomen, diminished bowel sounds, inability to pass flatus or feces, tachycardia, and decreased urine output secondary to dehydration. Bradycardia and hyperactive bowel sounds are not associated with peritonitis. DIF: Remembering/Knowledge REF: 1170 KEY: Inflammatory bowel disorder| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

6. A client who had a partial gastrectomy has several expected nutritional problems. What actions by the nurse are best to promote better nutrition? (Select all that apply.) a. Administer vitamin B12 injections. b. Ask the provider about folic acid replacement. c. Educate the client on enteral feedings. d. Obtain consent for total parenteral nutrition. e. Provide iron supplements for the client.

ANS: A, B, E After gastrectomy, clients are at high risk for anemia due to vitamin B12 deficiency, folic acid deficiency, or iron deficiency. The nurse should provide supplements for all these nutrients. The client does not need enteral feeding or total parenteral nutrition. DIF: Understanding/Comprehension REF: 1141 KEY: Gastrointestinal disorders| anemia| supplements MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this client's assessment? (Select all that apply.) a. "Which food types cause an exacerbation of symptoms?" b. "Where is your pain and what does it feel like?" c. "Have you lost a significant amount of weight lately?" d. "Are your stools soft, watery, and black in color?" e. "Do you experience nausea associated with defecation?"

ANS: A, B, E The nurse should ask the client about factors that may cause exacerbations of symptoms, including food, stress, and anxiety. The nurse should also assess the location, intensity, and quality of the client's pain, and nausea associated with defecation or meals. Clients who have IBS do not usually lose weight and stools are not black in color. DIF: Applying/Application REF: 1145 KEY: Irritable bowel| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

7. A nurse is preparing to administer pantoprazole (Protonix) intravenously. What actions by the nurse are most appropriate? (Select all that apply.) a. Administer the drug through a separate IV line. b. Infuse pantoprazole using an IV pump. c. Keep the drug in its original brown bag. d. Take vital signs frequently during infusion. e. Use an in-line IV filter when infusing.

ANS: A, B, E When infusing pantoprazole, use a separate IV line, a pump, and an in-line filter. A brown wrapper and frequent vital signs are not needed. DIF: Applying/Application REF: 1130 KEY: Gastrointestinal disorders| proton pump inhibitors MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

MULTIPLE RESPONSE 1. The nurse is caring for a client with sialadenitis. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying warm compresses b. Massaging salivary glands c. Offering fluids every hour d. Providing lemon-glycerin swabs e. Reminding the client to avoid speaking

ANS: A, C The UAP can apply warm compresses and offer fluids. Massaging salivary glands can be done, but not by the UAP. Lemon-glycerin swabs are drying and should not be used. Speaking has no effect on this condition. DIF: Applying/Application REF: 1108 KEY: Delegation| oral disorders| comfort measures| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

1. The nurse is aware of the 2014 American Cancer Society Screening Guidelines for colon cancer, which include which testing modalities for people over the age of 50? (Select all that apply.) a. Colonoscopy every 10 years b. Colonoscopy every 5 years c. Computed tomography (CT) colonography every 5 years d. Double-contrast barium enema every 10 years e. Flexible sigmoidoscopy every 10 years

ANS: A, C The options for colon cancer screening for people over the age of 50 include colonoscopy every 10 years and CT colonography, double-contrast barium enema, or flexible sigmoidoscopy every 5 years. DIF: Remembering/Knowledge REF: 1093 KEY: Gastrointestinal system| gastrointestinal assessment| cancer| health promotion MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance

6.A nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods should the nurse include in the teaching? (Select all that apply.) a. Chocolate b. Decaffeinated coffee c. Citrus fruits d. Peppermint e. Tomato sauce

ANS: A, C, D, E Chocolate, citrus fruits such as oranges and grapefruit, peppermint and spearmint, and tomato-based products all contribute to the reflux associated with GERD. Caffeinated teas, coffee, and sodas should be avoided. DIF:Understanding/ComprehensionREF:1111 KEY:Gastrointestinal disorders| patient education MSC:Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

1. The nurse understands that malnutrition can occur in hospitalized clients for several reasons. Which are possible reasons for this to occur? (Select all that apply.) a. Cultural food preferences b. Family bringing snacks c. Increased need for nutrition d. Need for NPO status e. Staff shortages

ANS: A, C, D, E Many factors increase the hospitalized client's risk for nutritional deficits. Cultural food preferences may make hospital food unpalatable. Ill clients have increased nutritional needs but may be NPO for testing or treatment, or have a loss of appetite from their illness. Staff shortages impact clients who need to be fed or assisted with meals. The family may bring snacks that are either healthy or unhealthy, so without further information, the nurse cannot assume the snacks are leading to malnutrition. DIF: Remembering/Knowledge REF: 1237 KEY: Nutritional disorders MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. A nurse is teaching a community group about food poisoning and gastroenteritis. Which statements by the nurse are accurate? (Select all that apply.) a. Rotavirus is more common among infants and younger children. b. Escherichia coli diarrhea is transmitted by contact with infected animals. c. Don't drink water when swimming to prevent E. coli infection. d. All clients with botulism require hospitalization. e. Parasitic diseases may not show up for 1 to 2 weeks after infection.

ANS: A, C, D, E Rotavirus is more common among the youngest of clients, not drinking water while swimming can help prevent E. coli infection, people with botulism need to be hospitalized to monitor for respiratory failure and paralysis, and parasitic diseases may take up to 2 weeks to become symptomatic. The other statements are not accurate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Teaching/Learning COMPLETION

2. A nurse teaches a client how to avoid becoming ill with Salmonella infection again. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Wash leafy vegetables carefully before eating or cooking them." b. "Do not ingest water from the garden hose or the pool." c. "Wash your hands before and after using the bathroom." d. "Be sure meat is cooked to the proper temperature." e. "Avoid eating eggs that are sunny side up or undercooked."

ANS: A, C, D, E Salmonella is usually contracted via contaminated eggs, beef, poultry, and green leafy vegetables. It is not transmitted through water in garden hoses or pools. Clients should wash leafy vegetables well, wash hands before and after using the restroom, make sure meat and eggs are cooked properly, and, because it can be transmitted by flies, keep flies off of food. DIF: Applying/Application REF: 1191 KEY: Inflammatory bowel disorder| infection control MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

2. A nurse studying cancer knows that job-related risks for developing oral cancer include which occupations? (Select all that apply.) a. Coal miner b. Electrician c. Metal worker d. Plumber e. Textile worker

ANS: A, C, D, E The occupations of coal mining, metal working, plumbing, and textile work produce exposure to polycyclic aromatic hydrocarbons (PAHs), which are known carcinogens. Electricians do not have this risk. DIF: Remembering/Knowledge REF: 1103 KEY: Oral disorders| nursing assessment| cancer MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

1. The client asks the nurse how to avoid becoming ill with Salmonella infection again. Which are appropriate responses from the nurse? (Select all that apply.) a. "Wash leafy vegetables carefully before eating or cooking them." b. "Do not ingest water from the garden hose or the pool." c. "Wash your hands before and after using the bathroom." d. "Be sure meat is cooked to the proper temperature." e. "Avoid eating eggs that are sunny side up or undercooked." f. "When eating outdoors, be sure to keep flies off your food."

ANS: A, C, D, E, F Salmonella is usually contracted via contaminated eggs, beef, poultry, and green leafy vegetables. It is not transmitted through water in garden hoses or pools. Clients should wash leafy vegetables well, wash hands before and after using the restroom, make sure eggs and meat are cooked properly, and, because it can be transmitted by flies, keep flies off of food. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Teaching/Learning

4. A nurse teaches a community group about food poisoning and gastroenteritis. Which statements should the nurse include in this group's teaching? (Select all that apply.) a. "Rotavirus is more common among infants and younger children." b. "Escherichia coli diarrhea is transmitted by contact with infected animals." c. "To prevent E. coli infection, don't drink water when swimming." d. "Clients who have botulism should be quarantined within their home." e. "Parasitic diseases may not show up for 1 to 2 weeks after infection."

ANS: A, C, E Rotavirus is more common among the youngest of clients. Not drinking water while swimming can help prevent E. coli infection. Parasitic diseases may take up to 2 weeks to become symptomatic. People with botulism need to be hospitalized to monitor for respiratory failure and paralysis. Escherichia coli is not transmitted by contact with infected animals. DIF: Applying/Application REF: 1172 KEY: Inflammatory bowel disorder| infection control MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

5. A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with this diagnosis? (Select all that apply.) a. Serum potassium of 2.8 mEq/L b. Loss of 15 pounds without dieting c. Abdominal pain in upper quadrants d. Low-pitched bowel sounds e. Serum sodium of 121 mEq/L

ANS: A, C, E Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range is 3.5 to 5.0 mEq/L) and hyponatremic (normal range is 136 to 145 mEq/L). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions. DIF: Applying/Application REF: 1159 KEY: Intestinal obstruction| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

1. A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.) a. Performs hand hygiene and positions the client in high-Fowler's position, with pillows behind the head and shoulders b. Instructs the client to extend the neck against the pillow once the NG tube has reached the oropharynx c. Checks for correct placement by checking the pH of the fluid aspirated from the tube d. Secures the NG tube by taping it to the client's nose and pinning the end to the pillowcase e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent

ANS: A, C, E The client's head should be flexed forward once the NG tube has reached the oropharynx. The NG tube should be secured to the client's gown, not to the pillowcase, because it could become dislodged easily. All the other actions are appropriate. DIF: Applying/Application REF: 1159 KEY: Intestinal obstruction MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. A client has dumping syndrome. What menu selections indicate the client understands the correct diet to manage this condition? (Select all that apply.) a. Canned unsweetened apricots b. Coffee cake c. Milk shake d. Potato soup e. Steamed broccoli

ANS: A, D Canned apricots and potato soup are appropriate selections as they are part of a high-protein, high-fat, low- to moderate-carbohydrate diet. Coffee cake and other sweets must be avoided. Milk products and sweet drinks such as shakes must be avoided. Gas-forming foods such as broccoli must also be avoided. DIF: Remembering/Knowledge REF: 1141 KEY: Gastrointestinal disorders| nutrition| patient education MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. A nurse teaches a community group ways to prevent Escherichia coli infection. Which statements should the nurse include in this group's teaching? (Select all that apply.) a. "Wash your hands after any contact with animals." b. "It is not necessary to buy a meat thermometer." c. "Stay away from people who are ill with diarrhea." d. "Use separate cutting boards for meat and vegetables." e. "Avoid swimming in backyard pools and using hot tubs."

ANS: A, D Washing hands after contact with animals and using separate cutting boards for meat and other foods will help prevent E. coli infection. The other statements are not related to preventing E. coli infection. DIF: Applying/Application REF: 1172 KEY: Inflammatory bowel disorder| infection control MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

2. A nurse is teaching a community group ways to prevent Escherichia coli infection. Which statements made by the nurse are accurate? (Select all that apply.) a. "Wash your hands after any contact with animals." b. "It is not necessary to buy a meat thermometer." c. "Stay away from people who are ill with diarrhea." d. "Use separate cutting boards for meat and vegetables." e. "Avoid swimming in backyard pools and using hot tubs."

ANS: A, D Washing hands after contact with animals and using separate cutting boards for meat and other foods will help prevent E. coli infection. The other statements are not related to preventing E. coli infection. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Teaching/Learning

3. The nurse is caring for a client who will undergo a gastrectomy the following day. Which interventions are included in the postoperative plan of care for the client? (Select all that apply.) a. Monitor and record accurate intake and output (I&O). b. Remind the client to use the incentive spirometer twice daily. c. Change abdominal dressings daily using medical asepsis. d. Remind the client daily to use patient-controlled analgesia (PCA) before pain becomes severe. e. Keep the head of the client's bed elevated whenever possible. f. Irrigate the nasogastric tube with normal saline every 8 hours PRN.

ANS: A, D, E I&O should be recorded to monitor for fluid overload or deficit. Pain medication is most effective when taken before pain becomes severe. Keep the client's head of the bed elevated to prevent reflux. The spirometer should be used at least every hour to prevent atelectasis and pneumonia. Surgical asepsis (sterile technique) must be used for dressing changes and the site must be assessed each shift, necessitating a dressing change each shift. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Planning)

8. A nurse cares for a client who has a nasogastric (NG) tube. Which actions should the nurse take? (Select all that apply.) a. Assess for proper placement of the tube every 4 hours. b. Flush the tube with water every hour to ensure patency. c. Secure the NG tube to the client's upper lip. d. Disconnect suction when auscultating bowel peristalsis. e. Monitor the client's skin around the tube site for irritation.

ANS: A, D, E The nurse should assess for proper placement, tube patency, and output every 4 hours. The nurse should also monitor the skin around the tube for irritation and secure the tube to the client's nose. When auscultating bowel sounds for peristalsis, the nurse should disconnect suction. DIF: Applying/Application REF: 1159 KEY: Drain MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control SHORT ANSWER

1. The nurse is helping a student prepare to insert a nasogastric tube for an adult client with a bowel obstruction. Which actions by the student indicate to the nurse that a review of the procedure is needed? (Select all that apply.) a. Gathering supplies, including an 8 Fr Levin tube, sterile gloves, tape, and water-soluble lubricant b. Performing hand hygiene and positioning the client in high Fowler's position, with pillows behind the head and shoulders c. Attaching a 60-mL irrigation syringe to the end of the nasogastric tube before inserting it into the nose d. Instructing the client to extend the neck against the pillow once the nasogastric tube has reached the oropharynx e. Checking for correct placement by checking the pH of the fluid aspirated from the tube f. Securing the nasogastric tube by taping it to the client's nose and pinning the end to the pillowcase g. Connecting the nasogastric tube to intermittent medium suction with an anti-reflux valve on the air vent

ANS: A, D, F An 8 Fr nasogastric tube is too small for drainage of thick stomach contents. Sterile gloves are not needed for the procedure. The tube should be secured to the client's gown, not to the pillowcase, because it could become dislodged easily. The client's head should be flexed forward once the tube has reached the oropharynx. All the other actions are appropriate. A 60-mL irrigation syringe should be attached to the end of the tube before insertion so that gastric fluid does not erupt from the tube when it enters the stomach. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Implementation)

3. A nurse is reviewing laboratory values for several clients. Which value causes the nurse to conduct nutritional assessments as a priority? a. Albumin: 3.5 g/dL b. Cholesterol: 142 mg/dL c. Hemoglobin: 9.8 mg/dL d. Prealbumin: 28 mg/dL

ANS: B A cholesterol level below 160 mg/dL is a possible indicator of malnutrition, so this client would be at highest priority for a nutritional assessment. The albumin and prealbumin levels are normal. The low hemoglobin could be from several problems, including dietary deficiencies, hemodilution, and bleeding. DIF: Remembering/Knowledge REF: 1239 KEY: Nutritional disorders| nutritional assessment| laboratory values MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

26. A nurse is caring for a client hospitalized with botulism. The nurse obtains the following vital signs: temperature—99.8° F (37.6° C), pulse—100, respiratory rate—10 and shallow, and blood pressure—100/62 mm Hg. What action by the nurse is most appropriate? a. Allow the client rest periods without interruption. b. Stay with the client while another nurse calls the physician. c. Check the client's IV rate and document all findings. d. Help the client order appropriate food items from the menu.

ANS: B A client with botulism is at risk for respiratory failure. This client's respiratory rate is slow and shallow, which could indicate impending respiratory distress or failure. The nurse should remain with the client while another nurse notifies the provider. Nothing is allowed by mouth until all respiratory function and swallowing are normal. The nurse should monitor and document the IV infusion per protocol, but this does not take priority. Allowing the client to rest and ordering food items are not appropriate actions. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Analysis)

5.The nurse is working with clients who have esophageal disorders. The nurse should assess the clients for which manifestations? (Select all that apply.) a. Aphasia b. Dysphagia c. Eructation d. Halitosis e. Weight gain

ANS: B, C, D Common signs of esophageal disorders include dysphagia, eructation, halitosis, and weight loss. Aphasia is difficulty with speech, commonly seen after stroke. DIF:Remembering/KnowledgeREF:1124 KEY:Gastrointestinal disorders| nursing assessment MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

15. A nurse assesses a client who is hospitalized for botulism. The client's vital signs are temperature: 99.8° F (37.6° C), heart rate: 100 beats/min, respiratory rate: 10 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take? a. Decrease stimulation and allow the client to rest. b. Stay with the client while another nurse calls the provider. c. Increase the client's intravenous fluid replacement rate. d. Check the client's blood glucose and administer orange juice.

ANS: B A client with botulism is at risk for respiratory failure. This client's respiratory rate is slow, which could indicate impending respiratory distress or failure. The nurse should remain with the client while another nurse notifies the provider. The nurse should monitor and document the IV infusion per protocol, but this client does not require additional intravenous fluids. Allowing the client to rest or checking the client's blood glucose and administering orange juice are not appropriate actions. DIF: Applying/Application REF: 1191 KEY: Inflammatory bowel disorder| respiratory distress/failure MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

9. After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I will avoid large crowds and people who are sick." b. "I will take this medication with my breakfast each morning." c. "Nausea and vomiting are common side effects of this drug." d. "I must wash my hands after I play with my dog."

ANS: B Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing. DIF: Applying/Application REF: 1183 KEY: Ulcerative colitis| medication safety MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

15. The nurse is caring for a client with severe ulcerative colitis who has been prescribed adalimumab (Humira). Which client statement indicates that additional teaching about the medication is needed? a. "I will avoid large crowds and people who are sick." b. "I will take this medication with food or milk." c. "Nausea and vomiting are common side effects." d. "I will wash my hands after I play with my dog."

ANS: B Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Nursing Process (Evaluation)

12. Which statement indicates that the client needs additional discharge teaching after gastric bypass surgery? a. "I hope my type 2 diabetes is cured and I won't need insulin anymore." b. "As soon as I get home, I'm going to enjoy a nice bowl of fruit." c. "If I get nauseated, I know I'm eating too much at one time." d. "I will be sure to report any back, shoulder, or abdominal pain."

ANS: B After gastric bypass surgery, clients are limited to fluids and pureed foods for about 6 weeks. Then the client can progress to a more normal diet. Eating fruit right after discharge would not be recommended. The other statements indicate good understanding. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Evaluation)

18. A nurse is caring for a morbidly obese client. What comfort measure is most important for the nurse to delegate to the unlicensed assistive personnel (UAP)? a. Designating "quiet time" so the client can rest b. Ensuring siderails are not causing excess pressure c. Providing oral care before and after meals and snacks d. Relaying any reports of pain to the registered nurse

ANS: B All actions are good for client comfort, but when dealing with an obese client, the staff should take extra precautions, such as ensuring the siderails are not putting pressure on the client's tissues. The other options are appropriate for any client, and are not specific to obese clients. DIF: Applying/Application REF: 1246 KEY: Nutritional disorders| obesity| comfort measures| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

6. An older female client has been prescribed esomeprazole (Nexium) for treatment of chronic gastric ulcers. What teaching is particularly important for this client? a. Check with the pharmacist before taking other medications. b. Increase intake of calcium and vitamin D. c. Report any worsening of symptoms to the provider. d. Take the medication as prescribed by the provider.

ANS: B All of this advice is appropriate for any client taking this medication. However, long-term use is associated with osteoporosis and osteoporosis-related fractures. This client is already at higher risk for this problem and should be instructed to increase calcium and vitamin D intake. The other options are appropriate for any client taking any medication and are not specific to the use of esomeprazole. DIF: Applying/Application REF: 1130 KEY: Gastrointestinal disorders| osteoporosis| proton pump inhibitors| patient education MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

4.A client with an esophageal tumor has difficulty swallowing and has been working with a speech-language pathologist. What assessment finding by the nurse indicates that the priority goal for this problem is being met? a. Choosing foods that are easy to swallow b. Lungs clear after meals and snacks c. Properly performing swallowing exercises d. Weight unchanged after 2 weeks

ANS: B All these assessment findings are positive for this client. However, this client is at high risk for aspiration. Clear lungs after eating indicates no aspiration has occurred. Choosing easy-to-swallow foods, performing swallowing checks, and having an unchanged weight do not assess aspiration, and therefore do not indicate that the priority goal has been met. DIF:Evaluating/SynthesisREF:118 KEY:Gastrointestinal disorders| respiratory assessment| patient safety MSC:Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which action should the nurse take? a. Assess the client's heart rate and blood pressure. b. Determine when the client last voided. c. Ask if the client is experiencing flatus. d. Auscultate all quadrants of the client's abdomen.

ANS: B Assessment findings indicate that the client may have an over-full bladder. In the immediate postoperative period, the client may experience difficulty voiding due to urinary retention. The nurse should assess when the client last voided. The client's vital signs may be checked after the nurse determines the client's last void. Asking about flatus and auscultating bowel sounds are not related to a hemorrhoidectomy. DIF: Applying/Application REF: 1165 KEY: Postoperative nursing| urinary retention MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. The nurse is performing a physical assessment for a client who underwent a hemorrhoidectomy the previous day. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which is the nurse's priority action? a. Assess the client's vital signs. b. Determine the last time the client voided. c. Insert a rectal tube to facilitate passage of flatus. d. Document the findings in the client's chart.

ANS: B Assessment findings indicate that the client may have an overfull bladder. In the immediate postoperative period, the client may experience difficulty voiding owing to urinary retention. A rectal tube should not be inserted for a client who had a hemorrhoidectomy the previous day. The client's vital signs may be checked after the nurse determines the client's last void. The nurse should document all findings and actions in the client's medical record. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

1. The student nurse studying the gastrointestinal system understands that chyme refers to what? a. Hormones that reduce gastric acidity b. Liquefied food ready for digestion c. Nutrients after being absorbed d. Secretions that help digest food

ANS: B Before being digested, food must be broken down into a liquid form. This liquid is called chyme. Secretin is the hormone that inhibits acid production and decreases gastric motility. Absorption is carried out as the nutrients produced by digestion move from the lumen of the GI tract into the body's circulatory system for uptake by individual cells. The secretions that help digest food include hydrochloric acid, bile, and digestive enzymes. DIF: Remembering/Knowledge REF: 1085 KEY: Gastrointestinal system MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is caring for a client who is having approximately 20 foul-smelling stools each day. Laboratory Gram stain testing indicates the presence of white blood cells (WBCs) and red blood cells (RBCs) in the stool. Which organism does the nurse expect to see in the culture report? a. Helicobacter pylori b. Campylobacter jejuni c. Clostridium botulinum d. Norwalk virus

ANS: B Campylobacter gastroenteritis causes foul-smelling diarrhea with up to 20 to 30 stools per day for 7 days. Both RBCs and WBCs are present in a Gram stain of the stools. Infection with Clostridium causes not diarrhea, but constipation, paralysis, and respiratory failure. H. pylori is a common cause of gastric ulcers, not gastroenteritis. Norwalk virus produces milder illness with diarrhea and vomiting. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis)

6. The nurse provides discharge teaching for a client who was hospitalized for Salmonella food poisoning. Which client statement indicates that additional teaching is needed? a. "I will let my husband do the cooking for my family." b. "I will take the ciprofloxacin (Cipro) until the diarrhea has resolved." c. "I will wash my hands with antibacterial soap before and after each meal." d. "I will make sure that my dishes go straight into the dishwasher after each meal."

ANS: B Cipro should be taken for 10 to 14 days to treat Salmonella infection, and should not be stopped once the diarrhea has cleared. Clients should be advised to take the entire course of medication. People with Salmonellashould not prepare foods for others because the infection may be spread in this way. Dishes and eating utensils should not be shared and should be cleaned thoroughly. Hands should be washed with antibacterial soap before and after eating to prevent spread of the bacteria. Clients can be carriers for up to 1 year. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

4. After teaching a client who was hospitalized for Salmonella food poisoning, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I will let my husband do all of the cooking for my family." b. "I'll take the ciprofloxacin until the diarrhea has resolved." c. "I should wash my hands with antibacterial soap before each meal." d. "I must place my dishes into the dishwasher after each meal."

ANS: B Ciprofloxacin should be taken for 10 to 14 days to treat Salmonella infection, and should not be stopped once the diarrhea has cleared. Clients should be advised to take the entire course of medication. People with Salmonella should not prepare foods for others because the infection may be spread in this way. Hands should be washed with antibacterial soap before and after eating to prevent spread of the bacteria. Dishes and eating utensils should not be shared and should be cleaned thoroughly. Clients can be carriers for up to 1 year. DIF: Applying/Application REF: 1173 KEY: Inflammatory bowel disorder| medications| antibiotics| medication safety MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

6.A client is scheduled for a traditional esophagogastrostomy. All preoperative teaching has been completed and the client and family show good understanding. What action by the nurse is best? a. Arrange an intensive care unit tour. b. Assess the client's psychosocial status. c. Document the teaching and response. d. Have the client begin nutritional supplements.

ANS: B Clients facing this long, difficult procedure are often anxious and fearful. The nurse should now assess the client's psychosocial status and provide the care and teaching required based on this assessment. An intensive care unit tour may help decrease stress but is too limited in scope to be the best response. Documentation should be thorough, but the nurse needs to do more than document. The client should begin nutritional supplements prior to the operation, but again this response is too limited in scope. DIF:Applying/ApplicationREF:1120 KEY: Gastrointestinal disorders| psychosocial response| nursing assessment| coping MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Psychosocial Integrity

11. A client who has been taking antibiotics reports severe, watery diarrhea. About which test does the nurse teach the client? a. Colonoscopy b. Enzyme-linked immunosorbent assay (ELISA) toxin A+B c. Ova and parasites d. Stool culture

ANS: B Clients taking antibiotics are at risk for Clostridium difficile infection. The most common test for this disorder is a stool sample for ELISA toxin A+B. Colonoscopy, ova and parasites, and stool culture are not warranted at this time. DIF: Understanding/Comprehension REF: 1093 KEY: Gastrointestinal system| gastrointestinal assessment| diagnostic testing| patient education MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

1. After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk

ANS: B Clients with IBS are advised to eat a high-fiber diet (30 to 40 g/day), with 8 to 10 cups of liquid daily. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants. DIF: Applying/Application REF: 1145 KEY: Irritable bowel| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

9. A client had an upper gastrointestinal hemorrhage and now has a nasogastric (NG) tube. What comfort measure may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Lavaging the tube with ice water b. Performing frequent oral care c. Re-positioning the tube every 4 hours d. Taking and recording vital signs

ANS: B Clients with NG tubes need frequent oral care both for comfort and to prevent infection. Lavaging the tube is done by the nurse. Re-positioning the tube, if needed, is also done by the nurse. The UAP can take vital signs, but this is not a comfort measure. DIF: Applying/Application REF: 1136 KEY: Gastrointestinal disorders| nasogastric tubes| comfort measures| delegation| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

1. A client has irritable bowel syndrome. Which menu selections by this client indicate good understanding of dietary teaching? a. Tuna salad on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed green beans, glass of apple juice c. Grilled cheese sandwich, small ripe banana, cup of hot tea with lemon d. Grilled steak, green beans, dinner roll with butter, cup of coffee with cream

ANS: B Clients with irritable bowel syndrome are advised to eat a high-fiber diet (30 to 40 grams a day), with 8 to 10 cups of liquid daily. This selection has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation)

3. The nurse is caring for an older client with Salmonella food poisoning. Which is the priority action of the nurse? a. Monitor vital signs. b. Maintain IV fluids. c. Provide perineal care. d. Initiate Isolation Precautions.

ANS: B Dehydration can occur quickly in older clients with Salmonella food poisoning caused by diarrhea, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions, but are of lower priority than fluid replacement. Contact Isolation is not regularly instituted for Salmonella infection. Standard Precautions are usually sufficient. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)

2. A nurse cares for an older adult client who has Salmonella food poisoning. The client's vital signs are heart rate: 102 beats/min, blood pressure: 98/55 mm Hg, respiratory rate: 22 breaths/min, and oxygen saturation: 92%. Which action should the nurse complete first? a. Apply oxygen via nasal cannula. b. Administer intravenous fluids. c. Provide perineal care with a premedicated wipe. d. Teach proper food preparation to prevent contamination.

ANS: B Dehydration caused by diarrhea can occur quickly in older clients with Salmonella food poisoning, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions but are of lower priority than fluid replacement. The nurse should teach the client about proper hand hygiene to prevent the spread of infection, and preparation of food and beverages to prevent contamination. DIF: Applying/Application REF: 1173 KEY: Inflammatory bowel disorder| hydration MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

12. The nurse is caring for a client who had ileostomy surgery 10 days ago. The client verbalizes concerns that the effluent has not become formed and is still liquid green. Which is the nurse's best response? a. "I will call your health care provider right away because the stool should be semi-solid by now." b. "Your stools will firm up in a few weeks as your body gets used to the ileostomy." c. "You should eat a high-fiber diet to help make the stool bulkier and more solid." d. "You can add buttermilk or yogurt to your diet and avoid carbonated soft drinks."

ANS: B Effluent from an ileostomy will become less liquid (but not solid) over time as the body adapts to loss of the large bowel. This process takes time and the client should be reassured of this. Clients with a new ileostomy should avoid high-fiber diets for the first few weeks because blockage of the bowel may occur. Buttermilk, yogurt, and carbonated drinks will not affect this process. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1277 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Teaching/Learning

5. The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to what organ dysfunctions? (Select all that apply.) a. Alanine aminotransferase: biliary system b. Ammonia: liver c. Amylase: liver d. Lipase: pancreas e. Urine urobilinogen: stomach

ANS: B, D Alanine aminotransferase and ammonia are related to the liver. Amylase and lipase are related to the pancreas. Urobilinogen evaluates both hepatic and biliary function. DIF: Remembering/Knowledge REF: 1091 KEY: Gastrointestinal system| gastrointestinal assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5.A client with an esophageal tumor is having extreme difficulty swallowing. For what procedure does the nurse prepare this client? a. Enteral tube feeding b. Esophageal dilation c. Nissen fundoplication d. Photodynamic therapy

ANS: B Esophageal dilation can provide immediate relief of esophageal strictures that impair swallowing. Enteral tube feeding is a method of providing nutrition when dysphagia is severe, but esophageal dilation would be attempted before this measure is taken. Nissen fundoplication is performed for severe gastroesophageal reflux disease. Photodynamic therapy is performed for esophageal cancer. DIF:Understanding/ComprehensionREF:1120 KEY:Gastrointestinal disorders| patient education MSC:Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

16. Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the client's record because "I just have to know how much she weighs!" What action by the client's nurse is most appropriate? a. Make an anonymous report to the charge nurse. b. State "That is a violation of client confidentiality." c. Tell the nurse "Don't look; I'll tell you her weight." d. Walk away and ignore the other nurse's behavior.

ANS: B Ethical practice requires the nurse to speak up and tell the other nurse that he or she is violating client confidentiality rules. The other responses do not address this concern. DIF: Applying/Application REF: 1248 KEY: Ethics| confidentiality MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

4. A client is receiving bolus feedings through a Dobhoff tube. What action by the nurse is most important? a. Auscultate lung sounds after each feeding. b. Check tube placement before each feeding. c. Check tube placement every 8 hours. d. Weigh the client daily on the same scale.

ANS: B For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than every 8 hours during the day. Auscultating lung sounds is also important, but this will indicate a complication that has already occurred. Weighing the client is important to determine if nutritional goals are being met. DIF: Applying/Application REF: 1243 KEY: Nutritional disorders| tube feedings| equipment safety MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

1.A client has been taught about alginic acid and sodium bicarbonate (Gaviscon). What statement by the client indicates that teaching has been effective? a. "I can only take this medicine at night." b. "I should take this on a full stomach." c. "This drug decreases stomach acid." d. "This should be taken 1 hour before meals."

ANS: B Gaviscon should be taken with food in the stomach. It can be taken with meals at any time. Its mechanism of action is not to decrease stomach acid. DIF:Evaluating/SynthesisREF:1113 KEY:Gastrointestinal disorders| antacids| patient education MSC:Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

11. Which client is at highest risk for developing dehydration and hypernatremia as a result of enteral feedings? a. Client receiving an isotonic enteral feeding solution and an IV of D5W (dextrose 5% in water) at 83 mL/hr b. Client receiving a hypertonic enteral feeding solution and an IV of normal saline (0.9 NS) at 125 mL/hr c. Client who can drink liquids and is receiving a supplemental hypertonic enteral feeding solution d. Client receiving a hypertonic enteral feeding solution and an IV of 0.45% NS (0.45 NS) infusing at 125 mL/hr

ANS: B Hypertonic enteral tube feedings can easily lead to dehydration and hypernatremia if not balanced with hypotonic IV solution. D5W and 0.45 NS are hypotonic solutions. A client with hypertonic feedings who can drink liquids should have enough oral fluid intake to prevent dehydration and hypernatremia. The client receiving both a hypertonic enteral feeding and an isotonic IV solution would be at highest risk. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Parenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Assessment)

14. A client underwent the first stage of a restorative proctocolectomy with ileo-anal anastomosis (RPC-IPAA). What topic is a high priority for the nurse to teach? a. Perineal care b. Ostomy care c. Nutrition therapy d. Relaxation techniques

ANS: B In the first stage of the RPC-IPAA procedure, the temporary ileostomy is created. Because the effluent is caustic, severe skin irritation can occur. The client needs good instruction on ostomy care and comfort measures. Perineal care is not needed because stool drains through the ostomy. Nutrition therapy and relaxation techniques are not as high a priority as preventing skin damage. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Personal Hygiene) MSC: Integrated Process: Nursing Process (Planning)

17. A nurse cares for a middle-aged male client who has irritable bowel syndrome (IBS). The client states, "I have changed my diet and take bulk-forming laxatives, but my symptoms have not gotten better. I heard about a drug called Amitiza. Do you think it might help?" How should the nurse respond? a. "This drug is still in the research phase and is not available for public use yet." b. "Unfortunately, lubiprostone is approved only for use in women." c. "Lubiprostone works well. I will recommend this prescription to your provider." d. "This drug should not be used with bulk-forming laxatives."

ANS: B Lubiprostone (Amitiza) is a new drug for IBS with constipation that works by simulating receptors in the intestines to increase fluid and promote bowel transit time. Lubiprostone is currently approved only for use in women. Trials with increased numbers of male participants are needed prior to Food and Drug Administration approval for men. DIF: Applying/Application REF: 1146 KEY: Irritable bowel| medications MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

25. A middle-aged male client has irritable bowel syndrome that has not responded well to diet changes and bulk-forming laxatives. He asks the nurse about the new drug lubiprostone (Amitiza). What information does the nurse provide him? a. "This drug is investigational right now for irritable bowel syndrome." b. "Unfortunately, this drug is approved only for use in women." c. "Lubiprostone works well only in a small fraction of irritable bowel cases." d. "Let's talk to your health care provider about getting you a trial prescription."

ANS: B Lubiprostone (Amitiza) is approved only for use in women. The other statements are not accurate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Teaching/Learning

13. A morbidly obese client is admitted to a community hospital that does not typically care for bariatric-sized clients. What action by the nurse is most appropriate? a. Assess the client's readiness to make lifestyle changes. b. Ensure adequate staff when moving the client. c. Leave siderails down to prevent pressure ulcers. d. Reinforce the need to be sensitive to the client.

ANS: B Many hospitals that see bariatric-sized clients have appropriate equipment for this population. A hospital that does not typically see these clients is less likely to have appropriate equipment, putting staff and client safety at risk. The nurse ensures enough staffing is available to help with all aspects of mobility. It may or may not be appropriate to assess the client's willingness to make lifestyle changes. Leaving the siderails down may present a safety hazard. The staff should be sensitive to this client's situation, but safety takes priority. DIF: Applying/Application REF: 1250 KEY: Nutritional disorders| obesity| patient safety| staff safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

19. A client is awaiting bariatric surgery in the morning. What action by the nurse is most important? a. Answering questions the client has about surgery b. Beginning venous thromboembolism prophylaxis c. Informing the client that he or she will be out of bed tomorrow d. Teaching the client about needed dietary changes

ANS: B Morbidly obese clients are at high risk of venous thromboembolism and should be started on a regimen to prevent this from occurring as a priority. Answering questions about the surgery is done by the surgeon. Teaching is important, but safety comes first. DIF: Applying/Application REF: 1251 KEY: Nutritional disorders| obesity| venous thromboembolism MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

13. The nurse is caring for a client with colon cancer and a new colostomy. The client wishes to talk with someone who had a similar experience. Which is the nurse's best response? a. "Most people who have had a colostomy are reluctant to talk about it." b. "I will make a referral to the United Ostomy Associations of America." c. "You can get all the information you need from the enterostomal therapist." d. "I do not think that we have any other clients with colostomies on the unit right now."

ANS: B Nurses need to become familiar with community-based resources to assist clients better. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. Many people are willing to share their ostomy experience in the hope of helping others. The nurse should not brush aside the client's request by saying that no colostomy clients are present on the unit at the time. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1253 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Referrals) MSC: Integrated Process: Caring

10. An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first? a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Obtain the client's complete health history.

ANS: B On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present, because this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or obtaining a complete health history is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity. DIF: Applying/Application REF: 1162 KEY: Gastrointestinal trauma| hemorrhage MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

15. The nurse is caring for a client who is brought to the emergency department following a motor vehicle crash. The nurse notes that the client has ecchymotic areas across the lower abdomen. Which is the priority action of the nurse? a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Ask whether the client was riding in the front or back seat of the car.

ANS: B On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present; this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or asking about seating in the car is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Implementation)

15. The nurse is caring for an obese client who will be taking orlistat (Xenical) to help her lose weight. Which statement indicates that the client understands teaching about orlistat? a. "This medication will help speed up my metabolism." b. "I may have loose stools after meals if I eat too much fat." c. "This medication will suppress my appetite so I won't be hungry." d. "This medication will make me feel full after I eat small amounts."

ANS: B Orlistat (Xenical) inhibits lipase, leading to partial hydrolysis of triglycerides. Fats are only partially digested and absorbed and are excreted in the feces. The client may experience nausea, cramps, and loose stools when fats are increased in the diet. Orlistat does not increase metabolism, suppress appetite, or make the client feel full after small meals. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Evaluation)

19. A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this client's plan of care? a. Low-fiber diet b. Skin protection c. Antibiotic administration d. Intravenous glucocorticoids

ANS: B Protecting the client's skin is the priority action for a client who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohn's disease includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids. DIF: Applying/Application REF: 1181 KEY: Crohn's disease| bowel care MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. A client has a pyloric obstruction and reports sudden muscle weakness. What action by the nurse takes priority? a. Document the findings in the chart. b. Request an electrocardiogram (ECG). c. Facilitate a serum potassium test. d. Place the client on bedrest.

ANS: B Pyloric stenosis can lead to hypokalemia, which is manifested by muscle weakness. The nurse first obtains an ECG because potassium imbalances can lead to cardiac dysrhythmias. A potassium level is also warranted, as is placing the client on bedrest for safety. Documentation should be thorough, but none of these actions takes priority over the ECG. DIF: Analyzing/Analysis REF: 1132 KEY: Gastrointestinal disorders| electrolyte imbalances| cardiac system MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

12. The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ? a. Kidneys b. Liver c. Spleen d. Stomach

ANS: B Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting proteins. The other organs are not related to this issue. DIF: Remembering/Knowledge REF: 1091 KEY: Gastrointestinal system| laboratory values| pathophysiology MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A nurse has conducted a community screening event for oral cancer. What client is the highest priority for referral to a dentist? a. Client who has poor oral hygiene practices b. Client who smokes and drinks daily c. Client who tans for an upcoming vacation d. Client who occasionally uses illicit drugs

ANS: B Smoking and alcohol exposure create a high risk for this client. Poor oral hygiene is not related to the etiology of cancer but may cause a tumor to go unnoticed. Tanning is a risk factor, but short-term exposure does not have the same risk as daily exposure to tobacco and alcohol. Illicit drugs are not related to oral cancers. DIF: Understanding/Comprehension REF: 1103 KEY: Oral disorders| health screening| primary prevention| nursing assessment MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Health Promotion and Maintenance

21. A nurse cares for a client with a new ileostomy. The client states, "I don't think my friends will accept me with this ostomy." How should the nurse respond? a. "Your friends will be happy that you are alive." b. "Tell me more about your concerns." c. "A therapist can help you resolve your concerns." d. "With time you will accept your new body."

ANS: B Social anxiety and apprehension are common in clients with a new ileostomy. The nurse should encourage the client to discuss concerns. The nurse should not minimize the client's concerns or provide false reassurance. DIF: Applying/Application REF: 1180 KEY: Ostomy care| coping| support MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

19. A client has a small-bore nasoenteric feeding tube. The nurse assesses the following vital signs: temperature, 100.2° F (37.8° C); pulse, 112 beats/min; respiratory rate, 22 breaths/min; and blood pressure, 106/62 mm Hg. Which action by the nurse takes priority? a. Remove the tube immediately and notify the heath care provider. b. Auscultate lung sounds and obtain oxygen saturation. c. Add blue dye to the feeding tube formula. d. Auscultate bowel sounds and slow the feeding down.

ANS: B The client may have aspirated. The nurse should further assess the client's respiratory and oxygenation status. The client may have another reason for the abnormal vital signs, so the nurse should not pull out the tube before performing other assessments. Adding blue dye to the tube feeding formula is not recommended to check for aspiration. Slowing the feeding down will not be helpful. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Assessment)

28. The nurse has taught self-care measures to a client with an anal fissure. Which action by the client requires the nurse to do additional teaching? a. Taking warm sitz baths several times daily b. Administering daily enemas to prevent constipation c. Using bulk-producing agents to aid elimination d. Self-administering anti-inflammatory suppositories

ANS: B The client should not use enemas to promote elimination, but rather should rely on bulk-producing agents such as psyllium hydrophilic mucilloid (Metamucil). The other actions are appropriate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation)

7. A nurse is caring for four clients. After receiving the hand-off report, which client should the nurse see first? a. Client having a radial neck dissection tomorrow who is asking questions b. Client who had a tracheostomy 4 hours ago and needs frequent suctioning c. Client who is 1 day postoperative for an oral tumor resection who is reporting pain d. Client waiting for discharge instructions after a small tumor resection

ANS: B The client who needs frequent suctioning should be seen first to ensure that his or her airway is patent. The client waiting for pain medication should be seen next. The nurse may need to call the surgeon to see the client who is asking questions. The client waiting for discharge instructions can be seen last. DIF: Applying/Application REF: 1104 KEY: Oral disorders| airway| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

6. The nurse is providing preoperative teaching for a client who will undergo herniorrhaphy surgery. Which instruction does the nurse give to the client? a. "Eat a low-residue diet for the first week after surgery." b. "Change the dressing every day until the staples are removed." c. "Take acetaminophen (Tylenol) 1000 mg every 4 hours for pain." d. "Cough and deep breathe every 2 hours for the first week after surgery."

ANS: B The dressing should be changed every day until the staples are removed, so the client can check the incision for signs of infection. Constipation is common following hernia surgery, so clients should include adequate amounts of fiber in the diet. The maximum daily dosage of Tylenol is 4000 mg. Taking 1000 mg of Tylenol every 4 hours means that intake is 6000 mg/day, which could cause toxicity and liver damage. The client should change positions and take deep breaths to facilitate lung expansion but should avoid coughing, which can place stress on the incision line. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Teaching/Learning

19. A client post-hemorrhoidectomy feels the need to have a bowel movement. Which action by the nurse is best? a. Have the client use the bedside commode. b. Stay with the client, providing privacy. c. Make sure toilet paper and the call light are in reach. d. Plan to send a stool sample to the laboratory.

ANS: B The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure needed items are within reach is an important nursing action too, but it does not take priority over client safety. The other two actions are not needed in this situation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Implementation)

12. A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, "I need to have a bowel movement." Which action should the nurse take? a. Obtain a bedside commode for the client to use. b. Stay with the client while providing privacy. c. Make sure the call light is in reach to signal completion. d. Gather supplies to collect a stool sample for the laboratory.

ANS: B The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure the call light is within reach is an important nursing action too, but it does not take priority over client safety. Obtaining a bedside commode and taking a stool sample are not needed in this situation. DIF: Applying/Application REF: 1165 KEY: Postoperative care| syncope MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

13. A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best? a. Allow the client cool liquids only. b. Assess the client's gag reflex. c. Remind the client to remain NPO. d. Tell the client to wait 4 hours.

ANS: B The local anesthetic used during this procedure will depress the client's gag reflex. After the procedure, the nurse should ensure that the gag reflex is intact before offering food or fluids. The client does not need to be restricted to cool beverages only and is not required to wait 4 hours before oral intake is allowed. Telling the client to remain NPO does not inform the client of when he or she can have fluids, nor does it reflect the client's readiness for them. DIF: Understanding/Comprehension REF: 1094 KEY: Gastrointestinal assessment| diagnostic testing| patient safety MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE

11. A client has a recurrence of gastric cancer and is in the gastrointestinal clinic crying. What response by the nurse is most appropriate? a. "Do you have family or friends for support?" b. "I'd like to know what you are feeling now." c. "Well, we knew this would probably happen." d. "Would you like me to refer you to hospice?"

ANS: B The nurse assesses the client's emotional state with open-ended questions and statements and shows a willingness to listen to the client's concerns. Asking about support people is very limited in nature, and "yes-or-no" questions are not therapeutic. Stating that this was expected dismisses the client's concerns. The client may or may not be ready to hear about hospice, and this is another limited, yes-or-no question. DIF: Applying/Application REF: 1139 KEY: Gastrointestinal disorders| cancer| therapeutic communication| psychosocial response MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

8. A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family members. Which action should the nurse take? a. Contact the provider and recommend a psychiatric consult for the client. b. Encourage the client to verbalize feelings about the diagnosis. c. Provide education about new treatment options with successful outcomes. d. Ask family and friends to visit the client and provide emotional support.

ANS: B The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the client's feelings with discussions related to cancer prognosis and treatment. The nurse should not assume that the client desires family or friends to visit or provide emotional support. DIF: Applying/Application REF: 1155 KEY: Colorectal cancer| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

14. After teaching a client who has a new colostomy, the nurse provides feedback based on the client's ability to complete self-care activities. Which statement should the nurse include in this feedback? a. "I realize that you had a tough time today, but it will get easier with practice." b. "You cleaned the stoma well. Now you need to practice putting on the appliance." c. "You seem to understand what I taught you today. What else can I help you with?" d. "You seem uncomfortable. Do you want your daughter to care for your ostomy?"

ANS: B The nurse should provide both approval and room for improvement in feedback after a teaching session. Feedback should be objective and constructive, and not evaluative. Reassuring the client that things will improve does not offer anything concrete for the client to work on, nor does it let him or her know what was done well. The nurse should not make the client convey learning needs because the client may not know what else he or she needs to understand. The client needs to become the expert in self-management of the ostomy, and the nurse should not offer to teach the daughter instead of the client. DIF: Applying/Application REF: 1179 KEY: Ostomy care| psychosocial response| coping MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

23. The nurse has completed the teaching session for a client with a new colostomy. Which feedback statement by the nurse is the most appropriate? a. "I realize that you had a tough time today, but it will get easier with practice." b. "You cleaned the stoma well. Now you need to practice putting on the appliance." c. "You seem to understand what I taught you today. What else can I help you with?" d. "You seem uncomfortable. Do you want your daughter to care for your ostomy?"

ANS: B The nurse should provide both approval and room for improvement in feedback after a teaching session. Feedback should be objective and constructive, and not evaluative. Reassuring the client that things will improve does not offer anything concrete for the client to work on, nor does it let him or her know what was done well. The nurse should not make the client convey learning needs because the client may not know what else he or she needs to understand. The client needs to become the expert in self-management of the ostomy, and the nurse should not offer to teach the daughter instead of the client. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning

16. An older client has gastric cancer and is scheduled to have a partial gastrectomy. The family does not want the client told about her diagnosis. What action by the nurse is best? a. Ask the family why they feel this way. b. Assess family concerns and fears. c. Refuse to go along with the family's wishes. d. Tell the family that such secrets cannot be kept.

ANS: B The nurse should use open-ended questions and statements to fully assess the family's concerns and fears. Asking "why" questions often puts people on the defensive and is considered a barrier to therapeutic communication. Refusing to follow the family's wishes or keep their confidence will not help move this family from their position and will set up an adversarial relationship. DIF: Applying/Application REF: 1142 KEY: Gastrointestinal disorders| ethics| communication MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE

12. A client with peptic ulcer disease asks the nurse about taking slippery elm supplements. What response by the nurse is best? a. "Slippery elm has no benefit for this problem." b. "Slippery elm is often used for this disorder." c. "There is no evidence that this will work." d. "You should not take any herbal remedies."

ANS: B There are several complementary and alternative medicine regimens that are used for gastritis and peptic ulcer disease. Most have been tested on animals but not humans. Slippery elm is a common supplement used for this disorder. DIF: Understanding/Comprehension REF: 1131 KEY: Gastrointestinal disorders| complementary therapy| patient education MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Health Promotion and Maintenance

1. The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the client's abdomen is tense and rigid. What action takes priority? a. Administer the prescribed pain medication. b. Notify the health care provider immediately. c. Percuss all four abdominal quadrants. d. Take and document a set of vital signs.

ANS: B This client has manifestations of a perforated ulcer, which is an emergency. The priority is to get the client medical attention. The nurse can take a set of vital signs while someone else calls the provider. The nurse should not percuss the abdomen or give pain medication since the client may need to sign consent for surgery. DIF: Applying/Application REF: 1132 KEY: Gastrointestinal disorders| nursing assessment| communication MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

10. A nurse assesses a client's oral cavity and observes the condition depicted in the photo below: What action by the nurse is best? a. Ask about the client's human immunodeficiency virus (HIV) status. b. Assess the client for dysphagia. c. Listen to the client's lung sounds. d. Refer the client to an oncologist.

ANS: B This client has oral candidiasis. If the infection extends down the pharynx, the client could have difficulty swallowing. Therefore, the nurse should assess the client for dysphagia. HIV status may or may not be related but is not the priority. Listening to the lungs is unrelated. Since oral candidiasis is an infectious condition, referral to an oncologist is not needed. DIF: Applying/Application REF: 1100 KEY: Oral disorders| nursing assessment| dysphagia MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. The nurse conducts a physical assessment for a client with severe right lower quadrant (RLQ) abdominal pain. The nurse notes that the abdomen is rigid and the client's temperature is 101.1° F (38.4° C). Which laboratory value does the nurse bring to the attention of the health care provider as a priority? a. A "left shift" in the white blood cell count b. White blood cell count, 22,000/mm3 c. Serum sodium, 149 mEq/L d. Serum creatinine, 0.7 mg/dL

ANS: B This client may have appendicitis based on RLQ pain. A white blood cell count of 22,000/mm3 is severely elevated and could indicate a perforated appendix, as could the fever. The nurse should bring these findings to the provider's attention as soon as possible. A left shift would be expected in uncomplicated appendicitis. The sodium reading is only slightly high; this could be due to hemoconcentration from vomiting or from decreased intake. The creatinine level is normal. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Analysis)

9. A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority? a. Auscultate for bowel sounds. b. Notify the provider immediately. c. Order an abdominal flat-plate x-ray. d. Palpate the mass and measure its size.

ANS: B This observation could indicate an abdominal aortic aneurysm, which could be life threatening and should never be palpated. The nurse notifies the provider at once. An x-ray may be indicated. Auscultation is part of assessment, but the nurse's priority action is to notify the provider. DIF: Remembering/Knowledge REF: 1090 KEY: Gastrointestinal system| gastrointestinal assessment| nursing assessment| communication MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

10.A client has a nasogastric (NG) tube after a Nissen fundoplication. The nurse answers the call light and finds the client vomiting bright red blood with the NG tube lying on the floor. What action should the nurse take first? a. Notify the surgeon. b. Put on a pair of gloves. c. Reinsert the NG tube. d. Take a set of vital signs.

ANS: B To avoid exposure to blood and body fluids, the nurse first puts on a pair of gloves. Taking vital signs and notifying the surgeon are also appropriate, but the nurse must protect himself or herself first. The surgeon will reinsert the NG tube either at the bedside or in surgery if the client needs to go back to the operating room. DIF:Applying/ApplicationREF:1114 KEY:Gastrointestinal disorders| Standard Precautions MSC:Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

8. After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I'll rinse my rectal area with warm water after each stool and apply zinc oxide ointment." b. "I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel." c. "I must take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry." d. "I shall clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment."

ANS: B Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not an effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry. DIF: Applying/Application REF: 1179 KEY: Bowel care| inflammatory bowel disorder MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

13. The nurse is caring for a client with perineal excoriation caused by diarrhea from acute gastroenteritis. Which client statement indicates that additional teaching about perineal care is needed? a. "I will rinse my rectal area with warm water after each stool and then apply zinc oxide ointment." b. "I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel." c. "I will take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry." d. "I will clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment."

ANS: B Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not an effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation)

1. A student nurse is providing care to an older client with stomatitis and dysphagia. What action by the student nurse requires the registered nurse to intervene? a. Assisting the client to perform oral care every 2 hours b. Preparing to administer a viscous lidocaine gargle c. Reminding the client not to swallow nystatin (Mycostatin) d. Teaching the client to use a soft-bristled toothbrush

ANS: B Viscous lidocaine gargles or mouthwashes are sometimes prescribed for clients with stomatitis and pain. However, the numbing effect can lead to choking or mouth burns from hot food. This client already has difficulty swallowing, so this medication is not appropriate. Therefore, the nurse should intervene when the student prepares to administer this preparation. The other options are correct actions. DIF: Applying/Application REF: 1102 KEY: Oral disorders| topical anesthetics| fungal infections MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

1. After teaching a client with a parasitic gastrointestinal infection, a nurse assesses the client's understanding. Which statements made by the client indicate that the client correctly understands the teaching? (Select all that apply.) a. "I'll have my housekeeper keep my toilet clean." b. "I must take a shower or bathe every day." c. "I should have my well water tested." d. "I will ask my sexual partner to have a stool test." e. "I must only eat raw vegetables from my own garden."

ANS: B, C, D Parasitic infections can be transmitted to other people. The client himself or herself should keep the toilet area clean instead of possibly exposing another person to the disease. Parasites are transmitted via unclean water sources and sexual practices with rectal contact. The client should test his or her well water and ask sexual partners to have their stool examined for parasites. Raw vegetables are not associated with parasitic gastrointestinal infections. The client can eat vegetables from the store or a home garden as long as the water source is clean. DIF: Applying/Application REF: 1190 KEY: Parasitic infection| infection control MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

2. After teaching a client who is recovering from a colon resection, the nurse assesses the client's understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. "I must change the ostomy appliance daily and as needed." b. "I will use warm water and a soft washcloth to clean around the stoma." c. "I might start bicycling and swimming again once my incision has healed." d. "Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown." e. "I will check the stoma regularly to make sure that it stays a deep red color." f. "I must avoid dairy products to reduce gas and odor in the pouch."

ANS: B, C, D The ostomy appliance should be changed as needed when the adhesive begins to decrease, placing the appliance at risk of leaking. Changing the appliance daily can cause skin breakdown as the adhesive will still be secured to the client's skin. The client should avoid using soap to clean around the stoma because it might prevent effective adhesion of the ostomy appliance. The client should use warm water and a soft washcloth instead. The tissue of the stoma is very fragile, and scant bleeding may occur when the stoma is cleaned. The flange should be cut to fit snugly around the stoma to reduce contact between excretions and the client's skin. Exercise (other than some contact sports) is important for clients with an ostomy. The stoma should remain a soft pink color. A deep red or purple hue indicates ischemia and should be reported to the surgeon right away. Yogurt and buttermilk can help reduce gas in the pouch, so the client need not avoid dairy products. DIF: Applying/Application REF: 1154 KEY: Colorectal cancer| postoperative care MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Health Promotion and Maintenance

2. The nurse is teaching a health promotion class about weight loss and asks students to list health risks that can occur as a result of obesity. Which student responses indicate that additional teaching is required? (Select all that apply.) a. Sleep apnea b. Infertility c. Rheumatoid arthritis d. Cervical cancer e. Cholecystitis f. Hypothyroidism

ANS: B, C, D, F Sleep apnea and cholecystitis are potential health risks that can occur as a result of obesity. The other conditions are not caused by obesity. DIF: Cognitive Level: Knowledge/Remembering REF: p. 1350 TOP: Client Needs Category: Health Promotion and Maintenance (Disease Prevention) MSC: Integrated Process: Teaching/Learning

4. A client's small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are best? (Select all that apply.) a. Attempt to dissolve the clog by instilling a cola product. b. Determine if any of the medications come in liquid form. c. Flush the tube before and after administering medications. d. Mix all medications in the formula and use a feeding pump. e. Try to flush the tube with 30 mL of water and gentle pressure.

ANS: B, C, E If the tube is obstructed, use a 50-mL syringe and gentle pressure to attempt to open the tube. Cola products should not be used unless water is not effective. To prevent future problems, determine if any of the medications can be dispensed in liquid form and flush the tube with water before and after medication administration. Do not mix medications with the formula. DIF: Remembering/Knowledge REF: 1243 KEY: Nutritional disorders| tube feedings| medication administration MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

2. The nurse is providing discharge teaching for a client who has undergone colon resection surgery with a colostomy. Which statements by the client indicate that the instruction was understood? (Select all that apply.) a. "I will change the ostomy appliance daily and as needed." b. "I will use warm water and a soft washcloth to clean around the stoma." c. "I will start bicycling and swimming again once my incision has healed." d. "I will notify the doctor right away if any bleeding from the stoma occurs." e. "I will check the stoma regularly to make sure that it stays a deep red color." f. "I will avoid dairy products to reduce gas and odor in the pouch." g. "I will cut the flange so it fits snugly around the stoma to avoid skin breakdown."

ANS: B, C, G The client should avoid using soap to clean around the stoma because it might prevent effective adhesive of the ostomy appliance. The client should use warm water and a soft washcloth instead. The stoma should remain a soft pink color. A deep red or purple hue indicates ischemia and should be reported to the surgeon right away. The tissue of the stoma is very fragile, and scant bleeding may occur when the stoma is cleaned. Yogurt and buttermilk can help reduce gas in the pouch, so the client need not avoid dairy products. Exercise (other than some contact sports) is important for clients with an ostomy. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation) COMPLETION

3. A nurse is designing a community education program to meet the Healthy People 2020 objectives for nutrition and weight status. What information about these goals does the nurse use to plan this event? (Select all that apply.) a. Decrease the amount of fruit to 1.1 cups/1000 calories. b. Increase the amount of vegetables to 1.1 cups/1000 calories. c. Increase the number of adults at a healthy weight by 25%. d. Reduce the number of adults who are obese by 10%. e. Reduce the consumption of saturated fat by nearly 10%.

ANS: B, D, E Some of the goals in this initiative include increasing fruit consumption to 0.9 cups/1000 calories, increasing vegetable intake to 1.1 cups/1000 calories, increasing the number of people at a healthy weight by 10%, decreasing the number of adults who are obese by 10%, and reducing the consumption of saturated fats by 9.5%. DIF: Remembering/Knowledge REF: 1243 KEY: Nutritional disorders| obesity| health promotion MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Health Promotion and Maintenance

2. The nurse is caring for a client with a nasogastric (NG) tube after an episode of GI bleeding. Which interventions are included in the nursing care plan? (Select all that apply.) a. Monitor and record intake and output every 8 hours. b. Monitor hemoglobin and hematocrit laboratory values. c. Ensure that suction is set on high continuous for Levin tubes. d. Measure the client's girth and/or assess for distention daily. e. Pin the tube to the client's gown, so it cannot be dislodged. f. Check vital signs and orthostatic blood pressure every 4 hours and PRN.

ANS: B, E, F The client with an NG tube post-GI bleeding should have his or her hemoglobin and hematocrit monitored and the tube pinned to the client's gown so it cannot be dislodged; also, vital signs should be checked every 4 hours. Intake and output should be assessed and recorded every 4 hours or more often as needed. Suction should be set on low intermittent suction for Levin tubes. The client should be observed for distention when the nurse makes other assessments. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment)

11. A client who has had fecal occult blood testing tells the nurse that the test was negative for colon cancer and wishes to cancel a colonoscopy scheduled for the next day. Which is the nurse's best response? a. "I will call and cancel the test for tomorrow." b. "You need two negative fecal occult blood tests." c. "This does not rule out the possibility of colon cancer." d. "You should wait at least a week to have the colonoscopy."

ANS: C A negative result does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed, so the entire colon can be visualized and a tissue sample taken for biopsy. The client need not wait a week before the colonoscopy. Two negative fecal occult blood tests do not rule out the presence of colorectal cancer (CRC). DIF: Cognitive Level: Comprehension/Understanding REF: p. 1247 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Teaching/Learning

7. A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, "My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it." How should the nurse respond? a. "Your doctor should not have given you that information prior to the colonoscopy." b. "The colonoscopy is required due to the high percentage of false negatives with the blood test." c. "A negative fecal occult blood test does not rule out the possibility of colon cancer." d. "I will contact your doctor so that you can discuss your concerns about the procedure."

ANS: C A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the client's concerns prior to contacting the provider. DIF: Understanding/Comprehension REF: 1151 KEY: Colorectal cancer| assessment/diagnostic examination MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

21. A nurse is weighing and measuring a client with severe kyphosis. What is the best method to obtain this client's height? a. Add the trunk and leg measurements. b. Ask the client how tall he or she is. c. Estimate by measuring clothing. d. Use knee-height calipers.

ANS: D A sliding blade knee-height caliper is used to obtain the height of a client who cannot stand upright, such as those with kyphosis or lower extremity contractures. The other methods will not yield accurate data. DIF: Remembering/Knowledge REF: 1236 KEY: Nutritional assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE

4. A client with a bleeding gastric ulcer is having a nuclear medicine scan. What action by the nurse is most appropriate? a. Assess the client for iodine or shellfish allergies. b. Educate the client on the side effects of sedation. c. Inform the client a second scan may be needed. d. Teach the client about bowel preparation for the scan.

ANS: C A second scan may be performed in 1 to 2 days to see if interventions have worked. The nuclear medicine scan does not use iodine-containing contrast dye or sedation. There is no required bowel preparation. DIF: Understanding/Comprehension REF: 1134 KEY: Gastrointestinal disorders| patient education| nuclear medicine MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best? a. Ask the client to call back if this happens again today. b. Instruct the client to go to the emergency department. c. Remind the client that a small amount of bleeding is possible. d. Tell the client to come in to the clinic this afternoon.

ANS: C After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse should remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness. DIF: Understanding/Comprehension REF: 1096 KEY: Gastrointestinal system| gastrointestinal assessment| patient education MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

12. A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority? a. Assess the client's pain. b. Check the surgical incision. c. Ensure an adequate airway. d. Program the morphine pump.

ANS: C All actions are appropriate care measures for this client; however, airway is always the priority. Bariatric clients tend to have short, thick necks that complicate airway management. DIF: Applying/Application REF: 1251 KEY: Nutritional disorders| obesity| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

17. The new nursing supervisor at a long-term care facility is concerned about the number of residents who appear malnourished. Which action by the nurse is best? a. Institute daily weighing for at-risk or underweight residents. b. Provide a supply of easy to access high-calorie snacks. c. Ask dining room personnel about residents coughing at meals. d. Assess the residents' opinions on the quality of food served.

ANS: C All actions would be helpful. However, because unrecognized dysphagia is common among older clients, the nurse should first assess for this. Weighing residents, providing snacks, and assessing their opinions on the quality of food will not be helpful if at-risk residents cannot swallow. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration) MSC: Integrated Process: Nursing Process (Assessment)

8. A nurse answers a client's call light and finds the client in the bathroom, vomiting large amounts of bright red blood. Which action should the nurse take first? a. Assist the client back to bed. b. Notify the provider immediately. c. Put on a pair of gloves. d. Take a set of vital signs.

ANS: C All of the actions are appropriate; however, the nurse should put on a pair of gloves first to avoid contamination with blood or body fluids. DIF: Applying/Application REF: 1128 KEY: Gastrointestinal disorders| Standard Precautions| infection control MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

18. The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the highest priority? a. Skin integrity b. Blood pressure c. Heart rate and rhythm d. Abdominal percussion

ANS: C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Abdominal percussion is an important part of physical assessment but has lower priority for this client than heart rate and rhythm. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

11. A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first? a. Inspection of oral mucosa b. Recent dietary intake c. Heart rate and rhythm d. Percussion of abdomen

ANS: C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this client than heart rate and rhythm. DIF: Applying/Application REF: 1172 KEY: Ulcerative colitis| hydration MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

10. A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, "I am having trouble swallowing this pill." Which action should the nurse take? a. Contact the clinical pharmacist and request the medication in suspension form. b. Empty the contents of the capsule into applesauce or pudding for administration. c. Ask the health care provider to prescribe the medication as an enema instead. d. Crush the pill carefully and administer it in applesauce or pudding.

ANS: C Asacol is the oral formula for mesalamine and is produced as an enteric-coated pill that should not be crushed, chewed, or broken. Asacol is not available as a suspension or elixir. If the client is unable to swallow the Asacol pill, a mesalamine enema (Rowasa) may be administered instead, with a provider's order. DIF: Applying/Application REF: 1176 KEY: Ulcerative colitis| medication safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

17. The nurse is caring for a client who just had colon resection surgery with a new colostomy. Which teaching objective does the nurse include in the client's plan of care? a. Understanding colostomy care and lifestyle implications b. Learning how to change the appliance independently c. Demonstrating the correct way to change the appliance by discharge d. Not being afraid to handle the ostomy appliance tomorrow

ANS: C Client learning goals must be measurable and objective with a time frame, so the nurse can determine whether they have been met. When the goal is to have the client demonstrate a particular skill, the nurse can easily determine whether the goal was met. The specific time frame of "by discharge" is easily measurable also. The other goals are all subjective and cannot be measured objectively. The first two options do not have time frames. "Tomorrow" is a vague time frame. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Teaching/Learning

18. A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this client's plan of care? a. "You may experience nausea and vomiting for the first few weeks." b. "Carbonated beverages can help decrease acid reflux from anastomosis sites." c. "Take a stool softener to promote softer stools for ease of defecation." d. "You may return to your normal workout schedule, including weight lifting."

ANS: C Clients recovering from a colon resection should take a stool softener as prescribed to keep stools a soft consistency for ease of passage. Nausea and vomiting are symptoms of intestinal obstruction and perforation and should be reported to the provider immediately. The client should be advised to avoid gas-producing foods and carbonated beverages, and avoid lifting heavy objects or straining on defecation. DIF: Applying/Application REF: 1155 KEY: Colorectal cancer| postoperative nursing| bowel care MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The client's respiratory rate is 8 breaths/min. What action by the nurse is best? a. Administer naloxone (Narcan). b. Call the Rapid Response Team. c. Provide physical stimulation. d. Ventilate with a bag-valve-mask.

ANS: C For an EGD, clients are given mild sedation but should still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurse's first action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for Versed. The Rapid Response Team is not needed at this point. The client does not need manual ventilation. DIF: Applying/Application REF: 1094 KEY: Gastrointestinal system| medication side effects| nursing implementation MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

4. The nurse is caring for a client who has a new small-bore nasoduodenal tube for feedings. Which intervention most effectively prevents clogging of the tube? a. Administering medications that have been thoroughly crushed and dissolved in cold water b. Flushing the feeding tube with 60 mL of cranberry juice or carbonated beverage four times daily c. Irrigating the tube with water before and after administration of medications using 20 to 30 mL d. Diluting the tube feeding to half-strength with cold water before infusion into the feeding tube

ANS: C Irrigating the feeding tube with 20 to 30 mL of warm water before and after medication administration will help maintain patency of the tube. Irrigation with cranberry juice or carbonated beverages is not recommended. Administration of only liquid medications (not crushed and dissolved in liquid) through the tube will help prevent clogging. Dilution of tube feeding should not be done without an order from the provider. DIF: Cognitive Level: Comprehension/Understanding REF: Chart 63-5, p. 1346 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Therapeutic Procedures) MSC: Integrated Process: Nursing Process (Implementation)

6. The nurse is caring for a client on a limited income who has been diagnosed with kwashiorkor. Which foods does the nurse suggest to improve the client's nutritional status with minimal increase in food costs? a. Oatmeal and bananas b. Tomato soup with oyster crackers c. Omelet made with cheddar cheese d. Whole wheat pasta with tomato sauce

ANS: C Kwashiorkor develops as a result of lack of protein intake despite adequate calories. The client needs to increase protein-containing foods. Eggs and cheese are high-protein foods that are less expensive than meats. Pasta, vegetables, fruit, and oatmeal have less protein than eggs and cheese. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration) MSC: Integrated Process: Teaching/Learning

2. A nursing student is studying nutritional problems and learns that kwashiorkor is distinguished from marasmus with which finding? a. Deficit of calories b. Lack of all nutrients c. Specific lack of protein d. Unknown cause of malnutrition

ANS: C Kwashiorkor is a lack of protein when total calories are adequate. Marasmus is a caloric malnutrition. DIF: Remembering/Knowledge REF: 1236 KEY: Nutritional disorders| nutritional assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

7.A client is 1 day postoperative after having Zenker's diverticula removed. The client has a nasogastric (NG) tube to suction, and for the last 4 hours there has been no drainage. There are no specific care orders for the NG tube in place. What action by the nurse is most appropriate? a. Document the findings as normal. b. Irrigate the NG tube with sterile saline. c. Notify the surgeon about this finding. d. Remove and reinsert the NG tube.

ANS: C NG tubes placed during surgery should not be irrigated or moved unless prescribed by the surgeon. The nurse should notify the surgeon about this finding. Documentation is important, but this finding is not normal. DIF:Applying/ApplicationREF:1123 KEY: Gastrointestinal disorders| postoperative nursing| nasogastric tubes| communication MSC:Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

16. After teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I'll ride my bike or take a long walk at least three times a week." b. "I must try to include at least 25 grams of fiber in my diet every day." c. "I will take a laxative nightly at bedtime to avoid becoming constipated." d. "I should use my legs rather than my back muscles when I lift heavy objects."

ANS: C Laxatives are not recommended for clients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining. DIF: Applying/Application REF: 1187 KEY: Diverticulitis| medication MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Health Promotion and Maintenance

27. The nurse is preparing a client with diverticulitis for discharge from the hospital. Which statement by the client indicates that additional teaching is needed? a. "I will ride my bike or take a long walk at least three times a week." b. "I will try to include at least 25 g of fiber in my diet every day." c. "I will take a senna laxative at bedtime to avoid becoming constipated." d. "I will use my legs rather than my back muscles when I lift heavy objects."

ANS: C Laxatives are not recommended for clients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation)

16. The nurse is caring for an older client with gastroenteritis. Which order does the nurse consult with the health care provider about? a. IV 0.45% NS at 50 mL/hr b. Clear liquids as tolerated c. Diphenoxylate hydrochloride/atropine sulfate (Lomotil) orally, after each loose stool d. Acetaminophen (Tylenol), 325-650 mg orally every 4 hr PRN pain

ANS: C Lomotil can cause drowsiness and can increase the older client's risk for falls. The nurse should consult with the provider to see if this medication is really necessary and, if an antidiarrheal medication is warranted, what other options might be available. The other orders are appropriate, although the nurse would have to monitor the client's total 24-hour Tylenol dosage to ensure that the client did not receive more than 4000 mg/24 hr. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Analysis)

13. A nurse is teaching a client about magnesium hydroxide with aluminum hydroxide (Maalox). What instruction is most appropriate? a. "Aspirin must be avoided." b. "Do not worry about black stools." c. "Report diarrhea to your provider." d. "Take 1 hour before meals."

ANS: C Maalox can cause hypermagnesemia, which causes diarrhea, so the client should be taught to report this to the provider. Aspirin is avoided with bismuth sulfate (Pepto-Bismol). Black stools can be caused by Pepto-Bismol. Maalox should be taken after meals. DIF: Understanding/Comprehension REF: 1129 KEY: Gastrointestinal disorders| antacids| patient education MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

9. A nurse cares for a client with colon cancer who has a new colostomy. The client states, "I think it would be helpful to talk with someone who has had a similar experience." How should the nurse respond? a. "I have a good friend with a colostomy who would be willing to talk with you." b. "The enterostomal therapist will be able to answer all of your questions." c. "I will make a referral to the United Ostomy Associations of America." d. "You'll find that most people with colostomies don't want to talk about them."

ANS: C Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). The nurse should not suggest that the client speak with a personal contact of the nurse. Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse should not brush aside the client's request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others. DIF: Applying/Application REF: 1157 KEY: Colorectal cancer| ostomy care| coping| support MSC: Integrated Process: Caring NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

16. Which dietary adjustments does the nurse recommend to an older adult client asking what changes she should institute to prevent or manage constipation? a. "Increase your calcium intake." b. "Limit your fluid intake." c. "Include plenty of fiber." d. "Take a laxative with every meal."

ANS: C Older adults are prone to constipation. To manage or prevent constipation, teach the older client to drink eight glasses of water daily and to take in plenty of fiber. These guidelines are good for other clients as well. The other suggestions will not prevent or help manage constipation. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1336 TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

11.A client has gastroesophageal reflux disease (GERD). The provider prescribes a proton pump inhibitor. About what medication should the nurse anticipate teaching the client? a. Famotidine (Pepcid) b. Magnesium hydroxide (Maalox) c. Omeprazole (Prilosec) d. Ranitidine (Zantac)

ANS: C Omeprazole is a proton pump inhibitor used in the treatment of GERD. Famotidine and ranitidine are histamine blockers. Maalox is an antacid. DIF:Remembering/KnowledgeREF:1113 KEY: Gastrointestinal disorders| proton pump inhibitors| patient education MSC:Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

29. A client is brought to the emergency department with an abrupt onset of vomiting, abdominal cramping, and diarrhea 2 hours after eating food at a picnic. Which infectious microorganism does the nurse suspect as the probable cause? a. Salmonella b. Giardia lamblia c. Staphylococcus aureus d. Clostridium botulinum

ANS: C Staphylococcus can be found in meat and dairy products and can be transmitted to people. Food poisoning occurs, especially if foods are left unrefrigerated over a period of time. Symptoms of Staphylococcus food poisoning include sudden onset of vomiting, abdominal cramping, and diarrhea within 2 to 4 hours. The client's symptoms are not consistent with infection by the other microorganisms. DIF: Cognitive Level: Knowledge/Remembering REF: p. 1290 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis)

7. The nurse caring for clients with gastrointestinal disorders should understand that which category best describes the mechanism of action of sucralfate (Carafate)? a. Gastric acid inhibitor b. Histamine receptor blocker c. Mucosal barrier fortifier d. Proton pump inhibitor

ANS: C Sucralfate is a mucosal barrier fortifier (protector). It is not a gastric acid inhibitor, a histamine receptor blocker, or a proton pump inhibitor. DIF: Remembering/Knowledge REF: 1135 KEY: Gastrointestinal disorders| mucosal barrier fortifier MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

10. The nurse is caring for a client who is scheduled to have fecal occult blood testing. Which instructions does the nurse give to the client? a. "You must fast for 12 hours before the test." b. "You will be given a cleansing enema the morning of the test." c. "You must avoid eating meat for 48 hours before the test." d. "You will be sedated and will require someone to accompany you home."

ANS: C The client is instructed to avoid meat, aspirin, vitamin C, and anti-inflammatory drugs for 48 hours before the test. The other directions are not accurate for this test. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1247 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Teaching/Learning

9.A client has a nasogastric (NG) tube. What action by the nursing student requires the registered nurse to intervene? a. Checking tube placement every 4 to 8 hours b. Monitoring and documenting drainage from the NG tube c. Pinning the tube to the gown so the client cannot turn the head d. Providing oral care every 4 to 8 hours

ANS: C The client should be able to turn his or her head to prevent pulling the tube out with movement. The other actions are appropriate. DIF:Applying/ApplicationREF:1123 KEY:Gastrointestinal disorders| nasogastric tube| supervision MSC:Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

19. A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client? a. "Eat low-fiber and low-residual foods." b. "White rice and bread are easier to digest." c. "Add vegetables such as broccoli and cauliflower to your new diet." d. "Foods high in animal fat help to protect the intestinal mucosa."

ANS: C The client should be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer. DIF: Applying/Application REF: 1149 KEY: Colorectal cancer| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

13.A nurse works on the surgical unit. After receiving the hand-off report, which client should the nurse see first? a. Client who underwent diverticula removal with a pulse of 106/min b. Client who had esophageal dilation and is attempting first postprocedure oral intake c. Client who had an esophagectomy with a respiratory rate of 32/min d. Client who underwent hernia repair, reporting incisional pain of 7/10

ANS: C The client who had an esophagectomy has a respiratory rate of 32/min, which is an early sign of sepsis; this client needs to be assessed first. The client who underwent diverticula removal has a pulse that is out of the normal range (106/min), but not terribly so. The client reporting pain needs pain medication, but the client with the elevated respiratory rate needs investigation first. The nurse should see the client who had esophageal dilation prior to and during the first attempt at oral feedings, but this can wait until the other clients are cared for. DIF:Analyzing/AnalysisREF:1121 KEY:Gastrointestinal disorders| sepsis| nursing assessment MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

2. The nurse is caring for a male client who is 6 feet, 1 inch tall and weighs 215 pounds. The client asks the nurse if his weight is appropriate for his height. Which is the nurse's best response? a. "Your weight is just about right for someone your height." b. "Your weight is a few pounds under the ideal for your height." c. "Your weight is a few pounds over the ideal for your height." d. "Your weight is quite a few pounds over the ideal for your height."

ANS: C The client's BMI is 28.4, indicating that the client is overweight. However, he is not obese. The nurse should not state that the client's weight is just about right, a few pounds under, or quite a bit over the ideal weight for his height. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Therapeutic Communications) MSC: Integrated Process: Nursing Process (Assessment)

5. A nurse assesses a client who is hospitalized with an exacerbation of Crohn's disease. Which clinical manifestation should the nurse expect to find? a. Positive Murphy's sign with rebound tenderness to palpitation b. Dull, hypoactive bowel sounds in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Reports of abdominal cramping that is worse at night

ANS: C The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn's disease. A positive Murphy's sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohn's disease. Nightly worsening of abdominal cramping is not consistent with Crohn's disease. DIF: Applying/Application REF: 1182 KEY: Crohn's disease| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

7. The nurse is caring for a client who is hospitalized with exacerbation of Crohn's disease. What does the nurse expect to find during the physical assessment? a. Positive Murphy's sign with rebound tenderness b. Dullness in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Abdominal cramping that the client says is worse at night

ANS: C The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn's disease. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohn's disease. Nightly worsening of abdominal cramping is not consistent with Crohn's disease. A positive Murphy's sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis)

12. The nurse is caring for a client who has been newly diagnosed with colon cancer. The client has become withdrawn from family members. Which strategy does the nurse use to assist the client at this time? a. Ask the health care provider for a psychiatric consult for the client. b. Explain the improved prognosis for colon cancer with new treatment. c. Encourage the client to verbalize feelings about the diagnosis. d. Allow the client to remain withdrawn as long as he or she wishes.

ANS: C The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the client's feelings with a generalization about cancer prognosis and treatment. The nurse should not ignore the client's withdrawal behavior. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication) MSC: Integrated Process: Caring

17. A nurse attempted to assist a morbidly obese client back to bed and had immediate pain in the lower back. What action by the nurse is most appropriate? a. Ask another nurse to help next time. b. Demand better equipment to use. c. Fill out and file a variance report. d. Refuse to assist the client again.

ANS: C The nurse should complete a variance report per agency policy. Asking another nurse to help and requesting better equipment are both good ideas, but the nurse may have an injury that needs care. It would be unethical to refuse to care for this client again. DIF: Applying/Application REF: 1246 KEY: Nutritional disorders| obesity| variance report MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

5. A client having a tube feeding begins vomiting. What action by the nurse is most appropriate? a. Administer an antiemetic. b. Check the client's gastric residual. c. Hold the feeding until the nausea subsides. d. Reduce the rate of the tube feeding by half.

ANS: C The nurse should hold the feeding until the nausea and vomiting have subsided and consult with the provider on the rate at which to restart the feeding. Giving an antiemetic is not appropriate. After vomiting, a gastric residual will not be accurate. The nurse should not continue to feed the client while he or she is vomiting. DIF: Applying/Application REF: 1244 KEY: Nutritional disorders| tube feedings MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

19. The nurse is preparing to begin teaching the client about how to care for a new ileostomy. Which consideration is the highest priority for the nurse when planning teaching for this client? a. Informing the client about what to expect with basic ostomy care b. Starting the teaching after the client has received pain medication c. Starting the teaching when the client is ready to look at the stoma d. Making sure that all needed supplies are ready at the client's bedside

ANS: C The nurse should wait until the client is ready to look at the ostomy and stoma before initiating teaching about ostomy care. The nurse should monitor clues from the client and encourage him or her to start taking an active role in management. Effective learning will occur only when the learner is ready. The other considerations are of lower priority for the client and nurse. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning

7. A nurse cares for a teenage girl with a new ileostomy. The client states, "I cannot go to prom with an ostomy." How should the nurse respond? a. "Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance." b. "The pouch won't be as noticeable if you avoid broccoli and carbonated drinks prior to the prom." c. "Let's talk to the enterostomal therapist about options for ostomy supplies and dress styles." d. "You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable."

ANS: C The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible. DIF: Applying/Application REF: 1180 KEY: Ostomy care| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

11. The nurse is caring for a teenage girl with a new ileostomy. She tells the nurse tearfully that she cannot go to the prom with an ostomy. Which is the nurse's best response? a. "You should get your prom dress one size larger to hide the ostomy appliance." b. "You should avoid broccoli and carbonated drinks so that the pouch won't fill with air under your dress." c. "Let's talk to the enterostomal therapist (ET) about options for ostomy supplies and dress styles so that you can look beautiful for the prom." d. "You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable."

ANS: C The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Referrals) MSC: Integrated Process: Caring

7. A nurse is caring for four clients receiving enteral tube feedings. Which client should the nurse see first? a. Client with a blood glucose level of 138 mg/dL b. Client with foul-smelling diarrhea c. Client with a potassium level of 2.6 mEq/L d. Client with a sodium level of 138 mEq/L

ANS: C The potassium is critically low, perhaps due to hyperglycemia-induced hyperosmolarity. The nurse should see this client first. The blood glucose reading is high, but not extreme. The sodium is normal. The client with the diarrhea should be seen last to avoid cross-contamination. DIF: Applying/Application REF: 1244 KEY: Nutritional disorders| tube feedings| electrolyte imbalances MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

9. The nurse is caring for an anorexic client who is severely malnourished. A nasogastric feeding tube is inserted, and tube feedings are started. Which laboratory finding is the best indication that the client's nutritional status is improving? a. Sodium has risen from 130 to 144 mg/dL. b. Creatinine has dropped from 1.9 to 0.5 mg/dL. c. Prealbumin level has risen from 9 to 13 mg/dL. d. Blood urea nitrogen (BUN) level has dropped from 15 to 11 mg/dL.

ANS: C The prealbumin level is a good measure of nutritional status because its half-life is only 2 days, so it reflects current nutritional status. The client's prealbumin level is rising and almost normal, indicating that the client's nutritional status is improving. The other laboratory values are more reflective of fluid balance and kidney function. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Assessment)

9. The nurse is performing a physical assessment of a client with a new diagnosis of colorectal cancer. The nurse notes the presence of visible peristaltic waves and, on auscultation, hears high-pitched bowel sounds. Which conclusion does the nurse draw from these findings? a. The tumor has metastasized to the liver and biliary tract. b. The tumor has caused an intussusception of the intestine. c. The growing tumor has caused a partial bowel obstruction. d. The client has developed toxic megacolon from the growing tumor.

ANS: C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. Assessment findings do not indicate metastasis to the liver, intussusception of the intestine, or toxic megacolon. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Analysis)

6. A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action should the nurse take? a. Ask if the client is experiencing pain in the right shoulder. b. Perform a rectal examination and assess for polyps. c. Contact the provider and recommend computed tomography. d. Administer a laxative to increase bowel movement activity.

ANS: C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. The nurse should contact the provider with these results and recommend a computed tomography scan for further diagnostic testing. This assessment finding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The registered nurse is not qualified to complete a rectal examination for polyps, and laxatives would not help this client. DIF: Applying/Application REF: 1151 KEY: Colorectal cancer| intestinal obstruction MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The client's blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate? a. Administer ibuprofen (Motrin). b. Call the Rapid Response Team. c. Start a large-bore IV with normal saline. d. Tell the client to remain lying down.

ANS: C This client has orthostatic changes to the blood pressure, indicating fluid volume loss. The nurse should start a large-bore IV with isotonic solution. Ibuprofen will exacerbate the ulcer. The Rapid Response Team is not needed at this point. The client should be put on safety precautions, which includes staying in bed, but this is not the priority. DIF: Applying/Application REF: 1136 KEY: Gastrointestinal disorders| fluid imbalances| nursing assessment MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

14.The following data relate to an older client who is 2 hours postoperative after an esophagogastrostomy: Physical Assessment Vital Signs Physician Orders Skin dry Urine output 20 mL/hr NG tube patent with 100 mL brown drainage/hr Restless Pulse: 128 beats/min Blood pressure: 88/50 mm Hg Respiratory rate: 20 on ventilator Cardiac output: 2.1 L/min Oxygen saturation: 99% Normal saline at 75 mL/hr Morphine sulfate 2 mg IV push every 1 hr PRN pain Intake and output every hour Vital signs every hour Vancomycin (Vancocin) 1 g IV every 8 hr What action by the nurse is best? a. Administer the prescribed pain medication. b. Consult the surgeon about a different antibiotic. c. Consult the surgeon about increased IV fluids. d. Have respiratory therapy reduce the respiratory rate.

ANS: C This client's vital signs, cardiac output, dry skin, and urine output indicate hypovolemia or possible hypotension resulting from pressure placed on the posterior heart during surgery. The client needs more fluids, so the nurse should consult with the surgeon about increasing the fluid intake. The client may be restless as a result of the hypotension and may not need pain medication at this time. There is no reason to request a different antibiotic. The respiratory rate does not need to be adjusted. DIF:Analyzing/AnalysisREF:1121 KEY: Gastrointestinal disorders| fluid and electrolyte imbalances| communication MSC:Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE

26. The nurse is to insert a nasogastric (NG) tube for a client with upper GI bleeding. Which instruction does the nurse give to the client before starting the procedure? a. "You may take some sips of water when I begin to insert the tube into your nose." b. "Please hold your breath when I insert the tube through your nose." c. "Tilt your head down to your chest when the tube gets to the back of your throat." d. "The distance from the end of your nose to your navel tells me which size tube to use."

ANS: C Tilting the head down toward the chest after the NG tube has reached the back of the throat will facilitate intubation of the esophagus rather than the trachea. The client should be encouraged to mouth-breathe and swallow during the procedure. The tube should be measured from the nose to the earlobe to the xiphoid process. Sips of water should be encouraged once the tube is at the back of the throat, not at the beginning of the procedure. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Teaching/Learning MULTIPLE RESPONSE

9. A client had an oral tumor removed this morning and now has a tracheostomy. What action by the nurse is the priority? a. Delegate oral care every 4 hours. b. Monitor and record the client's intake. c. Place the client in a high-Fowler's position. d. Remove the inner cannula for cleaning.

ANS: C To promote airway clearance, this client should be placed in a semi- or high-Fowler's position. Oral care can be delegated, but that is not the priority. Intake and output should also be recorded but again is not the priority. The inner cannula may or may not need to be cleaned, and the tracheostomy may or may not have a disposable cannula. DIF: Applying/Application REF: 1104 KEY: Oral disorders| airway MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

10. A client tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, for what additional data should the nurse assess as the priority? a. Economic ability to join a gym b. Food allergies and intolerances c. Psychosocial influences on weight d. Reasons for wanting to lose weight

ANS: C While all topics might be important to assess, people who lose and gain weight in cycles often are depressed or have poor self-esteem, which has a negative effect on weight-loss efforts. The nurse assesses the client's psychosocial status as the priority. DIF: Applying/Application REF: 1247 KEY: Nutritional disorders| psychosocial response| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Psychosocial Integrity

5. A nurse working with a client who has possible gastritis assesses the client's gastrointestinal system. Which findings indicate a chronic condition as opposed to acute gastritis? (Select all that apply.) a. Anorexia b. Dyspepsia c. Intolerance of fatty foods d. Pernicious anemia e. Nausea and vomiting

ANS: C, D Intolerance of fatty or spicy foods and pernicious anemia are signs of chronic gastritis. Anorexia and nausea/vomiting can be seen in both conditions. Dyspepsia is seen in acute gastritis. DIF: Remembering/Knowledge REF: 1128 KEY: Gastrointestinal disorders| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A nurse assesses a male client with an abdominal hernia. Which abdominal hernias are correctly paired with their physiologic processes? (Select all that apply.) a. Indirect inguinal hernia - An enlarged plug of fat eventually pulls the peritoneum and often the bladder into a sac b. Femoral hernia - A peritoneum sac pushes downward and may descend into the scrotum c. Direct inguinal hernia - A peritoneum sac passes through a weak point in the abdominal wall d. Ventral hernia - Results from inadequate healing of an incision e. Incarcerated hernia - Contents of the hernia sac cannot be reduced back into the abdominal cavity

ANS: C, D, E A direct inguinal hernia occurs when a peritoneum sac passes through a weak point in the abdominal wall. A ventral hernia results from inadequate healing of an incision. An incarcerated hernia cannot be reduced or placed back into the abdominal cavity. An indirect inguinal hernia is a sac formed from the peritoneum that contains a portion of the intestine and pushes downward at an angle into the inguinal canal. An indirect inguinal hernia often descends into the scrotum. A femoral hernia protrudes through the femoral ring and, as the clot enlarges, pulls the peritoneum and often the urinary bladder into the sac. DIF: Applying/Application REF: 1146 KEY: Herniation MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A nurse has delegated feeding a client to an unlicensed assistive personnel (UAP). What actions does the nurse include in the directions to the UAP? (Select all that apply.) a. Allow 30 minutes for eating so food doesn't get spoiled. b. Assess the client's mouth while providing premeal oral care. c. Ensure warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed.

ANS: C, D, E The UAP should make sure food items remain at the appropriate temperatures for maximum palatability. Removing items such as bedpans, urinals, or soiled linens helps make the atmosphere more conducive to eating. The UAP should sit, not stand, next to the client to promote a relaxing experience. The client, especially older clients who tend to eat more slowly, should not be rushed. Assessment is done by the nurse. DIF: Understanding/Comprehension REF: 1240 KEY: Nutritional disorders| nutrition| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

1. The nurse is caring for a client who has recently undergone a partial gastrectomy. The client asks the nurse which foods would be best for him to have for breakfast. Which menu items does the nurse recommend for the client?(Select all that apply.) a. Blueberry pancakes with maple syrup b. A half-grapefruit with a blueberry muffin c. Plain bagel with margarine or butter d. Raisin bran with milk and artificial sweetener e. Scrambled eggs with cheese and a slice of bacon f. One half cup of cottage cheese with canned pears

ANS: C, E, F Clients who have undergone gastrectomy surgery are at risk for dumping syndrome after meals. To help avoid dumping syndrome, clients should avoid concentrated sweets and fluids at mealtimes. Clients should choose foods that are relatively high in protein and fat, with relatively low carbohydrate content. Good choices are the bagel with butter or margarine, the scrambled egg breakfast, and the cottage cheese with unsweetened canned fruit. The pancakes and syrup are too sweet and have too many carbohydrates. The muffin is high in refined carbohydrates, and fresh fruit should be eaten with caution. Raisin bran is too high in fiber, and beverages (milk) should be taken between meals. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Teaching/Learning

21. A client with a mechanical bowel obstruction reports that abdominal pain, which was previously intermittent and colicky, is now more constant. Which is the priority action of the nurse? a. Measure the abdominal girth. b. Place the client in a knee-chest position. c. Medicate the client with an opioid analgesic. d. Assess for bowel sounds and rebound tenderness.

ANS: D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse need not measure abdominal girth. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse should not medicate the client until the physician has been notified of the change in his or her condition. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment)

14. A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? a. Administer intravenous opioid medications. b. Position the client with knees to chest. c. Insert a nasogastric tube for decompression. d. Assess the client's bowel sounds.

ANS: D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse should not medicate the client until the provider has been notified of the change in his or her condition. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse need not insert a nasogastric tube for decompression. DIF: Applying/Application REF: 1157 KEY: Intestinal obstruction| pain management MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

10. The nurse is teaching a client how to care for a new ileostomy. Which client statement indicates that additional teaching is needed? a. "I will consult the pharmacist before filling any new prescriptions." b. "I will empty the ostomy pouch when it is half-filled with stool or gas." c. "I will wash my hands with antibacterial soap before and after ostomy care." d. "I will call my health care provider if I have not had ostomy drainage for 3 hours."

ANS: D A client with an ileostomy should call the provider if no drainage has come from the ostomy in 6 to 12 hours. The other statements indicate good understanding of self-management. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation)

12.After hiatal hernia repair surgery, a client is on IV pantoprazole (Protonix). The client asks the nurse why this medication is given since there is no history of ulcers. What response by the nurse is best? a. "Bacteria can often cause ulcers." b. "This operation often causes ulcers." c. "The medication keeps your blood pH low." d. "It prevents stress-related ulcers."

ANS: D After surgery, anti-ulcer medications such as pantoprazole are often given to prevent stress-related ulcers. The other responses are incorrect. DIF:Understanding/ComprehensionREF:1113 KEY: Gastrointestinal disorders| proton pump inhibitors| patient education MSC:Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

13. An emergency room nurse cares for a client who has been shot in the abdomen and is hemorrhaging heavily. Which action should the nurse take first? a. Send a blood sample for a type and crossmatch. b. Insert a large intravenous line for fluid resuscitation. c. Obtain the heart rate and blood pressure. d. Assess and maintain a patent airway.

ANS: D All of the options are important nursing actions in the care of a trauma client. However, airway always comes first. The client must have a patent airway, or other interventions will not be helpful. DIF: Applying/Application REF: 1162 KEY: GI trauma| emergency nursing MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

20. A client is brought to the emergency department after being shot in the abdomen and is hemorrhaging heavily. Which action by the nurse is the priority? a. Draw blood for type and crossmatch. b. Start two large IVs for fluid resuscitation. c. Obtain vital signs and assess skin perfusion. d. Assess and maintain a patent airway.

ANS: D All options are important nursing actions in the care of a trauma client. However, airway always comes first. The client must have a patent airway, or other interventions will not be helpful. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Implementation)

10. A client is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result should the nurse report to the surgeon immediately? a. Albumin: 2.1 g/dL b. Hematocrit: 28% c. Hemoglobin: 8.1 mg/dL d. International normalized ratio (INR): 4.2

ANS: D An INR as high as 4.2 poses a serious risk of bleeding during the operation and should be reported. The albumin is low and is an expected finding. The hematocrit and hemoglobin are also low, but this is expected in gastric cancer. DIF: Applying/Application REF: 1140 KEY: Gastrointestinal disorders| cancer| laboratory values| communication MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

17. The nurse is caring for a client who is taking mesalamine (5-aminosalicylic acid) (Asacol, Rowasa) for ulcerative colitis. The client has trouble swallowing the pill. Which action by the nurse is most appropriate? a. Crush the pill carefully and administer it to the client in applesauce or pudding. b. Empty the contents of the capsule into applesauce or pudding for administration. c. Contact the client's health care provider to request an order for Asacol suspension. d. Contact the client's health care provider to request an order for Rowasa enemas instead.

ANS: D Asacol is enteric coated and should not be crushed, chewed, or broken. If the client is unable to swallow the Asacol pill, Rowasa enemas may be administered instead, with a provider's order. Asacol is not available as a suspension or elixir. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Nursing Process (Implementation)

20. A client is receiving total parenteral nutrition (TPN). What action by the nurse is most important? a. Assessing blood glucose as directed b. Changing the IV dressing each day c. Checking the TPN with another nurse d. Performing appropriate hand hygiene

ANS: D Clients on TPN are at high risk for infection. The nurse performs appropriate hand hygiene as a priority intervention. Checking blood glucose is also an important measure, but preventing infection takes priority. The IV dressing is changed every 48 to 72 hours. TPN does not need to be double-checked with another nurse. DIF: Applying/Application REF: 1245 KEY: Nutritional disorders| parenteral nutrition| infection control MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

6. After teaching a client with diverticular disease, a nurse assesses the client's understanding. Which menu selection made by the client indicates the client correctly understood the teaching? a. Roasted chicken with rice pilaf and a cup of coffee with cream b. Spaghetti with meat sauce, a fresh fruit cup, and hot tea c. Garden salad with a cup of bean soup and a glass of low-fat milk d. Baked fish with steamed carrots and a glass of apple juice

ANS: D Clients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup of bean soup) should be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet. DIF: Applying/Application REF: 1187 KEY: Diverticular disease| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

3. A female client hospitalized for an unrelated problem has a large pearly-white lesion on her lip, to which she continues to apply lipstick that she will not remove for inspection. The client refuses to discuss the lesion with the nurse or health care provider. What action by the nurse is best? a. Ask the client why her appearance is so important. b. Ignore the lesion since the client will not discuss it. c. Inform the client that early-stage cancer is curable. d. Work with the client to establish a trusting relationship.

ANS: D Clients with oral cancers often have body image difficulties due to the location of the tumor or the results of surgical treatment. This client appears to be using denial to cope with this problem. The nurse should work to establish a helping-trusting relationship in hopes that the client will be amenable to future discussions about the lesion. Asking "why" questions often puts people on the defensive and should be avoided. Ignoring the lesion is not being an advocate for the client. Education is important, but right now the client is in denial, so this information will not seem relevant to her. DIF: Applying/Application REF: 1103 KEY: Oral disorders| psychosocial response| coping| communication MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

5. A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer? a. A 37-year-old who drinks eight cups of coffee daily b. A 44-year-old with irritable bowel syndrome (IBS) c. A 60-year-old lawyer who works 65 hours per week d. A 72-year-old who eats fast food frequently

ANS: D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer. DIF: Applying/Application REF: 1149 KEY: Colorectal cancer| health screening MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

8. The nurse is screening clients at a community health fair. Which client is at highest risk for development of colorectal cancer? a. Young adult who drinks eight cups of coffee every day b. Middle-aged client with a history of irritable bowel syndrome c. Older client with a BMI of 19.2 who works 65 hours per week d. Older client who travels extensively and eats fast food frequently

ANS: D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Irritable bowel syndrome, a heavy workload, and coffee intake do not increase the risk for colon cancer. A BMI of 19.2 is within normal limits. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1246 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

8. The nurse is caring for a client who was started on total parenteral nutrition (TPN) 2 days previously. The client reports blurred vision, dry mouth, and frequent urination. Which is the nurse's priority action? a. Weigh the client. b. Assess the client's vital signs. c. Slow down the TPN infusion. d. Assess the client's blood sugar.

ANS: D Dry mouth, frequent urination, and blurred vision all are symptoms of hyperglycemia, a potential complication of TPN infusion. The nurse should assess the client's blood sugar level. Weighing the client and checking vital signs will not help with assessment of hyperglycemia. The nurse should obtain an order from the provider to slow the TPN solution. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Total Parenteral Nutrition) MSC: Integrated Process: Nursing Process (Implementation)

8. A nurse is examining a client reporting right upper quadrant (RUQ) abdominal pain. What technique should the nurse use to assess this client's abdomen? a. Auscultate after palpating. b. Avoid any palpation. c. Palpate the RUQ first. d. Palpate the RUQ last.

ANS: D If pain is present in a certain area of the abdomen, that area should be palpated last to keep the client from tensing up, which could possibly affect the rest of the examination. Auscultation of the abdomen occurs prior to palpation. DIF: Remembering/Knowledge REF: 1089 KEY: Gastrointestinal system| gastrointestinal assessment| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. The health care provider is prescribing medication to treat a client's severe gastroesophageal reflux disease (GERD). Which medication does the nurse anticipate teaching the client about? a. Magnesium hydroxide (Gaviscon) b. Ranitidine (Zantac) c. Nizatidine (Axid) d. Omeprazole (Prilosec)

ANS: D Proton pump inhibitors such as omeprazole are the main treatment for more severe cases of GERD. Gaviscon, Axid, and Zantac can be used to treat less severe cases. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Planning)

18. A nurse cares for a client who has food poisoning resulting from a Clostridium botulinum infection. Which assessment should the nurse complete first? a. Heart rate and rhythm b. Bowel sounds c. Urinary output d. Respiratory rate

ANS: D Severe infection with C. botulinum can lead to respiratory failure, so assessments of oxygen saturation and respiratory rate are of high priority for clients with suspected C. botulinum infection. The other assessments may be completed after the respiratory system has been assessed. DIF: Applying/Application REF: 1191 KEY: Hydration| inflammatory bowel disorder MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

31. The nurse is caring for a client who has food poisoning that may be the result of Clostridium botulinum infection. Which is the priority nursing assessment for this client? a. Heart rate and rhythm b. Bowel sounds and heart tones c. Fluid balance and urine output d. Oxygen saturation and respiratory rate

ANS: D Severe infection with Clostridium botulinum can lead to respiratory failure, so assessments of oxygen saturation and respiratory rate are of high priority for clients with suspected Clostridium botulinum infection. The other assessments may be completed after the respiratory system has been assessed. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Assessment)

22. The nurse is teaching self-care measures for a client who has hemorrhoids. Which nursing intervention does the nurse include in the plan of care for the client? a. Instruct the client to use dibucaine (Nupercainal) ointment whenever needed. b. Teach the client to choose low-fiber foods to make bowels move more easily. c. Tell the client to take his or her time on the toilet when needing to defecate. d. Encourage the client to dab with moist wipes instead of wiping with toilet paper.

ANS: D The client should be instructed to use wet wipes and dab the anal area after defecating to avoid further irritation. Dibucaine can be used only for short periods of time because long-term use can mask worsening symptoms. Clients with hemorrhoids require high-fiber foods. The client should not be encouraged to strain at stool or to spend long periods of time on the toilet, because this increases pressure in the rectal area, which can make hemorrhoids worse. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Teaching/Learning

24. A client has returned to the nursing unit after esophagogastroduodenoscopy (EGD). Which action by the nurse takes priority? a. Keep the client on strict bedrest for 8 hours. b. Delegate taking vital signs to the nursing assistant. c. Increase the IV rate to flush the kidneys. d. Assess the client's gag reflex.

ANS: D The client will receive moderate sedation and a numbing agent during the procedure. The client may temporarily lose his or her gag reflex; this should be checked before the client is permitted to eat anything by mouth. The client does not require strict bedrest for 8 hours or increased fluid to flush the kidneys. The nurse can delegate the taking of vital signs to unlicensed assistive personnel (UAP) such as the nursing assistant, but this is not the priority. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Assessment)

21. The nurse is caring for a client with Crohn's disease who has developed a fistula. Which nursing intervention is the highest priority? a. Monitor the client's hematocrit and hemoglobin. b. Position the client to allow gravity drainage of the fistula. c. Check and record blood glucose levels every 6 hours. d. Encourage the client to consume a diet high in protein and calories.

ANS: D The client with Crohn's disease is already at risk for malabsorption and malnutrition. Malnutrition impairs healing of the fistula and immune responses. Therefore, maintaining adequate nutrition is a priority for this client. The client will require 3000 calories per day to promote healing of the fistula. Monitoring the client's blood sugar and hemoglobin levels is important, but less so than encouraging nutritional intake. The client need not be positioned to facilitate gravity drainage of the fistula, because fistulas often are found in the abdominal cavity. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)

1. The nurse is caring for a female client who is 5 feet, 7 inches tall and weighs 115 pounds. The client asks the nurse if she needs to lose weight. Which response by the nurse is best? a. "Yes. Your body mass index suggests you are slightly overweight." b. "Maybe. Let's look at your risks for cardiovascular disease." c. "Your weight is just fine. Don't worry about it." d. "No. In fact, your body mass index suggests that you are already underweight."

ANS: D The client's body mass index (BMI) is 18.0, so she is already underweight. It is inaccurate to tell the client she is overweight, and it is unnecessary to consider her weight in light of any cardiovascular risk factors. The nurse should not reassure the client that her weight is just fine because she is underweight. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication) MSC: Integrated Process: Nursing Process (Assessment)

2.A client has returned to the nursing unit after an open Nissen fundoplication. The client has an indwelling urinary catheter, a nasogastric (NG) tube to low continuous suction, and two IVs. The nurse notes bright red blood in the NG tube. What action should the nurse take first? a. Document the findings in the chart. b. Notify the surgeon immediately. c. Reassess the drainage in 1 hour. d. Take a full set of vital signs.

ANS: D The drainage in the NG tube should initially be brown with old blood. The presence of bright red blood indicates bleeding. The nurse should take a set of vital signs to assess for shock and then notify the surgeon. Documentation should occur but is not the first thing the nurse should do. The nurse should not wait an additional hour to reassess. DIF:Applying/ApplicationREF:1116 KEY: Gastrointestinal disorders| postoperative nursing| nursing assessment MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

8. A female client is admitted with an exacerbation of ulcerative colitis. Which laboratory value does the nurse correlate with this condition? a. Potassium, 5.5 mEq/L b. Hemoglobin, 14.2 g/dL c. Sodium, 144 mEq/L d. Erythrocyte sedimentation rate (ESR), 55 mm/hr

ANS: D The erythrocyte sedimentation rate (ESR) is an indicator of inflammation, which is elevated during an exacerbation of ulcerative colitis. The normal range for the ESR is 0 to 33 mm/hr. Diarrhea caused by ulcerative colitis will result in loss of potassium and hypokalemia with levels lower than 3.5 mEq/L. Bloody diarrhea will lead to anemia, with hemoglobin levels lower than 12 g/dL in females. The sodium level is normal. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Assessment)

14. The nurse is caring for a client who has suffered abdominal trauma in a motor vehicle crash. Which laboratory finding indicates that the client's liver was injured? a. Serum lipase, 49 U/L b. Serum amylase, 68 IU/L c. Serum creatinine, 0.8 mg/dL d. Serum transaminase, 129 IU/L

ANS: D The level of serum transaminase, a liver enzyme, is elevated with liver trauma. The other laboratory values are within normal limits and are not specific for the liver. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Analysis)

7. The nurse is preparing to administer tube feedings through a client's new Salem sump nasogastric tube. The nurse is unable to withdraw any fluid from the tube before starting the feeding. Which is the priority action of the nurse? a. Start the tube feeding as ordered and check the residual in 30 minutes. b. Inject air into the nasogastric tube while auscultating the client's epigastric area. c. Lower the head of the client's bed and attempt to aspirate fluid again. d. Obtain orders for a chest x-ray to confirm placement before starting the feeding.

ANS: D The nurse must verify tube placement before beginning any tube feeding or administering any medications through a tube. The most accurate way to determine placement is via chest x-ray. The nurse could cause the client to aspirate if she or he started the feeding then checked later for placement. Insufflation does not provide accurate results and should not be used to verify tube placement. The nurse must keep the client's head elevated at least 30 degrees. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Implementation)

21. A nurse cares for a client who has a family history of colon cancer. The client states, "My father and my brother had colon cancer. What is the chance that I will get cancer?" How should the nurse respond? a. "If you eat a low-fat and low-fiber diet, your chances decrease significantly." b. "You are safe. This is an autosomal dominant disorder that skips generations." c. "Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer." d. "You should have a colonoscopy more frequently to identify abnormal polyps early."

ANS: D The nurse should encourage the client to have frequent colonoscopies to identify abnormal polyps and cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer. Changing the client's diet, preemptive chemotherapy, and removal of polyps will decrease the client's risk but will not prevent cancer. However, a client at risk for colon cancer should eat a low-fat and high-fiber diet. DIF: Applying/Application REF: 1155 KEY: Colorectal cancer| genetics MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE

1. What is the pH range of the distal esophagus? a. 1.5 to 2.0 b. 3.0 to 4.5 c. 4.5 to 6.0 d. 6.0 to 7.0

ANS: D The pH of the lower esophagus is neutral (normal). DIF: Cognitive Level: Knowledge/Remembering REF: p. 1204 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

11. A client asks the nurse about drugs for weight loss. What response by the nurse is best? a. "All weight-loss drugs can cause suicidal ideation." b. "No drugs are currently available for weight loss." c. "Only over-the-counter medications are available." d. "There are three drugs currently approved for this."

ANS: D There are three drugs available by prescription for weight loss, including orlistat (Xenical), lorcaserin (Belviq), and phentermine-topiramate (Qsymia). Suicidal thoughts are possible with lorcaserin and phentermine-topiramate. Orlistat is also available in a reduced-dose over-the-counter formulation. DIF: Understanding/Comprehension REF: 1249 KEY: Nutritional disorders| obesity| anorectic drugs MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

10. A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important? a. Ask the client about recent exposure to illness. b. Assess the client's stool for obvious food particles. c. Include the date and time on the specimen container. d. Put on gloves prior to collecting the sample.

ANS: D To avoid possible exposure to infectious agents, the nurse dons gloves prior to handling any bodily secretions. Recent exposure to illness is not related to collecting a stool sample. The nurse can visually inspect the stool for food particles, but it still needs analysis in the laboratory. The container should be dated and timed, but safety for the staff and other clients comes first. DIF: Applying/Application REF: 1091 KEY: Gastrointestinal system| Standard Precautions| infection control MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

5. A client is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is most important? a. Alcohol intake of 1 to 2 drinks per week b. Family history of H. pylori infection c. Former smoker still using nicotine patches d. Willingness to adhere to drug therapy

ANS: D Treatment for this infection involves either triple or quadruple drug therapy, which may make it difficult for clients to remain adherent. The nurse should assess the client's willingness and ability to follow the regimen. The other assessment findings are not as critical. DIF: Applying/Application REF: 1127 KEY: Gastrointestinal disorders| nursing assessment| anti-ulcer therapy MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance

9. The nurse helps a client with diverticular disease choose appropriate dinner options. Which menu selections are most appropriate? a. Roasted chicken, rice pilaf, cup of coffee with cream b. Spaghetti with meat sauce, fresh fruit cup, hot tea with lemon c. Chicken Caesar salad, cup of bean soup, glass of low-fat milk d. Baked fish with steamed asparagus, dinner roll with butter, glass of apple juice

ANS: D Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup of bean soup) should be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning