NUR1306 Test #4 QUESTIONS GI

Which of the following would be the most important nursing assessment in a patient diagnosed with ascites? 1. Daily weight and measurement of abdominal girth 2. Auscultation of abdomen 3. Assessment of oral cavity for foul smelling breath 4. Palpation of abdomen for a fluid shift

1. Daily weight and measurement of abdominal girth

Peptic ulcer disease may be caused by which of the following? 1. Helicobacter pylori 2. Clostridium difficile 3. Candida albicans 4. Staphylococcus aureus

1. Helicobacter pylori

Nitrosocarcinogen production can be inhibited with intake of: 1. vitamin C. 2. vitamin E. 3. carbohydrates. 4. fiber.

1. vitamin C.

The nurse is preparing a discharge teaching plan for the male client who had umbilical hernia repair. What should the nurse include in the plan? 1. Irrigating the drain 2. Avoiding coughing 3. Maintaining bed rest 4. Restricting pain medication

2. Avoiding coughing Coughing is avoided following umbilical hernia repair to prevent disruption of tissue integrity, which can occur because of the location of this surgical procedure.

A patient has undergone a liver biopsy. Following the procedure, the nurse should place the patient in which of the following positions? 1. Trendelenburg 2. On the right side 3. On the left side 4. High Fowler's

2. On the right side

Which of the following medications is used to decrease portal pressure, halting bleeding of esophageal varices? 1. Nitroglycerin 2. Spironolactone (Aldactone) 3. Vasopressin (Pitressin) 4. Cimetidine (Tagamet)

3. Vasopressin (Pitressin) Vasopressin constricts the splanchnic arterial bed and decreases portal hypertension.

Which of the following indicates an overdose of lactulose? 1. Fecal impaction 2. Constipation 3. Hypo active bowel sounds 4. Watery diarrhea

4. Watery diarrhea

The nurse can expect a 60-year old patient with ischemic bowel to report a history of: 1. diabetes mellitus 2. asthma 3. Addison's Disease 4. cancer of the bowel

1. diabetes mellitus

The nurse must be alert for complications with *Sengstaken-Blakemore* intubation including: 1. pulmonary obstruction 2. pericardiectomy syndrome 3. pulmonary embolization 4. cor pulmonale

1. pulmonary obstruction

A nurse is preparing to administer pancrelipase to a client who has pancreatitis. Which of the following actions should the nurse take? 1. Instruct the client to chew the medication before swallowing 2. Offer 8 ounces of water following medication administration 3. Administer the medication 30 minutes before meals 4. Sprinkle the contents on peanut butter

2. Offer 8 ounces of water following medication administration This medication should not be chewed to reduce irritation and slow the release. It should be taken with every meal and snack. It should be sprinkled on non-protein food if administered with foods

Which condition is most likely to have a nursing diagnosis of fluid volume deficit? 1. Appendicitis 2. Pancreatitis 3. Cholecystitis 4. Gastric ulcer

2. Pancreatitis Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis.

Which of the following liver function studies is used to show the size of the liver and hepatic blood flow and obstruction? 1. Angiography 2. Radioisotope liver scan 3. EEG 4. MRI

2. Radioisotope liver scan

Patients with esophageal varices would reveal the following assessment: 1. increased blood pressure. 2. increased heart rate. 3. decreased respiratory rate. 4. increased urinary output.

2. increased heart rate.

Ursodeoxycholic acid Has been used to dissolve small, radiolucent gallstones. Which duration of therapy is required to dissolve the stones? 1. 1 to 4 months 2. Over a year 3. 6 to 12 months 4. 4 to 6 months

3. 6 to 12 months

Which of the following is an age related change of the hepatobiliary system? 1. Decreased prevalence of gallstones 2. Increased drug clearance capability 3. Decreased blood flow 4. Liver enlargement

3. Decreased blood flow

Patients with chronic liver dysfunction have problems with insufficient vitamin intake. Which of the following may occur as a result of a vitamin C deficiency? 1. Night blindness 2. Beriberi 3. Scurvy 4. Hypoprothrombinemia

3. Scurvy

The nurse identifies which of the following types of jaundice and an adult experiencing a transfusion reaction? 1. Nonobstructive 2. Hepatocellular 3. Obstructive 4. Hemolytic

4. Hemolytic

A nurse is reinforcing nutrition teaching with a client who has pancreatitis. Which of the following statements by the client indicates understanding? Select all that apply 1. "I plan to eat small frequent meals." 2. "I will eat easy to digest foods with limited spice." 3. "I will use skim milk when cooking." 4. "I plan to drink regular cola." 5. "I will limit alcohol intake to two drinks per day."

1, 2 and 3 The client should drink caffeine free beverages to reduce GI stimulation. The client should also avoid all alcohol.

The nurse is assessing a patient with hepatic cirrhosis for mental deterioration. For what clinical manifestations will the nurse monitor? Select all that apply 1. Alterations in mood 2. Agitation 3. Decreased deep tendon reflexes 4. Insomnia 5. Complaints of headache

1, 2 and 4

A nurse is caring for a client who has cirrhosis. Which of the following medications should the nurse expect to administer to this client? Select all that apply 1. Diuretic 2. Beta blocking agent 3. Opioid analgesic 4. Lactulose 5. Sedative

1, 2 and 4 The liver metabolizes opioids and sedatives. A client with cirrhosis should not take these medications.

A nurse is reinforcing teaching with a client who has hepatitis B about home care. Which of the following instructions should the nurse include? Select all that apply 1. Limit physical activity 2. Avoid alcohol 3. Take acetaminophen for comfort 4. Wear a mask when in public places 5. Eat small frequent meals

1, 2 and 5

The nurse is preparing a care plan for a patient with hepatic cirrhosis. Which of the following nursing diagnosis are appropriate? Select all that apply 1. Disturbed body image related to changes in appearance, sexual dysfunction and role function 2. Risk for injury related to altered clotting mechanisms 3. Urinary incontinence related to general debility and muscle wasting 4. Altered nutrition, more than body requirements, related to decreased activity and bedrest 5. Activity intolerance related to fatigue, general debility, muscle wasting and discomfort

1, 2 and 5

A patient admitted with severe epigastric abdominal pain radiating to the back is vomiting and complaining of difficulty breathing. Upon assessment, the nurse determines that the patient is experiencing tachycardia and hypotension. Which of the following actions is a priority intervention for this patient? Select all that apply 1. Administer pain relieving medication 2. Assist the patient to a semi Fowler's position 3. Administer plasma 4. Administer a low-fat diet 5. Administer electrolytes

1, 2, 3 and 5 The treatment goals for acute pancreatitis focus on relieving pain, maintaining circulatory and fluid volume and decreasing production of pancreatic enzymes. IV fluid replacement should be done immediately. Plasma should be administered to maintain BP within an acceptable range. Low serum calcium and magnesium levels may occur and require prompt treatment. Semi Fowler's will decrease pressure on the diaphragm.

A male client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing is: 1. "Tell me about your husband's alcohol usage." 2. "Is your husband being treated for tuberculosis?" 3. "Has your husband recently fallen or injured his chest?" 4. "Describe spices and condiments your husband uses on food."

1. "Tell me about your husband's alcohol usage." A Mallory-Weiss tear is associated with massive bleeding after a tear occurs in the mucous membrane at the junction of the esophagus and stomach. There is a strong relationship between ethanol usage, resultant vomiting, and a Mallory-Weiss tear.

A female client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurse's best response? 1. "You may have eaten contaminated restaurant food." 2. "You could have gotten it by using I.V. drugs." 3. "You must have received an infected blood transfusion." 4. "You probably got it by engaging in unprotected sex."

1. "You may have eaten contaminated restaurant food."

Nurse Ryan is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents and checks the contents for pH. The nurse verifies correct tube placement if which pH value is noted? 1. 3.5 2. 7.0 3. 7.35 4. 7.5

1. 3.5

The nurse is planning care for a patient following an incisional cholecystectomy for cholelithiasis. Which of the following interventions is the highest nursing priority for this patient? 1. Assisting the patient to turn, cough and deep breathe every two hours 2. Assisting the patient to ambulate the evening of the operative day 3. Performing range of motion leg exercises hourly while the patient is awake 4. Teaching the patient to choose low-fat foods from the menu

1. Assisting the patient to turn, cough and deep breathe every two hours

A nurse is reviewing nutrition teaching for a client who has cholecystitis. The nurse should identify that which of the following food choices is most likely to trigger cholecystitis? 1. Brownie with nuts 2. Bowl of mixed fruit 3. Grilled turkey 4. Baked potato

1. Brownie with nuts A low calorie, liquid protein diet can trigger it. Also rapid weight loss can trigger it

Which of the following nursing interventions should the nurse perform for a female client receiving enteral feedings through a gastrostomy tube? 1. Change the tube feeding solutions and tubing at least every 24 hours. 2. Maintain the head of the bed at a 15-degree elevation continuously. 3. Check the gastrostomy tube for position every 2 days. 4. Maintain the client on bed rest during the feedings

1. Change the tube feeding solutions and tubing at least every 24 hours. Tube feeding solutions and tubing should be changed every 24 hours, or more frequently if the feeding requires it. Doing so prevents contamination and bacterial growth. The head of the bed should be elevated 30 to 45 degrees continuously to prevent aspiration.

The nurse is reviewing the record of a female client with Crohn's disease. Which stool characteristics should the nurse expect to note documented in the client's record? 1. Diarrhea 2. Chronic constipation 3. Constipation alternating with diarrhea 4. Stools constantly oozing from the rectum

1. Diarrhea Crohn's disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity.

Which diagnostic test would be used first to evaluate a client with upper GI bleeding? 1. Endoscopy 2. Upper GI series 3. Hemoglobin (Hb) levels and hematocrit (HCT) 4. Arteriography

1. Endoscopy Endoscopy permits direct evaluation of the upper GI tract and can detect 90% of bleeding lesions. An upper GI series, or barium study, usually isn't the diagnostic method of choice, especially in a client with acute active bleeding who's vomiting and unstable. An upper GI series is also less accurate than endoscopy. Although an upper GI series might confirm the presence of a lesion, it wouldn't necessarily reveal whether the lesion is bleeding. Hb levels and HCT, which indicate loss of blood volume, aren't always reliable indicators of GI bleeding because a decrease in these values may not be seen for several hours. Arteriography is an invasive study associated with life-threatening complications and wouldn't be used for an initial evaluation.

A female client being seen in a physician's office has just been scheduled for a barium swallow the next day. The nurse writes down which instruction for the client to follow before the test? 1. Fast for 8 hours before the test 2. Eat a regular supper and breakfast 3. Continue to take all oral medications as scheduled 4. Monitor own bowel movement pattern for constipation

1. Fast for 8 hours before the test A barium swallow is an x-ray study that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal tract. The client should fast for 8 to 12 hours before the test, depending on physician instructions. Most oral medications also are withheld before the test.

Dr. Smith has determined that the client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D

1. Hepatitis A Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.

Nurse Oliver checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is appropriate action for the nurse to take? 1. Hold the feeding 2. Reinstill the amount and continue with administering the feeding 3. Elevate the client's head at least 45 degrees and administer the feeding 4. Discard the residual amount and proceed with administering the feeding

1. Hold the feeding Unless specifically indicated, residual amounts more than 100 mL require holding the feeding.

The nurse is teaching a female client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do? 1. Increase fluid intake 2. Place heat on the abdomen 3. Perform the irrigation in the evening 4. Reduce the amount of irrigation solution

1. Increase fluid intake To enhance effectiveness of the irrigation and fecal returns, the client is instructed to increase fluid intake and to take other measures to prevent constipation.

A patient has become very depressed postoperatively after receiving colostomy for GI cancer. He does not participate in his colostomy care or look at the stoma. An appropriate nursing diagnosis for this situation is: 1. Ineffective Individual Coping 2. Knowledge Deficit 3. Impaired Adjustment 4. Anxiety

1. Ineffective Individual Coping

While a female client is being prepared for discharge, the nasogastric (NG) feeding tube becomes cloggeD. To remedy this problem and teach the client's family how to deal with it at home, what should the nurse do? 1. Irrigate the tube with cola 2. Advance the tube into the intestine 3. Apply intermittent suction to the tube 4. Withdraw the obstruction with a 30-ml syringe

1. Irrigate the tube with cola The nurse should irrigate the tube with cola because its effervescence and acidity are suited to the purpose, it's inexpensive, and it's readily available in most homes.

A patient with cirrhosis has a massive hemorrhage from esophageal varices. Balloon Tamponade therapy is used temporarily to control hemorrhage and stabilize the patient. In planning care, the nurse gives the highest priority to which of the following goals? 1. Maintaining the airway 2. Controlling bleeding 3. Maintaining fluid volume 4. Relieving the patient's anxiety

1. Maintaining the airway

Young patient with anorexia, fatigue and Jandus is diagnosed with hepatitis B and has just been admitted to the hospital. The patient asked the nurse how long she needs to stay in the hospital. In planning care for the patient, the nurse identifies impaired psychosocial issues and assigns the highest priority to which of the following patient outcomes? 1. Minimizing social isolation 2. Establishing a stable home environment 3. Identifying the source of exposure to hepatitis 4. Reducing the spread of the disease

1. Minimizing social isolation

A male client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond? 1. Notify the physician 2. Reposition the tube 3. Irrigate the tube 4. Increase the suction level

1. Notify the physician An NG tube that fails to drain during the postoperative period should be reported to the physician immediately. It may be clogged, which could increase pressure on the suture site because fluid isn't draining adequately. Repositioning or irrigating an NG tube in a client who has undergone gastric surgery can disrupt the anastomosis. Increasing the level of suction may cause trauma to GI mucosa or the suture line.

A nurse is gathering equipment and preparing to assist with a sterile bedside procedure to withdraw fluid from the patient's abdomen. The procedure trey contains the following equipment: trocar, syringe, needles and drainage tube. The patient is placed in a high Fowlers position and a blood pressure cuff is secured around the arm in preparation for which of the following procedures? 1. Paracentesis 2. Dialysis 3. Abdominal ultrasound 4. Liver biopsy

1. Paracentesis

Nurse Juvy is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of: 1. Pork 2. Milk 3. Chicken 4. Broccoli

1. Pork The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes.

Your patient's ABG reveal an acidic pH, an acidic CO2 and a normal bicarbonate level. Which of the following indicates this acid-base disturbance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1. Respiratory acidosis

Which of the following laboratory values would be the most important to monitor for a patient with pancreatic cancer? 1. Serum glucose 2. Radioimmunoassay (RIA) 3. Creatine phosphokinase (CPK) 4. Carcinoembryonic antigen (CEA)

1. Serum glucose In pancreatitis, hypersecretion of the insulin from a tumor may affect the islets of Langerhans, resulting in hyperinsulinemia, a complication of pancreatic cancer.

A nursing instructor is explaining the pathophysiology and clinical manifestations of pancreatitis to a group of nursing students. The instructor evaluates the teaching as effective when a student correctly identifies which of the following symptoms as the most common complaint of patients with pancreatitis? 1. Severe, radiating abdominal pain 2. Tarry black stools and dark urine 3. Increased and painful urination 4. Increased appetite and weight gain

1. Severe, radiating abdominal pain

The nurse is monitoring a female client for the early signs and symptoms of dumping syndrome. Which of the following indicate this occurrence? 1. Sweating and pallor 2. Bradycardia and indigestion 3. Double vision and chest pain 4. Abdominal cramping and pain

1. Sweating and pallor Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

You are caring for Rona, a 35-year-old female in a hepatic coma. Which evaluation criteria would be the most appropriate? 1. The patient demonstrates an increase in level of consciousness. 2. The patient exhibits improved skin integrity. 3. The patient experiences no evident signs of bleeding. 4. The patient verbalize decreased episodes of pain.

1. The patient demonstrates an increase in level of consciousness.

A nursing intervention for a patient with hepatitis B would include which of the following types of isolation. 1. Universal precautions 2. Blood transfusions 3. Enteric isolation 4. Strict isolation

1. Universal precautions

A male client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of: 1. increasing fluid intake to prevent dehydration 2. wearing an appliance pouch only at bedtime 3. consuming a low-protein, high-fiber diet 4. taking only enteric-coated medications

1. increasing fluid intake to prevent dehydration Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake.

A clinical manifestation of acute pancreatitis is epigastric pain. Your nursing intervention to facilitate relief of pain would place the patient in a: 1. knee-chest position 2. semi-Fowler's position 3. recumbent position 4. low-Fowler's position

1. knee-chest position Flexion of the trunk lessens the pain and decreases restlessness.

You observe changes in mentation, irritability, restlessness, and decreased concentration in a patient with cancer of the liver. Hepatic encephalopathy is suspected and the patient is ordered neomycin enemas. Which of the following information in the patient's history would be a contraindication of this order? 1. left nephrectomy 2. glaucoma in both eyes 3. myocardial infarction 4. peripheral neuropathy

1. left nephrectomy Neomycin prevents the release of ammonia from the intestinal bacteria flora and from the breakdown of red blood cells. Common side-effects of this drug are nephrotoxicity and ototoxicity.

A patient with severe cirrhosis of the liver develops hepatorenal syndrome. Which of the following nursing assessment data would support this? 1. oliguria and azotemia 2. metabolic alkalosis 3. decreased urinary concentration 4. weight gain of less than 1 pound per week

1. oliguria and azotemia

A male client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: 1. yellow sclera 2. light amber urine 3. circumoral pallor 4. black, tarry stools

1. yellow sclera

A nurse is reviewing discharge instructions with a client who is postoperative following open cholecystectomy with a T tube placement. Which of the following instructions should the nurse include in the teaching? Select all that apply 1. Take baths rather than showers 2. Clamp T tube for one hour before and after meals 3. Replace the drainage system daily 4. Expect to have the T tube removed three days postoperatively 5. Expect brown green drainage from the tube

2 and 5 The tube will be in place for 1 to 3 weeks. The drainage does not have to be changed, only emptied. Clamping the tube one hour before and after meals allows bile needed for digestion of food to remain in the body.

A nurse is preparing a patient for an endoscopic retrograde cholangiopancreatography ERCP. The patient ask what the test is used for. Which of the following statements made by the nurse explains how an ERCP can determine the difference between pancreatitis and other biliary disorders? Select all that apply 1. It can assess for ecchymosis in the body 2. It can assess the anatomy of the pancreas and the pancreatic and biliary ducts 3. It can evaluate the presence and location of ductal stones and aid in stone removal. 4. It can detect unhealthy tissue in the pancreas and assess for abscesses and pseudocyst 5. It is used in the diagnostic evaluation of acute pancreatitis

2, 3 and 4

A nurse is collecting data from a client who has advanced cirrhosis. Which of the following findings indicates the client is experiencing hepatic encephalopathy? Select all that apply 1. Anorexia 2. Change in orientation 3. Asterixis 4. Ascites 5. Fetor hepaticus

2, 3 and 5

To prevent gastroesophageal reflux in a male client with hiatal hernia, the nurse should provide which discharge instruction? 1. "Lie down after meals to promote digestion." 2. "Avoid coffee and alcoholic beverages." 3. "Take antacids with meals." 4. "Limit fluid intake with meals."

2. "Avoid coffee and alcoholic beverages." To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating.

A nurse is reviewing preoperative teaching with a client scheduled for a laparoscopic cholecystectomy. Which of the following should the nurse include? 1. "The scope will be passed through your rectum." 2. "You might have shoulder pain after surgery." 3. "You will have a Jackson Pratt drain in place after the surgery." 4. "You should limit how often you walk for 1 to 2 weeks."

2. "You might have shoulder pain after surgery."

A male client is recovering from a small-bowel resection. To relieve pain, the physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours. How soon after administration should meperidine onset of action occur? 1. 5 to 10 minutes 2. 15 to 30 minutes 3. 30 to 60 minutes 4. 2 to 4 hours

2. 15 to 30 minutes Meperidine onset of action is 15 to 30 minutes. It peaks between 30 and 60 minutes and has a duration of action of 2 to 4 hours.

The nurse is monitoring a female client receiving paregoric to treat diarrhea for drug interactions. Which drugs can produce additive constipation when given with an opium preparation? 1. Antiarrhythmic drugs 2. Anticholinergic drugs 3. Anticoagulant drugs 4. Antihypertensive drugs

2. Anticholinergic drugs

The nurse completing a plan of care for a patient with cirrhosis who has ascites and 4+ pitting edema of the feet and legs identifies a nursing diagnosis of risk for impaired skin integrity. Which of the following is an appropriate nursing intervention for this problem? 1. Re-position the patient every four hours 2. Arrange for a low air loss bed 3. Performed passive range of motion exercises four times daily 4. Re-strict dietary protein intake

2. Arrange for a low air loss bed

Which of the following interventions should be included in the plan of care for a patient who has undergone a cholecystectomy? 1. Placing the patient in the semi Fowler's position immediately following surgery 2. Assessing the color of the sclera every shift 3. Clamping the T tube immediately after surgery 4. Placing the patient on NPO status for two days following surgery

2. Assessing the color of the sclera every shift

The nurse is caring for a male client postoperatively following creation of a colostomy. Which nursing diagnosis should the nurse include in the plan of care? 1. Sexual dysfunction 2. Body image, disturbed 3. Fear related to poor prognosis 4. Nutrition: more than body requirements, imbalanced

2. Body image, disturbed Body image, disturbed relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch).

Which foods should be avoided following acute gallbladder inflammation? 1. Mashed potatoes 2. Cheese 3. Cooked fruits 4. Coffee

2. Cheese The patient should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas forming vegetables and alcohol.

A very ill patient with acute cholecystitis is scheduled for surgery. The surgeon plans to create an incision in the common bile duct to remove stones. The nurse correctly documents this surgery in the electronic medical record using which of the following terms? 1. Choledochoduodenostomy 2. Cholecystectomy 3. Choledochostomy 4. Cholecystostomy

2. Choledochostomy

The nurse is instructing the male client who has an inguinal hernia repair how to reduce postoperative swelling following the procedure. What should the nurse tell the client? 1. Limit oral fluid 2. Elevate the scrotum 3. Apply heat to the abdomen 4. Remain in a low-fiber diet

2. Elevate the scrotum Following inguinal hernia repair, the client should be instructed to elevate the scrotum and apply ice packs while in bed to decrease pain and swelling. The nurse also should instruct the client to apply a scrotal support when out of bed.

A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis? 1. Elevated hemoglobin level 2. Elevated serum bilirubin level 3. Elevated blood urea nitrogen level 4. Decreased erythrocyte sedimentation rate

2. Elevated serum bilirubin level Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated erythrocyte sedimentation rates, and leukopenia.

What laboratory finding is the primary diagnostic indicator for pancreatitis? 1. Elevated blood urea nitrogen (BUN) 2. Elevated serum lipase 3. Elevated aspartate aminotransferase (AST) 4. Increased lactate dehydrogenase (LD)

2. Elevated serum lipase Elevation of serum lipase is the most reliable indicator of pancreatitis because this enzyme is produced solely by the pancreas.

Which dietary modification is utilized for a patient diagnosed with acute pancreatitis? 1. High fat diet 2. Elimination of coffee 3. High protein diet 4. Low carbohydrate diet

2. Elimination of coffee Patients with acute pancreatitis should not have coffee or spicy foods as it increases gastric secretions. A high carbohydrate, low-fat, low protein diet should be implemented.

Which of the following conditions in a patient with pancreatitis makes it necessary for the nurse to check fluid intake and output, hourly urine output and monitor electrolyte levels? 1. High glucose levels in the blood 2. Frequent vomiting leading to a loss of fluid volume 3. Dry mouth which makes the patient thirsty 4. Acetone in the urine

2. Frequent vomiting leading to a loss of fluid volume

A male client with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse position the client for this test initially? 1. Lying on the right side with legs straight 2. Lying on the left side with knees bent 3. Prone with the torso elevated 4. Bent over with hands touching the floor

2. Lying on the left side with knees bent

A nurse is planning care for a patient with acute pancreatitis. Which of the following patient outcomes does the nurse assigned as the highest priority? 1. Maintaining satisfactory pain control 2. Maintenance of normal respiratory function 3. Developing no acute complications from the pancreatitis 4. Adequate fluid and electrolyte balance

2. Maintenance of normal respiratory function Acute pancreatitis produces retroperitoneal edema, elevation of the diaphragm, pleural effusion and inadequate lung ventilation.

The nurse identifies a potential collaborative problem of electrolyte in balance for a patient with severe acute pancreatitis. Which of the following assessment findings would alert the nurse to an electrolyte imbalance associated with acute pancreatitis? 1. Hypotension 2. Muscle twitching and finger numbness 3. Elevated blood glucose levels 4. Paralytic ileus and abdominal distention

2. Muscle twitching and finger numbness Hypocalcemia is a potential complication of acute pancreatitis. Calcium may be prescribed to prevent tetany

When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? 1. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture 2. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix 3. The appendix may develop gangrene and rupture, especially in a middle-aged client 4. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage

2. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion.

The nurse is teaching a patient who was admitted to the hospital with acute hepatic encephalopathy and ascites about an appropriate diet. The nurse determines that the teaching has been effective when the patient chooses which of the following food choices from the menu? 1. Omelette with green peppers, onions, mushrooms and cheese with milk 2. Pancakes with butter honey and orange juice 3. Baked chicken with sweet potato french fries, corn bread and tea 4. Ham and cheese sandwich, baked beans, potatoes and coffee

2. Pancakes with butter honey and orange juice Patients should select a diet high in carbohydrates with protein consistent with liver function. Moderate to high protein in cirrhosis and hepatitis, low protein in hepatic failure. The patient with acute hepatic encephalopathy is placed on low protein to decrease ammonia levels. All the other options also have high sodium and the ascites requires a low sodium diet.

The patient is admitted to the healthcare center with hyperglycemia, a 15 pound weight loss and complaints of vague upper and mid abdominal pain that increases in intensity at night. His health history record indicates that he is an alcoholic, smokes a pack a cigarettes daily and has had diabetes for the past 20 years. On examination, the nurse finds swelling in his feet and abdominal ascites. Based on the clinical manifestations, which of the following is most likely to be the diagnosis? 1. Acute pancreatitis with edema 2. Pancreatic carcinoma 3. Pancreatic pseudocyst 4. Cholecystitis

2. Pancreatic carcinoma Pain, jaundice and weight loss are classic signs of pancreatic carcinoma. Symptoms of insulin deficiency are in important sign at the onset of symptoms.

What is the primary nursing diagnosis for a 4th to 10th day postoperative liver transplant patient? 1. Excess Fluid Volume 2. Risk for Rejection 3. Impaired Skin Integrity 4. Decreased Cardiac Output

2. Risk for Rejection

A nurse is teaching a patient about the cause of acute pancreatitis. The nurse evaluates the teaching as effective when the patient correctly identifies which of the following conditions as a cause of acute pancreatitis? 1. Use of loop diuretics to increase the incidence of pancreatitis 2. Self digestion of the pancreas by its own proteolytic enzymes 3. Calcification of the pancreatic duct leading to its blockage 4. Fibrosis and atrophy of the pancreatic gland

2. Self digestion of the pancreas by its own proteolytic enzymes Trypsin is the predominant enzyme that causes acute pancreatitis.

A patient comes to the emergency department with severe abdominal pain, nausea and vomiting. The physician plans to rule out possible acute pancreatitis. The nurse would expect the diagnosis to be confirmed with which of the following elevated laboratory test? 1. Serum potassium 2. Serum amylase 3. Serum bilirubin 4. Serum calcium

2. Serum amylase

To inhibit pancreatic secretions, which pharmacologic agent would you anticipate administering to a patient with acute pancreatitis? 1. Nitroglycerin 2. Somatostatin 3. Pancrelipase 4. Pepcid

2. Somatostatin Somatostatin, a treatment for acute pancreatitis, inhibits the release of pancreatic enzymes.

The nurse is performing a colostomy irrigation on a male client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action? 1. Notify the physician 2. Stop the irrigation temporarily 3. Increase the height of the irrigation 4. Medicate for pain and resume the irrigation

2. Stop the irrigation temporarily If cramping occurs during a colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too much pressure.

A female client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge? 1. The client doesn't exhibit rectal tenesmus 2. The client is free from esophagitis and achalasia 3. The client reports diminished duodenal inflammation 4. The client has normal gastric structures

2. The client is free from esophagitis and achalasia

The nurse is completing a morning assessment on a patient with cirrhosis. Which data obtained by the nurse will be of most concern? 1. The patient complains of nausea and anorexia 2. The patient's hands flap back-and-forth when the arms are extended 3. The patient has gained 2 kg from the previous day 4. The patient's skin on the abdomen has multiple spider shaped blood vessels

2. The patient's hands flap back-and-forth when the arms are extended

A patient is admitted to the healthcare center with severe abdominal pain rated a 10 on a 1 to 10 scale. He has tachycardia, hypertension, and muscle spasms. The nurse immediately administers morphine sulfate 4 mg slow IVP as ordered. The nurse plans for which of the following goals following the administration of this medication? 1. To control blood pressure 2. To increase the patient's pain threshold 3. To control muscle spasms 4. To diagnose the cause of the abdominal pain

2. To increase the patient's pain threshold by depressing the central nervous system

A nurse is reviewing the medical record of a client who has a new diagnosis of hepatitis C. Which of the following laboratory findings should the nurse expect? 1. Prothrombin time eight seconds 2. Total bilirubin 4.5 mg/dL 3. AST 35 units per liter 4. ALT 15 international units per liter

2. Total bilirubin 4.5 mg/dL All other values are within normal limits

The nurse is caring for a male client with a diagnosis of chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin E

2. Vitamin B12 Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of the function of the parietal cells. The source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia.

A male client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note: 1. severe abdominal pain radiating to the shoulder 2. anorexia, nausea, and vomiting 3. eructation and constipation 4. abdominal ascites

2. anorexia, nausea, and vomiting Hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and weakness.

When evaluating a male client for complications of acute pancreatitis, the nurse would observe for: 1. increased intracranial pressure 2. decreased urine output 3. bradycardia 4. hypertension

2. decreased urine output Acute pancreatitis can cause decreased urine output, which results from the renal failure that sometimes accompanies this condition.

The correct sequence for abdominal assessment is: 1. inspection, percussion, palpation, auscultation. 2. inspection, auscultation, palpation, percussion. 3. inspection, palpation, auscultation, percussion. 4. inspection, percussion, auscultation, palpation.

2. inspection, auscultation, palpation, percussion.

A male client with pancreatitis complains of pain. The nurse expects the physician to prescribe meperidine (Demerol) instead of morphine to relieve pain because: 1, meperidine provides a better, more prolonged analgesic effect. 2. morphine may cause spasms of Oddi's sphincter. 3. meperidine is less addictive than morphine. 4. morphine may cause hepatic dysfunction.

2. morphine may cause spasms of Oddi's sphincter.

A male client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to: 1. call the physician 2. place saline-soaked sterile dressings on the wound 3. take a blood pressure and pulse 4. pull the dehiscence closed

2. place saline-soaked sterile dressings on the wound The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the client's vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.

Nurse Berlinda is assigned to a 41-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of: 1. 45 units/L 2. 100 units/L 3. 300 units/L 4. 500 units/L

3. 300 units/L The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value.

A patient is admitted with lacerated liver as a result of blunt abdominal trauma. Which of the following nursing interventions would NOT be appropriate for this patient? 1. Monitor for respiratory distress. 2. Monitor for coagulation studies. 3. Administer pain medications as ordered. 4. Administer normal saline, crystalloids as ordered.

3. Administer pain medications as ordered. Pain medication may mask signs and symptoms of hemorrhage, further decrease blood pressure, and interfere with assessment of neurologic status and additional abdominal injury.

A patient complaining of shortness of breath is admitted with a diagnosis of cirrhosis. A nursing assessment reveals an enlarged abdomen with striae, an umbilical hernia, and 4+ pitting edema of the feet and legs. What is the most important data for the nurse to monitor? 1. Bilirubin 2. Temperature 3. Albumin 4. Hemoglobin

3. Albumin

Mandy, an adolescent girl is admitted to an acute care facility with severe malnutrition. After a thorough examination, the physician diagnoses anorexia nervosa. When developing the plan of care for this client, the nurse is most likely to include which nursing diagnosis? 1. Hopelessness 2. Powerlessness 3. Chronic low self-esteem 4. Deficient knowledge

3. Chronic low self-esteem Young women with Chronic low self-esteem — are at highest risk for anorexia nervosa because they perceive being thin as a way to improve their self-confidence.

Nurse Joy is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse would: 1. Position the client supine to assist in medication absorption 2. Aspirate the nasogastric tube after medication administration to maintain patency 3. Clamp the nasogastric tube for 30 minutes following administration of the medication 4. Change the suction setting to low intermittent suction for 30 minutes after medication administration

3. Clamp the nasogastric tube for 30 minutes following administration of the medication If a client has a nasogastric tube connected to suction, the nurse should wait up to 30 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. Aspirating the nasogastric tube will remove the medication just administered.

Which of the following is a clinical manifestation of cholelithiasis? 1. Upper left quadrant abdominal pain 2. Nonpalpable abdominal mass 3. Clay colored stools 4. Epigastric distress prior to a meal

3. Clay colored stools

A male client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse would offer which full liquid item to the client? 1. Tea 2. Gelatin 3. Custard 4. Popsicle

3. Custard

A 70-year-old patient is admitted with acute pancreatitis. The nurse understands the mortality rate associated with a Q pancreatitis increases with advanced age and attributes this to which of the following gerontological considerations associated with the pancreas? 1. Increases in the bicarbonate output by the kidneys 2. Development of local complications 3. Decreases in the physiologic function of major organs 4. Increases in the rate of pancreatic secretions

3. Decreases in the physiological function of major organs

A nurse in the clinic is reviewing the laboratory reports of a client who has suspected cholelithiasis. Which of the following is an expected finding? 1. Serum amylase 80 units per liter 2. White blood cell count 9000 per millimeter cubed 3. Direct bilirubin 2.1 mg/dL 4. Alkaline phosphatase ALP 25 units per liter

3. Direct bilirubin 2.1 mg/dL The bilirubin level should be 0.1 - 1.2

Which of the following factors can cause hepatitis A? 1. Contact with infected blood 2. Blood transfusions with infected blood 3. Eating contaminated shellfish 4. Sexual contact with an infected person

3. Eating contaminated shellfish Hepatitis A can be caused by consuming contaminated water, milk, or food — especially shellfish from contaminated water. Hepatitis B is caused by blood and sexual contact with an infected person. Hepatitis C is usually caused by contact with infected blood, including receiving blood transfusions.

Which of the following tests can be useful as a diagnostic and therapeutic tool in the biliary system? 1. Ultrasonography. 2. MRI 3. Endoscopic retrograde cholangiopancreatography (ERCP) 4. Computed tomography scan (CT scan)

3. Endoscopic retrograde cholangiopancreatography (ERCP) ERCP permits direct visualization of the pancreatic and common bile ducts. Its therapeutic value is in retrieving gallstones from the distal and common bile ducts and dilating strictures.

A patient has an elevated serum ammonia level and is exhibiting mental status change. The nurse should suspect which of the following conditions? 1. Asterixis 2. Portal hypertension 3. Hepatic encephalopathy 4. Cirrhosis

3. Hepatic encephalopathy

Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? 1. Bradycardia 2. Polyuria 3. Hypotension 4. Warm moist skin

3. Hypotension

The nurse is reviewing the medication record of a female client with acute gastritis. Which medication, if noted on the client's record, would the nurse question? 1. Digoxin (Lanoxin) 2. Furosemide (Lasix) 3. Indomethacin (Indocin) 4. Propranolol hydrochloride (Inderal)

3. Indomethacin (Indocin) Indomethacin (Indocin) is an NSAID

A nurse is collecting data from a client who has pancreatitis. Which of the following actions should the nurse take to check for the presence of Cullen's sign? 1. Tap lightly at the costovertebral margin on the client's back 2. Palpate the right lower quadrant 3. Inspect the skin around the umbilicus 4. Auscultate the area below the scapula

3. Inspect the skin around the umbilicus

The nurse is caring for a female client following a Billroth II procedure. Which postoperative order should the nurse question and verify? 1. Leg exercises 2. Early ambulation 3. Irrigating the nasogastric tube 4. Coughing and deep-breathing exercises

3. Irrigating the nasogastric tube In a Billroth II procedure, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically ordered by the physician.

The nurse is providing discharge instructions to a male client following gastrectomy and instructs the client to take which measure to assist in preventing dumping syndrome? 1. Ambulate following a meal 2. Eat high carbohydrate foods 3. Limit the fluid taken with meal 4. Sit in a high-Fowler's position during meals

3. Limit the fluid taken with meal Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a Billroth II procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low-Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed.

The nurse is performing an abdominal assessment and inspects the skin of the abdomen. The nurse performs which assessment technique next? 1. Palpates the abdomen for size 2. Palpates the liver at the right rib margin 3. Listens to bowel sounds in all four quadrants 4. Percusses the right lower abdominal quadrant

3. Listens to bowel sounds in all four quadrants

The nurse is reviewing the physician's orders written for a male client admitted to the hospital with acute pancreatitis. Which physician order should the nurse question if noted on the client's chart? 1. NPO status 2. Nasogastric tube inserted 3. Morphine sulfate for pain 4. An anticholinergic medication

3. Morphine sulfate for pain Meperidine (Demerol) rather than morphine sulfate is the medication of choice to treat pain because morphine sulfate can cause spasms in the sphincter of Oddi.

The nurse is caring for a female client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission? 1. Regular diet 2. Skim milk 3. Nothing by mouth 4. Clear liquids

3. Nothing by mouth Shock and bleeding must be controlled before oral intake, so the client should receive nothing by mouth.

The nurse is caring for a male client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? 1. Dyspnea and fatigue 2. Ascites and orthopnea 3. Purpura and petechiae 4. Gynecomastia and testicular atrophy

3. Purpura and petechiae A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae.

The nurse is caring for a hospitalized female client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician? 1. Hypotension 2. Bloody diarrhea 3. Rebound tenderness 4. A hemoglobin level of 12 mg/dL

3. Rebound tenderness Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis.

A male client with a peptic ulcer is scheduled for a vagotomy and the client asks the nurse about the purpose of this procedure. Which response by the nurse best describes the purpose of a vagotomy? 1. Halts stress reactions 2. Heals the gastric mucosa 3. Reduces the stimulus to acid secretions 4. Decreases food absorption in the stomach

3. Reduces the stimulus to acid secretion A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion.

A patient with hepatic cirrhosis questions the nurse about the possible use of a herbal supplement, milk thistle, to help heal the liver. Which of the following would be the most appropriate response from the nurse? 1. You should not use herbal supplements in conjunction with medical treatment 2. You can use milk thistle instead of the medications you have been prescribed 3. Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis. However, you should always notify your PCP of any herbal remedies being used so drug interactions can be evaluated. 4. Herbal supplements are approved by the FDA, so there should be no problem with their usage if you check with your PCP.

3. Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis. However, you should always notify your PCP of any herbal remedies being used so drug interactions can be evaluated.

A patient who is been having recurring attacks of severe abdominal pain over the past few months informs the physician about a 25 pound weight loss in the last year. The nurse attributes which of the following is the most likely cause of the weight loss? 1. Malabsorption 2. Vomiting after having meals 3. Skipping meals out of fear of painful attacks 4. Ingesting a low fat diet to prevent abdominal pains

3. Skipping meals out of fear of painful attacks

A nurse is preparing to remove a nasogastric tube from a female client. The nurse should instruct the client to do which of the following just before the nurse removes the tube? 1. Exhale 2. Inhale and exhale quickly 3. Take and hold a deep breath 4. Perform a Valsalva maneuver

3. Take and hold a deep breath When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep breath. This will close the epiglottis. This allows for easy withdrawal through the esophagus into the nose. The nurse removes the tube with one smooth, continuous pull.

A patient has a nasogastric tube for suction and is in Pio following a pancreaticoduodenectomy. Which of the following explanations made by the nurse is the major purpose of this treatment? 1. The tube will help control fluid and electrolyte imbalance 2. The tube will provide relief from nausea and vomiting 3. The tube will allow the G.I. tract to rest 4. The tube will allow the removal of toxins

3. The tube will allow the G.I. tract to rest

The physician has written the following orders, bedrest, NPO and administration of TPN for a new patient admitted with pancreatitis. The nurse attributes which of the following as the cause for NPO status? 1. To prevent the occurrence of fibrosis 2. To drain the pancreatic bed 3. To avoid inflammation of the pancreas 4. To aid opening up the pancreatic duct

3. To avoid inflammation of the pancreas

A patient with end stage liver disease is scheduled to undergo a liver transplant and tells the nurse, "I am worried that my body will reject the liver." Which of the following statements is the nurse's best response to the patient? 1. The problem of rejection is not as common liver transplant as another organ transplants 2. It is easier to get a good tissue match with liver transplants than with other types of transplants 3. You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs. 4. You would not be scheduled for a transplant if there was a concern about rejection

3. You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs.

Pain control with peptic ulcer disease includes all of the following except: 1. promoting physical and emotional rest. 2. identifying stressful situations. 3. eating meals when desired. 4. administering medications that decrease gastric acidity.

3. eating meals when desired.

The nurse would anticipate using which medication if sclerotherapy has not been used? 1. neomycin 2. propranolol 3. vasopressin 4. cimetidine

3. vasopressin Vasopressin is the drug of choice when sclerotherapy is contraindicated. Neomycin is used in preventing encephalopathy when blood is broken down. Propranolol may or may not be used to decrease cardiac output and hepatic venous pressure.

A female client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should: 1. place the client in a private room 2. wear a mask when handling the client's bedpan 3. wash the hands after touching the client 4. wear a gown when providing personal care for the client

3. wash the hands after touching the client To maintain enteric precautions, the nurse must wash the hands after touching the client or potentially contaminated articles and before caring for another client.

A nurse is preparing to care for a female client with esophageal varices who just had a Sengstaken-Blakemore tube inserted. The nurse gathers supplies, knowing that which of the following items must be kept at the bedside at all times? 1. An obturator 2. Kelly clamp 3. An irrigation set 4. A pair of scissors

4. A pair of scissors When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client's bedside at all times. The client needs to be observed for sudden respiratory distress, which occurs if the gastric balloon ruptures and the entire tube moves upward. If this occurs, the nurse immediately cuts all balloon lumens and removes the tube.

The nurse is monitoring a female client with a diagnosis of peptic ulcer. Which assessment findings would most likely indicate perforation of the ulcer? 1. Bradycardia 2. Numbness in the legs 3. Nausea and vomiting 4. A rigid, board-like abdomen

4. A rigid, board-like abdomen Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and board-like. Nausea and vomiting may occur.

The nurse caring for a client with small-bowel obstruction would plan to implement which nursing intervention first? 1. Administering pain medication 2. Obtaining a blood sample for laboratory studies 3. Preparing to insert a nasogastric (NG) tube 4. Administering I.V. fluids

4. Administering I.V. fluids I.V. infusions containing normal saline solution and potassium should be given first to maintain fluid and electrolyte balance. For the client's comfort and to assist in bowel decompression, the nurse should prepare to insert an NG tube next.

A nurse is teaching a patient about the types of chronic liver disease. The patient teaching is determined to be effective based on the correct identification of which of the following types of cirrhosis caused by scar tissue surrounding the portal areas? 1. Compensated cirrhosis 2. Biliary cirrhosis 3. Post necrotic cirrhosis 4. Alcoholic cirrhosis

4. Alcoholic cirrhosis

A patient who had developed jaundice two months previous is brought to the ED after attending a party and developing excruciating pain that radiated over the abdomen and into the back. Upon assessment, which additional symptoms would the nurse expect this patient to have? 1. Weight loss 2. Hypertension 3. Warm, dry skin 4. Bile stained vomiting

4. Bile stained vomiting

A patient with acute pancreatitis has been started on TPN. Following the administration of the TPN, which of the following should the nurse plan to monitor? 1. Auscultate the abdomen for bowel sounds every four hours 2. Complaints of nausea and vomiting 3. Measure the abdominal girth every shift 4. Blood glucose levels every 4 to 6 hours

4. Blood glucose levels every 4 to 6 hours

When caring for a patient with advanced cirrhosis and hepatic encephalopathy, which of the following assessment findings should the nurse report immediately? 1. Weight loss of 2 pounds in three days 2. Anorexia for more than three days 3. Constipation for more than two days 4. Change in the patient's hand writing and or cognitive performance

4. Change in the patient's hand writing and or cognitive performance

What assessment finding of a patient with acute pancreatitis would indicate a bluish discoloration around the umbilicus? 1. Grey-Turner's sign 2. Homan's sign 3. Rovsing's sign 4. Cullen's sign

4. Cullen's sign Cullen's sign is associated with pancreatitis when a hemorrhage is suspected. Grey-Turner's sign is ecchymosis in the flank area suggesting retroperitoneal bleed. Homan's sign is calf pain elicited by the dorsiflexion of the foot and suggests deep vein thrombosis. Rovsing's sign is associated with appendicitis when pain is felt with pressure at McBurney's point.

The nurse is assessing a male client 24 hours following a cholecystectomy. The nurse noted that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is appropriate? 1. Clamp the T-tube 2. Irrigate the T-tube 3. Notify the physician 4. Document the findings

4. Document the findings Following cholecystectomy, drainage from the T-tube is initially bloody and then turns to a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day.

A nurse is collecting data from a newly admitted client who has pancreatitis. Which of the following findings should the nurse expect? 1. Pain in right upper quadrant radiating to right shoulder 2. Pain that is worse when sitting upright 3. Pain that is worse when in a fetal position 4. Epigastric pain radiating to the left shoulder

4. Epigastric pain radiating to the left shoulder Cholecystitis will report pain in the right upper quadrant radiating to the right shoulder. Pancreatitis will report severe epigastric pain that radiates to the back left flank or left shoulder. Pain Will be relieved in the fetal position or sitting up and worse when lying down.

Polyethylene glycol-electrolyte solution (GoLYTELY) is prescribed for the female client scheduled for a colonoscopy. The client begins to experience diarrhea following administration of the solution. What action by the nurse is appropriate? 1. Start an IV infusion 2. Administer an enema 3. Cancel the diagnostic test 4. Explain that diarrhea is expected

4. Explain that diarrhea is expected

A nurse is collecting data from a client who has acute pancreatitis. Which of the following findings is the priority to report? 1. History of cholelithiasis 2. Elevated serum amylase levels 3. Decrease in bowel sounds upon auscultation 4. Hand spasms when blood pressure is checked

4. Hand spasms when blood pressure is checked

While palpating a female client's right upper quadrant (RUQ), the nurse would expect to find which of the following structures? 1. Sigmoid colon 2. Appendix 3. Spleen 4. Liver

4. Liver The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of the colon, portions of the ascending and transverse colon, and a portion of the right kidney.

To reduce risk of injury for a patient with liver disease, what initial measure can the nurse implement? 1. Apply soft wrist restraints 2. Raise all four side rails on the bed 3. Prevent visitors so as to not agitate the patient 4. Pad the side rails on the bed

4. Pad the side rails on the bed to reduce injury if the patient becomes agitated or restless.

Which of the following is the major cause of morbidity and mortality in patients with acute pancreatitis? 1. Tetany 2. Shock 3. Multiple organ dysfunction syndrome 4. Pancreatic necrosis

4. Pancreatic necrosis

A nurse is contributing to the plan of care for a client who has hepatitis B with ascites. Which of the following interventions should the nurse recommend? 1. Initiate contact precautions 2. Weigh the client weekly 3. Measure abdominal girth every 48 hours 4. Provide a high calorie high carbohydrate diet

4. Provide a high calorie, high carbohydrate diet to promote healing of the liver tissue Standard precautions are adequate. Weight should be obtained daily.

A nurse is inserting a nasogastric tube in an adult male client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the appropriate nursing action? 1. Quickly insert the tube 2. Notify the physician immediately 3. Remove the tube and reinsert when the respiratory distress subsides 4. Pull back on the tube and wait until the respiratory distress subsides

4. Pull back on the tube and wait until the respiratory distress subsides During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides.

A nurse is reviewing a new prescription for ursodiol with a client who has cholelithiasis. Which of the following information should the nurse include? 1. This medication is used to decrease acute biliary pain 2. This medication requires thyroid function monitoring every six months 3. This medication is not recommended for clients who have diabetes 4. This medication dissolve gallstones gradually over a period of up to two years

4. This medication dissolves gallstones gradually over a period of up to two years

A patient discharged following a laparoscopic cholecystectomy calls the surgeon's office complaining of severe right shoulder pain 24 hours after surgery. Which of the following statements is the correct information for the nurse to provide to this patient? 1. This may be the beginning symptoms of infection. You need to come see the surgeon today for an evaluation 2. This pain may be caused by a bile duct injury. You will need to go to the hospital immediately to have this evaluated 3. This pain is caused from your incision. Take analgesics as needed and as prescribed and report to the surgeon if pain is unrelieved even with analgesic use 4. This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort.

4. This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort.

Nurse Hannah is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention: 1. a sedentary lifestyle and smoking. 2. a history of hemorrhoids and smoking 3. alcohol abuse and a history of acute renal failure 4. alcohol abuse and smoking

4. alcohol abuse and smoking

A female client with hepatitis C develops liver failure and GI hemorrhage. The blood products that would most likely bring about hemostasis in the client are: 1. whole blood and albumin 2. platelets and packed red blood cells 3. fresh frozen plasma and whole blood 4. cryoprecipitate and fresh frozen plasma

4. cryoprecipitate and fresh frozen plasma The liver is vital in the synthesis of clotting factors, so when it's diseased or dysfunctional, as in hepatitis C, bleeding occurs. Treatment consists of administering blood products that aid clotting. These include fresh frozen plasma containing fibrinogen and cryoprecipitate, which have most of the clotting factors.

Peritonitis can occur as a complication of: 1. septicemia 2. multiple organ failure 3. hypovolemic shock 4. peptic ulcer disease

4. peptic ulcer disease

During initial assessment of a patient post-endoscopy, the nurse notes absent bowel sounds, tachycardia, and abdominal distention. The nurse would anticipate: 1. ischemic bowel 2. peritonitis 3. hypovolemic shock 4. perforated bowel

4. perforated bowel

Which phase of hepatitis would the nurse incur strict precautionary measures at? 1. icteric 2. non-icteric 3. post-icteric 4. pre-icteric

4. pre-icteric Pre-icteric is the infective phase and precautionary measures should be strictly enforced. However, most patients are not always diagnosed during this phase.

During preparation for bowel surgery, a male client receives an antibiotic to reduce intestinal bacteria. Antibiotic therapy may interfere with synthesis of which vitamin and may lead to hypoprothrombinemia? 1. vitamin A 2. vitamin D 3. vitamin E 4. vitamin K

4. vitamin K

Which type of positioning should be utilized for a patient undergoing a paracentesis? 1. Supine 2. Up right at the edge of the bed with feet supported on a stool 3. Trendelenburg 4. Prone

Up right at the edge of the bed with feet supported on a stool Fowler's position should be used by the patient confined to bed.