NURS 3700 EXAM 3

Which statement by a patient with dumping syndrome should lead the nurse to determine that further dietary teaching is needed? A. "I should eat bread and jam with every meal." B. "I should avoid drinking fluids with my meals." C. "I should eat smaller meals about 6 times a day." D. "I need to lie down for 30 to 60 minutes after my meals."

A. "I should eat bread and jam with every meal."

The nurse determines a patient undergoing ileostomy surgery understands the provider when the patient states A. "I should only have to change the pouch every 4 to 7 days" B. "The drainage in the pouch will look like my normal stools." C. "I may not need to wear a drainage pouch if I irrigate it daily." D. "Limiting my fluid intake should decrease the amount of output."

A. "I should only have to change the pouch every 4 to 7 days"

Which instruction would the nurse include in a teaching plan for a patient with mild GERD? A. "The best time to take an as-needed antacid is 1 to 3 hours after meals." B. "A glass of warm milk at bedtime will decrease your discomfort at night." C. "Do not chew gum; the excess saliva will cause you to secrete more acid." D. "Limit your intake of foods high in protein because they take longer to digest."

A. "The best time to take an as-needed antacid is 1 to 3 hours after meals."

1.The nurse is preparing to insert a NG tube into a patient with a suspected small intestinal obstruction that is vomiting. The patient asks the nurse why this procedure is necessary. What response by the nurse is the most appropriate? A. "The tube will help to drain the stomach contents and prevent further vomiting." B. "The tube will push past the area that is blocked and help stop the vomiting." C. The tube is just a standard procedure before many types of surgery to the abdomen." D. The tube will let us measure your stomach contents so we can give you the right IV fluid replacement."

A. "The tube will help to drain the stomach contents and prevent further vomiting." NG tube allows for drainage and decompression of stomach contents, allowing for symptom reduction.

Which patient is at highest risk of having a gastric ulcer? A. 55-year-old female smoker with nausea and vomiting B. 45-year-old female admitted for illict drug detoxification C. 27-year-old male who is being divorced and has back pain D. 37-year-old male smoker who was in an accident while looking for a job

A. 55-year-old female smoker with nausea and vomiting

What type of gastritis is most likely to occur in a college student who has an isolated drinking binge? A. Acute gastritis B. Chronic gastritis C. Pylori gastritis D. Autoimmune metaplastic atrophic gastritis

A. Acute gastritis

The nurse is planning to teach the patient with GERD about foods or beverages that decrease LES pressure. What should be included in this list? (Select all that apply) A. Alcohol B. Root Beer C. Chocolate D. Citrus Foods E. Fatty Foods F. Cola Sodas

A. Alcohol C. Chocolate E. Fatty Foods F. Cola Sodas

Mike, a 43-year-old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise that decreased with rest. The nurse assesses Mike's symptoms as being associated with peripheral arterial disease. The nursing diagnosis is probably: A. Alteration in tissue perfusion related to compromised circulation B. Dysfunctional use of extremities related to muscle spasms C. Impaired mobility related to stress associated with pain D. Impairment in muscle use associated with pain on exertion

A. Alteration in tissue perfusion related to compromised circulation

A patient who has undergone peripheral artery bypass surgery report increased pain and tingling in the extremities. The nurse notes the loss of a previously palpable pulse and cyanosis. Which condition is consistent with these findings? A. Blockage of the graft B. Compartment syndrome C. Thoracic aortic aneurysms D. Superficial vein thrombosis

A. Blockage of the graft

The nurse provides post-op care 8 hours after a patient underwent a laparotomy. The nurse assesses the drainage rom the nasogastric tube and notifies the health care provider immediately about which finding? A. Bright red drainage B. Bright green drainage C. Dark-brown drainage D. Dark-red drainage

A. Bright red drainage

A patient with a gastric outlet obstruction has been treated with NG decompression. After the first 24 hours, the patient develops nausea and increased upper abdominal bowel sounds. What is the priority action by the nurse? A. Check the patency of the NG tube B. Place the patient in a recumbent position C. Asses the patient's vital signs and circulatory status D. Encourage the patient to deep breath and consciously relax

A. Check the patency of the NG tube

The nurse provides postoperative care to a patient who underwent peripheral artery bypass surgery. Thirty minutes after the initial assessment, the nurse reassesses the patient and detects a change in the Doppler sound over a pulse. What action should the nurse take? A. Contact the health care provider B. Administer an oral anticoagulant C. Measure the ankle-brachial index D. Recheck the pulse in another 30 minutes

A. Contact the health care provider

When teaching a patient about rest pain with PAD, what should the nurse explain as the cause of the pain? A. Decrease in blood flow to the nerves of the feet B. Vasospasm of cutaneous arteries in the feet C. Increase in retrograde venous perfusion to the lower legs D. Construction in blood flow to leg muscles during exercise

A. Decrease in blood flow to the nerves of the feet

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? A. Diarrhea B. Chronic constipation C. Constipation alternating with diarrhea D. Stools constantly oozing from the rectum

A. Diarrhea

The nurse provides postoperative care one day after a patient undergoes colotomy surgery. The patient's stoma is most and dark pink, with no obvious drainage. Which action does the nurse take? A. Document the normal findings B. Consult the wound, ostomy, and continence nurse C. Irrigate the ostomy with normal saline D. Palpate the abdomen around the stoma

A. Document the normal findings

A patient presents with symptoms of VTE in the calf. Which study would the nurse expect to be prescribed to investigate for VTE? A. Duplex ultrasound B. Contrast venography C. Magnetic resonance venography D. Computed tomography venography

A. Duplex ultrasound

The patient comes to the HCP office with pain, edema, and warm skin on her lower left leg. What test should the nurse expect to be ordered first? A. Duplex ultrasound B. CBC C. Magnetic resonance angiography D. Computed venography (phlebogram)

A. Duplex ultrasound

The nurse plans teaching for the patient with a colostomy, but the patient refuses to look at the nurse or the stoma, stating, "I just can't see myself with this thing." What is the best nursing intervention for this patient? A. Encourage the patient to share concerns and ask questions B. Refer the patient to a chaplain to help cope with this situation C. Explain that there is nothing the patient can do about it and must take care of it D. Tell the patient that learning about it will prevent stool leaking and the sounds of flatus

A. Encourage the patient to share concerns and ask questions

A patient is admitted to the ED with profuse bright-red hematemesis. During the initial care of the patient, what is the nurse's first priority? A. Establish 2 IVs sites with large-gauge catheters B. Perform a focused nursing assessment of the patient's areas C. Obtain a thorough health history to assist in determining the cause of the bleeding D. Perform a gastric lavage with cool tap water in preparation for endoscopic examination

A. Establish 2 IVs sites with large-gauge catheters

A young woman with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? A. Fistulas can form between the bowel and bladder. B. Bacteria in the perianal area can enter the urethra. C. Drink adequate fluids to maintain normal hydration. D. Empty the bladder before and after sexual intercourse.

A. Fistulas can form between the bowel and bladder.

A patient reports nausea and burning epigastric pain. The patient takes NSAIDS on a regular basis to relieve headaches. Which condition would the nurse suspect? A. Gastritis B. Achalasia C. Oral cancer D. Esophageal varices

A. Gastritis

Assessment findings of a patient include anorexia, nausea, and vomiting, and epigastric tenderness. Which condition would the nurse suspect? A. Gastritis B. Achalasia C. Stomach cancer D. Upper GI bleeding

A. Gastritis

The nurse is assessing the client diagnosed with long-term peripheral artery disease. Which assessment data support the diagnosis? A. Hairless skin on legs B. Brittle flaky toenails C. Petechiae on the soles of feet D. Nonpitting ankle edema

A. Hairless skin on legs The lack of oxygen rich blood will cause the loss of hair on the tops of the feet and the lower legs

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? A. Hypotension B. Bloody diarrhea C. Rebound tenderness D. A hemoglobin level of 12 mg/dL

A. Hypotension

The nurse teaches self-care of a stoma to a patient who as undergone ostomy surgery. Which statement made by the patient indicated need for further teaching? A. I should limit my fluid intake B. I should empty my pouch before it is one-third full C. I can irrigate the colostomy to stimulate emptying of my colon D. I should replace the skin barrier when the one in place no longer lies flat on my skin and is leaking.

A. I should limit my fluid intake

The nurse provides discharge teaching for a patient's caregiver about stoma care, one week after the patient underwent ostomy surgery. Which statement made by the caregiver indicates effective learning? A. I will observe the stoma color every four hours B. I will measure the size of the stoma using a properly calibrated scale C. I will contact the health care provider if the stoma color is rosy pink to red D. I will contact the health care provider if the swelling of the stoma persists for more than a week after surgery.

A. I will observe the stoma color every four hours

Nursing management of the patient with chronic gastritis includes teaching the patient to- A. Maintain a nonirritating diet with 6 small meals a day B. Take antacids before meals to decrease stomach acidity C. Eliminate alcohol and caffeine from the diet when symptoms occur D. Use NSAIDS instead of aspirin for minor pain relief.

A. Maintain a nonirritating diet with 6 small meals a day

A patient with ulcerative colitis undergoes the first phase of a total proctocolectomy with formation of a terminal ileum stoma. What is the most important nursing intervention for this patient postoperatively? A. Measure the ileostomy output to determine the status of the patient's fluid balance. B. Change the ileostomy appliance every 3 to 4 hours to prevent leakage of drainage onto the skin. C. Emphasize that the ostomy is temporary and the ileum will be reconnected when the large bowel heals. D. Teach the patient about the high-fiber, low-carbohydrate diet required to maintain normal ileostomy drainage.

A. Measure the ileostomy output to determine the status of the patient's fluid balance.

What type of bleeding will a patient with PUD with a slow upper GI source of bleeding have? A. Melena B. Occult blood C. Coffee-ground emesis D. Profuse bright-red hematemesis

A. Melena

The nurse assesses a patient and suspects appendicitis based on which findings? Select all that apply A. Muscle guarding B. High grade fever C. Pain at McBurney's point D. Pain decreased by coughing E. Patient prefers to lie still, with the right leg flexed

A. Muscle guarding C. Pain at McBurney's point E. Patient prefers to lie still, with the right leg flexed

For the patient hospitalized with IBD, which treatments would be used to rest the bowel? (Select all that apply) A. NPO B. IV Fluids C. Bed rest D. Sedatives E. NG suction F. Parental nutrition

A. NPO B. IV Fluids E. NG suction F. Parental nutrition

A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and slight edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is: A. Normal because of the increased blood flow through the leg B. Slightly deteriorating and should be monitored for another hour C. Moderately impaired, and the surgeon should be called. D. Adequate from the arterial approach, but venous complications are arising.

A. Normal because of the increased blood flow through the leg As blood flow is re-established to the limb it can become red, warm, slight edematous and painful.

The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first? A. Obtain vital signs. B. Teach wound care. C. Assess pedal pulses. D. Check the wound site

A. Obtain vital signs Bleeding is a possible complication. First action is to assess for changes to vital signs that may indicate hemorrhage Other options are correct but need to assess vital signs first.

A patient with IBD has a nursing diagnosis of impaired nutritional status; etiology: decreased nutritional intake and decreased intestinal absorption. What assessment data support this nursing diagnosis? A. Pallor and hair loss B. Frequent diarrhea stools C. Anorectal excoriation and pain D. Hypotension and urine output bellow 30 mL/hr

A. Pallor and hair loss

A nurse is caring for a patient diagnosed with PUD. Which complication would result in gastric contents spilling into the patient's peritoneal cavity? A. Perforation B. Hemorrhage C. Dumping syndrome D. Gastric outlet obstruction

A. Perforation

The nurse performed a detailed assessment of the abdomen of a patient with a possible bowel obstruction, knowing that manifestations of an obstruction in the large intestine are (select all that apply) A. Persistent abdominal pain B. Marked abdominal distention C. Diarrhea that is loose or liquid D. Colicky, severe, intermittent pain E. Profuse vomiting that relieves abdominal pain

A. Persistent abdominal pain B. Marked abdominal distention

What are the characteristics of Raynaud's phenomenon? (Select all that apply) A. Predominant in young females B. May be associated with autoimmune disorders C. Precipitated by exposure to cold, caffeine, and tobacco D. Involves small cutaneous arteries of the fingers and toes E. Inflammation of small and medium-sized arteries and veins F. Episodes involve white, blue, and red color changes of fingertips

A. Predominant in young females B. May be associated with autoimmune disorders C. Precipitated by exposure to cold, caffeine, and tobacco D. Involves small cutaneous arteries of the fingers and toes F. Episodes involve white, blue, and red color changes of fingertips

The nurse teaches the patient with any venous disorder that the best way to prevent venous stasis and increase venous return is to A. Take short walks B. Sit with the legs elevates C. Frequently rotate the ankles D. Always wear elastic compression stockings

A. Take short walks

A patient who is 2 days post femoral popliteal bypass graft to the right leg is being cared for on the vascular unit. Which action by a licensed practical/vocational nurse (LPN/VN) caring for the patient requires the registered nurse (RN) to intervene? A. The LPN/VN tells the patient sit in a chair for 2 hours. B. The LPN/VN gives the prescribed aspirin after breakfast. C. The LPN/VN assists the patient to walk 40 ft in the hallway. D. The LPN/VN places the patient in Fowler's position for meals.

A. The LPN/VN tells the patient sit in a chair for 2 hours. Patient should not sit for prolonged periods of time because of increase stress on the suture line caused by edema and because of risk of DVT.

When selecting the site for a patient's ostomy, which consideration does the health team make? A. The patient should be able to see the site B. Outside the rectus muscle area is the best site C. It is ideal if an abdominal stoma site can easily be bend D. The ostomy should be conveniently located to allow for routine irrigation.

A. The patient should be able to see the site

Intravenous heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available on the nursing unit? A. Vitamin K B. Potassium chloride C. Enoxaparin (Lovenox) D. Protamine sulfate

A. Vitamin K

Which characteristics describe the anticoagulant warfarin (Coumadin)? (Select all that apply) A. Vitamin K is the antidote B. Protamine sulfate is the antidote C. May be given orally or subcutaneously D. May be given intravenously or subcutaneously E. Monitor dosage using INR F. Monitor dosage using aPTT

A. Vitamin K is the antidote E. Monitor dosage using INR

A patient treated for vomiting is to begin oral intake when the symptoms have subsided. To promote water rehydration, the nurse plans to administer which fluid first? A. Water B. Hot Tea C. Gatorade D. Warm Broth

A. Water

A 20-year-old patient with a history of Crohn's disease comes to the clinic with persistent diarrhea. What are the common characteristics of Crohn's disease? A. Weight loss B. Rectal bleeding C. Abdominal pain D. Toxic megacolon E. Has segmented distribution F. Involves the entire thickness of the bowel wall

A. Weight loss C. Abdominal pain E. Has segmented distribution F. Involves the entire thickness of the bowel wall

Which instructions should the nurse include in a teaching plan for an older adult patient newly diagnosed with peripheral artery disease (PAD)? A. "Exercise only if you do not experience any pain." B. "It is very important that you stop smoking cigarettes." C. "Try to keep your legs elevated whenever you are sitting." D. "Put elastic compression stockings on early in the morning."

B. "It is very important that you stop smoking cigarettes." A- you would exercise to the point of pain, rest then resume walking C-elevation will decrease blood flow D-No compression or TED hose for PAD, it further decreases blood flow

The patient with VTE is receiving therapy with heparin and asks the nurse whether the drug will dissolve the clot in her leg. What is the best response by the nurse? A. "This drug will break up and dissolve the clot so that circulation in the vein can be restored." B. "The purpose of the heparin is to prevent growth of the clot or formation of new clots where the circulation is slowed." C. "Heparin won't dissolve the clot, but it will inhibit the inflammation around the clot and delay the development of new clots." D. "The heparin will dilate the vein, preventing turbulence of blood flow around the clot that may cause it to break new clots."

B. "The purpose of the heparin is to prevent growth of the clot or formation of new clots where the circulation is slowed."

Which patient is at highest risk for venous thromboembolism (VTE)? A. A 62- year- old man with spider veins who is having arthroscopic knee surgery B. A 32- year- old woman who smokes, takes oral contraceptives, and is planning a trip to Europe C. A 26- year- old woman who is 3 days postpartum and received maintenance IV fluids for 12 hours during her labor. D. An active 72-year-old man at home recovering from transurethral resection of the prostate for benign prostatic hyperplasia

B. A 32- year- old woman who smokes, takes oral contraceptives, and is planning a trip to Europe

A patient is hospitalized with abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. The nurse expects which assessment findings? A. Diarrhea and absent bowel sounds B. Abdominal distention and high-pitched bowel sounds above the obstruction C. Localized abdominal pain and generalized hypoactive bowel sounds D. High pitched and hypoactive bowel sounds below the area of obstruction

B. Abdominal distention and high-pitched bowel sounds above the obstruction

A patient reports periumbilical pain that increases after coughing and sneezing. The patient prefers to lie still with the right leg flexed. Which condition does the nurse suspect? A. Peritonitis B. Appendicitis C. Gastroenteritis D. Ulcerative Colitis

B. Appendicitis

A patient with a gunshot wound to the abdomen reports increasing abdominal pain several hours after surgery to repair the bowel. What action should the nurse take first? A. Notify the HCP B. Assess the patient's vital signs C. Position the patient with the knees flexed D. Determine the patient's IV intake since the end of surgery

B. Assess the patient's vital signs

The nurse provides care for a patient one day after the patient underwent peripheral artery bypass surgery. Which intervention will the nurse include in the patient's care? A. Maintain patient bed rest B. Assist the patient with walking several times C. Encourage the patient to sit in the chair several times D. Place the patient in a side-lying position with the knees flexed.

B. Assist the patient with walking several times

The health care provider prescribes warfarin for a patient VTE. Which information would the nurse include in the patient's discharge teaching plan? A. No routine laboratory monitoring is needed B. Avoid contact sports and high risk activities C. Increase daily intake of dark-green, leafy vegetables. D. Continue to use garlic as a dietary supplement.

B. Avoid contact sports and high risk activities

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? A. Sexual dysfunction B. Body image, disturbed C. Fear related to poor prognosis D. Nutrition: more than body requirements, imbalanced

B. Body image, disturbed

The patient is diagnosed with a SVT. Which characteristic should the nurse know about the SVT. A. Embolization to lungs may result in death B. Clot ay extend to deeper veins if untreated C. Vein is tender to pressure and there is edema D. Typically found in the iliac, inferior, or superior vena cava

B. Clot ay extend to deeper veins if untreated

The nurse assigns which diagnostic statement as the highest priority in the plan of care for a patient who has ulcerative colitis? A. Activity intolerance B. Deficient fluid volume C. Impaired tissue integrity D. Risk for impaired skin integrity

B. Deficient fluid volume

When caring for a patient with IBS, what is most important for the nurse to do? A. Recognize that IBS is a psychogenic illness that cannot be definitively diagnosed B. Develop a trusting relationship with the patient to provide support and symptomatic care C. Teach the patient that a diet high in fiber will relieve the symptoms of both diarrhea and constipation D. Inform the patient that new medications are available and effective for treatment of IBS manifested by either diarrhea or constipation

B. Develop a trusting relationship with the patient to provide support and symptomatic care

Older patient may have cardiac or renal insufficiency and be more susceptible to problems from vomiting and antiemetic drug side effects. What nursing intervention is most important to implement with these patients? A. Keep the patient flat in bed to decrease dizziness B. Do hourly visual checks and implement fall precaution C. Give IV fluids as rapidly as possible to prevent dehydration D. Keep the patient NPO until nausea and vomiting have stopped

B. Do hourly visual checks and implement fall precaution

The nurse provides teaching to a patient with Raynaud's phenomenon about how to prevent recurrent episodes. Which actions would the nurse instruct the patient to avoid? Select all that apply. A. Wearing gloves B. Drinking caffeinated coffee C. Exposure to sun D. Emotional upsets E. Cigarette smoking

B. Drinking caffeinated coffee D. Emotional upsets E. Cigarette smoking

A patient reports gas pains and abdominal distention 2 days after a small bowel resection. Which nursing action should the nurse take? A. Administer morphine sulfate. B. Encourage the patient to ambulate. C. Offer the prescribed promethazine. D. Instill a mineral oil retention enema.

B. Encourage the patient to ambulate.

A patient who has been vomiting for several days from an unknown cause is admitted to the hospital. What should the nurse anticipate will first be included in inter-professional care? A. Oral administration of broth and tea B. IV replacement of fluid and electrolytes C. Administration of parental antiemetics D. Insertion of a NG tube for suction

B. IV replacement of fluid and electrolytes

The results of a patient's recent endoscopy indicate the presence of PUD. Which teaching point would the nurse provide to the patient? A. You'll need to drink 2 to 3 glasses of milk daily B. It would be beneficial for you to eliminate drinking alcohol. C. Many people find that a minced or pureed diet eases the symptoms of PUD. D. Medications will allow you to maintain your present diet while minimizing symptoms.

B. It would be beneficial for you to eliminate drinking alcohol.

. In preparation for the discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include: A. Walking several times each day as an exercise program B. Keeping the heat up so that the environment is warm C. Wearing TED hose during the day D. Using hydrotherapy for increasing oxygenation

B. Keeping the heat up so that the environment is warm You want to avoid cold as this causes vasoconstriction and can precipitate an exacerbation. You don't want constrict blood flow so you would not wear TED hose.

With peripheral arterial disease, leg pain during rest can be reduced by: A. Elevating the limb above heart level B. Lowering the limb so it is dependent C. Massaging the limb after application of cold compresses D. Placing the limb in a plane horizontal to the body

B. Lowering the limb so it is dependent Lower the legs will help blood flow to the limb by allowing gravity to help. A cold compress with cause vasoconstriction. Elevating the limb or placing it in a plane horizontal to the body will further decrease blood flow to the limb.

Which clinical findings should the nurse expect in a person with an acute lower extremity VTE? (Select all that apply) A. Pallor and coolness of foot and calf B. Mild to moderate calf pain and tenderness C. Grossly decreased or absent pedal pulses D. Unilateral edema and induration of the thigh E. Palpable cord along a superficial varicose vein

B. Mild to moderate calf pain and tenderness D. Unilateral edema and induration of the thigh E. Palpable cord along a superficial varicose vein

Which statements describe the use of antacids for PUD? (select all that apply) A. Used in patients with verified H. Pylori B. Neutralize HCL in the stomach C. Produce quick, short-lived relief of heartburn D. Cover the ulcer, protecting it from erosion by acids E. High incidence of side effects and contraindications F. May be given hourly after an acute phase of GI bleeding

B. Neutralize HCL in the stomach C. Produce quick, short-lived relief of heartburn F. May be given hourly after an acute phase of GI bleeding

A patient with acute gastritis has an NG tube to low-intermittent suction with bilious drainage. Later the nurse observes that the drainage is blood-tinged. What action would the nurse take next? A. Assess the patient's pain B. Obtain a set of vital signs C. Page the health care provider D. Document the data in the patient's record

B. Obtain a set of vital signs

An important nursing intervention for a patient with a small intestinal obstruction who has an NG tube is to- A. Offer ice chips to suck as needed B. Provide mouth care frequently C. Irrigate the tube with normal saline every 8 hours D. Keep the patient supine with the head of the bed elevated 30 degrees

B. Provide mouth care frequently

A patient is admitted with GI bleeding. Which findings would support the nurse's conclusion that the patient is in shock? Select all that apply. A. Warm skin B. Rapid, weak pulse C. Slow capillary refill D. High BP E. Increased temperature

B. Rapid, weak pulse C. Slow capillary refill

A patient reports fingers and toes that change color from pallor to cyanosis to rubor when exposed to cold temperatures. The patient states that, after the color change, the digits are throbbing, achy, and tingly. Which condition would the nurse suspect? A. Aortic aneurysm B. Raynaud's phenomenon C. Post- thrombotic syndrome D. Superficial vein thrombus

B. Raynaud's phenomenon

A 72-year old patient was admitted with epigastric pain caused by a gastric ulcer. Which patient assessment warrants an urgent change in the nursing plan of care? A. Chest pain relived with eating or drinking water B. Back pain three or four hours after eating a meal C. Burning epigastric pain 90 minutes after breakfast B. Rigid abdomen

B. Rigid abdomen

Which symptom would the nurse expect in a patient who has a gastric ulcer perforation? A. Pyrosis B. Rigid abdomen C. Bright-red emesis D. Clay-colored stools

B. Rigid abdomen

To prevent the recurrence of gastritis, which instruction would the nurse provide to the patient? A. Take Tylenol and ibuprofen for pain B. Stop smoking and drinking C. Consume a regular diet with moderate spices and seasonings D. Request a prescription for corticosteroids from the health care provider

B. Stop smoking and drinking

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

B. Stop the irrigation temporarily

Which clinical manifestations of inflammatory bowel disease are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply)? A. Restricted to rectum B. Strictures are common. C. Bloody, diarrhea stools D. Cramping abdominal pain E. Lesions penetrate intestine.

B. Strictures are common. C. Bloody, diarrhea stools D. Cramping abdominal pain

What should the nurse emphasize when teaching patients at risk for upper GI bleeding to prevent bleeding episodes? A. All stools and vomits must be tested in the presence of blood B. The use of OTC medications of any kind should be avoided C. Antacids should be taken with all prescribed medications to prevent gastric irritation D. Misoprostol (Cytotec) should be used to protect the gastric mucosa in individuals with peptic ulcers.

B. The use of OTC medications of any kind should be avoided

What are characteristics of PAD? (Select all that apply) A. Pruritus B. Thickened, brittle nails C. Dull ache in calf or thigh D. Decreased peripheral pulses E. Pallor on elevation of the legs F. Ulcers over bony prominences on toes and feet

B. Thickened, brittle nails D. Decreased peripheral pulses E. Pallor on elevation of the legs F. Ulcers over bony prominences on toes and feet

A male Hispanic patient is diagnosed with PAD. The patient's health history includes smoking and depression. Which risk factor does this patient have for PAD? A. Gender B. Tobacco C. Ethnicity D. Comorbidity

B. Tobacco

A 50 year old woman who weights 95 kg has a history of tobacco use, high blood pressure, high sodium intake, and sedentary lifestyle. Which is the most important risk factor for PAD to address in the nursing plan of care? A. Salt intake B. Tobacco use C. Excess weight D. Sedentary lifestyle

B. Tobacco use

Which surgical treatment may result in the complications of weight loss, dumping syndrome, and impaired wound healing? A. Mandibulectomy B. Total gastrectomy C.Hemiglossectomy D. Nissen Fundoplication

B. Total gastrectomy

A patient reports hematemesis and burning pain in the stomach. The nurse suspects peptic ulcer disease and anticipates that which diagnostic test will be prescribed. A. Colonoscopy B. Upper GI study C. Abdominal ultrasound D. MRI

B. Upper GI study

A patient with PAD has a nursing diagnosis of ineffective tissue perfusion. What should be included in the teaching plan for this patient?(select all that apply) A. Apply cold compresses when the legs become swollen B. Wear protective footwear and avoid hot or cold extremes C. Walk at least 30 minutes per day, at least 3 times a week D. Use nicotine replacement therapy as a substitute for smoking E. Inspect lower extremities for pulses, temperature, or any injury

B. Wear protective footwear and avoid hot or cold extremes C. Walk at least 30 minutes per day, at least 3 times a week E. Inspect lower extremities for pulses, temperature, or any injury

A patient who is scheduled for gastric bypass surgery asks for information about dumping syndrome. How does the nurse explain dumping syndrome? A. The inability to digest high-fat foods B. When the passage of food into the small intestine occurs too rapidly C. A decrease in the secretion of insulin caused by carbohydrates. D. An increase in secretion of both bile and pancreatic enzymes.

B. When the passage of food into the small intestine occurs too rapidly

A patient with PUD starts vomiting. Which type of emesis is associated with the bleeding in the stomach? A. Fecal B. Bilious C. "Coffee Ground" D. Undigested food

C. "Coffee Ground"

The nurse determines that teaching for the patient with PUD has been effective when the patient makes which statement? A. "I should stop all my medications if I develop any side effects" B. "I should continue my treatment regimen as long as I have pain" C. "I have learned some relaxation strategies that decrease my stress." D. "I can buy whatever antacids that are on sale because they all have the same effect."

C. "I have learned some relaxation strategies that decrease my stress."

A postoperative patient asks the nurse why the provider ordered daily administration of enoxaparin (lovenox). Which reply by the nurse is accurate? A. "This medication will help prevent breathing problems after surgery, such as pneumonia" B. "This medication will help lower your blood pressure to a safer level, which is very important after surgery" C. "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal" D. "This medication is a narcotic pain medication that will help take away any muscle aches caused by positioning on the operating room table"

C. "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal"

When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows not to expect therapeutic benefits for: A. At least 12 hours B. The first 24 hours C. 2-3 days D. 1 week

C. 2-3 days Coumadin- onset 48-72hrs Peak (therapeutic) 5-7days Duration 2-5 days

During the care of the patient following femoral bypass graft surgery, the nurse immediately notifies the HCP if the patient has- A. Fever and redness at the incision site B. 2+ edema of the extremity at the incision site C. A loss of palpable pulse and numbness and tingling of the feet D. Increasing ankle-brachial indices and serous drainage from the incision

C. A loss of palpable pulse and numbness and tingling of the feet

A young adult patient tells the health care provider about experiencing cold, numb fingers and Raynaud's phenomenon is suspected. What type of testing should the nurse anticipate explaining to the patient? A. Hyperglycemia B. Hyperlipidemia C. Autoimmune disorders D. Coronary artery disease

C. Autoimmune disorders Patients with Raynaud's disease should have routine follow-up to monitor for the development of connective tissue or auto-immune disorders. Secondary Raynaud's has underlying disease.

The teaching plan for the patient being discharged after an acute episode of upper GI bleeding includes information about the importance of A. Limiting alcohol intake to 1 serving a day B. Only taking aspirin with milk or bread products C. Avoiding taking aspirin and drugs containing aspirin D. Only taking drugs prescribed by the HCP E. Taking all drugs 1 hour before mealtime to prevent further bleeding

C. Avoiding taking aspirin and drugs containing aspirin D. Only taking drugs prescribed by the HCP

A patient with abdominal trauma is at a risk for the development of hypovolemic shock. The nurse expect which assessment finding? A. Respiratory rate of 16 BPM B. Heart rate of 58 BPM C. BP of 80/42 mmHg D. Increased pulse pressure

C. BP of 80/42 mmHg

A patient reports gastric distress that occurs to to five hours after meals, with "burning" and "cramping" pain just below the xiphoid process. Which disorder would the nurse suspect that the patient may have? A. Esophagitis B. Gastric ulcer C. Bacterial peritonitis D. Chronic gastritis

C. Bacterial peritonitis

The nurse is caring for a patient with PUD. On a follow up visit, the health care provider identifies spillage of gastric contents into the space between the abdominal cavity and the abdominal wall. Which complication may occur if the condition is untreated? A. Pernicious anemia B. Bile reflux gastritis C. Bacterial peritonitis D. Postprandial hypoglycemia

C. Bacterial peritonitis

The nurse is performing a physical assessment on a patient with CVI. Which manifestation involving the lower extremities would the nurse expect? A. Shiny skin B. Absent pulses C. Brownish color D. Lack of sensation

C. Brownish color

Four hours after a bowel resection, a 74-yr-old male patient with a nasogastric tube to suction reports nausea and abdominal distention. What should be the nurse's first action? A. Auscultate for hypotonic bowel sounds. B. Notify the patient's health care provider. C. Check for tube placement and reposition it. D. Remove the tube and replace it with a new one.

C. Check for tube placement and reposition it.

The nurse notes that a patient who had a total gastrectomy the day before has a very small amount of fluid draining from the NG tube. Which action would the nurse take? A. Increase the power on the suction device B. Irrigate the NG tube with 50 mL of sterile saline C. Continue to monitor the patient and the drainage D. Notify the health care provider immediately.

C. Continue to monitor the patient and the drainage

Following a gastrectomy performed for PUD, the patient is ready for discharge. Which instructions would the nurse include in discharge teaching? A. Take fluids along with meals B. Reduce protein and fats in the diet C. Divide meals into six small feedings D. Use concentrated sweets like honey, jam, and jelly.

C. Divide meals into six small feedings

The nurse assess the stoma of a patient who has undergone ostomy surgery and identifies that which finding indicates ischemia? A. Pale stoma B. Dark-pink stoma C. Dusky-blue stoma D. Brown-black stoma

C. Dusky-blue stoma

What does the nurse include when teaching a patient with newly diagnosed PUD? A. Maintain a bland, soft, low-residue diet B. Use alcohol and caffeine in moderation and always with food C. Eat as normally as possible, eliminating foods that cause pain and discomfort D. Avoid milk and milk products because they stimulate gastric acid production

C. Eat as normally as possible, eliminating foods that cause pain and discomfort

The client is receiving a low molecular weight heparin subcutaneously to prevent DVT following a hip replacement and complains of small purple hemorrhagic area on the upper abdomen. Which action should the nurse implement? A. Notify the HCP immediately B. Check the client's PTT levels C. Explain this results from the medication D. Assess the client's vital signs

C. Explain this results from the medication This is not hemorrhaging, and the client should be reassured that this is a side effect of the medication

What is the most important measure in the treatment of venous leg ulcers? A. Elevation of the affected leg B. Application of topical antibiotics C. Graduated compression stockings D. Application of moist dry dressings

C. Graduated compression stockings

The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT) who is scheduled for an emergency appendectomy. Vitamin K is ordered for immediate administration. The international normalized ratio (INR) is 1.0. Which nursing action is most appropriate? A. Administer the medication as ordered B. Hold the medication, record in the electronic medical record, and notify the provider C. Hold the medication until the lab result is repeated to verify results D. Administer the medication and seek an increased dose from the health care provider

C. Hold the medication until the lab result is repeated to verify results Vitamin K is the antagonist for warfarin and is commonly used to lower INR levels prior to emergent surgery. In this case the INR is not elevated, therefore the vitamin K should not be given. The lab should be double checked, as the patient may be on coumadin due to their history of DVTG and the low INR may be an erroneous result. The risk of surgery on a patient with a high INR is worth rechecking the value.

The patient has peritonitis, which is a major complication of ruptured appendix. What treatment should the nurse plan to include? A. Peritoneal lavage B. Peritoneal dialysis C. IV fluid replacement D. Increased oral fluid intake

C. IV fluid replacement

Duodenal and gastric ulcers have similar as well as differentiating features. What characteristics are unique to duodenal ulcers? (select all that apply) A. Pain is relieved with eating food B. They have a high recurrence rate C. Increase gastric acid secretion D. Associated with Pylori infection E. Hemorrhage, perforation, and obstruction may result F. There is burning and cramping in the mid-epigastric area

C. Increase gastric acid secretion F. There is burning and cramping in the mid-epigastric area

A patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102° F (38.3° C), pulse 120 beats/min, respirations 32 breaths/min, and blood pressure (BP) 82/54 mm Hg. Which prescribed intervention should the nurse implement first? A. Administer IV ketorolac 15 mg for pain relief. B. Send a blood sample for a complete blood count (CBC). C. Infuse a liter of lactated Ringer's solution over 30 minutes. D. Send the patient for an abdominal computed tomography (CT) scan

C. Infuse a liter of lactated Ringer's solution over 30 minutes.

A patient in the emergency department has just been diagnosed with peritonitis from a ruptured diverticulum. Which prescribed intervention will the nurse implement first? A. Send the patient for a CT scan. B. Insert a urinary catheter to drainage. C. Infuse metronidazole (Flagyl) 500 mg IV. D. Place a nasogastric tube to intermittent low suction.

C. Infuse metronidazole (Flagyl) 500 mg IV.

A patient who is admitted to the hospital with a duodenal ulcer develops signs of acute duodenal perforation. Which action would the nurse expect to take first. A. Administer an H2 blocker B. Administer pain medication C. Insert an NG tube D. Prepare the patient for a laparoscopic surgery

C. Insert an NG tube

Which assessment finding is considered a classic manifestation in lower extremity PAD? A. Rest pain B. Skin ulcerations C. Intermittent claudication D. Paresthesia in the feet and bones

C. Intermittent claudication

The client is being admitted with Coumadin (Warfarin) toxicity. Which laboratory data should the nurse monitor? A. Blood urea nitrogen (BUN) B. Unfractionated heparin (UFH) C. International normalized ratio (INR) D. Partial thromboplastin time (PTT)

C. International normalized ratio (INR)

To help prevent embolization of a thrombus in a patient with acute VTE and severe edema and limb pain, what should the nurse teach the patient to do first? A. Dangle on the edge of the bed every 2-3 hours B. Ambulate around the bed 3 to 4 times a day C. Keep the affected leg elevated above the level of the heart D. Maintain bed rest until edema is relieved and anticoagulation is established

C. Keep the affected leg elevated above the level of the heart

After the patient has undergone an esophagogastroduodenoscopy (EGD), which is the nursing priority. A. Provide warm saline gargles for relief of sore throat B. Assess the patient's bowel sounds C. Keep the patient NPO until the gag reflex returns D. Address the patient's anxieties about the results of the EGD

C. Keep the patient NPO until the gag reflex returns

A patient with a gastric ulcer develops abdominal pain, a rigid board like abdomen, and shallow grunting respirations. Which procedure would the nurse expect to be planned for the patient. A. Vagotomy B. Endoscopy C. Laparoscopy D. Pyloroplasty

C. Laparoscopy

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? A. Ambulate following a meal B. Eat high carbohydrate foods C. Limit the fluid taken with meal D. Have three larger meals instead of multiple smaller meals

C. Limit the fluid taken with meal

The nurse is assessing a patient with lower extremity PAD. Which clinical manifestation would the nurse expect to find. A. Presence of peripheral pulses B. Heaviness in the calf or thigh C. Loss of hair on legs, feet, and toes D. Presence of edema in the lower leg

C. Loss of hair on legs, feet, and toes

A 54 year old patient admitted with cancer has not been able to eat because of nausea. What strategies would the nurse implement? (Select all that apply) A. Serve foods that are warm-to-hot in temperature B. Offer the patient meats and foods with mild spices C. Offer a diet that appeals to the patient's preferences D. Administer antiemetics one hour before meals to prevent nausea E. Offer the patient foods such as cooked cereal and soft or canned fruits.

C. Offer a diet that appeals to the patient's preferences D. Administer antiemetics one hour before meals to prevent nausea E. Offer the patient foods such as cooked cereal and soft or canned fruits.

The nursing care area is very busy with new surgical patients. What care could the registered nurse delegate to the UAP for a patient with VTE? A. Assess the patient's use of herbs B. Measure the patient for elastic compression stockings C. Remind the patient to flex and extend the legs and feet every 2 hours. D. Teach the patient to call emergency response system with sigs of pulmonary embolism.

C. Remind the patient to flex and extend the legs and feet every 2 hours. (measuring compression stockings are delegated to an LPN)

How should the nurse teach the patient with a hiatal hernia or GERD to control symptoms? A. Drink 10 to 12 ounces of water with each meal B. Space 6 small meals a day between breakfast to bedtime C. Sleep with the head of the bed elevated on 4 to 6 inch blocks D. Perform daily exercises of toe-touching, sit-ups, and weight lifting

C. Sleep with the head of the bed elevated on 4 to 6 inch blocks

A patient with a history of PUD is hospitalized with symptoms of a perforation. During the initial assessment, what should the nurse expect to report? A. Vomiting of bright-red blood B. Projectile vomiting of undigested food C. Sudden, severe generalized abdominal and back pain D. Hyperactive bowel sounds and upper abdominal swelling

C. Sudden, severe generalized abdominal and back pain

A patient with VTE is to be discharged on long-term warfarin therapy and is taught about prevention and continuing treatment of VTE. The nurse determines that discharge teaching for the patient has been effective when the patient states? A. "I should expect that Coumadin will cause my stools to be somewhat black." B. "I should avoid all dark green and leafy vegetables while i am taking coumadin." C. "Massaging my legs several times a day will help increase my venous circulation." D. "Swimming is a good activity to include in my exercise program to increase my circulation."

D. "Swimming is a good activity to include in my exercise program to increase my circulation."

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

D. A rigid, board-like abdomen

On examining a patient 8 hours after having surgery to create a colostomy, what should the nurse expect to find? A. Hyperactive, high pitched bowel sounds B. A brick-red, puffy stoma that oozes blood C. A purplish stoma, shiny and moist with mucus D. A small amount of liquid fecal drainage from the stoma

D. A small amount of liquid fecal drainage from the stoma

A patient receives a prescription for 60 mg enoxaparin. Which injection site would the nurse use to administer the medication safely? A. Flank B. Thigh C. Deltoid D. Abdomen

D. Abdomen

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

D. Abdominal cramping and pain Dumping syndrome: Large bolus of hypertonic fluids enter the intestine; s/s -weakness, sweating, palpitations, dizziness, loud abdominal sounds and cramping within 30 min of eating - last less than 1 hour

A significant cause of venous thrombosis is: A. Altered blood coagulation B. Stasis of blood C. Vessel wall injury D. All of the above

D. All of the above (Virchow's Triad)

The nurse provides preoperative care for a patient with a ruptured appendix and the presence of peritonitis. The nurse prepares to administer which type of medication? A. Benzodiazepine B. Antiemetic C. NSAID D. Antibiotic

D. Antibiotic

The nurse is planning care and teaching for a patient with venous leg ulcers. What is the most important patient action in healing and control of this condition? A. Following activity guidelines B. Using moist environmental dressings C. Taking horse chestnut seed extract daily D. Applying graduated compression stockings

D. Applying graduated compression stockings

When caring for a patient with an acute exacerbation of a peptic ulcer, the nurse finds the patient doubled up in bed with shallow, grunting respirations. Which action should the nurse take first? A. Irrigate the patient's NG tube B. Notify the HCP C. Place a patient in high-Fowler's position D. Assess the patient's abdomen and vital signs

D. Assess the patient's abdomen and vital signs

When obtaining a health history from a 72-year-old with PAD of the lower extremities, he nurse asks about a history of related conditions, including A. Venous thrombosis B. Venous stasis ulcers C. Pulmonary embolism D. Coronary Artery Disease

D. Coronary Artery Disease

The nurse evaluates that management of the patient with the upper GI bleeding is effective when assessment and laboratory findings reveal which result? A. Hematocrit (Hct) of 35% B. Urinary Output of 20 mL/hr C. Urine specific gravity of 1.030 D. Decreasing blood urea nitrogen (BUN)

D. Decreasing blood urea nitrogen (BUN)

A 22-year-old patient calls the outpatient clinic reporting nausea and vomiting and lower abdominal pain. What should the nurse advise the patient to do? A. Use a heating pad to relax the muscles at the site of the pain B. Drink at least 2 quart of juice to replace the fluid lost in vomiting C. Take a laxative to empty the bowel before examination at the clinic D. Have the symptoms evaluated right away by a HCP at a hospital's ED

D. Have the symptoms evaluated right away by a HCP at a hospital's ED

The health care provider prescribes an infusion of heparin and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). Which action should the nurse include in the plan of care? A. Obtain a Doppler for monitoring bilateral pedal pulses. B. Decrease the infusion when the PTT value is 65 seconds. C. Avoid giving IM medications to prevent localized bleeding. Co D. Have vitamin K available in case reversal of the heparin is needed.

D. Have vitamin K available in case reversal of the heparin is needed. You are looking for the correct statement. Heparin is an anti coagulant which thins the blood. Patient is at risk of bleeding and IM injections should be avoided. A- Pulse is not affected by VTE B- PTT is in therapeutic range D- Vitamin K is used for warfarin, protamine is used for heparin.

Which organism causes gastritis? A. Streptococcus B. Fusiform bacteria C. Candida albicans D. Helicobacter Pylori

D. Helicobacter Pylori

The nurse is caring for a patient with an acute onset of abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. When auscultating the patient's abdomen, the nurse expects which bowel sounds? A. Borborygmus B. Absent C. Low-pitched below the area of the obstruction D. High-pitched above the area of obstruction

D. High-pitched above the area of obstruction

The nurse is giving a patient instructions regarding the management of GERD. What statement indicates that further teaching is required? A. I should avoid drinking any red wine B. Chewing gum may help me relieve my symptoms C. I should eat small, frequent meals throughout the day D. I can have warm milk at bedtime but not chocolate milk

D. I can have warm milk at bedtime but not chocolate milk

The patient with a new ileostomy needs discharge discharge teaching. What should the nurse plan to include in this teaching? A. The pouch can be worn for up to 2 weeks before changing it. B. Decrease the amount of fluid intake to decrease the amount of drainage. C. The pouch can be removed when bowel movements have been regulated. D. If leakage occurs, promptly remove the pouch, clean the skin, and apply a new pouch

D. If leakage occurs, promptly remove the pouch, clean the skin, and apply a new pouch

The nurse provides education about a double-barreled stoma for a group of nursing students and includes which information? A. It has distal functioning stoma called a mucus fistula B. It involves the creation of a proximal nonfunctioning stoma C. IT is usually performed in a patient who requires a permanent ostomy D. It involves brining both the proximal and distal ends through the abdominal wall as two separate stomas

D. It involves brining both the proximal and distal ends through the abdominal wall as two separate stomas

An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. After the nurse notifies the health care provider, what should the nurse do next? A. Apply a compression stocking to the leg. B. Elevate the leg above the level of the heart. C. Assist the patient in gently exercising the leg. D. Keep the patient in bed in the supine position.

D. Keep the patient in bed in the supine position. Patient's signs and symptoms are consistent with arterial occlusion. Resting the leg will decrease the oxygen demand of the tissues and minimized ischemic damage until circulation can be restored. Elevation or elastic wrap will further compromise blood flow and exercise will increase oxygen demand.

Which indirect thrombin inhibitor is only given subcutaneously and does not need routine coagulation tests? A. Warfarin (Coumadin) B. Unfractioned heparin C. Hirudin derivatives (bivalirudin [Angiomax]) D. Low-molecular-weight heparin (enoxaparin [Lovenox])

D. Low-molecular-weight heparin (enoxaparin [Lovenox])

The RN coordinating care for a patient who is 2 days postoperative following an abdominal-perineal resection (APR) with colostomy may delegate which intervention to the licensed practical nurse (LPN)? (select all that apply) A. Irrigate the colostomy B. Teach ostomy and skin care C. Assess and document stoma appearance D. Monitor and record the volume, color, and odor of the drainage E. Empty the ostomy bag and measure and record the amount of drainage

D. Monitor and record the volume, color, and odor of the drainage E. Empty the ostomy bag and measure and record the amount of drainage

What type of medication increases a patient's risk for upper GI bleeding? A. Antacids B. Anticholinergics C. Tricyclic antidepressants D. NSAIDS

D. NSAIDS

A patient who is being admitted with severe abdominal pain vomits a large amount of emesis that looks like coffee grounds. Which action would the nurse take first? A. Ask the patient about the timing of the last meal B. Complete the admission history and documentation C. Monitor the patient for any further episodes of nausea and vomiting D. Notify the health care provider about the patient's condition

D. Notify the health care provider about the patient's condition

While caring for a patient following a subtotal gastrectomy with a gastroduodenostomy anastomosis, the nurse determines that the NG tube is obstructed. Which action should the nurse take first? A. Replace the tube with a new one B. Irrigate the tube until return can be aspirated C. Reposition the tube and then attempt irrigation D. Notify the surgeon to reposition or replace the tube

D. Notify the surgeon to reposition or replace the tube

Which condition is the most common cause for hematemesis? A. Thalassemia B. Sickle cell disease C. Pernicious anemia D. PUD

D. PUD

A patient at the clinic says, "I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though." What focused assessment should the nurse make? A. Look for the presence of tortuous veins bilaterally on the legs. B. Ask about any skin color changes that occur in response to cold. C. Assess for unilateral swelling, redness, and tenderness of either leg. D. Palpate for the presence of dorsalis pedis and posterior tibial pulses.

D. Palpate for the presence of dorsalis pedis and posterior tibial pulses. This question suggests the patient has PAD, look for the answer that has signs and symptoms of PAD. A is signs of venous insufficiency, B is signs of Raynaud's and C is signs of DVT.

The nurse is teaching the patient and family that peptic ulcers are A. Caused by a stressful life's and other acid- projecting factores such as H. Pylori B. Inherited within families and reinforces by bacterial spread of staphylococcus aureus in childhood C. Promoted by factores that cause over-secretion of acid, such as excess dietary fats, smoking, and alcohol use D. Promoted by a combination of factions that cause erosion of the gastric mucosa, including certain drugs and H. Pylori

D. Promoted by a combination of factions that cause erosion of the gastric mucosa, including certain drugs and H. Pylori

What is the rationale for treating acute exacerbation of PUD with NG intubation? A. Stop spillage of GI contents into the peritoneal cavity B. Remove excess fluids and undigested food from the stomach C. Feed the patient the nutrients missing from lack of indigestion D. Remove stimulant for HCL acid and pepsin secretion by keeping stomach empty.

D. Remove stimulant for HCL acid and pepsin secretion by keeping stomach empty.

Which intervention would the nurse include in the care of a patient who has CVI? A. Application of topical antibiotics to venous ulcers B. Administering oral or subcutaneous anticoagulants C. Maintaining the patient's legs in a dependent position D. Teaching the patient the correct use of compression stockings

D. Teaching the patient the correct use of compression stockings

Which condition involves inflammation of all layers of the bowel wall? A. Peritonitis B. Gastroenteritis C. Crohn's Disease D. Ulcerative Colitis

D. Ulcerative Colitis

The nurse is caring for a patient in the initial postoperative period after an ileostomy surgery. Which is the priority nursing action? A. Using charcoal filters to release patient flatus B. Providing the patient with a list of foods to avoid C. Giving the patient the names and contact information for their support groups. D. Using transparent pouches for the patient

D. Using transparent pouches for the patient

The patient comes to the HCP office with pain, edema, and warm skin on her lower left leg. What test should the nurse expect to be ordered first? a Duplex Ultrasound b Complete Blood Count c Magnetic Resonance Angiography e Computed Venography

a Duplex Ultrasound

The nurse plans teaching for the patient with a colostomy, but the patient refused to look at the nurse of the stoma, stating, " I just can't see myself with this thing." What is the best nursing intervention for this patient? a. Encourage the patient to share concerns and ask questions. b. Refer the patient to a chaplain to help cope with this situation. c. Explain that there is nothing the patient can do about it and must take care of it. d. Tell the patient that learning about it will prevent stool leaking and the sound of flatus.

a. Encourage the patient to share concerns and ask questions. Encouraging a patient to share concerns and ask questions will help the patient begin to adapt to living with a colostomy.

Which instruction is a key aspect of teaching for the patient on anticoagulant therapy? A. Monitor for and report any signs of bleeding B. Do not take Tylenol for a headache C. Decrease your dietary intake for foods containing vitamin K D. Arrange to have blood drawn twice a week to check drug effects

a. Monitor for and report any signs of bleeding.

A patient with inflammatory bowel disease has a nursing diagnosis of impaired nutritional status; etiology: decreased nutritional intake and decreased intestinal absorption. Which assessment findings support this nursing diagnosis? a. Pallor and hair loss b. Frequent diarrhea stools c. Anorectal excoriation and pain d. Hypotension and urine output less than 30ml/hr

a. Pallor and hair loss Symptoms of malnutrition include pallor from anemia, hair loss, bleeding, cracked gums and muscle weakness. Those support a nursing diagnosis that identifies poor nutrition. Diarrhea would contribute to poor nutrition but is not a defining characteristic, anorectal excoriation and pain are related to problems with skin integrity. Hypotension is related to problems with fluid deficit.

The surgery area calls the transfer report for a 68 y.o., postmenopausal, female patient who smokes and takes hormone therapy. She is returning to the clinical unit after a lengthy hip replacement surgery. Which factors present in this patient increase her risk for developing venous thromboembolism related to Virchow's Triad? (select all that apply) a. Smoking b. IV therapy c. Dehydration d. Estrogen therapy e. Orthopedic surgery f. Prolonged immobilization

a. Smoking b. IV therapy d. Estrogen therapy e. Orthopedic surgery f. Prolonged immobilization

The surgery area calls the transfer report for a 68-year-old, postmenopausal, female patient who smokes and takes hormone therapy. She is returning to the floor after a lengthy hip replacement surgery. Which factors present in this patient increase her risk for developing venous thromboembolism (VTE) related to Virchow's triad (select all that apply)? a. Smoking b. IV therapy c. Dehydration d. Estrogen therapy e. Orthopedic surgery f. Prolonged immobilization

a. Smoking b. IV therapy d. Estrogen therapy e. Orthopedic surgery f. Prolonged immobilization

The nurse teaches the patient with any venous disorder that the best way to prevent venous stasis and increase venous return. a. Take short walks b. Sit with the legs elevated c. Frequently rotate the ankles d. Always wear elastic compression stockings

a. Take short walks During walking, the muscles of the legs continuously knead the veins, promoting movement of venous blood towards the heart. Walking is the best measure to prevent venous stasis and will be increased gradually. Elevation will help decrease edema. The other methods will help venous return, but they do not provide the benefit that ambulation does.

A 20 year-old patient with a history of Crohn's disease come to the clinic with persistent diarrhea. What are common characteristics of Crohn's disease? Select all that apply. a. Weight loss b. Rectal bleeding c. Abdominal pain d. Toxic megacolon e. Has segmented distribution f. Involves the entire thickness of the bowel wall

a. Weight loss c. Abdominal pain e. Has segmented distribution f. Involves the entire thickness of the bowel wall

Assessment findings suggestive of peritonitis include (select all that apply) a. rebound abdominal pain b. a soft, distended abdomen c. dull, continuous abdominal pain d. observing that the patient is restless e. shallow respirations with bradypnea

a. rebound abdominal pain d. observing that the patient is lying still Rationale: With peritoneal irritation, the abdomen is hard, like a board, and the patient has severe abdominal pain that is worse with any sudden movement. The patient lies very still. Palpating the abdomen and releasing the hands suddenly causes sudden movement within the abdomen and severe pain. This is called rebound tenderness.

On examining a patient 8 hours after having surgery to create a colostomy, what should the nurse expect to find? a. hyperactive, high-pitched bowel sounds b. A brick-red, puffy stoma that oozes blood c. A purplish stoma, shiny and moist with mucus d. A small amount of liquid fecal drainage from the stoma

b. A brick-red, puffy stoma that oozes blood New ileostomies should be red, puffy and small amounts of blood when touched is normal. Bowel sounds would be diminished after surgery, a purplish stoma is not normal and signifies inadequate blood flow. The colostomy will not have fecal drainage for 2-4 days but there can be earlier mucus or serosanguinous drainage.

Which conditions characterize critical limb ischemia (select all that apply) a. Cold feet b. Arterial leg ulcers c. Gangrene of the leg d. No palpable peripheral pulses e. Rest pain lasting more than 2 weeks

b. Arterial leg ulcers c. Gangrene of the leg e. Rest pain lasting more than 2 weeks

The patient is diagnosed with a superficial vein thrombosis, which characteristics should the nurse know about superficial vein thrombosis? a. Embolization to lungs may result in death b. Clot may extend to deeper veins if untreated c. Vein is tender to pressure and there is edema d. Typically found in the iliac, inferior, or superior vena cava

b. Clot may extend to deeper veins if untreated If left untreated, a superficial vein thrombosis may extend to deeper veins and VTE may occur. Superficial vein thrombosis occur in superficial leg veins and have tenderness, itching, redness, warmth, pain, inflammation, and induration along the course of the superficial vein. Embolization to lungs occurs with deep vein thrombosis along with tender to pressure and there is edema.

When teaching the patient with PAD about modifying risk factors associated with the condition, what should the nurse emphasize? a. Amputation is the ultimate outcome if the patient does not alter lifestyle behaviors. b. Modifications will reduce the risk of other atherosclerotic conditions, such as stroke. c. Risk-reducing behaviors started after angioplasty can stop the progression of the disease. d. Maintenance of normal body weight is the most important factor in controlling arterial disease

b. Modifications will reduce the risk of other atherosclerotic conditions, such as stroke. PAD occurs as a result of atherosclerosis and risk factors are the same as for other diseases associated with atherosclerosis, such as CAD, cerebrovascular disease and aneurysms. Major risk factors are tobacco abuse, hyperlipidemia, elevated C-reactive protein, diabetes, obesity, and uncontrolled HTN.

The patient has persistent and continuous pain at McBurney's point. The nursing assessment reveals rebound tenderness and muscle guarding with the patient preferring to lie still with the right leg flexed. What should the nursing interventions for this patient include? a. Laxatives to move the constipated bowel b. NPO status in preparation for possible appendectomy c. Parenteral fluids and antibiotic therapy for 6 hours before surgery d. NG tube inserted to decompress the stomach and prevent aspiration

b. NPO status in preparation for possible appendectomy

The patient has persistent and continuous pain at McBurney's point. The nursing assessment reveals rebound tenderness and muscle guarding with the patient preferring to lie still with the right leg flexed. What should the nursing interventions for this patient include? a. Laxative to move the constipated bowel b. NPO status in preparation for possible appendectomy c. Parenteral fluids and antibiotic therapy for 6 hours before surgery. d. NG tube insertion to decompress the stomach and prevent aspiration.

b. NPO status in preparation for possible appendectomy The patient is having symptoms of appendicitis. After CT and lab confirmation the patient will have surgery. Laxatives should not be used, NG tube is more common with abdominal trauma, 6hours of fluids and antibiotics before surgery is used if the appendix is ruptured.

An important nursing intervention for a patient with a small intestinal obstruction who has an NG tube is to a. Offer ice chips b. Provide mouth care frequently c. Irrigate the tube with normal saline every 8 hours d. Keep the patient supine with the head of the bed elevated 30 degrees.

b. Provide mouth care frequently Mouth care should be done frequently for the patient with small intestinal obstruction who has an NG tube because of vomiting, fecal taste and odor, and mouth breathing. No ice chips should be given because of obstruction, The NG tube should only be irrigated as ordered and the patient position should be for comfort. They do not have to be supine. The HOB at 30 degrees helps prevent aspiration but is more important with feeding.

The patient with VTE is receiving therapy with heparin and asks the nurse whether the drug with dissolve the clot in her leg. What is the best response by the nurse? a. This drug will break up and dissolve the clot so that circulation in the vein can be resolved b. The purpose of the heparin is to prevent growth of the clot or formation of new clots where the circulation is slowed c. Heparin won't dissolve the clot, but it will inhibit the inflammation around the clot and delay the development of new clots d. The heparin will dilate the vein, preventing turbulence of blood flow around the clot may cause it to break off and travel to the lungs

b. The purpose of the heparin is to prevent growth of the clot or formation of new clots where the circulation is slowed Anticoagulation therapy does not dissolve clots but prevents them from getting bigger and prevents the development of new clots.

What are characteristics of PAD (select all) a. Pruritius b. Thickened, brittle nails c. Dull ache in calf or thigh d. Decreased peripheral pulses e. Pallor on elevation of the legs f. Ulcers over bony prominences on toes and feet

b. Thickened, brittle nails d. Decreased peripheral pulses e. Pallor on elevation of the legs

M.J. calls the clinic and tells the nurse that her 85-year-old mother has been nauseated all day and has vomited twice. Before the nurse hangs up and calls the HCP, she should tell M.J. to a. administer antiemetic drugs and observe skin turgor. b. give her mother sips of water and elevate the head of her bed to prevent aspiration. c. offer her mother a high-protein liquid supplement to drink to maintain her nutritional needs. d. offer her mother large quantities of Gatorade to decrease the risk of sodium depletion.

b. give her mother sips of water and elevate the head of her bed to prevent aspiration.

After the nurse teaches a patient with gastroesophageal reflux disease (GERD) about recommended dietary modifications, which statement by the patient indicates that the teaching has been effective? a. "I can have a glass of low-fat milk at bedtime." b. "I will have to eliminate all spicy foods from my diet." c. "I will have to use herbal teas instead of caffeinated drinks." d. "I should keep something in my stomach all the time to neutralize the excess acids."

c. "I will have to use herbal teas instead of caffeinated drinks."

During care of the patient following femoral bypass graft surgery, the nurse immediately notifies the health care provider if the patient has a. Fever and redness at the incision site b.2+ edema of the extremity and pain at the incision site c. A loss of palpable pulses ad numbness and tingling of the feet d. Increasing ankle-brachial indices and serous drainage from the incision

c. A loss of palpable pulses ad numbness and tingling of the feet Loss of palpable pulses, numbness and tingling of the extremity, extremity pallor, cyanosis, or cold are indications of occlusion of the bypass graft and need immediate medical attention. Pain, redness, and serous drainage at the incision site are expected postoperatively. Ankle brachial index measurements are not recommended because of increased risk of graft thrombosis, but this would decrease with occlusion

What laboratory findings are expected in ulcerative colitis because of diarrhea and vomiting? a. Increased albumin b. Elevated WBCs c. Decreased serum Na+, K+, Mg+, Cl-, and HCO3- d. Decreased hemoglobin and hematocrit.

c. Decreased serum Na+, K+, Mg+, Cl-, and HCO3- In a patient with ulcerative colitis decrease in serum Na, K, Mg, Cl and HCO3 are a result of vomiting and diarrhea. Albumin would be decreased with severe disease, elevated WBCs would indicate infection and toxic megacolon, decreased hemoglobin and hematocrit occur with bloody diarrhea leading to anemia.

What is the most important measure in the treatment of venous leg ulcers? a. Elevation of the affected leg b. Application of topical antibiotics c. Graduated compression stockings d. Application of moist to dry dressings

c. Graduated compression stockings Although leg elevation, moist dressings and systemic antibiotics are useful in treatment of venous stasis ulcers, the most important factor of venous stasis ulcers is compression, which minimizes venous stasis, venous hypertension, and edema and prevents reoccurrence. Compression may be applied with various methods including stockings, elastic bandages, or wraps or a Velcro wrap.

Following teaching about medications for PAD, the nurse determines that more instructions is needed when the patient makes which statement? a. I should take 1 aspirin a day to prevent clotting in my legs b. The lisinopril I use for my blood pressure may help me walk further without pain c. I will need to have frequent blood test to evaluate the effect of the pentoxifylline I will be taking d. Cilostrazol should help me increase my walking distance and speed and help prevent pain in my legs

c. I will need to have frequent blood test to evaluate the effect of the pentoxifylline I will be taking Pentoxifylline allows blood to pass through the small vessels, but there is not blood tests related to it. All other statements are correct in relation to treatment of PAD

The patient has peritonitis, which is a major complication of ruptured appendix. What treatment should the nurse plan to include? a. Peritoneal lavage b. Peritoneal dialysis c. IV fluid replacement d. Increase in oral fluid intake

c. IV fluid replacement IV fluid replacement along with antibiotics NG tube insertion, analgesics and potential surgery would be expected. Peritoneal lavage may be used to determine abdominal trauma. Peritoneal dialysis would not be used, and oral fluids are avoided with peritonitis.

To help prevent embolization of a thrombus in a patient with acute VTE and severe edema and limb pain, what should the nurse teach the patient to do first? a Dangle on the edge of the bed q2-3hrs b Ambulate around the bed 3-4 times a day c Keep the affected leg elevated about the level of the heart d Maintain bed rest until edema is relieved and anticoagulation is established

d Maintain bed rest until edema is relieved and anticoagulation is established With acute VTE, prevention of emboli formation, decreased edema and pain can be achieved initially by bed rest and limiting movement of the involved extremity. Ambulation will be the next priority. Dangling the legs promotes venous stasis and further clot formation. Elevating the affected limb will promote venous return, but it does not prevent embolization.

When obtaining a health history from a 72 y.o. man wit peripheral arterial disease of the lower extremities, the nurse asks about a history of related conditions, including a. Venous thrombosis b. Venous stasis ulcers c. Pulmonary embolism d. Coronary artery disease

d. Coronary artery disease Regardless of the location, atherosclerosis is responsible for PAD and is related to other CV disease risk factors, such as CAD and carotid artery disease. Venous thrombosis, venous stasis ulcers, and pulmonary embolism are diseases of the veins and are not related to atherosclerosis.

What extra-intestinal manifestations are seen in both ulcerative colitis and Crohn's disease? a. Celiac disease and gallstones b. Peptic ulcer disease and uveitis c. Conjunctivitis and colonic dilation d. Erythema nodosum and osteoporosis

d. Erythema nodosum and osteoporosis

A 22 year-old patient calls the outpatient clinic reporting nausea and vomiting and right lower abdominal pain. What should the nurse advise the patient to do? a. Use a heating pad to relax the muscles at the site of pain. b. Drink at least 2 quarts of juice to replace the fluid lost to vomiting. c. Take a laxative to empty the bowel before examination at the clinic d. Have the symptoms evaluated right away by the health care provider at the emergency department

d. Have the symptoms evaluated right away by the health care provider at the emergency department The patient is having symptoms of an acute abdomen and should be evaluated immediately by a provider. Heat application and laxative should not be given with undiagnosed abdominal pain since it could cause inflammation and perforation of the appendix with appendicitis. Fluids should not be given until vomiting is controlled and held until determined if surgery is needed.

The patient with a new ileostomy needs discharge teaching. What should the nurse plan to include in this teaching? a. The pouch can be worn for up to 2 weeks before changing it. b. Decrease the amount of fluid intake to decrease the amount of drainage c. The pouch can be removed when bowel movements have been regulated d. If leakage occurs, promptly remove the pouch, clean the skin, and apply a new pouch

d. If leakage occurs, promptly remove the pouch, clean the skin, and apply a new pouch The ileostomy drainage is extremely irritating to the skin so the skin must be cleaned, and a new skin barrier and pouch should be applied immediately to prevent skin irritation and breakdown. The pouch should be changed every 4-7 days, unless it is leaking. The amount of fluid intake should be increased not decreased. The couch is always worn, you cannot regulate stool from an ileostomy.

The patient comes to the ED with intermittent crampy abdominal pain, nausea, projectile vomiting, and dehydration. The nurse suspects a GI obstruction. Based on the manifestations, what area of the bowel should the nurse suspect is obstructed? a. Large intestine b. Esophageal sphincter c. Distal small intestine d. Proximal small intestine

d. Proximal small intestine Intermittent crampy abdominal pain, nausea, projectile vomiting and dehydration are characteristic of proximal small intestine obstruction. Large bowel obstruction is characterized by constipation, low-grade abdominal pain, and abdominal distention. Esophageal sphincter blockage or achalasia feels like food is stuck in the chest. Fecal emesis is seen with distal small bowel obstruction.