ATI GI System Practice Questions

A nurse is developing a plan of care for a client who has gastroesophageal reflux disease (GERD). The nurse should plan to monitor the client for which of the following complications? A. Aspiration B. Infection C. Anemia D. Weight loss

Correct Answer: A. Aspiration Aspiration is a common complication of GERD, which results when the esophageal sphincter malfunctions and allows gastric acid and undigested food to back up into the esophagus. This places the client at risk of aspiration. GERD causes effortless, uncontrolled regurgitation whether the client is in an upright position or reclining. The most common results of regurgitation are heartburn and indigestion; however, aspiration is also possible. Therefore, the nurse should monitor the client for crackles in the lung fields, which are an indication of aspiration. Incorrect Answers: B. Infection is not a common complication of GERD. Although the client can develop esophageal tissue damage, a client whose immune system is healthy does not have an increased risk of infection. C. Anemia is not a complication of GERD. Although the client can develop esophageal tissue damage, hemorrhage is rare. In addition, GERD does not affect a client's ability to digest food; therefore, it does not cause malnutrition or vitamin deficiency, which can result in anemia. D. Nausea, vomiting, and resulting weight loss are rare in clients who have GERD.

A nurse is assessing a client who has cholecystitis. Which of the following findings should the nurse expect? A. Blumberg's sign B. Ascites C. Gastrointestinal bleeding D. Kehr's sign

Correct Answer: A. Blumberg's sign The nurse should expect to find rebound tenderness (Blumberg's sign) in a client who has cholecystitis. This response can be an indication of peritoneal inflammation. Incorrect Answers:B. The nurse should expect to find ascites in a client who has chronic pancreatitis or pancreatic cancer. C. The nurse should expect to find gastrointestinal bleeding in a client who has pancreatic cancer. D. The nurse should expect to find a positive Kehr's sign in a client who has liver trauma.

A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? A. Children B. Older adults C. Women who are pregnant D. Middle-aged men

Correct Answer: A. Children The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The hepatitis A virus can be contracted from the feces, bile, and blood of infected clients. The usual mode of transmission is the fecal-oral route. Children and young adults are most often affected by the hepatitis A virus. Typically, a child or young adult acquires the infection at school, through poor hygiene, through hand-to-mouth contact, or via another form of close contact. Incorrect Answers:B. Older adults are not often affected by or at risk for developing hepatitis A. C. Women who are pregnant are not often affected by or at risk for developing hepatitis A. D. Middle-aged men are not often affected by or at risk for developing hepatitis A.

A nurse is caring for a client who is 3 days postoperative following abdominal surgery. The client states, "Something just popped when I coughed." Which of the following actions should the nurse take first? A. Cover the client's wound with a sterile, moist dressing B. Flex the client's knees C. Reassure the client D. Instruct the client to avoid coughing

Correct Answer: A. Cover the client's wound with a sterile, moist dressing The greatest risk to this client is an injury from infection due to wound exposure. Therefore, the first action the nurse should take is to cover the wound with a sterile, moist dressing. Incorrect Answers:B. The nurse should flex the client's knees to reduce abdominal strain, which can increase wound evisceration. However, the nurse should take another action first. C. The nurse should reassure the client to reduce the client's anxiety. However, the nurse should take another action first. D. The nurse should instruct the client to avoid coughing to prevent acute discomfort and additional strain on the incision. However, the nurse should take another action first.

A nurse is teaching a group of clients about the functions of the liver and gallbladder. Which of the following should the nurse include in the teaching as the purpose of bile? A. Digesting fats B. Producing chyme C. Stimulating gastric acid secretion D. Providing energy

Correct Answer: A. Digesting fats Bile is a product of the liver and aids in the digestion of fats. Incorrect Answers:B. Chyme is a semi-solid mixture of food and gastric secretions that is formed in the stomach. C. Gastrin is a hormone produced by the stomach mucosa that stimulates the release of gastric secretions during the process of digestion. D. Glycogen is stored in the liver and is released in the form of glucose to meet the body's energy needs.

A nurse is teaching a client who has a colostomy about ways to reduce flatus and odor. Which of the following strategies should the nurse include? A. Eat crackers and yogurt regularly B. Chew minty gum throughout the day C. Drink orange juice every day D. Put an aspirin in the pouch

Correct Answer: A. Eat crackers and yogurt regularly Crackers, toast, and yogurt can help reduce flatus, which contributes to odor. Incorrect Answers:B. Chewing any flavor of gum can increase flatus, which contributes to odor. C. Cranberry juice and buttermilk can help prevent odor. D. Aspirin in the pouch can cause ulceration of the stoma.

A nurse is assessing a client who has a bleeding duodenal ulcer. Which of the following findings should the nurse expect? A. Emesis with a coffee-ground appearance B. Increased blood pressure C. Decreased heart rate D. Bright green stools

Correct Answer: A. Emesis with a coffee-ground appearance The nurse should expect a client who has a bleeding duodenal ulcer to have emesis that resembles coffee-grounds or is bright red in color. Hematemesis indicates upper gastrointestinal bleeding, occurring at or above the duodenojejunal junction. Incorrect Answers:B. A client who has a bleeding duodenal ulcer will have a decreased blood pressure due to bleeding and fluid loss. C. A client who has a bleeding duodenal ulcer will have a decreased heart rate due to bleeding and fluid loss. D. A client who has a bleeding duodenal ulcer will have melena stools, which are tarry or dark in color and sticky.

A nurse is caring for a client who has an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take? A. Ensure bowel rest B. Offer sparkling water frequently C. Administer a stool softener D. Offer plain warm tea frequently

Correct Answer: A. Ensure bowel rest Clients who have an exacerbation of Crohn's disease usually require NPO status to ensure bowel rest and promote healing and recovery. Incorrect Answers:B. Carbonated beverages can worsen an exacerbation of Crohn's disease. C. A client with an exacerbation of Crohn's disease is already having many stools per day. A stool softener might worsen the situation. D. Caffeinated beverages and alcohol can worsen an exacerbation of Crohn's disease.

A nurse is caring for a client with a history of cirrhosis who has been admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? A. Gamma-glutamyl transferase (GGT) B. Alkaline phosphatase (ALP) C. Serum bilirubin D. Alanine aminotransferase (ALT)

Correct Answer: A. Gamma-glutamyl transferase (GGT) The GGT laboratory test is specific to the hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. Therefore, it is useful for monitoring drug toxicity and excessive alcohol use. Incorrect Answers:B. ALP is elevated in biliary obstruction and most forms of liver dysfunction. It does not differentiate between alcohol and other causative factors for liver disease. C. The serum bilirubin test is used to detect the function of the liver and its ability to excrete bilirubin. Elevated levels can determine liver disease or biliary tract disease. D. The largest concentration of the enzyme ALT is found in liver tissue. However, it is also present in kidney, heart, and skeletal muscle tissues. Because it is elevated in various types of tissue damage, it is not helpful in identifying excessive alcohol use.

A nurse is teaching dietary-modification strategies to a client who has been newly diagnosed with cirrhosis. Which of the following foods should the nurse recommend? A. Grilled chicken B. Potato soup C. Fish sticks D. Baked ham

Correct Answer: A. Grilled chicken The nurse should identify that a client who has cirrhosis requires protein to compensate for disease-related weight loss. Increasing protein intake from animal or plant sources will also provide the client with more energy. Incorrect Answers:B. A client who has cirrhosis should avoid foods that are high in sodium content, especially if ascites is present; therefore, the nurse should recommend another food choice. C. A client who has cirrhosis should avoid foods that are high in fat, especially if the client is experiencing steatorrhea; therefore, the nurse should recommend another food choice. D. A client who has cirrhosis should avoid foods that are high in sodium, especially if ascites is present; therefore, the nurse should recommend another food choice.

A nurse is caring for a client who is NPO and has an NG tube to suction. When the client reports nausea, which of the following actions should the nurse take? A. Irrigate the tube with normal saline solution B. Provide oral hygiene C. Clamp the tube for 30 min D. Increase the amount of suction

Correct Answer: A. Irrigate the tube with normal saline solution When a client with an NG tube develops nausea, the nurse should first attempt to irrigate the tube to determine patency. If the tube is not patent, gastric pressure cannot decrease, and the steady or increasing pressure can cause nausea. Incorrect Answers:B. Although oral hygiene is an appropriate comfort measure for a client who is NPO, it will not eliminate the client's nausea. C. Clamping the NG tube will likely worsen the client's nausea. D. Increasing the suction can either be ineffective or increase the risk of tissue injury.

A nurse is recommending dietary modifications for a client who has GERD. The nurse should suggest eliminating which of the following foods from the client's diet? A. Oranges and tomatoes B. Carrots and bananas C. Potatoes and squash D. Whole wheat and beans

Correct Answer: A. Oranges and tomatoes Symptoms of GERD worsen following the oral intake of substances that decrease lower esophageal stricture (LES) pressure. These include alcohol, caffeine, nicotine, chocolate, fatty foods, citrus fruits, tomatoes, and peppermint. Incorrect Answers:B. Carrots and bananas do not worsen symptoms of GERD. C. Potatoes and squash do not worsen symptoms of GERD. D. Whole wheat and beans do not worsen symptoms of GERD.

A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube serves which of the following purposes? A. Prevents excessive pressure on suture lines B. Allows gastric lavage after surgery C. Allows early postoperative feeding D. Facilitates obtaining gastric specimens for testing

Correct Answer: A. Prevents excessive pressure on suture lines The NG tube remains in place after surgery to prevent excessive pressure on suture lines postoperatively. It drains the air and fluid that can cause pressure from inside the gastrointestinal (GI) tract. In doing so, it also prevents vomiting and GI distention. Incorrect Answers:B. Gastric lavage is a therapy for upper gastrointestinal bleeding, but it is not necessary after a gastric resection. C. Unless specific problems prevent oral nutrition, the client will begin taking clear liquids by mouth and progress accordingly. D. Before administering an enteral feeding via an NG tube, the nurse should aspirate gastric contents to test pH; however, the client will not receive enteral feedings following gastric resection.

A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following laboratory findings should the nurse monitor prior to the procedure? A. Prothrombin time B. Serum lipase C. Bilirubin D. Calcium

Correct Answer: A. Prothrombin time A major complication following a liver biopsy is hemorrhage. Many clients who have liver disease have clotting defects and are at risk of bleeding. In addition to prothrombin time (PT), activated partial thromboplastin time (aPTT) and platelet count should be monitored. Liver dysfunction causes the production of blood clotting factors to be reduced, which leads to an increased incidence of bruising, nosebleeds, bleeding from wounds, and gastrointestinal bleeding. This is due to a deficient absorption of vitamin K from the gastrointestinal tract caused by the inability of liver cells to use vitamin K to make prothrombin. Incorrect Answers:B. Serum lipase is monitored to detect pancreatic disease and does not need to be assessed prior to this procedure. C. Bilirubin is monitored to detect biliary obstruction and does not need to be assessed prior to this procedure. D. Calcium is monitored to detect kidney failure or pancreatitis and does not need to be assessed prior to this procedure.

A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? A. Right shoulder pain B. Urine output 20 mL/hr C. Temperature 38.4°C (101.1°F) D. Oxygen saturation 92%

Correct Answer: A. Right shoulder pain The client can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1 to 2 days. Mild analgesics and a recumbent position can promote client comfort. Incorrect Answers:B. Urine output following surgery should be at least 30 mL/hr. A lower output can indicate hypovolemia or renal complications and should be reported to the provider immediately. C. A temperature of >38.4°C (101.1°F) can indicate infection and should be reported to the provider immediately. D. An oxygen saturation of <95% can indicate an impaired gas exchange following surgery and should be reported to the provider immediately.

A nurse is teaching a newly licensed nurse about caring for a client who is scheduled for an esophagogastric balloon tamponade tube to treat bleeding esophageal varices. Which of the following pieces of information should the nurse include in the teaching? A. The client will be placed on mechanical ventilation prior to this procedure. B. The tube will be inserted into the client's trachea. C. The client will receive a bowel preparation with cathartics prior to this procedure. D. The tube allows the application of a ligation band to the bleeding varices.

Correct Answer: A. The client will be placed on mechanical ventilation prior to this procedure. The client will require intubation and mechanical ventilation prior to this procedure to protect the airway. Incorrect Answers:B. The tube is inserted through the client's nose or mouth into the client's stomach to stop the bleeding in the esophageal varices. C. A client will receive a bowel preparation with cathartics prior to a colonoscopy, not an esophagogastric balloon tamponade tube. D. The tube is use to provide pressure to the varices to stop the bleeding. An endoscopic variceal ligation involves the application of a ligation band to the bleeding varices.

A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove from the client's meal tray? A. Wheat toast B. Tapioca pudding C. Hard-boiled egg D. Mashed potatoes

Correct Answer: A. Wheat toast Celiac disease is an autoimmune disorder characterized by a permanent intolerance to wheat, barley, and rye. Wheat toast contains gluten and should be removed from the client's tray. Incorrect Answers:B. Tapioca pudding is rich in dairy and does not contain gluten. Therefore, it is an acceptable food to include in the client's diet. C. A hard-boiled egg does not contain gluten and is a good source of protein. Therefore, it is an acceptable food to include in the client's diet. D. Mashed potatoes do not contain gluten and are a good source of potassium. Therefore, mashed potatoes are an acceptable food to include in the client's diet.

A nurse is caring for a client who has acute diverticulitis. While the client has active inflammation, the nurse should instruct the client to include which of the following foods in her diet? A. White bread and plain yogurt B. Shredded wheat cereal and blueberries C. Broccoli and kidney beans D. Oatmeal and fresh pears

Correct Answer: A. White bread and plain yogurt Because of the acute inflammation of diverticulitis, the client should maintain a diet very low in fiber. The client can consume low-fiber foods like white bread, low-fat milk, yogurt with active cultures, poached eggs, and canned soft fruit. Incorrect Answers:B. Foods like shredded wheat cereal and blueberries can worsen the inflammation of acute diverticulitis. C. Foods like broccoli and kidney beans can worsen the inflammation of acute diverticulitis. D. Foods like oatmeal and fresh pears can worsen the inflammation of acute diverticulitis.

A nurse is preparing a community education program about hepatitis B. Which of the following statements should the nurse include in the teaching? A. "A hepatitis B immunization is recommended for those who travel, especially military personnel." B. "A hepatitis B immunization is given to infants and children." C. "Hepatitis B is acquired by eating foods that are contaminated during handling." D. "Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation."

Correct Answer: B. "A hepatitis B immunization is given to infants and children." Hepatitis B immune globulin is given as part of the standard childhood immunizations. It can be administered as early as birth, especially in infants born to mothers that are negative for hepatitis B surface antigen (HBsAg). These infants should receive the second dose between 1 and 4 months of age. Incorrect Answers:A. The hepatitis A vaccine is recommended for those who travel, especially military personnel. It is also recommended for other at-risk groups. C. Hepatitis A is acquired by eating fruits, vegetables, shellfish, or other foods that are contaminated during handling. Hepatitis B is acquired by exposure to blood or body fluids from an infected person. D. Good personal hygiene habits and proper sanitation can help prevent the spread of hepatitis A.

A nurse is providing discharge teaching to the partner of a client who has a new diagnosis of hepatitis A. Which of the following instructions should the nurse include in the teaching? A. "During this illness, she may take acetaminophen for fevers or discomfort." B. "Encourage her to eat foods that are high in carbohydrates." C. "The provider will prescribe a medication to help her liver heal faster." D. "Have her perform moderate exercise to restore her strength more quickly."

Correct Answer: B. "Encourage her to eat foods that are high in carbohydrates." The client's diet should be high in carbohydrates and calories with only moderate amounts of protein and fat, especially if nausea is present. Incorrect Answers:A. The client should not take acetaminophen or any other over-the-counter (OTC) medications without checking with the health care provider. Acetaminophen and many other OTC medications are metabolized by the liver. C. There is no approved medication available to treat hepatitis A. D. While complete bed rest is usually unnecessary, the client should alternate frequent periods of rest with light activity. The client should be encouraged to increase activity gradually.

A nurse is caring for a client who has ulcerative colitis. The provider prescribes bed rest with bathroom privileges. When the client asks the nurse why he has to stay in bed, which of the following responses should the nurse provide? A. "You need to conserve energy at this time." B. "Lying quietly in bed helps slow down the activity in your intestines." C. "Staying in bed promotes the rest and comfort you need." D. "Staying in bed will help prevent injury and minimize your fall risk."

Correct Answer: B. "Lying quietly in bed helps slow down the activity in your intestines." The greatest risk to the client is complications from severe diarrhea such as dehydration, electrolyte imbalances, and gastrointestinal bleeding and trauma. Activity restriction can help reduce intestinal peristalsis and diarrhea. Incorrect Answers:A. While bed rest does conserve energy, this is not the priority reason for this prescription. C. While bed rest does promote rest and comfort, this is not the priority reason for this prescription. D. While bed rest does help prevent injury, this is not the priority reason for this prescription.

A nurse is teaching a client with Barrett's esophagus who is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? A. "This procedure is performed to measure the presence of acid in your esophagus." B. "This procedure can determine how well the lower part of your esophagus works." C. "This procedure is performed while you are under general anesthesia." D. "This procedure can determine if you have colon cancer."

Correct Answer: B. "This procedure can determine how well the lower part of your esophagus works." An EGD is useful in determining the function of the esophageal lining and the extent of inflammation, potential scarring, and strictures. Incorrect Answers:A. A pH probe study, which involves the insertion of a specially designed probe into the distal esophagus, is performed to monitor for the presence of acid in the normally alkaline esophagus. C. An EGD is performed while the client receives moderate sedation. D. A colonoscopy is performed to detect colon cancer.

A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect? A. Jaundice B. Anorexia C. Dark urine D. Pale feces

Correct Answer: B. Anorexia Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product. Incorrect Answers:A. Jaundice is a late manifestation of hepatitis A. C. Dark urine is a late manifestation of hepatitis A. D. Pale feces is a late manifestation of hepatitis A.

A nurse in a provider's office is assessing a client who has GERD. When documenting the client's history, the nurse should expect the client to report that symptoms worsen with which of the following actions? A. Stair-climbing B. Bending over C. Sitting D. Walking

Correct Answer: B. Bending over Gastroesophageal reflux symptoms are most evident with activities that increase intraabdominal pressure (e.g. bending over, straining, lifting, and lying down). Incorrect Answers:A. Stair-climbing does not increase intra-abdominal pressure. C. Sitting does not increase intra-abdominal pressure. D. Walking does not increase intra-abdominal pressure.

A nurse is obtaining a guaiac test from a client. This test is performed to detect which of the following? A. Fecal material in vomit B. Blood in stool C. Infestation of parasites D. Microorganisms in urine

Correct Answer: B. Blood in stool A guaiac test detects the presence of blood in the stool. It is a commonly used point-of-care test for fecal occult blood. Incorrect Answers:A. A guaiac test does not detect the presence of fecal material in vomit. The nurse should report this finding, as it can indicate a small-bowel obstruction. C. A guaiac test does not detect the presence of a gastrointestinal infestation. Infestations are usually detected by gross examination of feces in the laboratory. D. A guaiac test does not detect the presence of microorganisms in urine. If the client is experiencing dysuria, frequency, or urgency, the provider can write a prescription for a urine culture and sensitivity to determine the microorganisms in the urine.

A nurse is caring for a client who has recovered from acute diverticulitis. The nurse should instruct the client to increase his intake of which of the following foods when the inflammation subsides? A. Cucumbers and tomatoes B. Cabbage and peaches C. Strawberries and corn D. Figs and nuts

Correct Answer: B. Cabbage and peaches When the acute inflammation has subsided, the client should increase his intake of foods that are high in fiber, such as wheat bran, whole-grain bread, and fresh fruits and vegetables that do not contain seeds. Incorrect Answers:A. Foods like cucumbers and tomatoes can contribute to obstructing the diverticulum and cause or worsen the inflammation. C. Foods like strawberries and corn can contribute to obstructing the diverticulum and cause or worsen inflammation. D. Foods like figs and nuts can contribute to obstructing the diverticulum and cause or worsen the inflammation.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? A. Place the drainage bag on the client's abdomen when transferring from a bed to cart B. Empty the drainage bag when half-full of urine C. Rest the drainage bag on the floor when closing the drainage spigot during emptying D. Disconnect the drainage bag when obtaining a urine specimen

Correct Answer: B. Empty the drainage bag when half-full of urine The nurse should empty the drainage bag when half-full of urine. A drainage bag that is too full can place tension on the catheter tubing, resulting in trauma to the urethra and urinary meatus. Incorrect Answers:A. The nurse should always hang the drainage bag below the level of the client's bladder to prevent backflow of the urine from the drainage bag and to maintain adequate drainage of the bladder at all times. C. The nurse should maintain the drainage bag in a hanging position and verify that the drainage spigot does not touch the floor when emptying to prevent contamination and maintain asepsis. D. The nurse should obtain a urine specimen through the collection port in the drainage tubing of the indwelling urinary catheter to prevent contamination and maintain asepsis.

A nurse is assessing a client who is 12 hr postoperative following an open cholecystectomy. Which of the following findings should the nurse report to the provider? A. Hypoactive bowel sounds B. Indwelling urinary catheter output of 25 mL/hr C. Heart rate of 96/min D. Serous drainage at the surgical incision site

Correct Answer: B. Indwelling urinary catheter output of 25 mL/hr The nurse should report a urinary output of <30 mL/hr to the provider, as this can indicate hypovolemia or renal complication. Incorrect Answers:A. Hypoactive bowel sounds are an expected finding during the initial postoperative period due to decreased peristalsis from anesthesia and analgesic medications. C. A heart rate of 96/min is within the expected range of 60 to 100/min. This is an expected finding for a client who is postoperative. An elevated heart rate can indicate hemorrhage, shock, or pain. D. A small to moderate amount of serous drainage at the surgical incision site is an expected finding during the immediate postoperative period. An increased amount of drainage can indicate the possibility of wound dehiscence.

A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? A. Flush the tube with water B. Place the client in the semi-Fowler's position C. Cleanse the skin around the tube site D. Aspirate the tube for residual contents

Correct Answer: B. Place the client in the semi-Fowler's position The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second priority because adequate ventilatory effort is essential for oxygen exchange to occur. Circulation is the third priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. A client who is receiving PEG tube feedings should be positioned with the head of the bed elevated at least 30° during and after feedings to decrease the risk of aspiration. Therefore, this is the priority action by the nurse. Incorrect Answers:A. A client receiving PEG tube feedings should have the tube thoroughly flushed. However, there is another action the nurse should take first. C. A client who has a PEG tube requires frequent observation and good skin hygiene at the insertion site to prevent breakdown and irritation. However, there is another action the nurse should take first. D. Prior to each feeding, the PEG tube should be aspirated for residual gastric contents from the previous feeding. However, there is another action the nurse should take first.

A nurse is providing dietary teaching to a client who has ulcerative colitis. Which of the following food selections by the client indicates an understanding of the teaching? A. Raw vegetable salad with low-fat dressing B. Roast chicken and white rice C. Fresh fruit salad and milk D. Peanut butter on whole wheat bread

Correct Answer: B. Roast chicken and white rice Clients who have ulcerative colitis are restricted to a low-fiber diet, which omits whole grains and raw fruits and vegetables. Roast chicken with white rice is the best choice. Incorrect Answers:A. Raw vegetables should be avoided because they are high in fiber. Clients who have ulcerative colitis are generally prescribed low-fiber diets. C. Raw fruits should be avoided because they are high in fiber. Clients who have ulcerative colitis are generally prescribed low-fiber diets and should avoid foods and beverages containing lactose, such as milk. D. Whole grains should be avoided because they are high in fiber. Clients who have ulcerative colitis are generally prescribed low-fiber diets.

A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is for which of the following reasons? A. To visualize polyps in the colon B. To detect an ulceration in the stomach C. To identify an obstruction in the biliary tract D. To determine the presence of free air in the abdomen

Correct Answer: B. To detect an ulceration in the stomach An EGD is used to visualize the esophagus, stomach, and duodenum with a lighted tube to detect a tumor, ulceration, or obstruction. Incorrect Answers:A. A sigmoidoscopy or barium enema is used to visualize the lower gastrointestinal tract, where polyps are found. C. Identifying an obstruction in the biliary tract occurs during endoscopic retrograde cholangiopancreatography (ERCP). D. The measurement of free air (a gas) is obtained using fluoroscopy or an X-ray, not an EGD.

A nurse is providing preoperative teaching to a client who will undergo surgery to create a temporary colostomy. The client asks the nurse about the difference between colostomies and ileostomies. Which of the following responses should the nurse make? A. "A colostomy drains stool, and an ileostomy drains urine." B. "A colostomy is temporary, and an ileostomy is permanent." C. "A colostomy is from the large intestine, and an ileostomy is from the small intestine." D. "An ileostomy requires dietary restrictions, while a colostomy does not."

Correct Answer: C. "A colostomy is from the large intestine, and an ileostomy is from the small intestine." The name of the ostomy reflects the region the surgeon brings to the surface of the abdominal wall. Therefore, when the colon is the site of surgical intervention, the site is a colostomy (colon + ostomy). When the ileum is the site of surgical intervention, the abdominal stoma is an ileostomy (ileum + ostomy). Incorrect Answers:A. Both a colostomy and an ileostomy involve the gastrointestinal system. B. Colostomies and ileostomies can be either temporary or permanent. D. Dietary changes can help facilitate adjustment to and ongoing management of both a colostomy and an ileostomy.

A nurse is caring for a client who is 2 days postoperative following gastric surgery and has an NG tube inserted. Which of the following findings should the nurse report to the provider? A. Dryness of the mucous membranes B. Hypoactive bowel sounds in all quadrants C. 200 mL of bright red drainage from the NG tube D. Suction set at continuous low suction

Correct Answer: C. 200 mL of bright red drainage from the NG tube The nurse should notify the provider immediately if 200 mL of bright red drainage comes from the NG tube 2 days following gastric surgery. Drainage should be either a yellow-green color or clear. Bright red drainage indicates blood loss and can be the result of a disrupted suture line or other internal bleeding. Volume loss from blood is a medical emergency, and the provider should be immediately notified. Incorrect Answers:A. The nurse should expect a client who has an NG tube following gastric surgery to have a dry mouth and nose, accompanied by thirst. The nurse can offer a lubricant for the nose and lips and provide ice chips, if they are approved by the provider. B. The nurse should expect bowel sounds to be hypoactive following gastric surgery. Resumption of bowel sounds occurs slowly and indicates a return of peristalsis, which promotes healing. When peristalsis returns, the NG tube can be removed. D. The nurse should expect the NG suction to be set at low continuous suction unless otherwise noted by the provider. The nurse can check the suction canister for drainage and the client's stomach for bloating and distention to determine if the decompression is effective.

A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should return to the expected reference range within 72 hr of treatment beginning? A. Aldolase B. Lipase C. Amylase D. Lactic dehydrogenase

Correct Answer: C. Amylase Pancreatitis is the most common diagnosis for marked elevations in serum amylase. Serum amylase begins to increase about 3 to 6 hours following the onset of acute pancreatitis. The amylase level peaks in 20 to 30 hours and returns to the expected reference range within 2 to 3 days. Incorrect Answers:A. Elevated aldolase levels are caused by inflammation of the muscles, also known as myositis. Aldolase levels are not affected by pancreatic disorders. B. Lipase levels in clients who have pancreatitis increase after a rise in serum amylase and stay elevated for up to 14 days longer than amylase levels. D. Lactic dehydrogenase (LDH) increases are typically seen in clients who have anemia, leukemia, or liver damage.

A nurse is planning discharge teaching for a client who is postoperative following a traditional open cholecystectomy. Which of the following learning needs of the client is the nurse's priority? A. Dietary recommendations B. Incision care C. Coughing and deep-breathing exercises D. Pain management

Correct Answer: C. Coughing and deep-breathing exercises The greatest risk to the client is respiratory compromise. Therefore, learning how to perform coughing and deep-breathing exercises to promote lung expansion and secretion removal is the priority. Incorrect Answers:A. Learning dietary restrictions is important because a low-fat diet can help prevent nausea and discomfort if bile flow is decreased. However, prioritizing needs by body system and by safety risks indicates that this is not the client's greatest learning need at this time. B. Learning incision care allows the client to recognize signs of infection or separation and report them to the surgeon. However, prioritizing needs by body system and safety risks indicates that this is not the client's greatest learning need at this time. D. Learning about pain management is important because excessive pain can significantly impede recovery. Clients who have pain might not want to cough, breathe deeply, ambulate, or turn. Failure to perform these activities can eventually lead to complications. However, prioritizing the client's immediate needs by body system and safety risks indicates that this is not the client's greatest learning need at this time.

A nurse is planning care for a client who has cholelithiasis. Which of the following interventions should the nurse include in the plan? A. Restrict the client's fluid intake B. Restrict the client's calcium intake C. Decrease the client's fat intake D. Decrease the client's potassium intake

Correct Answer: C. Decrease the client's fat intake The nurse should decrease the client's fat intake to reduce the occurrence of biliary colic. Incorrect Answers:A. The nurse should not restrict fluid intake for a client who has cholelithiasis to reduce the risk of dehydration. B. The nurse might restrict the intake of calcium for a client who has calcium phosphate kidney stones. D. The nurse should decrease potassium intake for a client who has chronic kidney disease to reduce the risk of hyperkalemia.

A nurse is caring for a child who had her spleen removed following a bicycle accident. The child's parent asks the nurse about the role of the spleen in the body. The nurse should explain that the spleen performs which of the following functions? A. Maintains fluid balance B. Regulates calcium in the blood C. Destroys old blood cells D. Produces prothrombin

Correct Answer: C. Destroys old blood cells The nurse should tell the parent that the spleen destroys old blood cells, filters antigens, and stores platelets. A client without a spleen has an increased risk of infection and sepsis due to a reduced immune function. Incorrect Answers:A. Fluid balance is maintained by a variety of regulators, including the renal and endocrine systems. However, the spleen is not involved in maintaining fluid balance. B. The parathyroid glands, which are located behind the thyroid gland, regulate calcium levels in the blood. D. Prothrombin is a clotting factor produced in the liver, not in the spleen.

A nurse is caring for a client from the Middle East who has celiac disease. Which of the following actions should the nurse perform regarding the client's diet? A. Provide foods prepared according to kosher dietary law B. Ask the kitchen to prepare grits to meet the client's dietary need for grains C. Determine the client's dietary preferences D. Prepare a diet tray that includes vegetable and barley soup

Correct Answer: C. Determine the client's dietary preferences While generalizations are often made regarding the traditional eating practices of clients based on their cultural backgrounds, individual food choices can deviate from these generalizations. The nurse should assess the client's dietary habits before planning to meet dietary needs. Incorrect Answers:B. Although clients who have celiac disease are unable to consume grains such as wheat, rye, and barley, it is not culturally sensitive to request the preparation of certain foods without consulting the client. D. Clients who have celiac disease are unable to process certain grains, including wheat, rye, and barley. If consumed, these grains can result in diarrhea, abdominal pain, and weight loss.

A nurse is providing teaching to a client who has constipation. Which of the following instructions should the nurse include? A. Use bismuth subsalicylate regularly B. Consume a low-fiber diet C. Eat yogurt with live cultures D. Use bisacodyl suppositories regularly

Correct Answer: C. Eat yogurt with live cultures Yogurt with live bacterial cultures provides dietary probiotics that help maintain and promote bowel function. Incorrect Answers:A. Bismuth subsalicylate is an antidiarrheal agent and will increase constipation. B. Increasing fiber gradually can prevent constipation. A low-fiber diet is recommended for clients who have diarrhea. D. The regular use of stimulant laxatives can result in decreased defecation reflexes, causing a reliance on stimulant laxatives for bowel movements. This may eventually cause electrolyte imbalances and colitis.

A nurse is caring for a client who has abdominal pain and possible pancreatitis. Which of the following laboratory results should the nurse identify as an indication of pancreatitis? A. Decreased white blood cell (WBC) count B. Increased albumin level C. Increased serum lipase level D. Decreased blood glucose level

Correct Answer: C. Increased serum lipase level Due to the release of lipase into the pancreas and autodigestion, pancreatitis causes an increased serum lipase level. Incorrect Answers:A. With pancreatitis, the WBC count increases because of the inflammatory process. B. Pancreatitis decreases the albumin level as a result of the inflammatory process. D. With pancreatitis, blood glucose is elevated due to a drop in insulin production.

A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? A. Endoscopic sclerotherapy B. Liver lobectomy C. Liver transplant D. Transjugular intrahepatic portal-systemic shunt placement

Correct Answer: C. Liver transplant Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients. Incorrect Answers:A. Endoscopic sclerotherapy is the injection of a sclerotherapy agent during an endoscopy to target esophageal varices that are actively bleeding. This promotes thrombosis, which eventually leads to sclerosis. B. A liver lobectomy is used for localized cancer of a lobe of the liver. This is not appropriate for a client experiencing rapidly progressive liver failure. D. A transjugular intrahepatic portal-systemic shunt is placed to treat esophageal varices through a stent into the portal vein. The stent serves as a shunt between the portal circulation and the hepatic vein, thereby reducing portal hypertension. It is not used for fulminant hepatic failure.

A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings indicates that a possible bowel perforation has occurred? A. Elevated blood pressure B. Bowel sounds increased in frequency and pitch C. Rigid abdomen D. Emesis of undigested food

Correct Answer: C. Rigid abdomen Abdominal tenderness and rigidity indicate a bowel perforation. As fluid escapes into the peritoneal cavity, a reduction in circulating blood volume occurs, lowering blood pressure. Incorrect Answers:A. A client who has experienced a bowel perforation will not display an elevated blood pressure. However, hypotension or shock can be present. B. Intestinal peristalsis increases in frequency and intensity as the bowel attempts to move intestinal contents past the obstructed area. Bowel sounds are silent with a bowel perforation. D. Vomiting is frequent and copious with a small bowel obstruction. This does not indicate a bowel perforation.

A nurse is caring for a client who has cholelithiasis and will undergo a cholecystectomy. The client states she does not understand how she will be alright without her gallbladder. The nurse should explain to the client that which of the following is the main function of the gallbladder? A. Producing bile B. Adding digestive enzymes to bile C. Storing bile D. Eliminating bile

Correct Answer: C. Storing bile The primary function of the gallbladder is to store bile. Because this organ is only for storage, the client's liver will still produce the bile needed for digestion. Small amounts of bile will continuously enter the duodenum, where it will perform various functions. Incorrect Answers:A. The liver produces bile. B. The stomach, pancreas, and small intestines produce the various fluids and enzymes that help accomplish the process of digestion. D. The gastrointestinal tract eliminates bile as well as other byproducts and waste via feces.

A nurse is providing postoperative teaching about the management of dumping syndrome to a client who had a partial gastrectomy. Which of the following instructions should the nurse include in the teaching? A. "Consume at least 4 oz of fluid with meals." B. "Take a short walk after each meal." C. "Use honey to flavor foods such as cereal." D. "Eat protein with each meal."

Correct Answer: D. "Eat protein with each meal." The nurse should instruct the client to eat meals that are high in protein and fat with low to moderate carbohydrate content. Protein should be included in every meal because it delays digestion, which helps reduce the manifestations of dumping syndrome. Incorrect Answers:A. The client should avoid fluids at mealtimes to decrease gastric stimulation. B. The client should lie down when experiencing early manifestations of dumping syndrome (e.g. tachycardia, syncope, or sweating) to slow the progress of food through the gastrointestinal tract. C. The client should avoid simple carbohydrates such as honey, sugar, and syrup because they aggravate the stomach and worsen manifestations of dumping syndrome.

A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching? A. "Because most of my colon is still intact and functioning, my stool will be formed." B. "My stoma will appear large at first, but it will shrink over the next several weeks." C. "My colostomy will begin to function in 2 to 6 days after surgery." D. "I'll have to consume a soft diet after surgery."

Correct Answer: D. "I'll have to consume a soft diet after surgery." The nurse should identify that this statement requires further teaching. After surgery, the client quickly returns to a regular diet, and there are no food restrictions unless the client chooses to decrease the intake of foods that increase gas or odor. Incorrect Answers:A. A colostomy placed at the descending or sigmoid colon produces stool that is fairly solid and resembles what is normally expelled from the rectum; therefore, this statement does not require further teaching. B. The stoma is edematous at first because of trauma from surgery and manipulation of the colon, but it will shrink within 6 to 8 weeks after surgery as the edema decreases; therefore, this statement does not require further teaching. C. Because of the lack of bowel peristalsis after surgery and the client's NPO status, it is not unusual for only mucus to drain from the ostomy until 2 to 6 days after surgery; therefore, this statement does not require further teaching.

A nurse is caring for a client who has colitis and reported increased exacerbations due to stress at work. Which of the following responses should the nurse make? A. "I will contact the social worker so you can discuss career alternatives." B. "Have you thought about discussing the possibility of a part-time assignment with your employer?" C. "Why don't you ask your employer to relieve you of some work until you are stronger?" D. "Perhaps we should review your coping mechanisms and talk about other alternatives."

Correct Answer: D. "Perhaps we should review your coping mechanisms and talk about other alternatives." Reviewing coping mechanisms and alternative coping patterns will promote coping skills that can assist the client in reducing stress. Incorrect Answers:A. This response does not address the client's concerns and can cause additional stress for the client. B. The client might not want to work part-time. Also, part-time work might not relieve the client's stress. C. This response does not address the client's concerns and can cause additional stress.

A nurse is completing a history and physical assessment for a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? A. High-calorie diet B. Prior gastrointestinal illnesses C. Tobacco use D. Alcohol use

Correct Answer: D. Alcohol use Alcohol consumption is a major cause of chronic pancreatitis in the US. Long-term alcohol use disorder produces hypersecretion of protein in pancreatic secretions, which results in protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage to these cells is more likely to occur and to be more severe in clients whose diets are poor in protein content and either very high or very low in fat. Incorrect Answers:A. A high-calorie diet can contribute to heart disease and obesity, but it does not cause chronic pancreatitis. B. A prior gastrointestinal illness does not cause or contribute to chronic pancreatitis. C. Tobacco use can contribute to heart disease and increases the risk of cancer development, but it does not cause chronic pancreatitis.

A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect? A. Increased blood pressure B. Decreased heart rate C. Yellowing of the skin D. Boardlike abdomen

Correct Answer: D. Boardlike abdomen The nurse should expect this client who is experiencing perforation of a peptic ulcer to exhibit manifestations of a board-like abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation causes hemorrhaging. Incorrect Answers:A. The nurse should expect a client who is experiencing perforation of a peptic ulcer to exhibit manifestations of shock, including hypotension. B. The nurse should expect a client who is experiencing perforation of a peptic ulcer to exhibit manifestations of shock, including tachycardia. C. The nurse should expect a client who has liver disease to exhibit jaundice.

A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? A. Vanilla pudding B. Apple juice C. Diet ginger ale D. Clear liquids

Correct Answer: D. Clear liquids Clear liquids, such as water or broth, can be given for the first oral feeding but should be limited to only 30 mL (1 oz) per feeding. Water does not contain sugar, which could cause diarrhea due to hyperosmolarity. Incorrect Answers:A. Vanilla pudding contains sugar, which can cause diarrhea due to hyperosmolarity. Clear liquids should be given for the first oral feeding. B. The sugar content of apple juice can cause diarrhea due to hyperosmolarity. Clear liquids should be given as the first oral feeding. C. The client should avoid carbonated beverages because they can distend the stomach, causing pressure on the internal sutures or staples. Pressure can lead to leaking into the peritoneum and result in peritonitis.

A nurse is caring for a client who has diverticulitis and a new prescription for a low-fiber diet. Which of the following food items should the nurse remove from the client's meal tray? A. Canned fruit B. White bread C. Broiled hamburger D. Coleslaw

Correct Answer: D. Coleslaw Coleslaw contains raw cabbage, which is high in fiber. Clients who are following a low-fiber diet should avoid most raw vegetables. Incorrect Answers:A. Canned fruit is an appropriate low-fiber food for a client who is following a low-fiber diet. Fresh fruit contains more fiber. B. White bread is an appropriate low-fiber food for a client who is following a low-fiber diet. Wholegrain bread contains more fiber. C. Broiled hamburger is an appropriate low-fiber food for a client who is following a low-fiber diet. Fish and poultry are also low in fiber.

A nurse is caring for a client who has gastrointestinal bleeding. The provider suspects a bleeding lesion in the colon. The initial approach to treatment likely will involve which of the following procedures? A. Exploratory laparotomy B. Double-contrast barium enema C. Magnetic resonance imaging D. Colonoscopy

Correct Answer: D. Colonoscopy A colonoscopy requires the insertion of a flexible scope into the rectum. The provider advances the scope carefully until it enters the colon. It can provide direct visualization of the inside of the colon and helps the provider identify the exact cause and location of bleeding. Incorrect Answers:A. An exploratory laparotomy, although minimally invasive, is still a surgical procedure. A less-risky approach might help identify the source of the client's bleeding. B. A double-contrast barium enema, which instills air and barium into the colon, primarily offers visualization of small lesions and polyps. The provider likely will not use this procedure to find the source of the client's bleeding. C. Computed tomography and magnetic resonance imaging help locate masses and areas of metastasis in the gastrointestinal tract. The provider likely will not use these modalities to find the source of the client's bleeding.

A nurse is teaching a client who has cirrhosis of the liver and a history of alcohol consumption. The nurse should explain that alcohol can cause liver cirrhosis through which of the following actions? A. Increasing the workload of the liver by releasing stored glycogen B. Causing ulceration of liver tissue that can lead to bleeding C. Dilating veins in the portal circulation D. Destroying liver cells that are later replaced with scar tissue

Correct Answer: D. Destroying liver cells that are later replaced with scar tissue The development of cirrhosis in a client who consumes alcohol is related to liver inflammation and cell destruction. Over time, nonfunctional scar tissue and fibrosis replace the necrotic liver cells. Incorrect Answers:A. Alcohol consumption does not cause a release of stored glycogen that increases the workload of the liver. However, alcohol consumption can cause a decrease in liver function. B. Clients who have peptic ulcer disease can develop bleeding ulcers in the gastrointestinal lining. However, alcohol consumption does not cause ulceration of liver tissue. C. Portal hypertension is caused by the development of nodules that constrict blood flow through the liver veins. However, alcohol consumption does not cause dilated portal circulation.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? A. Hypertension B. Excessive thirst C. Fever D. Diaphoresis

Correct Answer: D. Diaphoresis The nurse should recognize that this client has the potential to develop hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger. Incorrect Answers:A. A client experiencing fluid volume overload will exhibit hypertension. B. A client experiencing hyperglycemia will exhibit excessive thirst. C. A client with an infection will have an increased temperature.

A nurse is updating the plan of care for a client who has dumping syndrome. Which of the following instructions should the nurse include? A. Consume beverages with meals B. Eat 3 large meals per day C. Include high-fiber foods in the diet D. Eat a source of protein with each meal

Correct Answer: D. Eat a source of protein with each meal The nurse should include in the client's plan of care the instruction to eat a source of protein with each meal because protein delays gastric emptying. Incorrect Answers:A. The nurse should recommend consuming beverages between meals, which delays gastric emptying. B. The nurse should recommend consuming small, frequent meals each day to delay gastric emptying and assist with digestion. C. The nurse should recommend including low-fiber foods in the diet to delay gastric emptying.

A nurse is assessing a client who has a complete intestinal obstruction. Which of the following findings should the nurse expect? A. Absence of bowel sounds in all 4 abdominal quadrants B. Passage of blood-tinged liquid stool C. Presence of flatus D. Hyperactive bowel sounds above the obstruction

Correct Answer: D. Hyperactive bowel sounds above the obstruction The nurse should expect the client to have hyperactive bowel sounds above the obstruction because the intestinal peristalsis above the obstruction attempts to push the obstruction through the intestines. With a complete intestinal obstruction, there are no bowel sounds below the obstruction. Incorrect Answers:A. The nurse should expect an absence of bowel sounds in all 4 quadrants in a client who has a paralytic ileus, rather than a complete intestinal obstruction. B. The nurse should expect diarrhea in a client who has a partial intestinal obstruction. A client who has a complete intestinal obstruction is unable to pass stool. C. The nurse should not expect a client who has a complete intestinal obstruction to pass flatus.

A nurse is teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse include? A. Smoking cessation B. Benefits of a diet high in cruciferous vegetables C. New types of ostomy appliances D. Importance of colonoscopy screening starting at age 50 years old

Correct Answer: D. Importance of colonoscopy screening starting at age 50 years old Screening examinations for colorectal cancer are secondary prevention (an action that promotes early detection of disease). Incorrect Answers:A. There is an association between long-term smoking and colorectal cancer; however, this is primary prevention (an action that prevents the development of a disease). B. Providing dietary teaching to prevent colorectal cancer is primary prevention (an action that prevents the development of a disease). C. Information about ostomy appliances and care is tertiary prevention (an action that minimizes the effects of a long-term disease or disability).

A nurse is providing dietary teaching to a client who has dumping syndrome following gastric bypass surgery 4 days ago. Which of the following recommendations should the nurse include in the teaching? A. Avoid foods containing protein B. Drink liquids during each meal C. Eat foods that contain simple sugars D. Maintain a supine position after meals

Correct Answer: D. Maintain a supine position after meals The nurse should instruct the client to lie supine after eating to help slow the rapid emptying of food into the small intestine. A client who has dumping syndrome should decrease the amount of food eaten at once, eat small meals more frequently, and eliminate fluids at mealtime. Fluid shifts occur in the upper gastrointestinal tract when food contents and simple sugars exit the stomach too rapidly, attracting fluid into the upper intestine and decreasing blood volume, which causes the client to experience nausea and vomiting, sweating, syncope, palpitations, increased heart rate, and hypotension. Incorrect Answers:A. The nurse should instruct the client to include foods containing protein at each meal and only to eat 1 or 2 foods from each food group at once. Protein, fats, and complex carbohydrates are better tolerated by a client who recently had gastric bypass surgery. B. The nurse should instruct the client to avoid drinking liquids during meals and to wait 30 to 60 minutes after eating solid foods to drink liquids. Drinking liquids with meals increases the motility of the gastrointestinal tract. C. The nurse should instruct the client to avoid eating foods that contain simple sugars. Simple sugars increase the hypertonicity of the gastrointestinal tract, which increases the movement of the food bolus.

A nurse is caring for a client who is postoperative following a laparotomy. The client has an indwelling urinary catheter and a Jackson-Pratt drain in place. Which of the following findings indicates that the client is developing a postoperative complication? A. Pain scale score of 5 out of 10 B. Urine output of 65 mL/hr C. 20 mL of bright red drainage from the drain D. Pulse oximetry of 85%

Correct Answer: D. Pulse oximetry of 85% After abdominal surgery, clients should have an oxygen saturation above 93%. A client whose oxygen saturation is 85% has hypoxemia and requires immediate intervention. Incorrect Answers: A. A pain score of 5 out of 10 immediately following surgery is an expected finding. The nurse should administer pain medication or initiate a revision of the pain management plan for this client. B. Clients who are recovering from abdominal surgery should have a urinary output that exceeds 30 mL/hr. C. Drainage of 20 mL of bright red fluid immediately following surgery is an expected finding for an adult client.

A nurse is performing a gastrointestinal assessment of a client who has liver cirrhosis with abdominal distention. Which of the following actions should the nurse take to assess for changes in the client's abdominal distention? A. Percuss the abdomen for tympanic sounds B. Inspect the contour of the abdominal wall C. Instruct the client to report increased abdominal discomfort D. Take serial measurements of the abdomen with a tape measure

Correct Answer: D. Take serial measurements of the abdomen with a tape measure Measuring the abdomen is the most effective way to assess for a change in abdominal distention because it provides concrete, objective data that can be compared at various points in time to monitor changes. Incorrect Answers:A. Percussing the abdomen for tympanic sounds is not the most effective way to assess for a change in abdominal distention. It will help the nurse identify the presence of distention but will not indicate any changes in the amount of distention. B. Visual inspection is not the most effective way to assess for a change in abdominal distention because it provides a visual estimate rather than measurable, objective data. C. Client reporting is not the most effective way to assess for a change in abdominal distention because it provides subjective rather than objective data.

A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings requires intervention? A. A full pitcher of water is sitting on the client's bedside table within the client's reach. B. The disposable feeding bag is from the previous day at 1000 and contains 200 mL of feeding. C. The client is lying on the right side with a visible dependent loop in the feeding tube. D. The head of the bed is elevated to 20°.

Correct Answer: D. The head of the bed is elevated to 20°. The head of the bed should be elevated to at least 30° (semi-Fowler's position) while the tube feeding is administered. This position uses gravity to help the feeding move through the digestive system and lessens the possibility of regurgitation. Incorrect Answers:A. The nurse should monitor the client's intake and output and should observe the client for manifestations of dehydration (e.g. dry mucous membranes, thirst, and decreased urinary output). A pitcher of water at the client's bedside does not require intervention by the nurse. B. The client's feeding bag should be changed every 24 hours. The 200 mL remaining in the bag is sufficient to last until the bag needs to be changed. Because the rate is 75 mL/hr, the nurse will need 150 mL to cover the 2 hours until the bag needs to be changed. The 50 mL left in the bag will ensure that the bag does not run dry and cause air to enter the client's stomach. C. This observation does not require intervention because the feeding is not by gravity but by a pump and is set at a constant rate. The client's side-lying position will not affect the pump's rate of flow unless the client is lying on the tubing.

A nurse is providing teaching to the guardian of a child who has celiac disease. Which of the following foods should the nurse instruct the guardian to omit from the child's diet? A. Cornflakes B. Reduced-fat milk C. Canned fruits D. Wheat bread

Correct Answer: D. Wheat bread Clients who have celiac disease should eliminate as much gluten as possible from their diets. Wheat, rye, and barley contain gluten and should be eliminated from the diet of a child who has celiac disease. Incorrect Answers:A. Cornflakes do not contain gluten and do not have to be omitted from the diet of a child who has celiac disease. B. Milk is gluten-free and does not have to be eliminated from the diet of a child who has celiac disease. C. Canned fruits without additives are gluten-free and do not have to be eliminated from the diet of a child who has celiac disease.

A nurse is admitting a client who has cirrhosis. Which of the following prescriptions should the nurse anticipate? (Select all that apply.) A. Obtain the client's PT and INR measurements B. Administer lactulose 30 mL PO 4 times daily C. Obtain daily weight and abdominal girth measurements D. Administer a daily multivitamin E. Place the client on a low-protein diet

Correct Answers: A. Obtain the client's PT and INR measurements B. Administer lactulose 30 mL PO 4 times daily C. Obtain daily weight and abdominal girth measurements D. Administer a daily multivitamin Cirrhosis interferes with the liver's ability to produce clotting factors, which places the client at risk of hemorrhage. The PT and INR are usually prolonged due to decreased synthesis of prothrombin. A client who has cirrhosis is unable to eliminate ammonia from the body once protein is broken down. Therefore, lactulose should be administered to increase the client's production of stool, which will help eliminate ammonia from the client's body. Additionally, the nurse should anticipate a prescription to assess the client's weight daily to assess the client's fluid status. An increase of 1 kg (2.2 lb) in the client's weight indicates 1 L of fluid retention. The nurse should also expect to measure the client's abdominal girth daily to determine if ascites is increasing or decreasing. Cirrhosis also leads to deficiencies in many daily vitamins; therefore, the nurse should anticipate a prescription to administer a daily multivitamin to the client. Incorrect Answer:E. Client who has cirrhosis needs a diet that is rich in protein, especially vegetable proteins.

A nurse is teaching a client who has diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include? (Select all that apply.) A. Bradycardia B. Diaphoresis C. Deep, rapid respirations D. Palpitations E. Shakiness

Correct Answers: B. Diaphoresis D. Palpitations E. Shakiness Diaphoresis, palpitations, and shakiness are sympathetic nervous system responses to hypoglycemia. Incorrect Answers:A. Tachycardia is a manifestation of the body's response to stimulation of the sympathetic nervous system due to hypoglycemia. C. Deep, rapid respirations, which are referred to as Kussmaul respirations, are a manifestation of hyperglycemia.

A nurse is planning an in-service training session regarding nutrition. Which of the following minerals should the nurse identify as involved in oxygen transportation? A. Zinc B. Iron C. Phosphorus D. Magnesium

Correct Answer: B. Iron Iron transports oxygen by means of hemoglobin and myoglobin. It is also a component of enzyme systems. Incorrect Answers:A. Zinc plays a role in tissue growth and wound healing and supports immune function, but it does not affect oxygen transport. C. Phosphorus plays a role in bone and teeth formation and energy metabolism, but it does not affect oxygen transport. D. Magnesium affects enzyme and neurochemical activities and the excitability of cardiac and skeletal muscles, but it does not affect oxygen transport.

A nurse is providing teaching about nutrients to a client. Which of the following statements should the nurse include? A. "Carbohydrates transport nutrients throughout the body." B. "Fats prevent ketosis." C. "Protein builds and repairs body tissue." D. "Carbohydrates help regulate body temperature."

Correct Answer: C. "Protein builds and repairs body tissue." The primary function of protein involves building and repairing body tissues (e.g. muscles, tendons, and collagen). The skin, hair, and nails are also made of protein structures. A diet that is low in protein can impair wound healing. Incorrect Answers:A. Proteins transport nutrients such as fats and fat-soluble vitamins throughout the body. Protein in the form of hemoglobin transports oxygen; in the form of albumin, it transports many medications. B, Ketosis develops when the body relies only on fats to meet energy needs. Carbohydrates prevent ketosis by allowing the body to use fat effectively as an energy source without the production of ketones. D. Fats help regulate body temperature by providing a protective layer when the environmental temperature drops.

A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend? A. Foods high in vitamin C B. Foods low in fat C. Foods high in fiber D. Foods low in calories

Correct Answer: C. Foods high in fiber Long-term low-fiber eating habits and increased intracolonic pressure lead to straining during bowel movements, causing the development of diverticula. High-fiber foods help strengthen and maintain the active motility of the gastrointestinal tract. Incorrect Answers:A. Vitamin C functions as an antioxidant as well as a coenzyme. It has been associated with the prevention of cancer of the stomach, esophagus, and colon. However, it does not improve or prevent acute diverticulitis attacks. B. Low-fat foods do not improve or prevent acute diverticulitis attacks. D. Low-calorie foods do not improve or prevent acute diverticulitis attacks.

A nurse is planning an in-service training session for a group of nurses regarding the role of enzymes in digestion. Which of the following enzymes plays a role in the digestion of protein? A. Amylase B. Lipase C. Steapsin D. Pepsin

Correct Answer: D. Pepsin Pepsin is an enzyme secreted by the gastric mucosa that breaks down protein into polypeptides. Other enzymes such as trypsin and aminopeptidase further break down the polypeptides into amino acids, which can be used by the body. Incorrect Answers:A. Amylase is an enzyme secreted by the pancreas and intestine that breaks down starches into glucose. B. Lipase is an enzyme secreted by the pancreas that breaks down triglycerides into monoglycerides. C. Steapsin is an enzyme secreted by the gastric mucosa that breaks down triglycerides into monoglycerides.

A nurse is presenting an in-service training session about nutrition. How many of the amino acids must be obtained from dietary intake? A. 6 B. 9 C. 11 D. 15

Correct Answer: B. 9 Proteins are made up of chains of amino acids, which are composed of carbon, hydrogen, oxygen, and nitrogen. Nine amino acids are considered essential for the human body and must be obtained from diet. These include histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine. Incorrect Answers:A. C. D. Of the 20 amino acids identified, the body is able to manufacture 11. These are defined as nonessential amino acids.

A nurse in the emergency department is caring for a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? A. Famotidine B. Esomeprazole C. Vasopressin D. Omeprazole

Correct Answer: C. Vasopressin Vasopressin constricts the splanchnic bed and decreases portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varices. Incorrect Answers:A. Famotidine is an H2 receptor antagonist used to treat stress ulcers. B. Esomeprazole is a proton pump inhibitor used to treat gastrointestinal reflux disease. D. Omeprazole is a proton pump inhibitor used to treat duodenal and gastric ulcers.

A nurse is monitoring the laboratory results of a client who has end-stage liver failure. Which of the following results should the nurse expect? A. Decreased lactate dehydrogenase B. Increased serum albumin C. Decreased serum ammonia D. Increased prothrombin time

Correct Answer: D. Increased prothrombin time Clients who have end-stage liver failure have an inadequate supply of clotting factors and an increased (i.e. prolonged) prothrombin time. Incorrect Answers:A. Lactate dehydrogenase levels increase for a client who has end-stage liver failure, indicating liver cell destruction. B. Serum albumin levels decrease for a client who has end-stage liver failure. C. Serum ammonia levels increase for a client who has end-stage liver failure.

A nurse in a provider's office is assessing a client who has GERD. The nurse should expect the client to report which of the following manifestations? (Select all that apply.) A. Regurgitation B. Nausea C. Belching D. Heartburn E. Weight loss

Correct Answers: A. Regurgitation B. Nausea C. Belching D. Heartburn Regurgitation and heartburn are primary manifestations of GERD. Nausea and belching are also common manifestations. Incorrect Answer:E. Clients who have GERD rarely experience unplanned weight loss.

A nurse is demonstrating colostomy care to a client who has a new colostomy. Which of the following actions should the nurse teach the client to perform? (Select all that apply.) A. Use antimicrobial ointment on the peristomal skin B. Empty the bag when it is one-third to one-half full C. Cut the skin barrier opening a little larger than the ostomy D. Wash the peristomal skin with mild soap and water E. Apply the skin barrier while the skin is slightly moist

Correct Answers: B. Empty the bag when it is one-third to one-half full C. Cut the skin barrier opening a little larger than the ostomy D. Wash the peristomal skin with mild soap and water Allowing the bag to become too full can cause leakage. The client should cut an opening that is about 1/16 to 1/8 larger than the stoma to avoid applying any constricting pressure to the stoma. The client should avoid moisturizing soaps because lubricants can affect adhesion of the appliance. Incorrect Answers:A. Oil-based ointments on the skin disrupt adhesion, and antimicrobials are not necessary unless prescribed by the provider to treat an infection. E. The skin must be dry before applying the skin barrier since the pouch will not adhere to moist skin.

A nurse is performing discharge teaching about ostomy care while at home for a client who has a newly placed ileostomy. Which of the following instructions should the nurse include in the teaching? A. "Empty your ostomy pouch when it becomes half full." B. "Place an aspirin in the ostomy pouch to eliminate odor." C. "Change the ostomy appliance every week." D. "Cleanse the site around the stoma with hydrogen peroxide and water."

Correct Answer: A. "Empty your ostomy pouch when it becomes half full." The nurse should instruct the client to empty the ostomy pouch when it is one-third to one-half full. This prevents the ostomy from becoming too full of stool and gas and exploding. Incorrect Answers:B. The nurse should instruct the client to avoid placing an aspirin in the ostomy pouch to eliminate odor. This can cause irritation of the skin and ulceration of the stoma. Instead, a breath mint can be placed in the ostomy pouch to assist with the odor. C. The nurse should instruct the client to change the ostomy appliance every 2 weeks. Changing it too frequently can irritate the client's skin. D. The nurse should instruct the client to cleanse the site around the stoma with mild soap and water prior to placing the appliance.

A nurse is assisting a provider with performing a paracentesis on a client. Which of the following actions should the nurse take? A. Ask the client to empty his bladder before the procedure B. Place the client leaning forward over the bedside table for the procedure C. Inform the client he will be sedated during the procedure D. Instruct the client to fast for 6 hr prior to the procedure

Correct Answer: A. Ask the client to empty his bladder before the procedure The nurse should ask the client to empty his bladder before the procedure to prevent injury to the bladder. Incorrect Answers:B. The client should lean forward over the bedside table for a thoracentesis to be performed. This gives the provider complete access to the client's chest and back and expands the spaces between the client's ribs where the pleural fluid has accumulated. C. The client will be fully awake during the procedure; sedation is not required. D. The client can eat or drink up until the procedure; fasting is not required.