Foundation 3 exam
The nurse is reviewing the results of a hemoccult test with the client. Which question asked by the nurse is important in screening for the potential of a false-positive result. Select all that apply.
"Are you prescribed regular strength aspirin daily?" "Can you tell me the amount of alcohol that you drink on an average week?" "When was the last time that you included red meat in your diet?
Endoscopy of a 60-year-old woman has revealed the presence of an esophageal peptic ulcer. The nurse who is providing this woman's care is assessing for risk factors that may have contributed to the development of this disease. What question most directly addresses these risk factors?
"Have you ever been diagnosed with reflux?"
A home care nurse is caring for a client with reports of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?
"I'll avoid eating or drinking anything 6 to 8 hours before the test."
A male patient's present signs and symptoms are suggestive of an incompetent cardiac sphincter, and he has been scheduled for an upper GI series (barium swallow). What preprocedure teaching should the nurse provide to this patient?
"Make sure that you don't eat anything after midnight the day before your test."
An obese male patient has sought advice from the nurse about the possible efficacy of medications in his efforts to lose weight. What should the nurse teach the patient about pharmacologic interventions for the treatment of obesity?
"Medications may be of some use, but they don't tend to resolve obesity on their own."
A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The health care provider has ordered a visualization of the small intestine via a capsule endoscopy. What will the nurse include in the client education about this procedure?
"You will need to swallow a capsule."
A patient has a gastric sump tube inserted and attached to low intermittent suction. The physician has ordered the tube to be irrigated with 30 mL of normal saline every 6 hours. When reviewing the patient's intake and output record for the past 24 hours, the nurse would expect to note that the patient received how much fluid with the irrigation?
120
The nurse inserts a nasogastric tube into the right nares of a patient. When testing the tube aspirate for pH to confirm placement, what does the nurse anticipate the pH will be if placement is in the lungs?
6
A nurse is preparing a presentation for a local community group of older adults about colon cancer. What would the nurse include as the primary characteristic associated with this disorder?
A change in bowel habits
A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis?
A liver biopsy
In addition to teaching a client with constipation to increase dietary fiber intake to 25 g/day, which of the following would the nurse include as important?
Adding fiber-rich foods to the diet gradually
When preparing a client for a hemorrhoidectomy, the nurse should take which action?
Administer an enema as ordered.
A nurse is aware that even though tube feedings are generally well-tolerated by most patients, there is a still a risk of dumping syndrome. Which of the following actions has the greatest potential to reduce a patient's risk of experiencing dumping syndrome?
Administering feedings at a low, continuous rate rather than by bolus
An elderly patient has developed Clostridium difficile-related diarrhea, a problem that has led to dehydration and hypokalemia. The increased peristalsis that characterizes diarrhea has the potential to cause fluid volume deficit and electrolyte deficits because:
An increase in peristalsis means that the colon cannot absorb the substances that it normally absorbs.
A nurse is completing an assessment on a client with a postoperative neck dissection. The nurse notices excessive bleeding from the dressing site and suspects possible carotid artery rupture. What action should the nurse take first?
Apply pressure to the bleeding site
An older woman has been receiving enteral feeds by nasogastric (NG) tube for the past several days due to a decrease in her level of consciousness. How can the nurse best assess the patient's tolerance of the current formula and rate of delivery?
Aspirate and measure the stomach contents on a regular basis.
A client is postoperative following a graft reconstruction of the neck. What intervention is the most important for the nurse to complete with the client?
Assess the graft for color and temperature.
When assisting with preparing a client scheduled for a barium swallow, which of the following would be appropriate to include?
Avoid smoking for at least 12 to 24 hours before the procedure.
The liver performs numerous functions that contribute to homeostasis, including the synthesis of bile. How is bile utilized in the processes of digestion and absorption?
Bile is produced in the liver but released by the gallbladder when needed for digesting fats.
A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects the client's stools to have which description?
Black and tarry
Which of the following would a nurse expect to assess in a client with peritonitis?
Board-like abdomen
Which clinical manifestation is not associated with hemorrhage?
Bradycardia
A 56-year-old presented to her nurse practitioner because she had been experiencing unprecedented constipation and the passage of pencil-like stools despite her high fluid and fiber intake. The nurse recognized the need to assess the patient for colorectal cancer and ordered diagnostic evaluations. What component of the patient's blood work would be most indicative of the presence of cancer?
Carcinoembryonic antigen (CEA)
When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately?
Change in the client's handwriting and/or cognitive performance
The nurse is irrigating a client's colostomy when the client begins to report cramping. What is the appropriate action by the nurse?
Clamp the tubing and allow client to rest.
A patient is suspected to have diverticulosis without symptoms of diverticulitis. What diagnostic test does the nurse anticipate educating the patient about prior to scheduling?
Colonoscopy
A nurse administered a full strength feeding with an increased osmolality through a jejunostomy tube to a client. Immediately following the feeding, the client expelled a large amount of liquid brown stool and exhibited a blood pressure of 86/58 and pulse rate of 112 beats/min. The nurse
Consults with the physician about decreasing the feeding to half-strength
An older adult client seeks help for chronic constipation. What factor related to aging can cause constipation in elderly clients?
Decreased abdominal strength
Which is one of the primary symptoms of irritable bowel syndrome (IBS)?
Diarrhea
Which of the following appears to be a significant factor in the development of gastric cancer?
Diet
A client receives a local anesthetic to suppress the gag reflex for a diagnostic procedure of the upper GI tract. Which nursing intervention is advised for this client?
Do not give any food and fluids until the gag reflex returns.
A nurse is providing follow-up teaching at a clinic visit for a client recovering from gastric resection. The client reports sweating, diarrhea, nausea, palpitations, and the desire to lie down 15 to 30 minutes after meals. Based on the client's assessment, what will the nurse suspect?
Dumping syndrome
The nurse is performing a community screening for colorectal cancer. Which characteristic should the nurse include in the screening?
Familial polyposis
Which of the following is a function of the stomach? Select all that apply.
Food storage Secretion of digestive fluids Propels partially digested food into small intestine
Postoperatively, a client with a radical neck dissection should be placed in which position?
Fowler
A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate?
Gastroesophageal reflux disease
The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds?
Hyperactive The frequency and character of the sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minute. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation, but these assessments are highly subjective (Li, Wang, & Ma, 2012).
Review the following four examples of ideal body weight (IBW), actual weight, and body mass index (BMI). Using three criteria for each example, select the body weight that indicates morbid obesity.
IBW = 145 lbs; weight = 290 lbs; BMI = 31 kg/m2
The nurse is preparing to administer an IV fat emulsion simultaneously with parenteral nutrition (PN). What approach to the administration of a fat emulsion is appropriate?
IV fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered.
An 81-year-old patient of a subacute geriatric medical unit has become incontinent of stool over the past several days. This development has coincided with a decline in the patient's cognition as a result of severe Alzheimer's disease. In light of the patient's fecal incontinence, what nursing diagnosis should the nurse prioritize when planning this patient's care?
Impaired skin integrity related to fecal incontinence
A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.)
It can be caused by ingestion of strong acids." "You may have ingested some irritating foods." "Is it possible that you are overusing aspirin."
Which enzyme aids in the digestion of fats?
Lipase
A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?
Loss of 2.2 lb (1 kg) in 24 hours
A 49-year-old man with a history of heavy alcohol use and liver cirrhosis has been admitted to the hospital's medical unit due to an exacerbation of his health problems that has resulted in massive ascites. The nurse should be prepared to implement which of the following interventions in an effort to resolve the patient's ascites?
Low-sodium diet and administration of diuretics
Which is a true statement regarding gastric cancer?
Most clients are asymptomatic during the early stage of the disease.
What part of the GI tract begins the digestion of food?
Mouth
Peptic ulcer disease occurs more frequently in people with which blood type?
O
A client is actively bleeding from esophageal varices. Which medication would the nurse mostexpect to be administered to this client?
Octreotide
A nurse practitioner prescribes drug therapy for a patient with peptic ulcer disease. Choose the drug that can be used for 4 weeks and has a 90% chance of healing the ulcer.
Omeprazole
A nurse practitioner examined a patient who had been diagnosed with hepatomegaly (enlarged liver) due to accumulated fat deposits in the liver, subsequent to obesity. The nurse would palpate the liver by placing:
One hand under the right lower rib cage and press downward with the other hand.
Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit?
Pancreatitis
A 37-year-old male patient presents at the emergency department complaining of nausea and vomiting and severe abdominal pain. While the nurse is assessing the patient, the patient's wife informs the nurse that the patient ingested 24 ounces of vodka last evening. The patient's abdomen is rigid, and there is bruising to the patient's flank. What is the patient exhibiting signs of?
Pancreatitis with possible peritonitis
A client is in the hospital for the treatment of peptic ulcer disease. The client reports vomiting and a sudden severe pain in the abdomen. The nurse then assesses a board-like abdomen. What does the nurse suspect these symptoms indicate?
Perforation of the peptic ulcer
The nurse is caring for a client who is scheduled for a percutaneous liver biopsy. Which diagnostic test is obtained prior?
Prothrombin time (PT)
A group of students are studying for an examination on the gastrointestinal (GI) system and are reviewing the structures of the esophagus and stomach. The students demonstrate understanding of the material when they identify which of the following as the opening between the stomach and duodenum?
Pyloric sphincter
Following ingestion of carrots or beets, the nurse would expect which alteration in stool color?
Red
Over the past 2 years, a 51-year-old man has been admitted to the hospital five times for problems related to alcohol abuse, including falls, acute alcohol withdrawal, and cirrhosis. The man's current admission has been precipitated by signs and symptoms of alcoholic liver disease (ALD). The care team is reasonably pleased with the patient's recovery to this point and discharge planning has begun. When organizing the patient's discharge planning, what psychosocial nursing diagnosis should be prioritized?
Risk for ineffective management of therapeutic regimen
The nurse is providing care for a patient whose cancer has metastasized to her small intestine. What does the small intestine do? Select all that apply.
Secretion Absorption Movement of nutrients into the blood stream.
A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake?
Six small meals daily with 120 mL fluid between meals
The nurse is caring for a patient who is scheduled for a gastroscopy. What preparation is needed for a gastroscopy?
Spray or gargle the back of the throat with local anesthetic.
A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?
The client's hepatic function is decreasing.
The nurse is conducting an abdominal assessment of a patient who is postoperative day 1 following an open cholecystectomy. During auscultation of the patient's abdomen, the nurse has noted that clicks and gurgles are audible approximately every 10 seconds. How should the nurse follow up this assessment finding?
The nurse should document normoactive bowel sounds.
A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is board-like and no bowel sounds are detected. What is the major concern for this patient?
The patient has developed peritonitis.
Which nursing instruction is correct to provide the client following a barium enema?
The stools may be a white or clay colored.
The presence of mucus and pus in the stools suggests which condition?
Ulcerative colitis
Which of the following interventions are appropriate for clients with gastritis? Select all that apply
Use a calm approach to reduce anxiety. Discourage cigarette smoking. Notify the physician of indicators of hemorrhagic gastritis.
The nurse is assessing a client for constipation. Which factor should the nurse review first to identify the cause of constipation?
Usual pattern of elimination
Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?
Vasopressin
The following appears on the medical record of a male patient receiving parenteral nutrition:
WBC: 6500/cu mm Potassium 4.3 mEq/L Magnesium 2.0 mg/dL Calcium 8.8 mg/dL Glucose 190 mg/dL
A client is admitted to the emergency department with reports right lower quadrant pain. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the health care provider immediately?
White blood cell (WBC) count 22.8/mm3
A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:
alcohol abuse and smoking.
A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:
cirrhosis.
A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
drink liquids only between meals.
Diet therapy for clients diagnosed with irritable bowel syndrome (IBS) includes:
high-fiber diet.
Which response is a parasympathetic response in the GI tract?
increased peristalsis
A client with enteritis reports frequent diarrhea. What assessment should the nurse should anticipate?
metabolic acidosis
The nurse recognizes that the client diagnosed with a duodenal ulcer will likely experience
pain 2 to 3 hours after a meal.
Which condition is caused by improper catheter placement and inadvertent puncture of the pleura?
pneumothorax
Which client requires immediate nursing intervention? The client who:
presents with a rigid, board-like abdomen.
A client tells the nurse that the stool was colored yellow. The nurse assesses the client for
recent foods ingested.
The nurse cares for a client who receives feedings through a nasogastric (NG) tube and assesses the client for signs and symptoms of pulmonary complications. The nurse determines the client may be experiencing pulmonary complications when which sign is noted?
respiratory rate of 30
After assessing a client with peptic ulcer disease, the nurse notifies the health care provider because the nurse suspects that the client may be experiencing perforation. Which assessment finding would support the nurse's suspicion? Select all that apply.
severe upper abdominal pain vomiting board-like abdomen
The nurse is assisting the physician in a percutaneous liver biopsy. In assisting with positioning, the nurse should assist the client into a:
supine position.
The most significant complication related to continuous tube feedings is
the increased potential for aspiration.
A client has received a diagnosis of oral cancer. During client education, the client expresses dismay at not having recognized any early signs or symptoms of the disease. The nurse tells the client that in early stages of this disease:
there are usually no symptoms.
The nurse is assessing a client for constipation. To identify the cause of constipation, the nurse should begin by reviewing the client's:
usual pattern of elimination.
Clients with Type O blood are at higher risk for which of the following GI disorders?
Duodenal ulcers
The nurse is obtaining a history on a patient who comes to the clinic. What symptom described by the patient is one of the first symptoms associated with esophageal disease?
Dysphagia
Which finding would alert the nurse to a problem?
Glucose level
A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, labored breathing, and appears to be confused. Which complication has the client most likely developed?
Hemorrhage
A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should the nurse include in her teaching plan?
Increase respiratory effectiveness.
A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess?
Increasing difficulty in swallowing
A nursing student is caring for a client with gastritis. Which of the following would the student recognize as a common cause of gastritis? Choose all that apply.
Ingestion of strong acids Irritating foods Overuse of aspirin
The nurse is aware that many of the diseases of the lower gastrointestinal tract can be identified by the characteristics of the patient's stool. What would voluminous, greasy stools suggest?
Intestinal malabsorption
While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the liklihood of liver problems? Select all that apply.
Jaundice Petechiae Ecchymoses
A 40-year-old woman who had fulminant liver failure received a liver transplant 36 hours ago and is now receiving care in the intensive care unit. Which of the following aspects of nursing care addresses one of the major threats to this patient's health at this time?
Maintaining meticulous hand hygiene and infection control
When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?
Measure abdominal girth according to a set routine.
A nurse is giving a client barium swallow test. What is the most important assessment a nurse would make to ensure that a client does not retain any barium after a barium swallow?
Monitoring the stool passage and its color.
A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered?
Permit the client to drink only clear liquids.
One difference between cholesterol stones (left) and the stones on the right are that the ones on the right account for only 10% to 25% of cases of stones in the United States. What is the name of the stones on the right?
Pigment
A nurse is interviewing a client about past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
Polyps
A 54 year-old man is postoperative day 1 following neck dissection surgery. Which of the following nursing actions should the nurse prioritize in the care of this patient?
Positioning the patient in a high Fowler's position to protect the airway
The nurse conducts education related to test preparation for a client scheduled to undergo an abdominal ultrasonography. The nurse should give the client which instruction?
Restrict eating of solid food for 8 to 12 hours before the test.
A client informs the nurse that he is taking a stimulant laxative in order to be able to have a bowel movement daily. What should the nurse inform the client about taking a stimulant laxative?
They can be habit forming and will require increasing doses to be effective.
The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason?
To reduce gastric and pancreatic secretions
The nurse is assisting the health care provider with a colonoscopy for a client with rectal bleeding. The health care provider requests the nurse to administer glucagon during the procedure. Why is the nurse administering this medication during the procedure?
To relax colonic musculature and reduce spasm.
The client describes a test previously completed to detect a small bowel obstruction prior to admission to the hospital. The client states that the test involved insertion of a tube through the nose and lasted over 6 hours. The nurse determines which test name should be documented?
upper GI enteroclysis
