Gastrointestinal Disorders

The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy? 1. Gastrointestinal bleeding. 2. Hypoalbuminemia. 3. Splenomegaly. 4. Hyperaldosteronism.

1 **1. Blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy.** 2. Decreased albumin would cause the client to develop ascites. 3. An enlarged spleen increases the rate at which RBCs, WBCs, and platelets are destroyed, which causes the client to develop anemia, leukopenia, and thrombocytopenia, but not hepatic encephalopathy. 4. An increase in aldosterone causes sodium and water retention that, in turn, causes the devel- opment of ascites and generalized edema. TEST-TAKING HINT: Some questions require the test taker to have specific knowledge to be able to identify the correct answer. This is one (1) of these questions.

The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the unlicensed assistant warrants intervention by the primary nurse? 1. Assisting the client to take a hot soapy shower. 2. Applying an emollient to the client's legs and back. 3. Putting mittens on both hands of the client. 4. Patting the client's skin dry with a clean towel.

1 **1. Hot water increases pruritus, and soap will cause dry skin, which increases pruritus; therefore, the nurse should discuss this with the assistant.** 2. This will help prevent dry skin, which will help decrease pruritus; therefore this would not require any intervention by the primary nurse. 3. Mittens will help prevent the client from scratching the skin and causing skin break- down. 4. The skin should be patted dry, not rubbed, because rubbing the skin will cause increased irritation. TEST-TAKING HINT: A concept that is accepted for most clients during A.M. care is not to use hot water because it causes dilatation of vessels, which may cause orthostatic hypoten- sion. This is not the rationale for not using hot water with a client who has pruritus, but some- times the test taker can apply broad concepts when answering questions.

The nurse is caring for clients on a medical unit. Which client information should be brought to the attention of the HCP immediately? 1. A serum sodium of 128 mEq/L in a client diagnosed with obstipation. 2. The client diagnosed with fecal impaction who had two (2) hard formed stools. 3. A serum potassium level of 3.8 mEq/L in a client diagnosed with diarrhea. 4. The client with diarrhea who had two (2) semiliquid stools totaling 300 mL.

1 **1. Normal serum sodium levels are 135 to 152 mEq/L, so the client's 128 mEq/L value requires intervention.** 2. The client diagnosed with a fecal impaction is beginning to move the stool; this indicates an improvement. 3. Normal potassium levels are 3.5 to 5.5 mEq/L. A level of 3.8 mEq/L is within normal limits and does not require intervention. 4. This client has been having diarrhea and now is having semiliquid stools, so this client is getting better. TEST-TAKING HINT: The test taker must determine if the client is experiencing a potentially life-threatening complication, such as potential for seizures. Answer options "2," "3," and "4" are expected for the disease process and are normal or show improvement.

The nurse writes the client problem "imbalanced nutrition: less than body require- ments" for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care? 1. Provide a high-calorie intake diet. 2. Discuss total parenteral nutrition (TPN). 3. Instruct the client to decrease salt intake. 4. Encourage the client to increase water intake.

1 **1. Sufficient energy is required for healing. Adequate carbohydrate intake can spare protein. The client should eat approximately 16 carbohydrate kilocalories for each kilogram of ideal body weight daily.** 2. TPN is not routinely prescribed for the client with hepatitis; the client would have to have lost a large of amount of weight and be unable to eat anything for TPN to be ordered. 3. Salt intake does not affect the healing of the liver. 4. Water intake does not affect healing of the liver, and the client should not drink so much water as to decrease caloric food intake. TEST-TAKING HINT: The test taker should key in on "less than body requirement" in the stem and select the answer that addresses in- creasing calories, which eliminates options "3" and "4."

The public health nurse is teaching day-care workers. Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? 1. Hepatitis A. 2. Hepatitis B. 3. Hepatitis C. 4. Hepatitis D.

1 **1. The hepatitis A virus is in the stool of infected people up to two (2) weeks before symptoms develop.** 2. Hepatitis B virus is spread through contact with infected blood and body fluids. 3. Hepatitis C virus is transmitted through infected blood and body fluids. 4. Hepatitis D virus only causes infection in people who are also infected with hepatitis B or C. TEST-TAKING HINT: This is a knowledge question; the nurse must be aware of how the various types of hepatitis virus are transmitted.

the nurse caring for the pt 1 day post op sigmoid resection notes a moderate amount of dark reddish brown drainage on the midline abdominal incision. Which intervention is first? 1. Mark the drainage on the dressing with the time and date. 2. Change the dressing immediately using sterile technique. 3. Notify the health care provider immediately. 4. Reinforce the dressing with a sterile gauze pad.

1 **1. The nurse should mark the drainage on the dressing to determine if active bleeding is occurring, because dark reddish-brown drainage indicates old blood. This allows the nurse to assess what is actually happening.** 2. Surgical dressings are initially changed by the surgeon; the nurse should not remove the dressing until the surgeon orders the dressing change to be done by the nurse. 3. The nurse should assess the situation before notifying the HCP. 4. The nurse may need to reinforce the dressing if the dressing becomes saturated, but this would be after a thorough assessment is completed.

The client presents to the emergency department experiencing frequent watery, bloody stools after eating some undercooked meat at a fast-food restaurant. Which intervention should be implemented first? 1. Obtain a stool sample from the client. 2. Initiate antibiotic therapy intravenously. 3. Have the laboratory draw a complete blood count. 4. Administer the antidiarrheal medication Lomotil.

1 **1. This client may have developed an infection from the undercooked meat. The nurse should obtain a stool specimen for the laboratory to analyze.** 2. Antibiotic therapy is initiated in only the most serious cases of infectious diarrhea; the diarrhea must be assessed first. A specimen for culture should be obtained before beginning medication. 3. A complete blood count will provide an estimate of blood loss, but it is not the first intervention. 4. An antidiarrheal medication would be administered after the specimen collection. TEST-TAKING HINT: All options in a priority-setting question may be interventions the nurse could implement, but the right answer will be the one (1) implemented first. Collecting a stool sample is assessment, which is the first step in the nursing process.

The client has dark, watery, and shiny-appearing stool. Which intervention should the nurse implement first? 1. Check for a fecal impaction. 2. Encourage the client to drink fluids. 3. Check the chart for sodium and potassium levels. 4. Apply a protective barrier cream to the perianal area.

1 **1. This is a symptom of diarrhea moving around an impaction higher up in the colon. The nurse should assess for an impaction when observing this finding.** 2. Encouraging the client to drink fluids should be done, but not the first intervention. 3. The sodium level is usually not a problem for clients experiencing diarrhea, but the potassium level may be checked. However, again, this is not the first intervention. 4. A protective cream can be applied to an excoriated perineum, but first the nurse should assess the situation. TEST-TAKING HINT: The first step of the nursing process is assessment, after which a nursing diagnosis and interventions follow. The nurse should assess first.

The 85 y.o. male client diagnosed with colon cancer asks the nurse, "Why did I get colon cancer?" Which is best response about colon cancer? 1. "Research shows a lack of fiber in the diet can cause colon cancer." 2. "It is not common to get colon cancer at your age; it is usually in young people." 3. "No one knows why anyone gets cancer, it just happens to certain people." 4. "Women usually get colon cancer more often than men but not always."

1 1. A long history of low-fiber, high-fat, and high-protein diets results in a prolonged transit time. This allows the carcinogenic agents in the waste products to have a greater exposure to the lumen of the colon.** 2. The older the client, the greater the risk of developing cancer of the colon. 3. Risk factors for cancer of the colon include increasing age; family history of colon cancer or polyps; history of IBD; genital or breast cancer; and eating a high-fat, high-protein, low-fiber diet. 4. Males have a slightly higher incidence of colon cancers than do females.

The public health nurse is discussing hepatitis B with a group in the community. Which health promotion activities should the nurse discuss with the group? Select all that apply. 1. Do not share needles or equipment. 2. Use barrier protection during sex. 3. Get the hepatitis B vaccines. 4. Obtain immune globulin injections. 5. Avoid any type of hepatotoxic medications

1, 2, 3 **1. Hepatitis B can be transmitted by sharing any type of needles, especially those used by drug abusers. **2. Hepatitis B can be transmitted through sexual activity; therefore the nurse should recommend abstinence, mutual monog- amy, or barrier protection. **3. Three doses of hepatitis B vaccine provide immunity in 90% of healthy adults. 4. Immune globulin injections are administered as post-exposure prophylaxis (after being exposed to hepatitis B), but encouraging these injections is not a health promotion activity. 5. Hepatotoxic medications should be avoided in clients who have hepatitis or who have had hepatitis. The health-care provider prescribes medications, and the person in the community does not know which medications are hepato- toxic. TEST-TAKING HINT: In this select-all-that apply type question, there may be only one (1) correct answer, there may be several, or all five options may be correct answers.

The client is in end-stage liver failure and has vitamin K deficiency. Which interven- tions should the nurse implement? Select all that apply. 1. Avoid rectal temperatures. 2. Use only a soft toothbrush. 3. Monitor the platelet count. 4. Use small-gauge needles. 5. Assess for asterixis.

1, 2, 3, 4 **1. Vitamin K deficiency causes impaired coag- ulation; therefore rectal thermometers should be avoided to prevent bleeding. **2. Soft toothbrushes will help prevent bleed- ing of the gums. **3. Platelet count, PTT/PT, and INR should be monitored to assess coagulation status. **4. Injections should be avoided, if at all possi- ble, because the client is unable to clot, but if they are absolutely necessarily, the nurse should use small-gauge needles. 5. Asterixis is a flapping tremor of the hands when the arms are extended and indicates an elevated ammonia level, but it is not associated with vitamin K deficiency. TEST-TAKING HINT: The test taker must know the function of specific vitamins. Vitamin K is responsible for blood clotting. This is an alternate-type question, which requires the test taker to select all interventions that apply; the test taker should select interventions that address bleeding.

The nurse is planning the care of a client who has had an abdominal-perineal resection for cancer of the colon. Which interventions should the nurse implement? Select all that apply. 1. Provide meticulous skin care to stoma. 2. Assess the flank incision. 3. Maintain the indwelling catheter. 4. Irrigate the JP drains every shift. 5. Position the client semirecumbent.

1, 3, 5 **1. Colostomy stomas are openings through the abdominal wall into the colon, through which feces exit the body. Feces can be irritating to the abdominal skin, so careful and thorough skin care is needed. 2. There are midline and perineal incisions, not flank incisions. **3. Because of the perineal wound, the client will have an indwelling catheter to keep urine out of the incision. 4. Jackson Pratt drains are emptied every shift, but they are not irrigated. **5. The client should not sit upright because this causes pressure on the perineum. TEST-TAKING HINT: The test taker could eliminate option "2" because flank and abdominal-perineal are not in the same areas. This is an alternative-type question requiring the test taker to choose more than one (1) option.

The client diagnosed with AIDS is experiencing voluminous diarrhea. Which interventions should the nurse implement? Select all that apply. 1. Monitor diarrhea, charting amount, character, and consistency. 2. Assess the client's tissue turgor every day. 3. Encourage the client to drink carbonated soft drinks. 4. Weigh the client daily in the same clothes and at the same time. 5. Assist the client with a warm sitz bath PRN.

1, 4, 5 **1. It is important to keep track of the amounts, color, and other characteristics of body fluids excreted.** 2. Skin turgor should be assessed at least every six (6) to eight (8) hours, not daily. 3. Carbonated soft drinks increase flatus in the GI tract, and the increased sugar will act as an osmotic laxative and increase diarrhea. **4. Daily weights are the best method of determining fluid loss and gain.** **5. Sitz baths will assist in keeping the client's perianal area clean without having to rub. The warm water is soothing, providing comfort.** TEST-TAKING HINT: The test taker should note the time frame for any answer option. "Every day" is not often enough to assess for dehydration in a client who is experiencing massive ("voluminous") fluid loss. If the test taker were not aware of the definition, then an associated word, "volume," would be a hint.

Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? 1. Airborne precautions. 2. Standard precautions. 3. Droplet precautions. 4. Exposure precautions.

2 1. Airborne precautions are required for trans- mission that occurs by dissemination of either airborne droplet nuclei or dust particles containing the infectious agent. **2. Standard Precautions apply to blood, all body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood.** 3. Droplet transmission involves contact of the conjunctivae of the eyes or mucous membranes of the nose or mouth with large-particle droplets generated during coughing, sneezing, talking, or suctioning. 4. There is no such precaution known as expo- sure precautions. TEST-TAKING HINT: The test taker must know that standard precautions are used by all health-care workers who have direct contact with clients or with their body fluids or have indirect contact with objects used by the clients who are infected, such as would be involved in emptying trash, changing linens, or cleaning the room.

The nurse is caring for a client who uses cathartics frequently. Which statement made by the client indicates an understanding of the discharge teaching? 1. "In the future I will eat a banana every time I take the medication." 2. "I don't have to have a bowel movement every day." 3. "I should limit the fluids I drink with my meals." 4. "If I feel sluggish, I will eat a lot of cheese and dairy products."

2 1. Bananas are encouraged for clients with potassium loss from diuretics; a banana is not needed for harsh laxative (cathartic) use. Harsh laxatives should be discouraged because they cause laxative dependence and a narrowing of the colon with long-term use. **2. It is not necessary to have a bowel movement every day to have normal bowel functioning.** 3. Limiting fluids will increase the problem; the client should be encouraged to increase the fluids in the diet. 4. If the client is feeling "sluggish" from not being able to have a bowel movement, these foods increase constipation because they are low in residue (fiber). TEST-TAKING HINT: The test taker must understand words such as "cathartic." Limiting fluids is used for clients in renal failure or congestive heart failure, but increasing fluids is recommended for most other conditions.

The dietitian and the nurse in a long-term care facility are planning the menu for the day. Which foods should be recommended for the immobile clients for whom swallowing is not an issue? 1. Cheeseburger and milk shake. 2. Canned peaches and a sandwich on whole-wheat bread. 3. Mashed potatoes and mechanically ground red meat. 4. Biscuits and gravy with bacon.

2 1. Cheeseburgers and milk shakes are low-residue foods and can make constipation worse. **2. Canned peaches are soft and can be chewed and swallowed easily while providing some fiber; whole-wheat bread is higher in fiber than white bread. These foods will be helpful for clients whose gastric motility is slowed as a result of lack of exercise or immobility.** 3. Mashed potatoes and mechanically ground meat do not provide high fiber. 4. Biscuits, gravy, and bacon are refined flour foods or processed meat (fat). These will not help clients to prevent constipation. TEST-TAKING HINT: The test taker must realize the consequences of immobility include constipation.

The client is being admitted to the outpatient psychiatric clinic diagnosed with bulimia. Which question should the nurse ask to identify behaviors suggesting bulimia? 1. "When was the last time you exercised?" 2. "What over-the-counter medications do you take?" 3. "How long have you had a positive self-image?" 4. "Do you eat a lot of high-fiber foods for bowel movements?"

2 1. Clients diagnosed with anorexia exercise excessively; clients diagnosed with bulimia do not. **2. Clients diagnosed with bulimia frequently take cathartic laxatives to prevent absorption of calories from the food consumed.** 3. Clients diagnosed with bulimia and anorexia have low self-esteem. The client feels ugly or unlovable if he or she is overweight (by his or her perception). 4. High-fiber foods do help the body to produce larger stools, but this client would use a cathartic laxative. TEST-TAKING HINT: The test taker must distinguish between bulimia and anorexia to answer this question. Clients with anorexia are usually underweight, whereas clients with bulimia may be of a normal or slightly larger size.

The client with a new colostomy is being discharged. Which statement made by the client indicates the need for further teaching? 1. "If I notice any skin breakdown, I will call the HCP." 2. "I should drink only liquids until the colostomy starts to work." 3. "I should not take a tub bath until the HCP okays it." 4. "I should not drive or lift more than five (5) pounds."

2 1. If the tissue around the stoma becomes excoriated, the client will be unable to pouch the stoma adequately, resulting in discomfort and leakage. The client understands the teaching. **2. The client should be on a regular diet, and the colostomy will have been working for several days prior to discharge. The client's statement indicates the need for further teaching.** 3. Until the incision is completely healed, the client should not sit in bath water because of the potential contamination of the wound by the bath water. The client understands the teaching. 4. The client has had major surgery and should limit lifting to minimal weight. The client understands the teaching.

The 22-year-old female who is obese is discussing weight loss programs with the nurse. Which information should the nurse teach? 1. Jog for two (2) to three (3) hours every day. 2. Lifestyle behaviors must be modified. 3. Eat one (1) large meal every day in the evening. 4. Eat 1,000 calories a day and don't take vitamins.

2 1. Jogging is not an appropriate exercise for a client who is obese: there is too much stress on the heart and joints. **2. If lifestyle behaviors such as patterns of eating and daily exercise are not modified, the client who loses weight will regain the weight and usually more.** 3. The client should eat frequent small meals during the day to keep from being hungry. Breakfast should not be skipped. 4. Diets containing fewer than 1,200 calories per day need to be supplemented with a multivitamin to provide the body with the nutrients needed to stay healthy. TEST-TAKING HINT: The test taker could eliminate answer option "4" because health-care professionals should not discourage health promotion activities.

Which instruction should the nurse discuss with the client who is in the icteric phase of hepatitis C? 1. Decrease alcohol intake. 2. Encourage rest periods. 3. Eat a large evening meal. 4. Drink diet drinks and juices.

2 1. The client must avoid alcohol altogether, not decrease intake, to prevent further liver damage and promote healing. **2. Adequate rest is needed for maintaining optimal immune function.** 3. Clients are more often anorexic and nauseated in the afternoon and evening; therefore the main meal should be in the morning. 4. Diet drinks and juices provide few calories, and the client needs an increased caloric diet for healing. TEST-TAKING HINT: The test taker must be aware of key words in both the stem and answer options. The "icteric" phase means the acute phase. The word "decrease" should cause the test taker to eliminate "1" as a possi- ble correct answer, and "large" should cause the test taker to eliminate "3" as a possible correct answer.

The client diagnosed with end-stage liver failure is admitted to the medical unit diag- nosed with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogas- tric tube (Sengstaken-Blakemore). Which nursing action should the nurse implement for this treatment? 1. Assess the gag reflex every shift. 2. Stay with the client at all times. 3. Administer the laxative lactulose (Chronulac). 4. Monitor the client's ammonia level.

2 1. The client's throat is not anesthetized during the insertion of a nasogastric tube, so the gag reflex does not need to be assessed. **2. While the balloons are inflated, the client must not be left unattended in case they become dislodged and occlude the airway. This is a safety issue.** 3. This laxative is administered to decrease the ammonia level, but the question does not say that the client's ammonia level is elevated. 4. Esophageal bleeding does not cause the ammonia level to be elevated. TEST-TAKING HINT: In most cases, the test taker should not select an option that contains the word "all," but in some instances, it may be the correct answer. Although the ammonia level is elevated in liver failure, the test taker must be clear as to what the question is asking. "Inflate" is the key to answering the question correctly.

The female nurse sticks herself with a dirty needle. Which action should the nurse implement first? 1. Notify the infection control nurse. 2. Cleanse the area with soap and water. 3. Request post-exposure prophylaxis. 4. Check the hepatitis status of the client.

2 1. The nurse must notify the infection control nurse as soon as possible so that treatment can start if needed, but this is not the first intervention. **2. The nurse should first clean the needle stick with soap and water to help remove any virus that is on the skin.** 3. Post-exposure prophylaxis may be needed, but this is not the first action. 4. The infection control nurse will check the status of the client that the needle was used on before the nurse stuck herself. TEST-TAKING HINT: The question requires the test taker to identify the first intervention. The test taker should think about which intervention will directly help the nurse—and that is to clean the area.

The client complains to the nurse of unhappiness with the health-care provider. Which intervention should the nurse implement next? 1. Call the HCP and suggest he or she talk with the client. 2. Determine what about the HCP is bothering the client. 3. Notify the nursing supervisor to arrange a new HCP to take over. 4. Explain the client cannot request another HCP until after discharge.

2 1. The nurse should first assess the situation prior to informing the HCP of the client's concerns and then allow the HCP and client to discuss the situation. **2. The nurse should determine what is concerning the client. It could be a misunderstanding or a real situation where the client's care is unsafe or inadequate.** 3. If a new HCP is to be arranged, it is the HCP's responsibility to arrange for another HCP to assume responsibility for the care of the client. 4. The choice of HCP is ultimately the client's. If the HCP cannot arrange for another HCP, the client may be discharged and obtain a new health-care provider.

The client diagnosed with liver problems asks the nurse, "Why are my stools clay-colored?" On which scientific rationale should the nurse base the response? 1. There is an increase in serum ammonia level. 2. The liver is unable to excrete bilirubin. 3. The liver is unable to metabolize fatty foods. 4. A damaged liver cannot detoxify vitamins.

2 1. The serum ammonia level is increased in liver failure, but it is not the cause of clay-colored stools. **2. Bilirubin, the byproduct of red blood cell destruction, is metabolized in the liver and excreted via the feces, which is what gives the feces the dark color. If the liver is damaged, the bilirubin is excreted via the urine and skin.** 3. The liver excretes bile into the gallbladder and the body uses the bile to digest fat, but it does not affect the feces. 4. Vitamin deficiency, resulting from the liver's inability to detoxify vitamins, may cause steatorrhea, but it does not cause clay-colored stool. TEST-TAKING HINT: The test taker should have a grasp of physiology to help answer this ques- tion. Clay-colored stool indicates no color in the feces. Because color in the feces is caused by bilirubin, lack of color would be the result of the liver's inability to excrete biliru- bin.

The charge nurse has just received the shift report. Which client should the nurse see first? 1. The client diagnosed with Crohn's disease who had two (2) semiformed stools on the previous shift. 2. The elderly client admitted from another facility who is complaining of constipation. 3. The client diagnosed with AIDS who had a 200-mL diarrhea stool and has elastic skin tissue turgor. 4. The client diagnosed with hemorrhoids who had some spotting of bright red blood on the toilet tissue.

2 1. This client is improving; semiformed stools are better than diarrhea. **2. This client has just arrived, so the nurse does not know if the complaint is valid and needs intervention unless assessed. The elderly have difficulty with constipation as a result of decreased gastric motility, medications, poor diet, and immobility.** 3. The client has diarrhea, but only 200 mL, and has elastic tissue turgor indicating the client is not dehydrated. 4. This is not normal, but it is expected for a client with hemorrhoids. TEST-TAKING HINT: The test taker should notice descriptive words such as "elderly," which should alert the test taker to the age range having an implication in answering the question. Answer options "3" and "4" are expected for the disease processes.

The client with hepatitis asks the nurse, "I went to an herbalist, who recommended I take milk thistle. What do you think about that?" Which statement is the nurse's best response? 1. "You are concerned about taking an herb." 2. "The herb has been used to treat liver disease." 3. "I would not take anything that is not prescribed." 4. "Why would you want to take any herbs?"

2 1. This is a therapeutic response and the nurse should provide factual information. **2. Milk thistle has an active ingredient, silymarin, which has been used to treat liver disease for more than 2000 years. It is a powerful oxidant and promotes liver cell growth.** 3. The nurse should not discourage complemen- tary therapies. 4. This is a judgmental statement and the nurse should encourage the client to ask questions. TEST-TAKING HINT: The test taker may not have any idea what milk thistle is but should apply test-taking strategies that include not select- ing options with "why" ("4") unless interview- ing the client. Only use therapeutic responses when unable to provide factual information. At times, the test taker may not like any answer option but should always apply the rules to help determine the correct answer.

The nurse identifies the client problem as "excess fluid volume" for the client in liver failure. Which short-term goal would be most appropriate for this problem? 1. The client will not gain more that two (2) kg a day. 2. The client will have no increase in abdominal girth. 3. The client's vital signs will remain within normal limits (WNL). 4. The client will receive a low-sodium diet.

2 1. Two (2) kg is more than four (4) pounds, which indicates severe fluid retention and is not an appropriate goal. **2. Excess fluid volume could be secondary to portal hypertension. Therefore, no increase in abdominal girth would be an appropriate short-term goal, indicating no excess of fluid volume.** 3. Vital signs are appropriate to monitor, but they do not yield specific information about fluid volume status. 4. Having the client receive a low-sodium diet does not ensure that the client will comply with the diet. The short-term goal must evaluate if the fluid volume is within normal limits. TEST-TAKING HINT: Remember that goals evaluate the interventions; therefore option "4" could be eliminated as the correct answer because it is an intervention, not a goal. Short-term weight fluctuations tend to reflect fluid balance, and any weight gain in 24 hours indicates retention of fluid, which is not an appropriate goal.

The client is admitted with end-stage liver failure and is prescribed the laxative lactulose (Chronulac). Which statement indicates the client needs more teaching concern- ing this medication? 1. "I should have two to three soft stools a day." 2. "I must check my ammonia level daily." 3. "If I have diarrhea, I will call my doctor." 4. "I should check my stool for any blood."

2 1. Two to soft three stools a day indicates the medication is effective. **2. There is no instrument that can be used at home to test daily ammonia levels. The ammonia level is a serum level that requires venipuncture and laboratory diagnostic equipment.** 3. Diarrhea indicates an overdosage, possibly requiring that the dosage be decreased. The HCP would need to make this change in dosage, so the client is correct. 4. The client should check the stool for bright- red blood as well as dark, tarry stool. TEST-TAKING HINT: This is an "except" ques- tion. The test taker must realize that three (3) options indicate an understanding of the teaching. If the test taker does not know the answer, notice that all the options except "2" have something to do with stool, and laxative affects the stool.

The nurse is caring for pts in an outpatient clinic. Which info should the nurse teach regarding the American Cancer Society's recommendations for early detection of colon cancer? 1. Beginning at age 60, a digital rectal exam should be done annually. 2. After pt reaches middle age, yearly fecal occult test. 3. At age 50, a colonoscopy, then once every 5-10 years. 4. A flexible sigmoidoscopy should be done yearly after age 40.

3 1. A digital rectal examination is done to detect prostate cancer and should be started at age 40 years. 2. "Middle age" is a relative term; specific ages are used for recommendation. **3. The American Cancer Society recommends a colonoscopy at age 50 and every five (5) to 10 years thereafter, and a flexible sigmoidoscopy and a barium enema every five (5) years.** 4. A flexible sigmoidoscopy should be done at five (5)-year intervals between the colonoscopy. TEST-TAKING HINT: A digital examination is an examination performed by the examiner's finger and does not examine the entire colon.

The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented? 1. Administer an antidiarrheal medication every day and PRN. 2. Perform bowel training every two (2) hours. 3. Administer an oil retention enema. 4. Prepare for an upper gastrointestinal (UGI) series x-ray.

3 1. An antidiarrheal medication would slow down the peristalsis in the colon, worsening the problem. 2. The client has an immediate need to evacuate the bowel, not a need for bowel training. **3. Oil retention enemas will help to soften the feces and evacuate the stool.** 4. A UGI series adds barium to the already hardened stool in the colon. Barium enemas x-ray the colon; a UGI series x-rays the stomach and jejunum. TEST-TAKING HINT: If the test taker understands fecal impaction is the opposite of diarrhea, then answer option "1" can be eliminated. Knowledge of anatomy and physiology eliminates option "4" because stool is formed in the colon and transported to the anus, part of the lower gastrointestinal tract.

The client is in end-stage liver failure. Which gastrointestinal assessment data would the nurse expect to find when assessing the client? 1. Hypoalbuminemia and muscle wasting. 2. Oligomenorrhea and decreased body hair. 3. Clay-colored stools and hemorrhoids. 4. Dyspnea and caput medusae.

3 1. Hypoalbuminemia, decreased albumin, and muscle wasting are metabolic effects, not gastrointestinal effects. 2. Oligomenorrhea is no menses, which is a reproductive effect, and decreased body hair is an integumentary effect. **3. Clay-colored stools and hemorrhoids are gastrointestinal effects of liver failure.** 4. Dyspnea is a respiratory effect, and caput medusae (dilated veins around the umbilicus) is an integumentary effect, although it is on the abdomen. TEST-TAKING HINT: The adjective "gastroin- testinal" is the key word that guides the test taker to select the correct answer. The test taker must rule out options that do not involve gastrointestinal symptoms. Although liver fail- ure affects every body system, the question asks for a gastrointestinal effect.

Which assessment question would be priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis? 1. How many years have you been drinking alcohol? 2. Have you completed an advanced directive? 3. When did you have your last alcoholic drink? 4. What foods did you eat at your last meal?

3 1. It really doesn't matter how long the client has been drinking alcohol. The diagnosis of alcoholic cirrhosis indicates the client has probably been drinking for many years. 2. An advance directive is important for the client who is terminally ill, but it is not the priority question. **3. The nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol.** 4. This is not a typical question asked by the nurse unless the client is malnourished, which is not information given in the stem. TEST-TAKING HINT: Because the word "alcohol" is in the stem of the question, and if the test taker had no idea what the correct answer is, the test taker should select options that have the word "alcohol" in them and look closely at options "1" and "3."

The client has had a liver biopsy. Which post-procedure intervention should the nurse implement? 1. Instruct the client to void immediately. 2. Keep the client NPO for eight (8) hours. 3. Place the client on the right side. 4. Monitor blood urea nitrogen (BUN) and creatinine level.

3 1. The client should empty the bladder immedi- ately prior to the liver biopsy, not after the procedure. 2. Foods and fluids are usually withheld two (2) hours after the biopsy, after which the client can resume the usual diet. **3. Direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure.** 4. BUN and creatinine levels are monitored for kidney function, not liver function, and the renal system is not affected with the liver biopsy. TEST-TAKING HINT: The adjective "post-proce- dure" should help the test taker rule out option "1." Knowing the anatomical position of the liver should help the test taker select "3" as the correct answer. The test taker must know laboratory data for each organ, which would help rule out "4" as a possible correct answer.

The patient presents with a complete blockage of the large intestine from a large tumor. Which HCP's order would the nurse question? 1. Obtain consent for a colonoscopy and biopsy. 2. Start an IV of 0.9% saline at 125 mL/hr. 3. Administer 3 liters of Go Lytely. 4. Give tap water enemas until it is clear.

3 1. The client will need to have diagnostic tests, so this is an appropriate intervention. 2. The client who has an intestinal blockage will need to be hydrated. **3. This client has an intestinal blockage from a solid tumor blocking the colon. Although the client needs to be cleaned out for the colonoscopy, GoLYTELY could cause severe cramping without a reasonable benefit to the client and could cause a medical emergency.** 4. Tap water enemas until clear would be instilling water from below the tumor to try to rid the colon of any feces. The client can expel this water.

Which task would be most appropriate for the nurse to delegate to the unlicensed nursing assistant? 1. Draw the serum liver function test. 2. Evaluate the client's intake and output. 3. Assist the client to the bedside commode. 4. Help the ward clerk transcribe orders.

3 1. The laboratory technician draws serum blood studies, not the nursing assistant. 2. The nursing assistant can obtain the intake and output, but the nurse must evaluate the data to determine if the results are normal for the client's disease process or condition. **3. The nursing assistant can assist a client to the bedside commode.** 4. The ward clerk has specific training that allows the transcribing of health-care provider orders. TEST-TAKING HINT: The test taker must be knowledgeable of delegation rules; the nurse cannot delegate assessing, teaching, medication administration, evaluating, and any task for an unstable client.

The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task would be most appropriate to assign to the LPN? 1. Assist the UAP to learn to perform blood glucose checks. 2. Monitor the potassium levels of a client with diarrhea. 3. Administer a bulk laxative to a client diagnosed with constipation. 4. Assess the abdomen of a client who has had complaints of pain.

3 1. The nurse will be responsible for signing off on the UAP as to being competent to perform the blood glucose. The nurse should do this to determine the competency of the UAP. 2. The laboratory values may require the nurse to interpret and act on the results. The nurse cannot delegate tasks requiring professional judgment. **3. The LPN can administer medications such as a laxative.** 4. The nurse cannot delegate assessment.

The client diagnosed with end-stage renal failure with ascites is scheduled for a para- centesis. Which client teaching should the nurse discuss with the client? 1. Explain that the procedure will be done in the operating room. 2. Instruct the client that a Foley catheter will have to be inserted. 3. Tell the client that vital signs will be taken frequently after the procedure. 4. Provide instructions on holding the breath when the HCP inserts the catheter.

3 1. The procedure is done in the client's room, with the client either seated on the side of the bed or in a chair. 2. The client should empty the bladder prior to the procedure to avoid bladder puncture, but there is no need for a Foley catheter to be inserted. **3. The client is at risk for hypovolemia; there- fore, vital signs will be assessed frequently to monitor for signs of hemorrhaging.** 4. The client does not have to hold the breath when the catheter is inserted into the peri- toneum; this is done when obtaining a liver biopsy. TEST-TAKING HINT: If the test taker had no idea what the answer is, knowing that vital signs are assessed after all procedures should make the test taker select this option.

The client is diagnosed with end-stage liver failure. The client asks the nurse, "Why is my doctor decreasing the doses of my medications?" Which statement is the nurse's best response? 1. "You are worried that your doctor has decreased the dosage." 2. "You really should ask your doctor. I am sure there is a good reason." 3. "You may have an overdose of the medication because your liver is damaged." 4. "The half-life is altered because the liver is damaged."

3 1. This is a therapeutic response and used to encourage the client to verbalize feelings, but it does not provide factual information. 2. This is passing the buck; the nurse should be able to answer this question. *3. This is the main reason the HCP decreases the client's medication dose, and it is an explanation appropriate for the client.** 4. This is the medical explanation as to why the medication dose is decreased, but it should not be used to explain to a layperson. TEST-TAKING HINT: The test taker should provide factual information when the client asks "why." Therefore, "1" and "2" could be eliminated as possible correct answers. Both "3" and "4" explain the rationale for decreasing the medication dose, but the nurse should answer in terms the client can understand. Would a layperson know what half-life means?

The clinic nurse is talking on the phone to a client who has diarrhea. Which intervention should the nurse discuss with the client? 1. Tell the client to measure the amount of stool. 2. Recommend the client come to the clinic immediately. 3. Explain the client should follow the BRAT diet. 4. Discuss taking an over-the-counter histamine-2 blocker.

3 1. The clinic nurse should not ask the client to measure stool at home; this is done in the acute care setting. 2. Unless the client has had diarrhea for longer than 48 hours, the client does not need to be seen in the clinic. **3. The BRAT (bananas, rice, applesauce, and toast) diet is recommended for a client with diarrhea because it is low residue and produces nutrition while not irritating the GI system.** 4. Histamine-2 blockers decrease gastric acid production and would not be prescribed for a client with diarrhea.

The client has been experiencing difficulty and straining when expelling feces. Which intervention should the nurse discuss with the client? 1. Explain some blood in the stool will be normal for the client. 2. Instruct the client in manual removal of feces. 3. Encourage the client to use a cathartic laxative on a daily basis. 4. Place the client on a high-fiber diet.

4 1. Blood may indicate a hemorrhoid, but it is not normal to expel blood when having a bowel movement. 2. Nurses manually remove feces; it is not a self-care activity. 3. Cathartic use on a daily basis creates dependence and a narrowing of the lumen of the colon, creating a much more serious problem. **4. A high-fiber (residue) diet provides bulk for the colon to use in removing the waste products of metabolism. Bulk laxatives and fiber from vegetables and bran assist the colon to work more effectively.** TEST-TAKING HINT: Blood is not normal in any circumstance. It may be expected but is not "normal" unless inside a vessel.

The client is in the preicteric phase of hepatitis. Which signs/symptoms would the nurse expect the client to exhibit during this phase? 1. Clay-colored stools and jaundice. 2. Normal appetite and pruritus. 3. Being afebrile and left upper quadrant pain. 4. Complaints of fatigue and diarrhea.

4 1. Clay-colored stools and jaundice occur in the icteric phase of hepatitis. 2. These signs/symptoms occur in the icteric phase of hepatitis. 3. Fever subsides in the icteric phase, and the pain is in the right upper quadrant. ***4. "Flu-like" symptoms are the first com- plaints of the client in the preicteric phase of hepatitis, which is the initial phase and may begin abruptly or insidiously.** TEST-TAKING HINT: The test taker must use anatomy knowledge in ruling out incorrect answers; "3" could be ruled out because the liver is in the right upper quadrant.

The school nurse is discussing ways to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the most important intervention that the school nurse must explain to the school teachers? 1. Do not allow students to eat or drink after each other. 2. Drink bottled water as much as possible. 3. Encourage protected sexual activity. 4. Thoroughly wash hands.

4 1. Eating after each other should be discouraged, but it is not the most important intervention. 2. Only bottled water should be consumed in Third World countries, but that precaution is not necessary in American high schools. 3. Hepatitis B and C, not hepatitis A, are trans- mitted by sexual activity. **4. Hepatitis A is transmitted via the fecal-oral route. Good hand washing helps to prevent its spread.** TEST-TAKING HINTS: The test taker must real- ize that good hand washing is the most impor- tant action in preventing transmission of any of the hepatitis viruses. Often, the test taker will not select the answer option that seems too easy—but remember, do not overlook the obvious.

The nurse writes a psychosocial problem of "risk for altered sexual functioning related to new colostomy. Which intervention should the nurse implement? 1. Tell pt. that there should be no intimacy for at least 3 months. 2. Ensure that the pt and partner are able to change the ostomy pouch. 3. Demonstrate with charts possible sexual positions for the pt. to assume. 4. Teach the pt. to protect the pouch from being dislodged during sex.

4 1. Intimacy involves more than sexual intercourse. The client can be sexually active whenever the wounds are healed sufficiently to not cause pain. 2. This is an appropriate nursing intervention for home care, but it has nothing to do with sexual activity. 3. The nurse is not a sexual counselor who would have these types of charts. The nurse should address sexuality with the client but would not be considered an expert capable of explaining the advantages and disadvantages of sexual positioning. **4. A pouch that becomes dislodged during the sexual act would cause embarrassment for the client, whose body image has already been dealt a blow.** TEST-TAKING HINT: Option "2" does not address the issue and option "3" is outside of the nurse's professional expertise. Option "1" could be eliminated because of the word "no," which is an absolute word.

The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication? 1. Restrict sodium intake to 2 g/day. 2. Limit oral fluids to 1500 mL/day. 3. Decrease the daily fat intake. 4. Reduce protein intake to 60 to 80 g/day.

4 1. Sodium is restricted to reduce ascites and gene- ralized edema, not for hepatic encephalopathy. 2. Fluids are calculated based on diuretic therapy, urine output, and serum electrolyte values; fluids do not affect hepatic encephalopathy. 3. A diet high in calories and moderate in fat intake is recommended to promote healing. **4. Ammonia is a byproduct of protein metab- olism and contributes to hepatic encepha- lopathy. Reducing protein intake should decrease ammonia levels.** TEST-TAKING HINT: The test taker could elimi- nate options "1" and "2" based on the knowl- edge that sodium and water work together and address edema, not encephalopathy. The test taker's knowledge of biochemistry—protein breaks down to ammonia, carbohydrates break down to glucose, and fat breaks down to ketones—may be helpful in selecting the correct answer.

The 36-year-old female client diagnosed with anorexia nervosa tells the nurse "I am so fat. I won't be able to eat today." Which response by the nurse is most appropriate? 1. "Can you tell me why you think you are fat?" 2. "You are skinny. Many women wish they had your problem." 3. "If you don't eat, we will have to restrain you and feed you." 4. "Not eating might cause physical problems."

4 1. The client does not have to explain her actions to the nurse; the nurse should not ask "why." 2. Telling the client she is skinny is belittling the client. 3. The client is 36 years old and has the right to refuse to eat, even to the detriment of her body. Restraining the client could be considered assault unless the psychiatric team had a court order. **4. "Might cause physical problems" is a factual statement to the client about the possible results if the client refuses nourishment.**

The client is placed on percutaneous endoscopic gastrostomy (PEG) tube feedings. Which occurrence warrants immediate intervention by the nurse? 1. The client tolerates the feedings being infused at 50 mL/hr. 2. The client pulls the nasogastric feeding tube out. 3. The client complains of being thirsty. 4. The client has green, watery stool.

4 1. The client is tolerating the feeding change, so there is no need for an immediate action. 2. The client has a PEG tube inserted into the stomach through the abdominal wall. The client does not have a nasogastric feeding tube. 3. Complaints of being thirsty should be addressed; the client may require some ice chips in the mouth or oral care, but this is not priority over assessing the client's ability to swallow. **4. This client needs to be cleaned immediately, the abdomen must be assessed, and a determination must be made regarding the type of feeding and the additives and medications being administered and skin damage occurring. This occurrence is priority.**

Which statement by the client diagnosed with hepatitis warrants immediate intervention by the clinic nurse? 1. "I will not drink any type of beer or mixed drink." 2. "I will get adequate rest so that I don't get exhausted." 3. "I had a big hearty breakfast this morning." 4. "I took some cough syrup for this nasty head cold."

4 1. The client should avoid alcohol to prevent further liver damage and promote healing 2. Rest is needed for healing of the liver and to promote optimum immune function. 3. Clients with hepatitis need increased caloric intake, so this is a good statement. ***4. The client needs to understand that some types of cough syrup have alcohol and all alcohol must be avoided to prevent further injury to the liver; therefore this statement requires intervention.** TEST-TAKING HINT: If the test taker did not know the answer, the test taker could apply the rule that any over-the-counter (OTC) medications should be avoided unless approved by a health-care provider.

The client who has had an abdominal perineal resection is being discharged. Which info should nurse teach? 1. The stoma should be a white, blue, or purple color. 2. Limit ambulation to prevent the pouch from coming off. 3. Take pain medication when the pain level is at an "8." 4. Empty the pouch when it is one-third to one-half full.

4 1. The stoma should be light to a medium pink, the color of the intestines. A blue or purple color indicates a lack of circulation to the stoma and is a medical emergency. 2. The stoma should be pouched securely for the client to be able to participate in normal daily activities. The client should be encouraged to ambulate to aid in recovery. 3. Pain medication should be taken before the pain level reaches a "5." Delaying taking medication will delay the onset of pain relief and the client will not receive full benefit from the medication. **4. The pouch should be emptied when it is one-third to one-half full to prevent the contents from becoming too heavy for the seal to hold and to prevent leakage from occurring.**

Which oral medication should the nurse question before administering to the client with peptic ulcer disease? 1. E-mycin, an antibiotic. 2. Prilosec, a proton pump inhibitor. 3. Flagyl, an antimicrobial agent. 4. Tylenol, a nonnarcotic analgesic.

1 **1. E-mycin is irritating to stomach, and its use in a client with peptic ulcer disease should be questioned.** 2. Prilosec, a proton pump inhibitor, decreases gastric acid production, and its use should not be questioned by the nurse. 3. Flagyl, an antimicrobial, is administered to treat peptic ulcer disease secondary to H. pylori bacteria. 4. Tylenol can be safely administered to a client with peptic ulcer disease.

The client has an eviscerated abdominal wound. Which intervention should the nurse implement? 1. Apply sterile normal saline dressing. 2. Use sterile gloves to replace protruding parts. 3. Place the client in reverse Trendelenburg position. 4. Administer intravenous antibiotic STAT.

1 **1. Evisceration is a life-threatening condition in which the abdominal contents protrude through the ruptured incision. The nurse must protect the bowel from the environment by placing a sterile normal saline gauze on it, which prevents the intestines from drying out and necrosing.** 2. The nurse should not attempt to replace the protruding bowel. 3. This position places the client with the head of the bed elevated, which will make the situation worse. 4. Antibiotics will not protect the protruding bowels, which must be priority. Antibiotics will be administered at a later time to prevent infection, but this is not urgent. TEST-TAKING HINT: The test taker must understand the word "evisceration" to answer this question.

Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning? 1. Fluid volume deficit. 2. Nausea. 3. Risk for aspiration. 4. Impaired urinary elimination.

1 **1. Fluid volume deficit secondary to diarrhea is the priority because of the potential for metabolic acidosis and hypokalemia, which are both life threatening, especially in the elderly.** 2. Nausea may occur, but it is not priority. However, excessive vomiting could lead to potential complications. 3. Risk for aspiration could result from vomiting; however, vomiting does not usually occur in food poisoning, but it may be secondary to botulism. 4. Impaired urinary elimination is not a priority. The client has diarrhea, not urine output problems. TEST-TAKING HINT: Always notice the client's age because it is usually a significant clue as to the correct answer. Prioritizing questions may have more than one (1) potential appropriate nursing problem but only one (1) has priority. Remember Maslow's hierarchy of needs

The nurse is caring for an adult client diagnosed with GERD. Which condition is the most common comorbid disease associated with GERD? 1. Adult-onset asthma. 2. Pancreatitis. 3. Peptic ulcer disease. 4. Increased gastric emptying.

1 **1. Of adult-onset asthma cases, 80% to 90% are caused by gastroesophageal reflux disease (GERD).** 2. Pancreatitis is not related to GERD. 3. Peptic ulcer disease is related to H. pylori bacterial infections and can lead to increased levels of gastric acid, but it is not related to reflux. 4. GERD is not related to increased gastric emptying. Increased gastric emptying would be a benefit to a client with decreased functioning of the lower esophageal sphincter. TEST-TAKING HINT: Some questions are knowledge-based. There are no test-taking strategies for knowledge-based questions.

The nurse is performing an admission assessment on a client diagnosed with GERD. Which signs and symptoms would indicate GERD? 1. Pyrosis, water brash, and flatulence. 2. Weight loss, dysarthria, and diarrhea. 3. Decreased abdominal fat, proteinuria, and constipation. 4. Midepigastric pain, positive H. pylori test, and melena.

1 **1. Pyrosis is heartburn, water brash is the feeling of saliva secretion as a result of reflux, and flatulence is gas—all symptoms of GERD.** 2. Gastroesophageal reflux disease does not cause weight loss. 3. There is no change in abdominal fat, no proteinuria (the result of a filtration problem in the kidney), and no alteration in bowel elimination for the client diagnosed with GERD. 4. Midepigastric pain, a positive H. pylori test, and melena are associated with gastric ulcer disease. TEST-TAKING HINT: Frequently, incorrect answer options will contain the symptoms of a disease of the same organ system.

The client is diagnosed with salmonellosis secondary to eating some slightly cooked hamburger meat. Which clinical manifestations should the nurse expect the client to report? 1. Abdominal cramping, nausea, and vomiting. 2. Neuromuscular paralysis and dysphagia. 3. Gross amounts of explosive bloody diarrhea. 4. Frequent "rice water stool" with no fecal odor.

1 **1. Symptoms develop 8 to 48 hours after ingesting the Salmonella bacteria and include diarrhea, abdominal cramping, nausea, and vomiting, along with low-grade fever, chills, and weakness.** 2. Neuromuscular paralysis and dysphagia occur with botulism, a severe lifethreatening form of food poisoning caused by Clostridium botulinum. 3. Gross explosive bloody diarrhea is a clinical manifestation of hemorrhagic colitis caused by Escherichia coli. 4. Gray-cloudy diarrhea with no fecal odor, blood, or pus is caused by cholera, which is endemic in parts of Asia, the Middle East, and Africa. TEST-TAKING HINT: Often when two (2) options have the same clinical manifestation, such as diarrhea and stool, this should make the test taker realize either one of these two (2) options is correct, so the other two (2) options can be eliminated, or both are incorrect.

The client who had an abdominal surgery has a Jackson Pratt (JP) drainage tube. Which assessment data warrant immediate intervention by the nurse? 1. The bulb is round and has 40 mL of fluid. 2. The drainage tube is taped to the dressing. 3. The JP insertion site is pink and has no drainage. 4. The JP bulb has suction and is sunken in.

1 **1. The JP bulb should be depressed, which indicates suction is being applied. A round bulb indicates the bulb is full and needs to be emptied and suction reapplied.** 2. The tube should be taped to the dressing to prevent accidentally pulling the drain out of the insertion site. 3. The insertion site should be pink and without any signs of infection, which include drainage, warmth, and redness. 4. The JP bulb should be sunken in or depressed, indicating suction is being applied. TEST-TAKING HINT: The stem is asking which data need intervention by the nurse. Option "2" can be ruled out because all tubes and drains should be secured. A pink insertion site with no drainage is expected, which would cause the test taker to eliminate option "3" as a possible correct answer.

The female client diagnosed with anorexia nervosa is admitted to the hospital. The client is 67 inches tall and weighs 40 kg. Which client problem has the highest priority? 1. Altered nutrition. 2. Low self-esteem. 3. Disturbed body image. 4. Altered sexuality.

1 **1. The client is 67 inches tall (5′7′′) and weighs 88 pounds (40 kg × 2.2 = 88). This client is severely underweight and nutrition is the priority.** 2. Clients with anorexia have a chronic low self-esteem problem, but this is a psychosocial problem and actual physical problems are priority. 3. Disturbed body image is a psychosocial problem manifested in a physical one. The physical problem is priority; this would be an appropriate long-term goal. 4. This client thinks her body is not appealing and this could be a problem, but it is a psychosocial issue and not priority. TEST-TAKING HINT: The test taker must decide which problem is priority when all the problems could apply to the client. Unless the client is considering suicide and has a plan to carry it out, physical problems are priority.

The nurse caring for a client diagnosed with GERD writes the client problem of "behavior modification." Which intervention should be included for this problem? 1. Teach the client to sleep with a foam wedge under the head. 2. Encourage the client to decrease the amount of smoking. 3. Instruct the client to take over-the-counter medication for relief of pain. 4. Discuss the need to attend Alcoholics Anonymous to quit drinking.

1 **1. The client should elevate the head of the bed on blocks or use a foam wedge to use gravity to help keep the gastric acid in the stomach and prevent reflux into the esophagus. Behavior modification is changing one's behavior.** 2. The client should be encouraged to quit smoking altogether. Referral to support groups for smoking cessation should be made. 3. The nurse should be careful when recommending OTC medications. This is not the most appropriate intervention for a client with GERD. 4. The client should be instructed to discontinue using alcohol, but the stem does not indicate the client is an alcoholic. TEST-TAKING HINT: Clients are encouraged to quit, not decrease, smoking. Current research indicates smoking is damaging to many body systems, including the gastrointestinal system. The test taker should not assume anything not in the stem of a question.

Which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis? 1. Twenty bloody stools a day. 2. Oral temperature of 102˚F. 3. Hard, rigid abdomen. 4. Urinary stress incontinence.

1 **1. The colon is ulcerated and unable to absorb water, resulting in bloody diarrhea. Ten (10) to 20 bloody diarrhea stools is the most common symptom of ulcerative colitis.** 2. Inflammation usually causes an elevated temperature but is not expected in the client with ulcerative colitis. 3. A hard, rigid abdomen indicates peritonitis, which is a complication of ulcerative colitis but not an expected symptom. 4. Stress incontinence is not a symptom of colitis.

The client who is morbidly obese has undergone gastric bypass surgery. Which immediate postoperative intervention has the greatest priority? 1. Monitor respiratory status. 2. Weigh the client daily. 3. Teach a healthy diet. 4. Assist in behavior modification.

1 **1. The morbidly obese client will have a large abdomen, preventing the lungs from expanding, which predisposes the client to respiratory complications.** 2. The client may be weighed daily, but this is not priority. 3. The client should be taught proper nutrition for weight loss, but this is not the priority in the immediate postoperative period. 4. This is very important for the long term, but respiratory status is priority. TEST-TAKING HINT: Regardless of the procedure or the size of the client, respiratory status is priority in the immediate postoperative period. The test taker should apply Maslow's hierarchy of needs.

The female client presents to the clinic for an examination because she has not had a menstrual cycle for several months and wonders if she could be pregnant. The client is 5′10′′ tall and weighs 45 kg. Which assessment data should the nurse obtain first? 1. Ask the client to recall what she ate for the last 24 hours. 2. Determine what type of birth control the client has been using. 3. Reweigh the client to confirm the data. 4. Take the client's pulse and blood pressure.

1 **1. This client is 5′10′′ tall and weighs 99 pounds (45 kg × 2.2 = 99). Menses will cease if the client is severely emaciated. A 24-hour dietary recall is a step toward assessing the client's eating patterns.** 2. The type of birth control could be asked, but the client is asking about missing menstrual periods. Birth control does not interfere with having a period; if anything, some forms of birth control will make the cycles more regular. 3. The nurse can look at the client and see a very thin young woman, which should confirm more assessment is needed, not reweighing. 4. The pulse and blood pressure will not provide the nurse any information as to why the client's menstrual cycles have ceased. TEST-TAKING HINT: The stem of the question provides information about the client's height and weight, and the test taker must determine if this is important information. Information in the stem must be eliminated as not pertinent to the question or closely regarded to let the test taker know what the question is asking.

Which data should the nurse expect to assess in the client who had an upper gastrointestinal (UGI) series? 1. Chalky white stools. 2. Increased heart rate. 3. A firm hard abdomen. 4. Hyperactive bowel sounds.

1 1. A UGI series requires the client to swallow barium, which passes through the intestines, making the stools a chalky white color. 2. Increased heart rate is abnormal data and would be cause for further assessment. 3. A firm, hard abdomen is not expected from the UGI series. 4. Hyperactive bowel sounds is not an expected sequela of a UGI series. TEST-TAKING HINT: Option "2" could be eliminated because it does not have anything to do with the gastrointestinal system. A firm, hard abdomen is seldom ever expected, so option "3" could be eliminated.

The client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement? 1. Apply a heating pad to the abdomen for 15 to 20 minutes. 2. Administer morphine sulfate intravenously after diluting with saline. 3. Contact the surgeon for an order to x-ray the right shoulder. 4. Apply a sling to the right arm, which was injured during surgery.

1 1. A heating pad should be applied for 15 to 20 minutes to assist the migration of the CO2 used to insufflate the abdomen. Shoulder pain is an expected occurrence. 2. Morphine sulfate does not affect the etiology of the pain. 3. The surgeon would not order an x-ray for this condition. 4. There is no indication an injury occurred during surgery. A sling would not benefit the migration of the CO2. Shoulder pain is expected. TEST-TAKING HINT: The test taker must understand laparoscopic surgery to be able to answer this question. Option "4" could be eliminated because of phrase "injured during surgery."

The 85-year-old male client diagnosed with cancer of the colon asks the nurse, "Why did I get this cancer?" Which statement is the nurse's best response? 1. "Research shows a lack of fiber in the diet can cause colon cancer." 2. "It is not common to get colon cancer at your age; it is usually in young people." 3. "No one knows why anyone gets cancer, it just happens to certain people." 4. "Women usually get colon cancer more often than men but not always."

1 1. A long history of low-fiber, high-fat, and high-protein diets results in a prolonged transit time. This allows the carcinogenic agents in the waste products to have a greater exposure to the lumen of the colon. 2. The older the client, the greater the risk of developing cancer of the colon. 3. Risk factors for cancer of the colon include increasing age; family history of colon cancer or polyps; history of IBD; genital or breast cancer; and eating a high-fat, high-protein, low-fiber diet. 4. Males have a slightly higher incidence of colon cancers than do females. TEST-TAKING HINT: The test taker should realize cancers in general have an increasing incidence with age. Cancer etiologies are not an exact science, but most cancers have some risk factor, if only advancing age.

Which physical examination should the nurse implement first when assessing the client diagnosed with peptic ulcer disease? 1. Auscultate the client's bowel sounds in all four quadrants. 2. Palpate the abdominal area for tenderness. 3. Percuss the abdominal borders to identify organs. 4. Assess the tender area progressing to nontender.

1 1. Auscultation should be used prior to palpation or percussion when assessing the abdomen. Manipulation of the abdomen can alter bowel sounds and give false information. 2. Palpation gives appropriate information the nurse needs to collect, but if done prior to auscultation, the sounds will be altered. 3. Percussion of the abdomen does not give specific information about peptic ulcer disease. 4. Tender areas should be assessed last to prevent guarding and altering the assessment. This includes palpation, which should be done after auscultation. TEST-TAKING HINT: The word "first" requires the test taker to rank in order the interventions needing to be performed. The test taker should visualize caring for the client. This will assist the test taker in making the correct choice.

The client with acute diverticulitis has a nasogastric tube draining green liquid bile. Which intervention should the nurse implement? 1. Document the findings as normal. 2. Assess the client's bowel sounds. 3. Determine the client's last bowel movement. 4. Insert the N/G tube at least 2 more inches.

1 1. Green bile contains hydrochloric acid and should be draining from the N/G tube; therefore, the nurse should take no action and document the findings. 2. There is no reason for the nurse to assess the client's bowel sounds because the drainage is normal. 3. The client's last bowel movement would not affect the N/G drainage. 4. Bile draining from the N/G tube indicates the tube is in the stomach and there is no need to advance the tube further. TEST-TAKING HINT: The test taker must know what drainage is normal for tubes inserted into the body. Any type of blood or coffee-ground drainage would be abnormal and require intervention by the nurse.

The client diagnosed with IBD is prescribed total parental nutrition (TPN). Which intervention should the nurse implement? 1. Check the client's glucose level. 2. Administer an oral hypoglycemic. 3. Assess the peripheral intravenous site. 4. Monitor the client's oral food intake.

1 1. TPN is high in dextrose, which is glucose; therefore, the client's blood glucose level must be monitored closely. 2. The client may be on sliding-scale regular insulin coverage for the high glucose level. 3. The TPN must be administered via a subclavian line because of the high glucose level. 4. The client is NPO to put the bowel at rest, which is the rationale for administering the TPN. TEST-TAKING HINT: The test taker may want to select option "3" because it has the word "assess," but the test taker should remember to note the adjective "peripheral," which makes this option incorrect. Remember, the words "check" and "monitor" are words meaning "assess."

The nurse is caring for a client diagnosed with rule-out peptic ulcer disease. Which test confirms this diagnosis? 1. Esophagogastroduodenoscopy. 2. Magnetic resonance imaging. 3. Occult blood test. 4. Gastric acid stimulation.

1 1. The esophagogastroduodenoscopy (EGD) is an invasive diagnostic test which visualizes the esophagus, stomach, and duodenum to accurately diagnose an ulcer and evaluate the effectiveness of the client's treatment. 2. Magnetic resonance imaging (MRI) shows cross-sectional images of tissue or blood flow. 3. An occult blood test shows the presence of blood, but not the source. 4. A gastric acid stimulation test is used to understand the pathophysiology of ulcer disease, but it has limited usefulness. TEST-TAKING HINT: If the test taker has no idea what the correct answer is, knowledge of anatomy can help identify the answer. A peptic ulcer is an ulcer in the stomach, and in option "1" the word "esophagogastroduodenoscopy" has "gastro," which refers to the stomach. Therefore, this would be best option to select as the correct answer.

The nurse caring for a client one (1) day postoperative sigmoid resection notes a moderate amount of dark reddish brown drainage on the midline abdominal incision. Which intervention should the nurse implement first? 1. Mark the drainage on the dressing with the time and date. 2. Change the dressing immediately using sterile technique. 3. Notify the health-care provider immediately. 4. Reinforce the dressing with a sterile gauze pad.

1 1. The nurse should mark the drainage on the dressing to determine if active bleeding is occurring, because dark reddish-brown drainage indicates old blood. This allows the nurse to assess what is actually happening. 2. Surgical dressings are initially changed by the surgeon; the nurse should not remove the dressing until the surgeon orders the dressing change to be done by the nurse. 3. The nurse should assess the situation before notifying the HCP. 4. The nurse may need to reinforce the dressing if the dressing becomes saturated, but this would be after a thorough assessment is completed. TEST-TAKING HINT: The question is asking the test taker to determine which intervention must be implemented first, and assessment is the first step of the nursing process. Options "2," "3," and "4" would not be implemented prior to assessing. Marking the dressing allows the nurse to assess the dressing and determine if active bleeding is occurring.

The client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client supports this diagnosis? 1. "My pain goes away when I have a bowel movement." 2. "I have bright red blood in my stool all the time." 3. "I have episodes of diarrhea and constipation." 4. "My abdomen is hard and rigid and I have a fever."

1 1. The terminal ileum is the most common site for regional enteritis, which causes right lower quadrant pain that is relieved by defecation. 2. Stools are liquid or semiformed and usually do not contain blood. 3. Episodes of diarrhea and constipation may be a sign/symptom of colon cancer, not Crohn's disease. 4. A fever and hard rigid abdomen are signs/ symptoms of peritonitis, a complication of Crohn's disease. TEST-TAKING HINT: The test taker should eliminate option "2" because of the word "all," which is an absolute. There are very few absolutes in the health-care arena.

The charge nurse is monitoring client laboratory values. Which value is expected in the client with cholecystitis who has chronic inflammation? 1. An elevated white blood cell count. 2. A decreased lactate dehydrogenase. 3. An elevated alkaline phosphatase. 4. A decreased direct bilirubin level.

1 1. The white blood cell count should be elevated in clients with chronic inflammation. 2. A decreased lactate dehydrogenase (LDH) indicates liver abnormalities. 3. An elevated alkaline phosphatase indicates liver abnormalities. 4. A decreased bilirubin indicates an obstructive process.

The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and T 102˚F. Which intervention should the nurse implement? 1. Notify the health-care provider. 2. Prepare to administer a Fleet's enema. 3. Administer an antipyretic suppository. 4. Continue to monitor the client closely.

1 1. These are signs of peritonitis, which is life threatening. The health-care provider should be notified immediately. 2. A Fleet's enema will not help a lifethreatening complication of diverticulitis. 3. A medication administered to help decrease the client's temperature will not help a life-threatening complication. 4. These are signs/symptoms indicating a possible life-threatening situation and require immediate intervention. TEST-TAKING HINT: In most instances, the test taker should not select the option stating to notify the HCP immediately, but in some situations, it is the correct answer. The test taker should look at all the other options and determine if the option is information the HCP requires or if it is an independent intervention which will help the client.

The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis? Select all that apply. 1. Eat a high-fiber diet. 2. Increase fluid intake. 3. Elevate the HOB after eating. 4. Walk 30 minutes a day. 5. Take an antacid every two (2) hours.

1, 2, 4 1. A high-fiber diet will help to prevent constipation, which is the primary reason for diverticulitis. 2. Increased fluids will help keep the stool soft and prevent constipation. 3. This will not do anything to help prevent diverticulitis. 4. Exercise will help prevent constipation. 5. No medications are prescribed to prevent an acute exacerbation of diverticulitis. Antacids are used to neutralize hydrochloric acid in the stomach. TEST-TAKING HINT: This is an alternatetype question where the test taker must select more than one option. To identify the correct answers, the test taker should think about what part of the GI system is affected. Knowing diverticulosis occurs in the sigmoid colon would help eliminate options "3" and "5" because these would be secondary to stomach disorders.

Which signs and symptoms should the nurse report to the health-care provider for the client recovering from an open cholecystectomy? Select all that apply. 1. Clay-colored stools. 2. Yellow-tinted sclera. 3. Amber-colored urine. 4. Wound approximated. 5. Abdominal pain.

1, 2, 5 1. Clay-colored stools are caused by recurring stricture of the common bile duct, which is a sign of postcholecystectomy syndrome. 2. Yellow-tinted sclera and skin indicate residual effects of stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome. 3. Amber-colored urine is a normal finding for a client, so this does not warrant intervention by the nurse. 4. An approximated wound indicates the incision is intact and does not warrant intervention by the nurse. 5. Abdominal pain indicates a residual effect of a stricture of the common bile duct, inflammation, or calculi, which is a sign of post-cholecystectomy syndrome. TEST-TAKING HINT: The test taker must use knowledge of anatomy to answer this question. All answer options have something to do with the abdominal area, and the common bile duct is anatomically near the hepatic duct, which causes liver signs/symptoms.

The nurse is caring for clients on a surgical unit. Which client should the nurse assess first? 1. The client who had an inguinal hernia repair and has not voided in four (4) hours. 2. The client who was admitted with abdominal pain who suddenly has no pain. 3. The client four (4) hours postoperative abdominal surgery with no bowel sounds. 4. The client who is one (1) day postappendectomy and is being discharged.

2 1. A client who has not voided within four (4) hours after any surgery is not priority. This is an acceptable occurrence, but if the client hasn't voided for eight (8) hours, then the nurse should assess further. **2. A sudden cessation of pain may indicate a ruptured appendix, which could lead to peritonitis, a life-threatening complication; therefore, the nurse should assess this client first.** 3. Bowel sounds should return within 24 hours after abdominal surgery. Absent bowel sounds at four (4) hours postoperative is not of great concern to the nurse. 4. The client being discharged is stable and not a priority for the nurse. TEST-TAKING HINT: The stem is asking which client the nurse should see first. Therefore, the test taker should look for life-threatening or serious complications or abnormal assessment data for the disease process.

Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease? 1. History of side effects experienced from all medications. 2. Use of nonsteroidal anti-inflammatory drugs (NSAIDs). 3. Any known allergies to drugs and environmental factors. 4. Medical histories of at least three (3) generations.

2 1. A history of problems the client has experienced with medications is taken during the admission interview. This information does not specifically address peptic ulcer disease. 2. Use of NSAIDs places the client at risk for peptic ulcer disease and hemorrhage. NSAIDs suppress the production of prostaglandin in the stomach, which is a protective mechanism to prevent damage from hydrochloric acid. 3. Allergies are included for safety, but this is not specific for peptic ulcer disease. 4. Information needs to be obtained about past generations so the nurse can analyze any potential health problems, but this is not specific for peptic ulcer disease.

The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy? 1. "My stoma should be pink and moist." 2. "I will irrigate my ileostomy every morning." 3. "If I get a red, bumpy, itchy rash I will call my HCP." 4. "I will change my pouch if it starts leaking."

2 1. A pink and moist stoma indicates viable tissue and adequate circulation. A purple stoma indicates necrosis. 2. An ileostomy will drain liquid all the time and should not routinely be irrigated. A sigmoid colostomy may need daily irrigation to evacuate feces. 3. A red, bumpy, itchy rash indicates infection with the yeast Candida albicans, which should be treated with medication. 4. The ileostomy drainage has enzymes and bile salts, which are irritating and harsh to the skin; therefore, the pouch should be changed if any leakage occurs. TEST-TAKING HINT: This is an "except" question, and the test taker must identify which option is not a correct action for the nurse to implement. Sometimes flipping the question—"Which interventions indicate the client understands the teaching?"—can assist in identifying the correct answer.

Which assessment data indicate to the nurse the client recovering from an open cholecystectomy may require pain medication? 1. The client's pulse is 65 beats per minute. 2. The client has shallow respirations. 3. The client's bowel sounds are 20 per minute. 4. The client uses a pillow to splint when coughing.

2 1. An increased pulse is expected in the client who is in acute pain. 2. An open cholecystecomy requires a large incision under the diaphragm. Deep breathing places pressure on the diaphragm and the incision, causing pain. Shallow respirations indicate inadequate pain control, and the nurse should intervene. 3. Twenty bowel sounds a minute is normal data and does not require further action. 4. Splinting the abdomen allows the client to increase the strength of the cough by increasing comfort and does not indicate a need for pain medication. TEST-TAKING HINT: The stem asks which data would warrant pain medication. Therefore, the test taker should select an answer not expected or not normal for clients who are postoperative abdominal surgery.

The nurse is caring for a client diagnosed with bulimia nervosa. Which nursing intervention should the nurse implement after the client's evening meal? 1. Praise the client for eating all the food on the tray. 2. Stay with the client for 45 minutes to an hour. 3. Allow the client to work out on the treadmill. 4. Place the client on bedrest until morning.

2 1. Clients diagnosed with bulimia will eat the entire meal and more food if available. This is not unusual behavior for a client diagnosed with bulimia. **2. By having someone stay with the client for 45 minutes to one (1) hour after a meal, the client will be prevented from inducing vomiting and ridding the body of the meal before it can be metabolized.** 3. Clients diagnosed with anorexia nervosa tend to overexercise to prevent weight gain and to lose imagined excess weight. 4. Bedrest is not needed for this client. TEST-TAKING HINT: The test taker must be able to differentiate between bulimia and anorexia. It can be difficult to keep these processes separate, especially because some clients have both anorexia and bulimia.

The male client tells the nurse he has been experiencing "heartburn" at night that awakens him. Which assessment question should the nurse ask? 1. "How much weight have you gained recently?" 2. "What have you done to alleviate the heartburn?" 3. "Do you consume many milk and dairy products?" 4. "Have you been around anyone with a stomach virus?"

2 1. Clients with heartburn are frequently diagnosed as having GERD. GERD can occasionally cause weight loss, but not weight gain. **2. Most clients with GERD have been selfmedicating with over-the-counter medications prior to seeking advice from a health-care provider. It is important to know what the client has been using to treat the problem.** 3. Milk and dairy products contain lactose, which are important if considering lactose intolerance, but are not important for "heartburn." 4. Heartburn is not a symptom of a viral illness. TEST-TAKING HINT: Clients will use common terms such as "heartburn" to describe symptoms. The nurse must be able to interpret or clarify the meaning of terms used with the client. Part of the assessment of a symptom requires determining what aggravates and alleviates the symptom.

The client diagnosed with gastroenteritis is being discharged from the emergency department. Which intervention should the nurse include in the discharge teaching? 1. If diarrhea persists for more than 96 hours, contact the health-care provider. 2. Instruct the client to wash hands thoroughly before handling any type of food. 3. Explain the importance of decreasing steroids gradually as instructed. 4. Discuss how to collect all stool samples for the next 24 hours.

2 1. If the diarrhea persists more than 48 hours, the client should notify the HCP. Diarrhea for more than 96 hours could lead to metabolic acidosis, hypokalemia, and possible death. **2. Washing hands should be done by the client at all times, but especially when the client has gastroenteritis. The bacteria in feces may be transferred to other people via food if hands are not washed properly.** 3. Steroids are not used in the treatment of gastroenteritis; antidiarrheal medication is usually prescribed. 4. The client may be asked to provide a stool specimen for culture, ova, parasites, and fecal leukocytes, but the client is not asked for a 24-hour stool collection. TEST-TAKING HINT: If the test taker did not know the answer to this question, hand washing should be selected because it is the number-one intervention for preventing any type of contamination or nosocomial infection.

The post-anesthesia care nurse is caring for a client who had abdominal surgery and is complaining of nausea. Which intervention should the nurse implement first? 1. Medicate the client with a narcotic analgesic IVP. 2. Assess the nasogastric tube for patency. 3. Check the temperature for elevation. 4. Hyperextend the neck to prevent stridor.

2 1. Medicating the client with an analgesic could increase the client's nausea unless the nausea is caused by pain. The nurse should assess the etiology to determine the interventions. **2. A client who had abdominal surgery usually has a nasogastric (N/G) tube in place. If the N/G tube is not patent, this will cause nausea. Irrigating the N/G tube may relieve nausea.** 3. Checking the temperature will not treat the nausea. 4. Hyperextending the neck will assist the client to breathe but will not treat nausea. TEST-TAKING HINT: Assessment is the first step in the nursing process. Checking the N/G tube for patency and taking the temperature are the only assessment interventions. Temperature does not correlate with nausea. Medication may be administered but it would be an antiemetic, not a narcotic analgesic.

Which statement made by the client indicates to the nurse the client may be experiencing GERD? 1. "My chest hurts when I walk up the stairs in my home." 2. "I take antacid tablets with me wherever I go." 3. "My spouse tells me I snore very loudly at night." 4. "I drink six (6) to seven (7) soft drinks every day."

2 1. Pain in the chest when walking up stairs indicates angina. **2. Frequent use of antacids indicates an acid reflux problem.** 3. Snoring loudly could indicate sleep apnea, but not GERD. 4. Carbonated beverages increase stomach pressure. Six (6) to seven (7) soft drinks a day would not be tolerated by a client with GERD.

The nurse is preparing to administer the initial dose of an aminoglycoside antibiotic to the client diagnosed with acute diverticulitis. Which intervention should the nurse implement? 1. Obtain a serum trough level. 2. Ask about drug allergies. 3. Monitor the peak level. 4. Assess the vital signs.

2 1. Peak and trough levels are drawn after the client has received at least three (3) to four (4) doses of medication, not on the initial dose because the client has just been admitted. 2. The nurse should always ask about allergies to medication when administering medications, but especially when administering antibiotics, which are notorious for allergic reactions. 3. The peak and trough levels are not drawn prior to the first dose; they are ordered after multiple doses. 4. The nurse should question when to administer the medication, but there is no vital sign preventing the nurse from administering an antibiotic. TEST-TAKING HINT: The test taker must read the stem closely to realize the client is receiving the initial dose, causing the test taker to eliminate options "1" and "3" as possible correct answers. Both options "2" and "4" are assessment data, but the test taker should ask which one will directly affect the administration of the medication.

The occupational health nurse is preparing a presentation to a group of factory workers about preventing colon cancer. Which information should be included in the presentation? 1. Wear a high-filtration mask when around chemicals. 2. Eat several servings of cruciferous vegetables daily. 3. Take a multiple vitamin every day. 4. Do not engage in high-risk sexual behaviors.

2 1. Some cancers have a higher risk of development when the client is occupationally exposed to chemicals, but cancer of the colon is not one of them. 2. Cruciferous vegetables, such as broccoli, cauliflower, and cabbage, are high in fiber. One of the risks for cancer of the colon is a high-fat, low-fiber, and high-protein diet. The longer the transit time (the time from ingestion of the food to the elimination of the waste products), the greater the chance of developing cancer of the colon. 3. A multiple vitamin may improve immune system function, but it does not prevent colon cancer. 4. High-risk sexual behavior places the client at risk for sexually transmitted diseases. A history of multiple sexual partners and initial sexual experience at an early age does increase the risk for the development of cancer of the cervix in females. TEST-TAKING HINT: The colon processes waste products from eating foods, and option "2" is the only option to mention food. Therefore, option "2" would be the best option to select if the test taker did not know the correct answer.

Which assessment data indicate to the nurse the client's gastric ulcer has perforated? 1. Complaints of sudden, sharp, substernal pain. 2. Rigid, boardlike abdomen with rebound tenderness. 3. Frequent, clay-colored, liquid stool. 4. Complaints of vague abdominal pain in the right upper quadrant.

2 1. Sudden sharp pain felt in the substernal area indicates angina or myocardial infarction. **2. A rigid, boardlike abdomen with rebound tenderness is the classic sign/symptom of peritonitis, which is a complication of a perforated gastric ulcer.** 3. Clay-colored stools indicate liver disorders, such as hepatitis. 4. Clients with gallbladder disease report vague to sharp abdominal pain in the right upper quadrant.

The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching is effective? 1. "I will take my lipid-lowering medicine at the same time each night." 2. "I may experience some discomfort when I eat a high-fat meal." 3. "I need someone to stay with me for about a week after surgery." 4. "I should not splint my incision when I deep breathe and cough."

2 1. This surgery does not require lipidlowering medications, but eating high-fat meals may cause discomfort. 2. After removal of the gallbladder, some clients experience abdominal discomfort when eating fatty foods. 3. Laparoscopic cholecystectomy surgeries are performed in day surgery, and clients usually do not need assistance for a week. 4. Using a pillow to splint the abdomen provides support for the incision and should be continued after discharge.

The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first? 1. Notify the health-care provider. 2. Assess the client for muscle weakness. 3. Request telemetry for the client. 4. Prepare to administer potassium IV.

2 1. The HCP should be notified so potassium supplements can be ordered, but this is not the first intervention. **2. Muscle weakness may be a sign of hypokalemia; hypokalemia can lead to cardiac dysrhythmias and can be life threatening. Assessment is priority for a potassium level just below normal level, which is 3.5 to 5.5 mEq/L.** 3. Hypokalemia can lead to cardiac dysrhythmias; therefore, requesting telemetry is appropriate, but it is not the first intervention. 4. The client will need potassium to correct the hypokalemia, but it is not the first intervention. TEST-TAKING HINT: When the question asks which action should be implemented first, remember assessment is the first step in the nursing process. If the answer option addressing assessment is appropriate for the situation in the question, then the test taker should select it as the correct answer.

The 79-year-old client diagnosed with acute gastroenteritis is admitted to the medical unit. Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Evaluate the client's intake and output. 2. Take the client's vital signs. 3. Change the client's intravenous solution. 4. Assess the client's perianal area.

2 1. The UAP can calculate the client's intake and output, but the nurse must evaluate the data to determine if it is normal for the elderly client diagnosed with acute gastroenteritis. **2. The UAP can take the vital signs for a client who is stable; the nurse must interpret and evaluate the vital signs.** 3. The UAP cannot administer medications, and IV solutions are considered to be medications. 4. The nurse cannot delegate assessment. The client may have an excoriated perianal area secondary to diarrhea; therefore, the nurse should assess the client. TEST-TAKING HINT: The nurse should not delegate any nursing task requiring judgment or assessment and cannot delegate the administration of medications. Words such as "evaluate" mean the same thing as "assess"; therefore, options "1," "3," and "4" can be eliminated.

The client is one (1) day postoperative major abdominal surgery. Which client problem is priority? 1. Impaired skin integrity. 2. Fluid and electrolyte imbalance. 3. Altered bowel elimination. 4. Altered body image.

2 1. The client has a surgical incision, which impairs the skin integrity, but it is not the priority because it is sutured under sterile conditions. **2. After abdominal surgery, the body distributes fluids to the affected area as part of the healing process. These fluids are shifted from the intravascular compartment to the interstitial space, which causes potential fluid and electrolyte imbalance.** 3. Bowel elimination is a problem, but after general anesthesia wears off, the bowel sounds will return, and this is not a lifethreatening problem. 4. Psychosocial problems are not priority over actual physiological problems. TEST-TAKING HINT: When identifying priority problems, the test taker can eliminate any psychosocial problem as a potential correct answer if there are applicable physiological problems.

The female client came to the clinic complaining of abdominal cramping and at least 10 episodes of diarrhea every day for the last two (2) days. The client just returned from a trip to Mexico. Which intervention should the nurse implement? 1. Instruct the client to take a cathartic laxative daily. 2. Encourage the client to drink lots of Gatorade. 3. Discuss the need to increase protein in the diet. 4. Explain the client should weigh herself daily.

2 1. The client would be taking antidiarrheal medication, not medications to stimulate bowel movements. **2. The client probably has traveler's diarrhea, and oral rehydration is the preferred choice for replacing fluids lost as a result of diarrhea. An oral glucose electrolyte solution, such as Gatorade, All-Sport, or Pedialyte, is recommended.** 3. The client should be encouraged to stay on liquids and eat bland foods of all three (3) food groups—carbohydrates, proteins, and fats. 4. There is no need for the client to weigh herself daily. Symptoms usually resolve within two (2) to three (3) days without complications. TEST-TAKING HINT: Be sure to note the adjectives and adverbs in the stem and the answer options, such as "cathartic" laxative and weigh "daily." These words are very often important in ruling out answers and identifying the correct answer.

The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement? 1. Provide a low-residue diet. 2. Rest the client's bowel. 3. Assess vital signs daily. 4. Administer antacids orally.

2 1. The client's bowel should be placed on rest and no foods or fluids should be introduced into the bowel. 2. Whenever a client has an acute exacerbation of a gastrointestinal disorder, the first intervention is to place the bowel on rest. The client should be NPO with intravenous fluids to prevent dehydration. 3. The vital signs must be taken more often than daily in a client who is having an acute exacerbation of ulcerative colitis. 4. The client will receive anti-inflammatory and antidiarrheal medications, not antacids, which are used for gastroenteritis. TEST-TAKING HINT: "Acute exacerbation" is the key phrase in the stem of the question. The word "acute" should cause the test taker to eliminate any daily intervention.

The client complains to the nurse of unhappiness with the health-care provider. Which intervention should the nurse implement next? 1. Call the HCP and suggest he or she talk with the client. 2. Determine what about the HCP is bothering the client. 3. Notify the nursing supervisor to arrange a new HCP to take over. 4. Explain the client cannot request another HCP until after discharge.

2 1. The nurse should first assess the situation prior to informing the HCP of the client's concerns and then allow the HCP and client to discuss the situation. 2. The nurse should determine what is concerning the client. It could be a misunderstanding or a real situation where the client's care is unsafe or inadequate. 3. If a new HCP is to be arranged, it is the HCP's responsibility to arrange for another HCP to assume responsibility for the care of the client. 4. The choice of HCP is ultimately the client's. If the HCP cannot arrange for another HCP, the client may be discharged and obtain a new health-care provider. TEST-TAKING HINT: The nurse should assess the situation; the first step in the nursing process is assessment.

The client is admitted to the medical floor with acute diverticulitis. Which collaborative intervention should the nurse anticipate the health-care provider ordering? 1. Administer total parenteral nutrition. 2. Maintain NPO and nasogastric tube. 3. Maintain on a high-fiber diet and increase fluids. 4. Obtain consent for abdominal surgery.

2 1. Total parenteral nutrition is not an expected order for this client. 2. The bowel must be put at rest. Therefore, the nurse should anticipate orders for maintaining the client NPO and a nasogastric tube. 3. These orders would be instituted when the client is getting better and the bowel is not inflamed. 4. Surgery is not the first consideration when the client is admitted into the hospital. TEST-TAKING HINT: "Collaborative" means the nurse must care for the client with another discipline, and the health-care provider would have to order all of the distracters. The test taker should remember food and fluid probably should be stopped in the client with lower gastrointestinal problems.

Which expected outcome should the nurse include for a client diagnosed with peptic ulcer disease? 1. The client's pain is controlled with the use of NSAIDs. 2. The client maintains lifestyle modifications. 3. The client has no signs and symptoms of hemoptysis. 4. The client takes antacids with each meal.

2 1. Use of NSAIDs increases and causes problems associated with peptic ulcer disease. 2. Maintaining lifestyle changes such as following an appropriate diet and reducing stress indicate the client is complying with the medical regimen. Compliance is the goal of treatment to prevent complications. 3. Hemoptysis is coughing up blood, which is not a sign or symptom of peptic ulcer disease. This would not be an expected outcome. 4. Antacids should be taken one (1) to three (3) hours after meals, not with each meal. TEST-TAKING HINT: Expected outcomes are positive completion of goals; maintaining lifestyle modifications would be an appropriate goal for any client with any chronic illness.

The client with a history of peptic ulcer disease is admitted into the intensive care unit with frank gastric bleeding. Which priority intervention should the nurse implement? 1. Maintain a strict record of intake and output. 2. Insert a nasogastric tube and begin saline lavage. 3. Assist the client with keeping a detailed calorie count. 4. Provide a quiet environment to promote rest.

2 1. Maintaining a strict record of intake and output is important to evaluate the progression of the client's condition, but it is not the most important intervention. **2. Inserting a nasogastric tube and lavaging the stomach with saline is the most important intervention because this directly stops the bleeding.** 3. A calorie count is important information assisting in the prevention and treatment of a nutritional deficit, but this intervention does not address the client's immediate and life-threatening problem. 4. Promoting a quiet environment aids in the reduction of stress, which can cause further bleeding, but this will not stop the bleeding. TEST-TAKING HINT: The test taker is required to rank the importance of interventions in the question. Using Maslow's hierarchy of needs to rank physiological needs first, the test taker should realize inserting a nasogastric tube and beginning lavage is solving a circulation or fluid deficit problem.

Which nursing interventions should be included in the care plan for the 84-year old client diagnosed with acute gastroenteritis? Select all that apply. 1. Assess the skin turgor on the back of the client's hands. 2. Monitor the client for orthostatic hypotension. 3. Record the frequency and characteristics of sputum. 4. Use Standard Precautions when caring for the client. 5. Institute safety precautions when ambulating the client.

2, 4, 5 1. The nurse should assess skin turgor over the sternum in the elderly client because loss of subcutaneous fat associated with aging makes skin turgor assessment on the arms less reliable. **2. Orthostatic hypotension indicates fluid volume deficit, which can occur in an elderly client who is having many episodes of diarrhea.** 3. The nurse should record frequency and characteristics of stool, not sputum, in the client diagnosed with gastroenteritis. **4. Standard Precautions, including wearing gloves and hand washing, help prevent the spread of the infection to others.** **5. The elderly client is at risk for orthostatic hypotension; therefore, safety precautions should be instituted to ensure the client doesn't fall as a result of a decrease in blood pressure.** TEST-TAKING HINT: This is an alternatetype question requiring the test taker to choose all interventions that apply. The test taker should look at each option and consider if this is an intervention for an "elderly" client. The elderly are a special population usually requiring specific interventions addressing the aging process no matter what the disease process.

The client who is obese presents to the clinic before beginning a weight loss program. Which interventions should the nurse teach? Select all that apply. 1. Walk for 30 minutes three (3) times a day. 2. Determine situations that initiate eating behavior. 3. Weigh at the same time every day. 4. Limit sodium in the diet. 5. Refer to a weight support group.

2, 5 1. Exercise recommendations for weight loss are to exercise for 30 minutes at least three (3) times per week, not three (3) times a day. **2. The client should be aware of situations triggering the consumption of food when the client is not hungry, such as anger, boredom, and stress. Food-seeking behaviors are not associated only with hunger in the client who is obese.** 3. The client should weigh himself or herself about once a week. If weight loss is not observed, the client becomes discouraged and feels powerless to control the weight. This can lead to diet failure. 4. Sodium is limited in clients with hypertension, not obesity. **5. Weight loss support groups such as Weight Watchers or Take Off Pounds Sensibly (TOPS) are helpful to keep the client participating in a weight loss program.** TEST-TAKING HINT: This is an alternatetype question. The test taker must judge each answer option for itself; one (1) option does not eliminate another. The NCLEX-RN gives credit for the entire question. The test taker must identify all the right answers or the answer will be counted as incorrect.

The nurse is caring for clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society's recommendations for the early detection of colon cancer? 1. Beginning at age 60, a digital rectal examination should be done yearly. 2. After reaching middle age, a yearly fecal occult blood test should be done. 3. Have a colonoscopy at age 50 and then once every five (5) to 10 years. 4. A flexible sigmoidoscopy should be done yearly after age 40.

3 1. A digital rectal examination is done to detect prostate cancer and should be started at age 40 years. 2. "Middle age" is a relative term; specific ages are used for recommendation. 3. The American Cancer Society recommends a colonoscopy at age 50 and every five (5) to 10 years thereafter, and a flexible sigmoidoscopy and a barium enema every five (5) years. 4. A flexible sigmoidoscopy should be done at five (5)-year intervals between the colonoscopy. TEST-TAKING HINT: A digital examination is an examination performed by the examiner's finger and does not examine the entire colon.

Which disease is the client diagnosed with GERD at greater risk for developing? 1. Hiatal hernia. 2. Gastroenteritis. 3. Esophageal cancer. 4. Gastric cancer.

3 1. A hiatal hernia places the client at risk for GERD; GERD does not predispose the client for developing a hiatal hernia. 2. Gastroenteritis is an inflammation of the stomach and intestine, usually caused by a virus. **3. Barrett's esophagus results from longterm erosion of the esophagus as a result of reflux of stomach contents secondary to GERD. This is a precursor to esophageal cancer.** 4. The problems associated with GERD result from the reflux of acidic stomach contents into the esophagus, which is not a precursor to gastric cancer. TEST-TAKING HINT: The test taker may associate hiatal hernia with GERD. One can be a result of the other, and this can confuse the test taker. If the test taker did not have any idea of the correct answer, option "3" has the word "esophageal" in it, as does the stem of the question, and therefore the test taker should select this as the correct answer.

The nurse is working in an outpatient clinic. Which client is most likely to have a diagnosis of diverticulosis? 1. A 60-year-old male with a sedentary lifestyle. 2. A 72-year-old female with multiple childbirths. 3. A 63-year-old female with hemorrhoids. 4. A 40-year-old male with a family history of diverticulosis.

3 1. A sedentary lifestyle may lead to obesity and contribute to hypertension or heart disease but usually not to diverticulosis. 2. Multiple childbirths are not a risk factor for developing diverticulosis. 3. Hemorrhoids would indicate the client has chronic constipation, which is a strong risk factor for diverticulosis. Constipation increases the intraluminal pressure in the sigmoid colon, leading to weakness in the intestinal lining, which, in turn, causes outpouchings, or diverticula. 4. A family history is not a risk factor. Having daily bowel movements and preventing constipation will decrease the chance of developing diverticulosis. TEST-TAKING HINT: The test taker must know constipation is the leading risk factor for diverticulosis, and if the test taker knows hemorrhoids are caused by constipation, it would lead the test taker to select option "3" as the correct answer.

Which medication should the nurse expect the HCP to order to treat the client diagnosed with botulism secondary to eating contaminated canned goods? 1. An antidiarrheal medication. 2. An aminoglycoside antibiotic. 3. An antitoxin medication. 4. An ACE inhibitor medication.

3 1. Antidiarrheal medications are contraindicated with botulism because the toxin needs to be expelled from the body. 2. Aminoglycoside antibiotics will not be ordered because there is no bacterium with botulism; it is caused by a neurotoxin. **3. A botulism antitoxin neutralizes the circulating toxin and is prescribed for a client with botulism.** 4. An angiotensin-converting enzyme (ACE) inhibitor is prescribed for a client diagnosed with cardiovascular disease. TEST-TAKING HINT: The key word in this question is "treat." Because botulism does not end in -itis, and thus is not an infection, the use of an antibiotic can be eliminated.

The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care? 1. Instruct the client to cough forcefully. 2. Encourage early ambulation. 3. Assess for return of a gag reflex. 4. Administer held medications.

3 1. Asking the client to cough forcefully may irritate the client's throat. 2. Early ambulation does not enhance safety since the client will be sedated. 3. The ERCP requires an anesthetic spray be used prior to insertion of the endoscope. If medications, food, or fluid are given orally prior to the return of the gag reflex, the client may aspirate. 4. Medications are not administered until the gag reflex has returned. TEST-TAKING HINT: The test taker must notice adjectives such as "endoscopic," which means the procedure includes going down the mouth; option "3" is the only option that has anything to do with the mouth. Selecting a distracter addressing assessment would be appropriate because assessment is the first step of the nursing process.

The nurse has received the a.m. shift report. Which client should the nurse assess first? 1. The 44-year-old client diagnosed with peptic ulcer disease who is complaining of acute epigastric pain. 2. The 74-year-old client diagnosed with acute gastroenteritis who has had four (4) diarrhea stools during the night. 3. The 65-year-old client diagnosed with IBD who has tented skin turgor and dry mucous membranes. 4. The 15-year-old client diagnosed with food poisoning who has vomited several times during the night shift.

3 1. Epigastric pain is expected in a client diagnosed with peptic ulcer disease. 2. Four (4) diarrheal stools are not unusual in a client diagnosed with gastroenteritis. **3. Tented skin turgor and dry mucus membranes indicate dehydration, which warrants the nurse assessing this client first.** 4. Vomiting is expected in a client diagnosed with food poisoning. TEST-TAKING HINT: When managing clients, the nurse must be able to prioritize care. Therefore, the test taker must be able to determine which client's complaints, signs, or symptoms are not expected of the disease process. The test taker should always look at the client's age because it may help determine the best answer.

The nurse is admitting a client to a medical floor with a diagnosis of adenocarcinoma of the rectosigmoid colon. Which assessment data support this diagnosis? 1. The client reports up to 20 bloody stools per day. 2. The client has a feeling of fullness after a heavy meal. 3. The client has diarrhea alternating with constipation. 4. The client complains of right lower quadrant pain.

3 1. Frequent bloody stools are a symptom of inflammatory bowel disease (IBD). IBD is a risk factor for cancer of the colon, but the symptoms are different when the colon becomes cancerous. 2. Most people have a feeling of fullness after a heavy meal; this does not indicate cancer. 3. The most common symptom of colon cancer is a change in bowel habits, specifically diarrhea alternating with constipation. 4. Lower right quadrant pain with rebound tenderness would indicate appendicitis. TEST-TAKING HINT: The test taker could eliminate option "4" based on anatomical position. The rectosigmoid colon is in the left lower quadrant.

The nurse is discussing the therapeutic diet for the client diagnosed with diverticulosis. Which meal indicates the client understands the discharge teaching? 1. Fried fish, mashed potatoes, and iced tea. 2. Ham sandwich, applesauce, and whole milk. 3. Chicken salad on whole-wheat bread and water. 4. Lettuce, tomato, and cucumber salad and coffee.

3 1. Fried foods increase cholesterol. Mashed potatoes do not have the peel, which is needed for increased fiber. 2. Applesauce does not have the peel, which is needed for increased fiber, and the option does not identify which type of bread; whole milk is high in fat. 3. Chicken salad, which has vegetables such as celery, grapes, and apples, and whole-wheat bread are high in fiber, which is the therapeutic diet prescribed for clients with diverticulosis. An adequate intake of water helps prevent constipation. 4. Tomatoes and cucumbers have seeds, and many health-care providers recommend clients with diverticulosis avoid seeds because of the possibility of the seeds entering the diverticulum and becoming trapped, leading to peritonitis. TEST-TAKING HINT: The test taker must know a high-fiber diet is prescribed for diverticulosis and at least five (5) to six (6) foods are encouraged or discouraged for the different types of diets. High-fiber foods are foods with peels (potato, apple) and whole-wheat products.

The client diagnosed with ulcerative colitis is prescribed a low-residue diet. Which meal selection indicates the client understands the diet teaching? 1. Grilled hamburger on a wheat bun and fried potatoes. 2. A chicken salad sandwich and lettuce and tomato salad. 3. Roast pork, white rice, and plain custard. 4. Fried fish, whole grain pasta, and fruit salad.

3 1. Fried potatoes, along with pastries and pies, should be avoided. 2. Raw vegetables should be avoided because this is roughage. **3. A low-residue diet is a low-fiber diet. Products made of refined flour or finely milled grains, along with roasted, baked, or broiled meats, are recommended.** 4. Fried foods should be avoided, and whole grain is high in fiber. Nuts and fruits with peels should be avoided. TEST-TAKING HINT: The test taker must know about therapeutic diets prescribed by health-care providers. Remember, low-residue is the same as low-fiber.

The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the HCP? 1. The client's Bernstein esophageal test was positive. 2. The client's abdominal x-ray shows a hiatal hernia. 3. The client's WBC count is 14,000/mm3. 4. The client's hemoglobin is 13.8 g/dL.

3 1. In a Bernstein test, acid is instilled into the distal esophagus, causing immediate heartburn for a client diagnosed with GERD. This would not warrant notifying the HCP. 2. Hiatal hernias are frequently the cause of GERD; therefore, this finding would not warrant notifying the HCP. **3. The client's WBC count is elevated, indicating a possible infection, which warrants notifying the HCP.** 4. This is a normal hemoglobin result and would not warrant notifying the HCP. TEST-TAKING HINT: When the test taker is deciding when to notify a health-care provider, the answer should be data not normal for the disease process or signaling a potential or life-threatening complication.

Which statement indicates to the emergency department nurse the client diagnosed with acute gastroenteritis understands the discharge teaching? 1. "I will probably have some leg cramps while I have gastroenteritis." 2. "I should decrease my fluid intake until the diarrhea subsides." 3. "I should reintroduce solid foods very slowly back into my diet." 4. "I should only drink bottled water until the abdominal cramping stops."

3 1. Leg cramps could indicate hypokalemia, which is a potential complication of excessive diarrhea and should be reported to the health-care provider. 2. The client should increase the fluid intake because oral rehydration is the primary treatment for gastroenteritis to replace lost fluid as a result of diarrhea and to prevent dehydration. **3. Reintroducing solid foods slowly, in small amounts, will allow the bowel to rest and the mucosa to return to normal functioning after acute gastroenteritis.** 4. Bottled water should be consumed when contaminated water is suspected, and and oral glucose-electrolyte solution, such as Gatorade or Pedialyte, should be recommended. TEST-TAKING HINT: Both options "2" and "4" refer to fluids, which should make the test taker either eliminate both of these or select from one (1) of these two (2) as the right answer.

The occupational health nurse observes the chief financial officer eat large lunch meals. The client disappears into the restroom after a meal for about 20 minutes. Which observation by the nurse would indicate the client has bulimia? 1. The client jogs two (2) miles a day. 2. The client has not gained weight. 3. The client's teeth are a green color. 4. The client has smooth knuckles.

3 1. Many clients jog one (1) to two (2) miles per day as part of their exercise program. This does not indicate bulimia. 2. Not gaining weight may be an end result of bulimia, but it does not identify bulimia. **3. Bulimia is characterized by bingeing and purging by inducing vomiting after a meal. Stomach contents are acidic and the acid wears away the enamel on the teeth, leaving the teeth a green color.** 4. The client has calluses on the knuckles from pushing them into the throat to induce vomiting. TEST-TAKING HINT: The question requires the nurse to be knowledgeable of the signs/symptoms of bulimia. Vomiting should lead the test taker to green teeth secondary to hydrochloric acid.

The nurse assesses a large amount of red drainage on the dressing of a client who is six (6) hours postoperative open cholecystectomy. Which intervention should the nurse implement? 1. Measure the abdominal girth. 2. Palpate the lower abdomen for a mass. 3. Turn client onto side to assess for further drainage. 4. Remove the dressing to determine the source.

3 1. Measuring the abdominal girth helps further assess internal bleeding, not external bleeding. 2. Palpating the lower abdomen assesses the bladder, not bleeding. 3. Turning the client to the side to assess the amount of drainage and possible bleeding is important prior to contacting the surgeon. 4. The first dressing change is usually done by the surgeon; the nurse can reinforce the dressing. TEST-TAKING HINT: The adjectives "large" and "red" indicate the client is bleeding, and assessment is always priority when the client is having a possible complication of a surgery. Remember, assessment is the first step in the nursing process.

The charge nurse is making assignments. Staffing includes a registered nurse with five (5) years of medical-surgical experience, a newly graduated registered nurse, and two (2) unlicensed assistive personnel (UAPs). Which client should be assigned to the most experienced nurse? 1. The 39-year-old client diagnosed with lower esophageal dysfunction who is complaining of pyrosis. 2. The 54-year-old client diagnosed with Barrett's esophagus who is scheduled to have an endoscopy this morning. 3. The 46-year-old client diagnosed with gastroesophageal reflux disease who has wheezes in all five (5) lobes. 4. The 68-year-old client who is three (3) days postoperative for hiatal hernia and needs to be ambulated four (4) times today.

3 1. Pyrosis is heartburn and is expected in a client diagnosed with GERD. The new graduate can care for this client. 2. Barrett's esophagus is a complication of GERD; new graduates can prepare a client for a diagnostic procedure. **3. This client is exhibiting symptoms of asthma, a complication of GERD. This client should be assigned to the most experienced nurse.** 4. This client can be cared for by the new graduate, and ambulating can be delegated to the unlicensed assistive personnel (UAP). TEST-TAKING HINT: The most experienced nurse should be assigned to the client whose assessment and care require more experience and knowledge about the disease process, potential complications, and medications. The term "most experienced" in the stem is the key to answering this question.

The client with type 2 diabetes is prescribed prednisone, a steroid, for an acute exacerbation of inflammatory bowel disease. Which intervention should the nurse discuss with the client? 1. Take this medication on an empty stomach. 2. Notify the HCP if experiencing a moon face. 3. Take the steroid medication as prescribed. 4. Notify the HCP if the blood glucose is over 160.

3 1. Steroids can cause erosion of the stomach and should be taken with food. 2. A moon face is an expected side effect of steroids. **3. This medication must be tapered off to prevent adrenal insufficiency; therefore, the client must take this medication as prescribed.** 4. Steroids may increase the client's blood glucose, but diabetic medication regimens are usually not altered for the short period of time the client with an acute exacerbation is prescribed steroids. TEST-TAKING HINT: The test taker should know few medications must be taken on an empty stomach, which would cause option "1" to be eliminated. All medications should be taken as prescribed—don't think the answer is too easy.

Which diagnostic test should the nurse monitor for the client diagnosed with severe anorexia nervosa? 1. Liver function tests. 2. Kidney function tests. 3. Cardiac function tests. 4. Bone density scan.

3 1. The client diagnosed with anorexia will have muscle tissue wasting; liver function tests will not monitor for this. 2. Kidney function tests will not monitor nutrition or muscle wasting. **3. The heart is a muscle; in severe anorexia (more than 60% under ideal body weight), muscle tissue is catabolized to provide energy to the body. The client is at risk for death from cardiac complications.** 4. The client's entire body will be involved in the process as a result of malnutrition, but bone density tests are not done. TEST-TAKING HINT: The test taker needs to be aware of the complications associated with specific disease processes.

The nurse is planning the care of a client diagnosed with lower esophageal sphincter dysfunction. Which dietary modifications should be included in the plan of care? 1. Allow any of the client's favorite foods as long as the amount is limited. 2. Have the client perform eructation exercises several times a day. 3. Eat four (4) to six (6) small meals a day and limit fluids during mealtimes. 4. Encourage the client to consume a glass of red wine with one (1) meal a day.

3 1. The client is instructed to avoid spicy and acidic foods and any food producing symptoms. 2. Eructation means belching, which is a symptom of GERD. **3. Clients should eat small, frequent meals and limit fluids with the meals to prevent reflux into the esophagus from a distended stomach.** 4. Clients are encouraged to forgo all alcoholic beverages because alcohol relaxes the lower esophageal sphincter and increases the risk of reflux. TEST-TAKING HINT: The word "any" in option "1" should give the test taker a clue that, unless there are absolutely no dietary restrictions, this is an incorrect answer. Option "2" requires knowledge of medical terminology.

The client is diagnosed with peritonitis. Which assessment data indicate to the nurse the client's condition is improving? 1. The client is using more pain medication on a daily basis. 2. The client's nasogastric tube is draining coffee-ground material. 3. The client has a decrease in temperature and a soft abdomen. 4. The client has had two (2) soft, formed bowel movements.

3 1. The client needing more pain medication indicates the client's condition is getting worse. 2. Coffee-ground material indicates old blood from the gastrointestinal system. **3. Because the signs of peritonitis are elevated temperature and rigid abdomen, a reversal of these signs indicates the client is getting better.** 4. Two soft-formed bowel movements are normal, but this does not have anything to do with peritonitis. TEST-TAKING HINT: The -itis of peritonitis means inflammation, which is associated with an elevated temperature. A decrease in temperature would be a sign the client is improving

The client is admitted to the medical unit with a diagnosis of acute diverticulitis. Which health-care provider's order should the nurse question? 1. Insert a nasogastric tube. 2. Start an IV with D5W at 125 mL/hr. 3. Put client on a clear liquid diet. 4. Place client on bedrest with bathroom privileges.

3 1. The client will have a nasogastric tube because the client will be NPO, which will decompress the bowel and remove hydrochloric acid. 2. Preventing dehydration is a priority with the client who is NPO. 3. The nurse should question a clear liquid diet because the bowel must be put on total rest, which means NPO. 4. The client is in severe pain and should be on bedrest, which will help rest the bowel. TEST-TAKING HINT: This is an "except" question. Therefore, the test taker must identify which answer option is incorrect for the stem. Sometimes flipping the question helps in selecting the correct answer. In this question, the test taker could ask, "Which HCP orders would be expected for a client diagnosed with diverticulitis?" The unexpected option would be the correct answer.

The client presents with a complete blockage of the large intestine from a tumor. Which health-care provider's order would the nurse question? 1. Obtain consent for a colonoscopy and biopsy. 2. Start an IV of 0.9% saline at 125 mL/hr. 3. Administer 3 liters of GoLYTELY. 4. Give tap water enemas until it is clear.

3 1. The client will need to have diagnostic tests, so this is an appropriate intervention. 2. The client who has an intestinal blockage will need to be hydrated. 3. This client has an intestinal blockage from a solid tumor blocking the colon. Although the client needs to be cleaned out for the colonoscopy, GoLYTELY could cause severe cramping without a reasonable benefit to the client and could cause a medical emergency. 4. Tap water enemas until clear would be instilling water from below the tumor to try to rid the colon of any feces. The client can expel this water. TEST-TAKING HINT: The stem states a "complete blockage," which indicates the client needs surgery. Therefore, options "1" and "2" are appropriate for surgery. The stem asks the test taker which order would be questioned, so this is an "except" question.

The 84-year-old client comes to the clinic complaining of right lower abdominal pain. Which question is most appropriate for the nurse to ask the client? 1. "When was your last bowel movement?" 2. "Did you have a high-fat meal last night?" 3. "Can you describe the type of pain?" 4. "Have you been experiencing any gas?"

3 1. The last bowel movement does not help identify the cause of the client's right lower abdominal pain. This might be appropriate for a client with left lower abdominal pain. 2. Information about a high-fat meal would be asked if the nurse suspected the client had a gallbladder problem. **3. An elderly client may experience a ruptured appendix with minimal pain; therefore, the nurse should assess the characteristics of the pain.** 4. The passage of flatus (gas) does not help determine the cause of right lower abdominal pain. TEST-TAKING HINT: The test taker should go back to basics and assess the client.

The client is diagnosed with gastroenteritis. Which laboratory data warrant immediate intervention by the nurse? 1. A serum sodium level of 137 mEq/L. 2. Arterial blood gases of pH 7.37, PaO2 95, PaCO2 43, HCO3 24. 3. A serum potassium level of 3.3 mEq/L. 4. A stool sample positive for fecal leukocytes.

3 1. The normal serum sodium level is 135 to 145 mEq/L; therefore, an intervention by the nurse is not needed. 2. These are normal arterial blood gas results; therefore, the nurse would not need to intervene. **3. In gastroenteritis, diarrhea often results in metabolic acidosis and loss of potassium. The normal serum potassium level is 3.5 to 5.5 mEq/L; therefore, a level of 3.3 mEq/L would require immediate intervention. Hypokalemia can lead to life-threatening cardiac dysrhythmias.** 4. A stool specimen showing fecal leukocytes supports the diagnosis of gastroenteritis and does not warrant immediate intervention by the nurse. TEST-TAKING HINT: The test taker should read the stem and be certain he or she understands what the question is asking—in this case, which date require "immediate intervention"? Therefore, the test taker is identifying an answer not normal for the disease process.

The nurse is assessing the client recovering from abdominal surgery who has a PCA pump. The client has shallow respirations and refuses to deep breathe. Which intervention should the nurse implement? 1. Insist the client take deep breaths. 2. Notify the surgeon to request a chest x-ray. 3. Determine the last time the client used the PCA pump. 4. Administer oxygen at 2 L/min via nasal cannula.

3 1. The nurse cannot force the client to do anything; this would be considered assault. 2. There are no data to support the need for a chest x-ray. **3. Shallow respirations and refusal to deep breathe could be the result of abdominal pain. The nurse should assess the client for pain and determine the last time the PCA pump was used.** 4. Based on the information given, the client does not need oxygen. TEST-TAKING HINT: If the test taker is unsure of the answer, identifying key words in the stem—"abdominal surgery" and "PCA"—should guide the test taker to select an option related to one (1) of these key words. "Determine" can be substituted for the word "assess," which is the first step of the nursing process.

The client who had abdominal surgery tells the nurse, "I felt something give way in my stomach." Which intervention should the nurse implement first? 1. Notify the surgeon immediately. 2. Instruct the client to splint the incision. 3. Assess the abdominal wound incision. 4. Administer pain medication intravenously.

3 1. The nurse may notify the surgeon if warranted, but it is not the first intervention. 2. The nurse should instruct the client to splint the incision when coughing, then take further action. **3. Assessing the surgical incision is the first intervention because this may indicate the client has wound dehiscence.** 4. The nurse should never administer pain medication without assessing for potential complications. TEST-TAKING HINT: The stem is asking which intervention is first. This means all four (4) answer options could be possible actions but only one (1) is first. The test taker should use the nursing process and select the option addressing assessment because it is the first step in the nursing process.

The client diagnosed with Crohn's disease is crying and tells the nurse, "I can't take it anymore. I never know when I will get sick and end up here in the hospital." Which statement is the nurse's best response? 1. "I understand how frustrating this must be for you." 2. "You must keep thinking about the good things in your life." 3. "I can see you are very upset. I'll sit down and we can talk." 4. "Are you thinking about doing anything like committing suicide?"

3 1. The nurse should never tell a client he or she understands what the client is going through. 2. Telling the client to think about the good things is not addressing the client's feelings. 3. The client is crying and is expressing feelings of powerlessness; therefore, the nurse should allow the client to talk. 4. The client is crying and states "I can't take it anymore," but this is not a suicidal comment or situation. TEST-TAKING HINT: There are rules applied to therapeutic responses. Do not say "understand" and do not ask "why." The test taker should select an option where some type of feeling is being reflected in the statement.

The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data require further intervention? 1. Bowel sounds auscultated fifteen (15) times in one (1) minute. 2. Belching after eating a heavy and fatty meal late at night. 3. A decrease in systolic BP of 20 mm Hg from lying to sitting. 4. A decreased frequency of distress located in the epigastric region.

3 1. The range for normoactive bowel sounds is from five (5) to 35 times per minute. This would require no intervention. 2. Belching after a heavy, fatty meal is a symptom of gallbladder disease. Eating late at night may cause symptoms of esophageal disorders. 3. A decrease of 20 mm Hg in blood pressure after changing position from lying, to sitting, to standing is orthostatic hypotension. This could indicate the client is bleeding. 4. A decrease in the quality and quantity of discomfort shows an improvement in the client's condition. This would not require further intervention. TEST-TAKING HINT: When the question asks about further intervention, the test taker should examine the answer options for an unexpected outcome requiring further assessment.

The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Check the abdominal dressings for bleeding. 2. Increase the IV fluid if the blood pressure is low. 3. Ambulate the client to the bathroom. 4. Auscultate the breath sounds in all lobes.

3 1. This is assessment and cannot be delegated. 2. This intervention would require nursing judgment, and increasing IV fluid is medication administration; neither task can be delegated. 3. A day surgery client can be ambulated to the bathroom, so this task can be delegated to the UAP. 4. This would require assessment and cannot be delegated.

The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement first? 1. Weigh the client daily and document in the client's chart. 2. Teach coping strategies such as dietary modifications. 3. Record the frequency, amount, and color of stools. 4. Monitor the client's oral fluid intake every shift.

3 1. Weighing the client daily will help identify if the client is experiencing malnutrition, but it is not the priority intervention during an acute exacerbation. 2. Coping strategies help develop healthy ways to deal with this chronic disease, which has remissions and exacerbations, but it is not the priority intervention. 3. The severity of the diarrhea helps determine the need for fluid replacement. The liquid stool should be measured as part of the total output. 4. The client will be NPO when there is an acute exacerbation of IBD to allow the bowel to rest. TEST-TAKING HINT: The test taker can apply Maslow's hierarchy of needs and select the option addressing a physiological need.

The nurse is caring for a client diagnosed with hemorrhaging duodenal ulcer. Which collaborative interventions should the nurse implement? Select all that apply. 1. Perform a complete pain assessment. 2. Assess the client's vital signs frequently. 3. Administer a proton pump inhibitor intravenously. 4. Obtain permission and administer blood products. 5. Monitor the intake of a soft, bland diet.

3, 4 1. A pain assessment is an independent intervention the nurse should implement frequently. 2. Evaluating vital signs is an independent intervention the nurse should implement. If the client is able, BPs should be taken lying, sitting, and standing to assess for orthostatic hypotension. 3. This is a collaborative intervention the nurse should implement. It requires an order from the HCP. 4. Administering blood products is collaborative, requiring an order from the HCP. 5. The diet requires an order by the healthcare provider, but a diet will not be ordered since the client is NPO. TEST-TAKING HINT: Descriptive words such as "collaborative" or "independent" can be the deciding factor when determining if an answer option is correct or incorrect. These are key words the test taker should identify.

The male client had abdominal surgery and the nurse suspects the client has peritonitis. Which assessment data support the diagnosis of peritonitis? 1. Absent bowel sounds and potassium level of 3.9 mEq/L. 2. Abdominal cramping and hemoglobin of 14 g/dL. 3. Profuse diarrhea and stool specimen shows Campylobacter. 4. Hard, rigid abdomen and white blood cell count 22,000/mm3.

4 1. Absent bowel sounds indicate a paralytic ileus, not peritonitis, and the potassium level is within normal limits (3.5 to 5.5 mEq/L). 2. Abdominal cramping would not make the nurse suspect peritonitis, and the hemoglobin is normal (13 to 17 g/dL). 3. Campylobacter is a cause of profuse diarrhea, but it does not support a diagnosis of peritonitis. **4. A hard, rigid abdomen indicates an inflamed peritoneum (abdominal wall cavity) resulting from an infection, which results in an elevated WBC level.** TEST-TAKING HINT: The -itis of peritonitis means inflammation, and if the test taker has no idea what the answer is, an elevated WBC count should provide a key to selecting option "4" as the correct answer.

The client is four (4) hours postoperative open cholecystectomy. Which data warrant immediate intervention by the nurse? 1. Absent bowel sounds in all four (4) quadrants. 2. The T-tube has 60 mL of green drainage. 3. Urine output of 100 mL in the past three (3) hours. 4. Refusal to turn, deep breathe, and cough.

4 1. After abdominal surgery, it is not uncommon for bowel sounds to be absent. 2. This is a normal amount and color of drainage. 3. The minimum urine output is 30 mL/hr. 4. Refusing to turn, deep breathe, and cough places the client at risk for pneumonia. This client needs immediate intervention to prevent complications. TEST-TAKING HINT: The test taker should recognize normal data such as the normal urine output and normal data for postoperative clients. The test taker should apply basic concepts when answering questions. Normal or expected outcomes do not require action.

Which problem is highest priority for the nurse to identify in the client who had an open cholecystectomy surgery? 1. Alteration in nutrition. 2. Alteration in skin integrity. 3. Alteration in urinary pattern. 4. Alteration in comfort.

4 1. Alteration in nutrition may be an appropriate client problem, but it is not priority. 2. Alteration in skin integrity may be an appropriate client problem, but is not priority. 3. Alteration in urinary elimination may be an appropriate client problem, but is not priority. 4. Acute pain management is the highest priority client problem after surgery because pain may indicate a life-threatening problem. TEST-TAKING HINT: When a question asks for the highest priority problem, the test taker should look for a life-threatening complication. Pain may be expected, but it may indicate a complication.

The client diagnosed with IBD is prescribed sulfasalazine (Asulfidine), a sulfonamide antibiotic. Which statement best describes the rationale for administering this medication? 1. It is administered rectally to help decrease colon inflammation. 2. This medication slows gastrointestinal motility and reduces diarrhea. 3. This medication kills the bacteria causing the exacerbation. 4. It acts topically on the colon mucosa to decrease inflammation.

4 1. Asulfidine cannot be administered rectally. Corticosteroids may be administered by enema for the local effect of decreasing inflammation while minimizing the systemic effects. 2. Antidiarrheal agents slow the gastrointestinal motility and reduce diarrhea. 3. IBD is not caused by bacteria. 4. Asulfidine is poorly absorbed from the gastrointestinal tract and acts topically on the colonic mucosa to inhibit the inflammatory process. TEST-TAKING HINT: If the test taker doesn't know the answer, then the test taker could eliminate options "2" and "3" because they do not contain the word "inflammation"; IBD is inflammatory bowel disease.

The nurse has administered an antibiotic, a proton pump inhibitor, and Pepto-Bismol for peptic ulcer disease secondary to H. pylori. Which data would indicate to the nurse the medications are effective? 1. A decrease in alcohol intake. 2. Maintaining a bland diet. 3. A return to previous activities. 4. A decrease in gastric distress.

4 1. Decreasing the alcohol intake indicates the client is making some lifestyle changes. 2. The client with PUD is prescribed a regular diet, but the type of diet does not determine if the medication is effective. 3. The return to previous activities indicates the client has not adapted to the lifestyle changes and has returned to the previous behaviors which precipitated the peptic ulcer disease. **4. Antibiotics, proton pump inhibitors, and Pepto-Bismol are administered to decrease the irritation of the ulcerative area and cure the ulcer. A decrease in gastric distress indicates the medication is effective.** TEST-TAKING HINT: To determine the effectiveness of a medication, the test taker must know the scientific rationale for administering the medication. Peptic ulcer disease causes gastric distress. If gastric distress is relieved, then the medication is effective.

The nurse writes a psychosocial problem of "risk for altered sexual functioning related to new colostomy." Which intervention should the nurse implement? 1. Tell the client there should be no intimacy for at least three (3) months. 2. Ensure the client and significant other are able to change the ostomy pouch. 3. Demonstrate with charts possible sexual positions for the client to assume. 4. Teach the client to protect the pouch from becoming dislodged during sex. 48.

4 1. Intimacy involves more than sexual intercourse. The client can be sexually active whenever the wounds are healed sufficiently to not cause pain. 2. This is an appropriate nursing intervention for home care, but it has nothing to do with sexual activity. 3. The nurse is not a sexual counselor who would have these types of charts. The nurse should address sexuality with the client but would not be considered an expert capable of explaining the advantages and disadvantages of sexual positioning. 4. A pouch that becomes dislodged during the sexual act would cause embarrassment for the client, whose body image has already been dealt a blow. TEST-TAKING HINT: Option "2" does not address the issue and option "3" is outside of the nurse's professional expertise. Option "1" could be eliminated because of the word "no," which is an absolute word.

The nurse is administering morning medications at 0730. Which medication should have priority? 1. A proton pump inhibitor. 2. A nonnarcotic analgesic. 3. A histamine receptor antagonist. 4. A mucosal barrier agent.

4 1. Proton pump inhibitors can be administered at routine dosing times, usually 0900 or after breakfast. 2. Pain medication is important, but a nonnarcotic medication, such as Tylenol, can be administered after a medication which must be timed. 3. A histamine receptor antagonist can be administered at routine dosing times. **4. A mucosal barrier agent must be administered on an empty stomach for the medication to coat the stomach.** TEST-TAKING HINT: Basic knowledge of how medications work is required to administer medications for peak effectiveness. There are very few medications requiring a specific time. The test taker should memorize these specific medications.

The female client is more than 10% over ideal body weight. Which nursing intervention should the nurse implement first? 1. Ask the client why she is eating too much. 2. Refer the client to a gymnasium for exercise. 3. Have the client set a realistic weight loss goal. 4. Determine the client's eating patterns.

4 1. The client does not owe the nurse an explanation. 2. If the HCP determines it is safe for the client to exercise, a gymnasium might be recommended, but walking is the best exercise, and this can be done in the neighborhood or at an enclosed shopping mall. 3. The client should set realistic weight loss goals. A realistic weight loss goal is one (1) to one and one-half (11/2) pounds per week, but this should be done after assessing the client. **4. Determining the client's eating patterns and what triggers the client to eat—stress or boredom, for example—and where and when the client consumes most of the calories—snacking in front of the TV at night, for example—is needed to assist the client to change eating behaviors.** TEST-TAKING HINT: This question is an example of using the nursing process to arrive at the correct answer. Assessing the client has priority.

The client developed a paralytic ileus after abdominal surgery. Which intervention should the nurse include in the plan of care? 1. Administer a laxative of choice. 2. Encourage client to increase oral fluids. 3. Encourage client to take deep breaths. 4. Maintain a patent nasogastric tube.

4 1. The client is NPO; therefore, no medication would be administered. 2. The client is NPO so no food or fluids are allowed. 3. Deep breathing will help prevent pulmonary complications, but does not address the client's paralytic ileus. **4. A paralytic ileus is the absence of peristalsis; therefore, the bowel will be unable to process any oral intake. A nasogastric tube is inserted to decompress the bowel until surgical intervention or until bowel sounds return spontaneously.** TEST-TAKING HINT: If the test taker realizes the stem of the question says part of the gastrointestinal system, the ileus, is paralyzed, the test taker should know allowing the client to take anything by mouth would be an inappropriate action, so options "1" and "2" could be eliminated. Deep breathing addresses the respiratory system, not the gastrointestinal system, so option "3" could also be eliminated.

The nurse is preparing a client diagnosed with GERD for discharge following an esophagogastroduodenoscopy. Which statement indicates the client understands the discharge instructions? 1. "I should not eat for at least one (1) day following this procedure." 2. "I can lie down whenever I want after a meal. It won't make a difference." 3. "The stomach contents won't bother my esophagus but will make me nauseous." 4. "I should avoid orange juice and eating tomatoes until my esophagus heals."

4 1. The client is allowed to eat as soon as the gag reflex has returned. 2. An esophagogastroduodenoscopy is a diagnostic procedure, not a cure. Therefore, the client still has GERD and should be instructed to stay in an upright position for two (2) to three (3) hours after eating. 3. Stomach contents are acidic and will erode the esophageal lining. **4. Orange juice and tomatoes are acidic, and the client diagnosed with GERD should avoid acidic foods until the esophagus has had a chance to heal.**

The nurse is caring for a client diagnosed with GERD. Which nursing interventions should be implemented? 1. Place the client prone in bed and administer nonsteroidal anti-inflammatory medications. 2. Have the client remain upright at all times and walk for 30 minutes three (3) times a week. 3. Instruct the client to maintain a right lateral side-lying position and take antacids before meals. 4. Elevate the head of the bed 30 degrees and discuss lifestyle modifications with the client.

4 1. The client is encouraged to lie with the head of the bed elevated, but this is difficult to achieve when on the stomach. NSAIDs inhibit prostaglandin synthesis in the stomach, which places the client at risk for developing gastric ulcers. The client is already experiencing gastric acid difficulty. 2. The client will need to lie down at some time, and walking will not help with GERD. 3. If lying on the side, the left side-lying position, not the right side, will allow less chance of reflux into the esophagus. Antacids are taken one (1) and three (3) hours after a meal. **4. The head of the bed should be elevated to allow gravity to help in preventing reflux. Lifestyle modifications of losing weight, making dietary modifications, attempting smoking cessation, discontinuing the use of alcohol, and not stooping or bending at the waist all help to decrease reflux.** TEST-TAKING HINT: Option "2" has an "all," which should alert the test taker to eliminate this option. If the test taker has no idea of the answer, lifestyle modifications are an educated guess for most chronic problems.

The nurse is teaching the client diagnosed with diverticulosis. Which instruction should the nurse include in the teaching session? 1. Discuss the importance of drinking 1,000 mL of water daily. 2. Instruct the client to exercise at least three (3) times a week. 3. Teach the client about a eating a low-residue diet. 4. Explain the need to have daily bowel movements.

4 1. The client should drink at least 3,000 mL of water daily to help prevent constipation. 2. The client should exercise daily to help prevent constipation. 3. The client should eat a high-fiber diet to help prevent constipation. 4. The client should have regular bowel movements, preferably daily. Constipation may cause diverticulitis, which is a potentially life-threatening complication of diverticulosis. TEST-TAKING HINT: The test taker must be careful to distinguish between -osis and -itis. Diverticulosis is the condition of having small pouches in the colon, and preventing constipation is the most important action the client can take to prevent diverticulitis (inflammation of the diverticulum).

Which data should the nurse expect to assess in the client diagnosed with acute gastroenteritis? 1. Decreased gurgling sounds on auscultation of the abdominal wall. 2. A hard, firm, edematous abdomen on palpation. 3. Frequent, small melena-type liquid bowel movements. 4. Bowel assessment reveals loud, rushing bowel sounds.

4 1. The client would have increased gurgling sounds revealing hyperactive bowel movements. 2. A hard, firm, edematous abdomen is not expected in a client with gastroenteritis; this would indicate a possible complication and require further assessment. 3. The client has increased liquid bowel movements (diarrhea) but should not have blood in the stool, which is the definition of melena. **4. Borborygmi, or loud, rushing bowel sounds, indicates increased peristalsis, which occurs in clients with diarrhea and is the primary clinical manifestation in a client diagnosed with acute gastroenteritis.** TEST-TAKING HINT: The test taker should realize that, in an acute condition, the assessment data would be abnormal, which may help select the correct answer for some questions.

The client is two (2) hours post-colonoscopy. Which assessment data warrant intermediate intervention by the nurse? 1. The client has a soft, nontender abdomen. 2. The client has a loose, watery stool. 3. The client has hyperactive bowel sounds. 4. The client's pulse is 104 and BP is 98/60.

4 1. The client's abdomen should be soft and nontender; therefore, this finding would not require immediate intervention. 2. The client had to clean the bowel prior to the colonoscopy; therefore, watery stool is expected. 3. The client was NPO and received bowel preparation prior to the colonoscopy; therefore, hyperactive bowel sounds might occur and do not warrant immediate intervention. 4. Bowel perforation is a potential complication of a colonoscopy. Therefore, signs of hypotension—decreased BP and increased pulse—warrant immediate intervention from the nurse. TEST-TAKING HINT: This is an "except" question. The test taker is being asked to select which data are abnormal for a procedure. The test taker should remember any invasive procedure could possibly lead to hemorrhaging, and signs of shock should always be considered a possible correct answer.

The nurse writes a problem "low self-esteem" for a 16-year-old client diagnosed with anorexia. Which client goal should be included in the plan of care? 1. The client will spend one (1) hour a day with the parents. 2. The client eats 50% of the meals provided. 3. Dietary will provide high-protein milk shakes t.i.d. 4. The client will verbalize one positive attribute.

4 1. The goal is written in terms of client behavior; this option is a nursing intervention, not a client goal. 2. Eating 50% of meals provided does not address low self-esteem. 3. High-protein shakes are a dietary intervention. **4. The problem of "low self-esteem" requires the client to verbalize psychosocial feelings. Identifying one positive attribute is an appropriate goal.** TEST-TAKING HINT: The test taker could eliminate distracter "3" as a health-care discipline intervention. Psychosocial problems require goals addressing a nonphysiological need.

Which assessment data support to the nurse the client's diagnosis of gastric ulcer? 1. Presence of blood in the client's stool for the past month. 2. Reports of a burning sensation moving like a wave. 3. Sharp pain in the upper abdomen after eating a heavy meal. 4. Complaints of epigastric pain 30 to 60 minutes after ingesting food.

4 1. The presence of blood does not specifically indicate diagnosis of an ulcer. The client could have hemorrhoids or cancer resulting in the presence of blood. 2. A wavelike burning sensation is a symptom of gastroesophageal reflux. 3. Sharp pain in the upper abdomen after eating a heavy meal is a symptom of gallbladder disease. 4. In a client diagnosed with a gastric ulcer, pain usually occurs 30 to 60 minutes after eating, but not at night. In contrast, a client with a duodenal ulcer has pain during the night often relieved by eating food. Pain occurs 1 to 3 hours after meals. TEST-TAKING HINT: This question asks the test taker to identify assessment data specific to the disease process. Many diseases have similar symptoms, but the timing of symptoms or their location may help rule out some diseases and provide the healthcare provider with a key to diagnose a specific disease—in this case, peptic ulcer disease. Nurses are usually the major source for information to the health-care team.

The client who has had an abdominal perineal resection is being discharged. Which discharge information should the nurse teach? 1. The stoma should be a white, blue, or purple color. 2. Limit ambulation to prevent the pouch from coming off. 3. Take pain medication when the pain level is at an "8." 4. Empty the pouch when it is one-third to one-half full.

4 1. The stoma should be light to a medium pink, the color of the intestines. A blue or purple color indicates a lack of circulation to the stoma and is a medical emergency. 2. The stoma should be pouched securely for the client to be able to participate in normal daily activities. The client should be encouraged to ambulate to aid in recovery. 3. Pain medication should be taken before the pain level reaches a "5." Delaying taking medication will delay the onset of pain relief and the client will not receive full benefit from the medication. 4. The pouch should be emptied when it is one-third to one-half full to prevent the contents from becoming too heavy for the seal to hold and to prevent leakage from occurring.

Which problems should the nurse include in the plan of care for the client diagnosed with peptic ulcer disease to observe for physiological complications? 1. Alteration in bowel elimination patterns. 2. Knowledge deficit in the causes of ulcers. 3. Inability to cope with changing family roles. 4. Potential for alteration in gastric emptying.

4 1. There is no indication from the question there is a problem or potential problem with bowel elimination. 2. Knowledge deficit does not address physiological complications. 3. This client may have problems from changing roles within the family, but the question asks for potential physiological complications, not psychosocial problems. 4. Potential for alteration in gastric emptying is caused by edema or scarring associated with an ulcer, which may cause a feeling of "fullness," vomiting of undigested food, or abdominal distention.

The client diagnosed with diverticulitis is complaining of severe pain in the left lower quadrant and has an oral temperature of 100.6˚F. Which intervention should the nurse implement first? 1. Notify the health-care provider. 2. Document the findings in the chart. 3. Administer an oral antipyretic. 4. Assess the client's abdomen.

4 1. These are classic signs/symptoms of diverticulitis; therefore, the HCP does not need to be notified. 2. These are normal findings for a client diagnosed with diverticulitis, but on admission the nurse should assess the client and document the findings in the client's chart. 3. The nurse should not administer any food or medications. 4. The nurse should assess the client to determine if the abdomen is soft and nontender. A rigid tender abdomen may indicate peritonitis. TEST-TAKING HINT: The test taker must remember to apply the nursing process when answering test questions. Assessment is the first step in the nursing process. Although the signs/symptoms are normal and could be documented, the nurse should always assess.

Which intervention should the nurse include when discussing ways to help prevent potential episodes of gastroenteritis from Clostridium botulism? 1. Make sure all hamburger meat is well cooked. 2. Ensure all dairy products are refrigerated. 3. Discuss why campers should drink only bottled water. 4. Discard damaged canned goods.

4 1. Well-cooked meat will help prevent gastroenteritis secondary to staphylococcal food poisoning. 2. Refrigerating dairy products will help prevent gastroenteritis secondary to eating foods kept at room temperature, causing staphylococcal food poisoning. 3. Drinking bottled water will help prevent gastroenteritis secondary to Escherichia coli found in contaminated water. **4. Any discolored food, food from a damaged can or jar, or food from a can or jar not having a tight seal should be destroyed without tasting or touching it.** TEST-TAKING HINT: The test taker should be careful with words such as "all," "only," and "never"; few absolutes exist in the health-care field.

Which outcome should the nurse identify for the client scheduled to have a cholecystectomy? 1. Decreased pain management. 2. Ambulate first day postoperative. 3. No break in skin integrity. 4. Knowledge of postoperative care.

4 1. The expected outcome is pain control for both preoperative and postoperative care. 2. Postoperative care includes ambulation. 3. Prevention of an additional impaired skin integrity is a desired postoperative outcome. The incision would be a break in skin integrity. 4. This would be an expected outcome for the client scheduled for surgery. This indicates preoperative teaching has been effective. TEST-TAKING HINT: The time element is important in this question. The expected outcome is required for the preoperative period. Option "1" is incorrect because of the adjective "decreased." Adjectives commonly determine the accuracy of the options.

The nurse is preparing to administer 250 mL of intravenous antibiotic to the client. The medication must infuse in one (1) hour. An intravenous pump is not available and the nurse must administer the medication via gravity with IV tubing at 10 gtts/min. At what rate should the nurse infuse the medication? _________

42 gtts/min