Test 3: GI Exam
The nurse is teaching a client with Crohn disease about managing the disease with the adalimumab Which instruction does the nurse emphasize to the client? A. "Avoid large crowds and anyone who is sick B. "Expect difficulty with wound healing while you are taking this drug." C. "Do not take the medication if you are allergic to foods with fatty acids." D. "Monitor your blood pressure and report any significant decrease in it."
A. "Avoid large crowds and anyone who is sick"- The immunosuppressing action of HUMIRA.(adalimumab) Injection for Subcutaneous use places patients at increased risk for serious infection.
The nurse is caring for a client who has an exacerbation of Chron's disease. For what complications will the nurse monitor? A. Anemia B. Constipation C. Weight gain D. Hyperkalemia
A. Anemia
The nurse is caring for a client diagnosed with peritonitis. The patient complains of abdominal pain of 7 on a scale of 10. What is the most appropriate initial action by the nurse? A. Assess the patient's vital signs B. Measure the patient's weight C. Administer IV Morphine D. Establish IV access
A. Assess the patient's vital signs- Although pain control and fluid balance are important, the prioritization must be based on the patient's assessment.
While taking a client history, which report is least likely to contribute to GI problems? A. Eating a high-fiber diet B. Smoking a half-pack of cigarettes per day C. Use of herbal preparations D. Taking NSAIDS daily
A. Eating a high fiber diet - Review GI health promotion. Eating a high-fiber diet contributes to gastrointestinal health.
A client known to have a sedentary lifestyle is diagnosed with morbid obesity and asks the nurse what actions he can take. Which is the nurses best response? A. Encourage the client to walk 20 min per day B. Encourage a carbohydrate free diet C. Encourage a fat free diet D. Explain that no one else can motivate him to improve his health
A. Encourage the client to walk 20 min per day- Walking 20 min/ day is evidenced to decrease obesity. The diets are not balanced and the last option is uninformative and insensitive.
The nurse assesses a client with a history of cirrhosis and notes significant fluid within the peritoneal cavity. How is this finding documented? A. jaundice B. hepatomegaly C. ascites D. icterus
A. Jaundice
When notifying the provider of a client's symptoms associated with acute gastritis, the nurse anticipates an order for an H2-blocker or PPI. Which of the following is an H2-blocker? A. Pepcid B. Prilosec C. Prevacid D. Protonix
A. Pepcid- (famotidine) is an H2- blocker. The others (Omeprazole, Lansoprazole & Pantoprazole) are proton pump inhibitors
The nurse is caring for a client who reports a history of Zenker's diverticulum. Which of the following orders should the nurse question? A. Place and nasogastric tube to low intermittent suction B. Obtain procedure consent for EGD C. Clear liquid diet D. Omeprazole oral suspension 40 mg by mouth daily
A. Place and nasogastric tube to low intermittent suction- Blind NG tube placement can cause esophageal perforation. Therefore the order for NGT placement should be questioned.
When assessing a client with hepatitis B, which assessment finding would NOT be an expected finding for hepatitis? A. Recent influenza infection B. Tea-colored urine C. Itching D. Right upper quadrant tenderness
A. Recent influenza infection- HBV is transmitted via blood & body fluid. Flu infections are not associated with hepatitis B.
In addition to remaining infection free, which of the following is a goal in recovery from hepatitis? A. Resting the liver B. Vaccination for HCV C. Controlling fever with Tylenol D. Weight loss to decrease fatty liver
A. Resting the liver- Resting the liver and adequate nutrition are goals in hepatitis recovery. Tylenol can stress the liver, and there is no HCV vaccine.
A nurse cares for a patient who is recovering from a hemorrhoidectomy. The patient states, "I need to have a bowel movement." Which safety action would the nurse take? A. Stay with the patient while providing privacy. B. Obtain a bedside commode for the patient to use. C. Make sure the call light is in reach to signal completion. D. Gather supplies to collect a stool sample for the laboratory.
A. Stay with the patient while providing privacy.- Post hemorrhoidectomy, significant bleeding and/or syncope are associated with the first post-op BM. Stay with the client.
How might the nurse partner with a family member to monitor nutritional status in the hospital as well as post discharge? A. Teach the family to record I&O B. Teach the family to use bed-scales C. Encourage the family to feed the patient D. Teach the family about nutritional requirements
A. Teach the family to record I&O- Patient and family education about monitoring I&O is helpful post hospital as well. Bed-scales will not go home with patients, and the other two answers are unrelated to monitoring.
A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. Which steps in this procedure are performed correctly? A. The nurse uses friction motion when washing for at least 15 seconds. B. The nurse removes all jewelry including a platinum wedding band. C. The nurse uses approximately two teaspoons of liquid soap. D. The nurse keeps hands higher than elbows when placing under faucet.
A. The nurse uses friction motion when washing for at least 15 seconds- The nurse should wash hands to one inch above the wrists, using friction motion for at least 15 seconds, then rinse thoroughly with water flowing toward fingertips.
A 68-year-old patient is being admitted with problems of the oral cavity. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? A. The patient has dysphasia. B. The patient has atrial fibrillation. C. The patient reports a loss of appetite. D. The patient has a history of oral cancer.
A. The patient has dysphasia- Difficulty swallowing places the patient at risk for impaired airway clearance.
An abdominoperineal resection is planned for a patient diagnosed with rectal cancer. The nurse understands that which of the following will NOT be surgically removed during this procedure? A. The transverse colon B. The sigmoid colon C. The rectum D. The anus
A. The transverse colon- Abdominoperineal resection involves removal of the sigmoid colon, the rectum, and the anus.
The preceptor asks the nursing student why Morphine is prescribed for the patient undergoing HIDA scan. What is the student's best response? A. To increase gallbladder visualization B. To control acute abdominal pain C. To improve pulmonary perfusion D. To slow the patient's respiratory rate
A. To increase gallbladder visualization- morphine can delay gallbladder emptying and improve visualization
Prevention is the best remedy for enteral tube occlusion A. True B. False
A. True
After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? A. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. B. Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain. C. Middle-aged client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography. D. Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL (13.1 mmol/L).
A. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min.- The young adult with pancreatitis and respiratory distress should take priority.
For which of the following patients would the nurse anticipate extracorporeal shock wave lithotripsy for removal of gallstones? A. A client with a history of cholesterol based gallstones B. A morbidly obese client C. A client with minimal ejection on HIDA scan D. A client with acalculous cholecystitis
A. a client with a history of cholesterol based gallstones- ESWL is evidenced to be effective in removal of cholesterol based stones. Acalculous disease is without stones, and obesity and impaired function are contraindications due to ineffectiveness.
A client has a new diagnosis of irritable bowel syndrome (IBS) with diarrhea. What health teaching by the nurse is appropriate for this client? A. "Avoid high-fiber foods in your diet." B. "Take a stool softener every day to ease defecation." C. "Avoid dairy products and caffeinated beverages." D. "Ask your primary health care provider for an antidepressant."
C. "Avoid dairy products and caffeinated beverages." - Diarrhea r/t IBS needs fiber to help provide bulk and does not need a stool softener as clients with constipation do. Not all clients with IBS have mental health problems, but dairy products are often not well tolerated and should be avoided to help decrease diarrhea.
The nurse is teaching a client about dietary methods to help manage exacerbations (flare-ups) of diverticulitis. What does the nurse advise the client? A. "Be sure to maintain an exclusively low-fiber diet to prevent pain on defecation." B. "Maintain a high-fiber diet to prevent the development of hemorrhoids that frequently accompany this condition." C. "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." D. "Make sure you consume a high-fiber diet while diverticulitis is active. When inflammation resolves, consume a low-fiber diet."
C. "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." - Clients should consume a low-fiber diet while diverticulitis is active. to rest the gut and decrease inflammation. When inflammation resolves, a high-fiber diet is recommended.
A client has been newly diagnosed with ulcerative colitis (UC). What does the nurse teach the client about diet and lifestyle choices? A. "Drinking carbonated beverages will help with your abdominal distress." B. "It's OK to smoke cigarettes, but you should limit them to ½ pack per day." C. "Lactose-containing foods should be reduced or eliminated from your diet." D. "Raw vegetables and high-fiber foods may help to diminish your symptoms."
C. "Lactose-containing foods should be reduced or eliminated from your diet." - Lactose can cause GI distress, as can carbonation. Vegetables should be cooked to reduce dietary roughage. Clients should be encouraged not to smoke.
The nurse is caring for a client who is scheduled for a minimally invasive esophagectomy, and finds the client in tears the night before her surgery. Which is the most appropriate statement by the nurse? A. "You must be worried about your diagnosis."" B. Don't worry, there are many advantages to the MIE." C. "You seem upset. Please, share with me your concern?" D. "Can I get you something for pain?"
C. "You seem upset. Please, share with me your concern?"- The nurse should not patronize nor make assumptions. Asking the client to share is the best response.
A nurse recognizes that an 80 year old female patient who takes solumedrol for an acute exacerbation of COPD, HCTZ for hypertension, and Lasix for symptoms associated with heart failure has how many risk factors for Drug Induced Pancreatitis? A. 2 B. 3 C. 5 D. 6
C. 5: Elderly, furosemide, hydrochlorothiazide, female, and immunosuppressed by steroids
When assessing a client experiencing a GI bleed, which laboratory finding supports suspected anemia? A. A WBC count of 13,000 B. A hemoglobin of 14 C. A hematocrit of 20 D. A systolic BP of 100
C. A hematocrit of 20- A hematocrit of 20 would correlate to a hemoglobin < 7 and anemia.
When admitting a patient diagnosed with Hepatitis D, what additional finding does the nurse anticipate? A. A hepatitis C infection B. A hepatitis A infection C. A hepatitis B infection D. Recent ingestion of shellfish
C. A hepatitis B infection- HDV has defective RNA & relies on the helper function of HBV
The nurse reads that a patient was excluded from receiving a liver transplant. Which finding in the medical record would best explain this decision? A. The client has a history of alcohol abuse B. Unsteady work history due to prolonged illness C. A history of lung cancer with metastasis to the liver D. The client had a stent placed in the right coronary artery 5 years ago
C. A history of lung cancer with metastasis to the liver- Metastatic disease is a contraindication for organ transplant.
A nurse is assessing a patient suspected of having acute cholecystitis. Which information about the last meal would best align with this diagnosis? A. A clear liquid diet for 18 hours B. NPO due to chronic nausea C. A large fatty meal an hour before onset of pain D. A low fat consistent carb diet
C. A large fatty meal an hour before onset of pain- Gallbladder attacks often occur following a large or high fat meal.
Immediately following a colonoscopy, which client behavior will the nurse report to the health care provider? A. Passing of flatus B. Blood pressure 128/80 C. Abdominal guarding D. Mild abdominal cramping
C. Abdominal guarding- Abdominal guarding indicates extreme pain. The other findings are normal.
The nurse is caring for a client who is diagnosed with cirrhosis. Which serum laboratory values will the nurse expect to be within normal limits? A. Prothrombin time B. Serum bilirubin C. Acid phosphatase D. Lactate dehydrogenase (LDH)
C. Acid phosphatase- Bilirubin, liver enzymes, and bleeding times will likely be abnormal. Acid phosphatase should be WNL.
A patient presents in the fetal position and is suspected of having acute pancreatitis. Knowing the patient will be in the supine position for a CT, which intervention does the nurse prioritize? A. Application of oxygen B. Auscultation of lung sounds C. Administration of IV hydromorphone D. Placing an NG tube to prevent vomiting
C. Administration of IV Hydromorphone-Evidence of pain is the only symptom described and pancreatic pain is worsened when lying flat (as in a CT scanner)
The nurse understands that the pathophysiology associate with a client's diagnosis of GERD is which of the following? A. An incompetent upper esophageal sphincter B. Hypersecretion of stomach acids C. An incompetent lower esophageal sphincter D. Herniation of the stomach into the thoracic cavity
C. An incompetent lower esophageal sphincter- GERD is caused by an incompetent lower esophageal sphincter.
A client is diagnosed with a duodenal ulcer. The nurse understands that the location of the ulcer is where? A. In the corpus body of the stomach B. In the fundus of the stomach C. At the beginning of the small intestine D. In the cardia of the stomach
C. At beginning of the small intestine (also called the small bowel) is the duodenum
While assessing a patient who presented with severe boring abdominal pain, the nursed notes bruising around the umbilicus. Which term correctly identifies this finding. A. Grey-Turner's sign B. Blumberg's sign C. Cullen's sign D. Kehr's sign
C. Cullen's Sign- Describes umbilical bruising and edema
While admitting a female patient with cirrhosis, the nurse notes multiple bruises in various stages of healing. What is the most likely cause? A. Domestic violence B. An excess of vitamin K C. Decreased absorption of fat-soluble vitamins D. Falls resulting from intoxication
C. Decreased absorption of fat- soluble vitamins
The nurse has an order to "obtain procedural consent for EGD". How will the nurse complete the consent form? A. Obtain no consent, as this is the physician's responsibility. B. Consent for "EGD" as written in the order C.Esophagogastroduodenoscopy D. Esophageal Gastric Dilatation
C. Esophagogastroduodenoscopy- Procedural consent can be obtained by the nurse, & EGD is the abbreviation for Esophagogastroduodenoscopy.
Which of the following must take priority in the nurses interventions for a patient who is morbidly obese? A. Encourage a food diary B. Discuss way to decrease fat and calorie intake C. Establish trust and rapport D. Encourage increased exercise
C. Establish trust and rapport- before we can speak to patients' barriers to a healthy weight, we must treat them with respect and establish rapport.
A client presents to the ER with the complaint of "a fish bone stuck in my throat". Which of the following symptoms would NOT be associated with a foreign body in the esophagus?. A. Odynophagia B. Dysphagia C. Hypertension D. Elevated temperature
C. Hypertension-Pain, dysphagia, infection and hypotension are associated with esophageal foreign body.
The nurse is teaching a family member about home care administration of TPN and what to do if the bag empties before a new bag is delivered. Which of the following indicates a need for further instruction? A. I will hang the reserve bag of 10% Dextrose B. I will monitor his blood glucose C. I will increase the rate on the new bag to make up for lost volume D. I will observe for signs and symptoms of hypoglycemia
C. I will increase the rate on the new bag to make up for lost volume- the new bag should be hung at the prescribed rate. The other behaviors are expected.
When planning care for a client post open fundoplication surgery, the nurse understands that which of the following is the priority problem? A. Pain r/t abdominal incision B. Risk for bleeding r/t abdominal surgery C. Impaired gas exchange r/t decreased diaphragmatic excursion D. Nutritional deficit r/t dietary changes
C. Impaired gas exchange r/t decreased diaphragmatic excursion- lung expansion must be prioritized. Pain may contribute to this priority problem but gas exchange is the priority problem.
The nurse is completing an initial assessment. Which of the following objective cues does NOT cause suspicion for liver disease? A. A flapping tremor of the hands B. White linier striation of the fingernails C. Left upper quadrant pain D. Scratches on the extremities
C. Left upper quadrant pain- CLAPS: clubbing, leukonychia, asterixis, palmar erythema, and scratching
When planning care for an 80 year old client, which of the following should the nurse keep in mind? A. Hepatic proteins syntheses increases with age B. Liver mass increases with age C. Medication metabolism may be delayed D. Liver enzyme production is unaffected by age
C. Medication metabolism may be delayed- The liver decreases in size and function with age, including protein synthesis, detoxification ,and waste metabolism.
A client presents to the ER with a complaint of vomiting blood. The client tells the nurse he had a STRETTA procedure 2 weeks earlier. Which of the following orders would the nurse question? A. NPO except for medications B. Acetaminophen elixir 650 mg po q 4 hr prn pain C. NG tube and lavage until clear D. Omeprazole 40 mg IV
C. NG tube and lavage until clear - NGT placement is contraindicated within 1 month of a STRETTA procedure.
A client who had a Whipple surgical procedure develops an internal fistula between the pancreas and stomach. For which complication would the nurse monitor? A. Peptic ulcer disease B. Cirrhosis C. Peritonitis D. Chronic pancreatitis
C. Peritonitis- the fistula places the patient at risk for intra- abdominal infection and peritonitis.
The nurse is providing instructions to a client with a history of stomatitis. Which instructions does the nurse include in the teaching plan? A. Encourage the client to eat acidic foods to decrease bacteria. B. Perform mouth care no more than twice daily, C. Rinse the mouth frequently with warm saline or sodium bicarbonate D. Use a medium-bristled toothbrush for oral care.
C. Rinse the mouth frequently with warm saline or sodium bicarbonate- Acidic foods may cause pain or trauma, mouth care should be done at least twice & more often as needed, a soft toothbrush will prevent trauma, Saline or Sodium bicarb will neutralize the pH while cleansing the oral cavity.
Which food does the nurse teach a client undergoing chemotherapy with secondary stomatitis to avoid? A. Broiled fish B. Ice cream C. Salted pretzels D. Scrambled eggs
C. Salted pretzels - Crunchy salty foods may worsen stomatitis.
The nurse is caring for a patient awaiting a gallbladder ultrasound. When asked why the patient must be NPO for the study, what is the nurse's best response? A. To prevent vomiting associated with gallbladder disease B. To decrease risk of aspiration during the procedure C. Stomach contents can interfere with imaging D. Your doctor must order a diet
C. Stomach contents can interfere with imaging - Stomach contents can block the transmission of sound waves used to create the image.
When teaching a client about diet change to manage GERD, which of the following is acceptable to include in the diet? A. Mint B. Caffeine C. Sweet potatoes D. Chocolate
C. Sweet potatoes- All but sweet potatoes are known to decrease sphincter tone contributing to GERD.
The nurse candidate documents a patient's complaint related to sever pain with swallowing. Which of the following statements requires clarification by the nurse preceptor? A. "The patient complains of odynophagia." B. "The patient rates her pain at 8/10." C. The patient complains of dysphasia. D. "The patient shows no signs of aspiration."
C. The patient complains of dysphasia."- Dysphagia refers to difficulty or inability to swallow. Odynaphagia refers to pain with swallowing. The other additional comments address severity of pain and patient safety.
Which assessment finding would prompt the nurse to contact the provider before implementing an order for Total Parenteral Nutrition? A. The patient has an NG tube B. The patient has no peripheral IV access C. The patient has no central venous access D. The patient is obese
C. The patient has no central venous access- central venous access is required for TPN administration
The nurse is caring for a client diagnosed with esophageal cancer. Which of the following is the goal of chemotherapeutic and surgical interventions? A. To eradicate the tumor B. To cure the cancer C. To improve swallowing D. To make the client feel better
C. To improve swallowing- the goal of therapy is to improve swallowing and nutritional status
Which of the following is NOT a DRI (dietary reference intake)? A. Dietary Guidelines for Americans B.USDA My Plate C. Vegetarian Diets D. Eating Well: Canada's Food Guide
C. Vegetarian Diets- vegetarian is a type of diet, but not a dietary guide, or dietary reference.
A 26 year old homeless patient diagnosed with hepatitis A (HAV) asks the nurse how she could have become infected. Which does the nurse suggest as a most likely cause? A. sharing needles B. prolonged or excessive alcohol intake C. eating without first washing her hands D. having unprotected sex with an infected partner
C. eating without first washing her hands- HAV is transmitted by fecal oral route. Hand washing is key.
When teaching about colonoscopy, which statement does the nurse recognize as indicating a need for clarification? A. "I will be sedated during the procedure.." B. "I will need to sign an informed consent." C. "I will have only clear liquids the day before the procedure." D. "If I do not complete my prep, the doctor can clean me out while I am sedated."
D. "If I do not complete my prep, the doctor can clean me out while I am sedated." - The client should understand that if the colon can't be visualized, the prep process may have to be repeated.
The patient admitted with cholecystitis due to cholelithiasis asks, "Why is my poop so white?" Which is the nurse's appropriate response? A. "The color of stool varies based on diet and is insignificant." B. "The disease is limiting the amount of bile your gallbladder produces." C. "The high fiber carbohydrate, low fat diet has changed the consistency of your stool." D. "The gallstones are blocking digestive fluids that add the color to your bowel movement"
D. "The gallstones are blocking digestive fluids that add the color to your bowel movement" - Gallstones are blocking bile entry into the GI tract .
A client diagnosed with gastric bleeding asks why she keeps vomiting coffee when she has had no caffeine intake in over 24 hours. Which is the best response from the nurse? A. "Caffeine can increase the risk for gastritis and ulcers." B. "Let me know if you vomit any bright red liquid." C. "I need to keep track of the amount you vomit." D. "When blood interacts with stomach acid it can develop a coffee-ground appearance."
D. "When blood interacts with stomach acid it can develop a coffee-ground appearance."- Although none of the responses are false, only one answers the client's question.
The nurse is caring for a client who has a nonmechanical intestinal obstruction. Which of the following likely contributed to this condition? A. Fibroids B. Adhesions C. Fecal impaction D. Abdominal surgery
D. Abdominal Surgery- Mechanical obstruction results from an identifiable barrier, whereas nonmechanical obstruction results from paralysis of the intestine, as in a post-op ileus.
The nurse is teaching a client about offenders that contribute to gastritis. Which of the following would not be contraindicated? A. Prednisone B. Aspirin C. Ibuprofen D. Acetaminophen
D. Acetaminophen- NSAIDS and steroid medications can aggravate gastritis. Acetaminophen is in neither category.
What action would be LEAST likely to achieve the desired outcomes for the client diagnosed with intestinal obstruction? A. IV hydration to achieve fluid balance B. Supplement potassium as needed based on electrolyte panel. C. Administer IV opioids to decrease pain to 2-3/10 D. Administer stimulant laxatives to increase GI elimination
D. Administer stimulant laxatives to increase GI elimination- The patient needs adequate hydration, electrolyte balance, and pain control. Stimulant laxatives will not resolve the obstruction and they can be habit forming.
After completing a patient assessment, nurse is highly suspicious of acute cholecystitis. Which of the following would be most helpful to include in the recommendation portion of an SBAR to the provider? A. A complete set of vital signs B. Trending of previous lab results C. A contrast enhanced CT scan D. An abdominal ultrasound
D. An abdominal ultrasound- An abdominal ultrasound is the best initial test to confirm acute cholecystitis. Vital signs and previous lab results would be in the assessment portion of SBAR, and a contrast CT is not indicated.
The nurse is caring for a patient diagnosed with hepatitis. Which of the following should be reported to the provider? A. abdominal pain B. jaundice C. icterus D. Changes in consciousness or behavior
D. Changes in consciousness or behavior- Abdominal pain, icterus, and jaundice are symptoms of hepatitis. The provider should be alerted to changes in level of consciousness.
Which teaching will the nurse provide when discharging a client with chronic pancreatitis? A.Weight reduction and daily exercise regimen B. Relaxation techniques and stress management C. Constipation precautions including daily laxative use D. Dietary adjustments to avoid high-fat foods, caffeine, and alcohol
D. Dietary adjustments to avoid high-fat foods, caffeine, and alcohol - Teaching should prioritize avoiding high-fat foods, caffeine, and alcohol
The nurse is working with a CNA on a med-surg unit. Which of the following should be prioritized in delegating tasks to the CNA? A. Obtaining vital signs B. Teaching about meal supplements C. Recording intake and output D. Feeding a client with burns to both hand
D. Feeding a client with burns to both hands- Burns increase metabolic requirements and feeding the client with burns to both hands will be time consuming and should be prioritized. The nurse can obtain VS and I&O as part of assessment / rounding, and education should not be delegated.
Which of the following reports would be the LEAST helpful when assessing a patient for possible over-feeding? A. Residual volumes B. Volume of emesis C. Frequency of nausea and vomiting D. Fingerstick blood glucose
D. Fingerstick blood glucose- Glucose and electrolytes are affected by refeeding syndrome. But overfeeding is a volume to GI capacity issue. Distension, N&V, ;and gastric residual should be monitored.
The nurse is teaching a group of senior citizens in a residential facility about how to prevent gastrointestinal (GI) infectious outbreaks, such as norovirus. What information will the nurse include as a priority intervention for the group? A. Avoiding group dining B. Keeping at least 6 feet apart C. Cooking all food and boiling water D. Handwashing and hand sanitizing
D. Handwashing and hand sanitizing- Norovirus is transmitted via a fecal oral route. So, handwashing is the priority prevention.
When caring for a patient with suspected liver trauma, which should the nurse prioritize? A. Stool for occult blood B. Assess ability to swallow C. IV Lactated Ringers D. IV Normal Saline
D. IV normal saline- IV NS will provide volume and is compatible with blood products. The pt will be NPO, LR is not compatible with blood & stool sample is not a priority.
The nurse is planning care for a patient postop gastric surgery. Which of the following problems should be prioritized? A. Pain r/t surgical incision B. Impaired gastric emptying r/t decreased peristalsis C. Risk for infection r/t skin integrity and hospitalization D. Impaired gas exchange r/t decreased diaphragmatic excursion
D. Impaired gas exchange r/t decreased diaphragmatic excursion- Although all of these are valid considerations for the postop patient, gas exchange must be prioritized.
In discharge planning for a client with ascites r/t cirrhosis, the nurse assesses understanding of signs of infection due to knowledge of which of the following about ascites? A. Increased risk for hepatitis B. Exposure to disease in hospital C. Increased risk for pneumonia D. Increased risk for peritonitis
D. Increased risk for peritonitis
Which of the following would be a later symptom of one diagnosed with liver cancer? A. fatigue B. weight loss C. Right upper quadrant pain D. Jaundice
D. Jaundice- Jaundice is a later sign of liver dysfunction.
A client with oral cancer who is to have a radical neck dissection reports being depressed. What is the nurse's priority response? A. Reassure that it is normal to feel depressed about the diagnosis. B. Suggest seeking support from a community group. C. Explain the grieving process. D. Listen to the client's concerns.
D. Listen to the client's concerns-The priority is to ASSESS the client's coping by listening.
When caring for a client whose condition is too unstable to undergo sedation for ERCP, which radiologic study does the nurse anticipate as a diagnostic equivalent alternative? A. HIDA scan B. Abdominal ultrasound C. CT without contrast D. MRCP
D. MRCP- The MRCP can visualize all the structures of the biliary system viewed by ERCP. through noninvasive MRI technology. The other studies are not as comprehensive.
Which of the following actions would the nurse delegate to a CNA while providing care for a client post-op esophagectomy? A. Teach Incentive Spirometry B. Assisting with a soft mechanical diet C. Evaluate intake and output for fluid balance D. Maintaining the client in Semi Fowler's position
D. Maintaining the client in Semi Fowler's position- The nurse should not delegate that which is inappropriate, or involves evaluation, assessment, or teaching.
An 83 year old is admitted for a GI work up. The CNA reports a complaint of nausea, hypotension, and tachycardia. On assessment, the nurse notes a firm and extremely tender abdomen. What is the most appropriate nursing action? A. Have the CNA recheck vitals following medication for nausea. B. Administer medication for nausea and reassess. C. Administer medication for pain and nausea. D. Notify the provider immediately
D. Notify the provider.- The provider should be notified immediately. Severe abdominal pain, nausea, and hypotension accompanied by abdominal rigidity can indicate perforation which is a medical emergency.
A client with an intestinal obstruction has pain that changes from a "colicky" intermittent type to constant discomfort. After a complete assessment, what action would the nurse plan implement at this time? A. Change the nasogastric suction level from "intermittent" to "continuous." B. Administer medication for pain based on the client's pain level. C. Position the client in a semi- or high-Fowler position. D. Notify the surgeon immediately
D. Notify the surgeon immediately-Transitioning from "colicky" intermittent pain associated with an obstruction to constant discomfort associated with perforation may require emergency surgery.
The nurse is documenting an assessment on an intubated patient. Which of the following indicates a tube that was inserted through the mouth with the distal tip resting in the stomach? A. nasogastric tube B. orotracheal tube C. nontracheal tube D. orogastric tube
D. Orogastric Tube- Oro/ oral indicates insertion through the mouth and gastric indicates the tube rests in the stomach
Which of the following treatments for obesity is associated with birth defects when taken during pregnancy and harm to breast feeding infants? A. Liraglutide B. Naltrexone-bupropion C. Orlistat D. Phentermine-topiramate
D. Phentermine- Topiramate: Pregnancy, planned pregnancy, and breast feeding must be determined before patients consider phentermine treatment
The nurse candidate is reviewing risk factors for colorectal cancer. Which of the following indicates a need for clarification by the preceptor? A. High-fat diet B. Family history C. Crohn's disease D. Rapid weight loss
D. Rapid Weight loss- Risk factors for CRC include: high-fat diet, Crohn's, Smoking, Alcoholism, Family history of CA, and Obesity. Rapid weight loss is not evidenced to be a risk factor.
The nurse is planning nutritional interventions. Which medical diagnosis results in increased metabolic demands that exceed the nutritional intake ? A. anorexia nervosa B. bulimia nervosa C. hypothyroidism D. sepsis
D. Sepsis- increases metabolic demands. Hypothyroidism decreases metabolic demand, and eating disorders decrease nutrition availability
The nurse is caring for a patient diagnosed with acute pancreatitis. Which of the following would be called to the provider? A. Serum potassium 3.7mmOl/L B. Serum sodium 144 mEq/L C. WBC 10,000/ microliter D. Serum Calcium 6.6 mg/dl
D. Serum Calcium 6.6 mg/dl- low calcium level should be reported.
The nurse is assessing a client who was admitted for complications associated with hiatal hernia. Which of the following should the nurse find upon entering the client's room? A. The client is lying in Sim's position B. The client is lying supine with the head of bed flat C. The client is in Trendelenburg position D. The client is in semi-Fowler's position
D. The client is in semi-Fowler's position- The client's head should be elevated. Semi-fowler's position is the only option that meets that criteria.
While palpating a patient's abdomen, a mass is palpated just below the right thorax associated with increased right upper quadrant pain on palpation. The findings alert the nurse to possible dysfunction in which organ? A. The right kidney B. The spleen C. The pancreas D. The liver
D. The liver- The bulk of the liver is located in the right upper quadrant.
The nurse is caring for a patient diagnosed with acalculous cholecystitis. Which of the following can be omitted from the teaching plan for this patient? A. Cardiovascular risk factors B. Effects of biliary stasis C. Signs and symptoms of infection D. Treatments for cholelithiasis
D. Treatments for cholelithiasis- The nurse can omit teaching about cholelithiasis because acalculous disease is without stones. The patient may experience any or all of the other options.
A client is admitted to the hospital with right lower quadrant abdominal pain, nausea, and vomiting. What assessment would the nurse monitor to identify a potentially life-threatening complication based on the client's condition? A. Abdominal assessment B. Intake and output C. Electrolyte values D. Vital signs
D. Vital Signs- Life threatening fluid imbalance will be detected through vital signs assessment.
The nurse is caring for a client who has cirrhosis of the liver with esophageal varices. The client's latest prothrombin time was prolonged. The nurse should prioritize assessment for which finding? A. deep vein thrombosis B. hematemesis C. pressure injury D. jaundice
D. hematemesis- The varices and prolonged bleeding place the patient at risk for esophageal bleeding.
A nurse is scheduling a surgical consult for a patient diagnosed with liver cancer. Which of the following is the goal of surgical intervention? A. relieving symptoms B. alleviating pain C. curing the cancer D. reducing or removing the obstructing tumor
D. reducing or removing the obstructing tumor- In addition to biopsy, interventions are aimed at reducing or removing the obstructing tumor.
A nurse working provides discharge teaching for a male client who had a minimally invasive hernia repair this morning. Which statement by the client indicates a need for further teaching? A. "I should avoid coughing if at all possible." B. "I can't go back to work for at least 6 weeks." C. "I should use an ice pack to help relieve my pain." D. "I can shower in day or two after I remove my surgical bandage."
B. "I can't go back to work for at least 6 weeks." - Minimally invasive surgery (MIS) allows the client to be discharged on the same day as surgery and return to work in 1-2 weeks rather than wait the usual 6 weeks after a conventional open surgical procedure.
The nurse is caring for a female patient with acute cholecystitis. Which statement by the patient indicates an urgent need for further teaching? A. "The pain is a symptom of the bile from my liver being obstructed by stones." B. "I'm not concerned. Gallbladder attacks happen everyday to someone. It's not like it can hurt me." C. "I have been on a high fiber, low fat diet, and drink plenty of water." D. "I understand I can have my gallbladder removed with no visible scars at all."
B. "I'm not concerned. Gallbladder attacks happen everyday to someone. It's not like it can hurt me." - Gallbladder disease can lead to life-threatening complications if untreated. The pain is a symptom of bile stasis; a high fiber diet low in fat is recommended, and the NOTES procedure affords female patients a Lap-cholecystectomy with no externally visible incision.
The nurse is caring for a client who has been diagnosed with esophageal cancer. The client appears anxious, and asks the nurse, "Does this mean I am going to die?". Which nursing response is appropriate? A. "No, surgery can cure you." B. "It sounds like death frightens you." C. "Let me call the hospital chaplain to talk with you." D. "You can beat this disease if you just put your mind to it."
B. "It sounds like death frightens you."- Restating for clarification may help clients to share their feelings.
The nurse candidate notes that a client is scheduled for a biopsy of the esophagus to confirm a suspected diagnosis of cancer. When asked what treatment the client will receive, what is the preceptor's best response? A. "The esophageal cancer prognosis is poor regardless of the treatment." B. "The treatment will include the regimen evidenced to have the best outcome for the cells identified in the biopsy." C. "Probably chemotherapy and radiation." D. "Whatever the oncologist orders."
B. "The treatment will include the regimen evidenced to have the best outcome for the cells identified in the biopsy."- Cancer diagnosis and treatment is based on biopsy findings.
While reading a physician's note, the nurse understands that the patient grimaced on palpation of the right upper abdomen during inspiration. Which of the following terms describe this impression? A. (+) Ker's sign B. (+) Murphy's sign C. (+) Cullen's sign D. (+) Blumberg's sign
B. (+) Murphy's sign- Murphy's sign indicates patient wincing or grimace with RUQ abdominal palpation. Ker's sign is peritoneal pain radiation to the shoulder, Blumberg's sign is peritoneal pain exacerbation with stretching, and Cullen's sign is bruising around the umbilicus.
The nurse is calculating BMI. For a male patient who is 1.8 meters tall and weighs 109kg, what is the calculated BMI? A. 60.5 B. 33.6 C. 30.3 D. 26
B. 33.6 - 1.8 squared = 3.34, so 109/3.24 = 33.64
After evaluating vital signs reported by the CNA, which patient would the nurse see first? A. A 57 year old with chronic pancreatitis and abdominal pain at 6/10 B. A 23 yo with acute pancreatitis and an oral temp of 103.4F C. A 34 year old with acute pancreatitis with a BP of 106/ 74 D. A 42 year old with a respiratory rate of 26 after showering
B. A 23 yo with acute pancreatitis and an oral temp of 103.4F- We must be alert to symptoms of pancreatic abscess such as fever.
The nurse is caring for a client diagnosed with aphthous ulcers. Which food will the nurse recommend? A. Nuts B. Apple sauce C. Baked potato D. Pasta with marinara
B. Apple Sauce- Apple sauce is a bland soft food. Nuts, hot foods, and tomato sauce are not recommended.
When caring for a patient diagnosed with pancreatic cancer, the nurse understands that the course of treatment will be guided by which of the following? A. Physician preference B. Biopsy results C. The degree of metastasis D. Analgesia for pain control
B. Biopsy Results- as with any cancer, the course of treatment is guided by pathology of biopsy.
The nurse is caring for a client with peritonitis from a perforated appendix. Which abdominal assessment finding will the nurse most likely expect? A. Soft abdomen B. Board-like abdomen C. Absent bowel sounds D. Slightly distended abdomen
B. Board-like abdomen - A board-like abdomen is one of the cardinal signs of peritonitis. Bowel sounds may or may not be present and severe distention is common .
The nurse is preparing and SBAR report to alert the provider of suspected pancreatitis. Which of the following is a symptom associated with acute pancreatitis? A. Intermittent epigastric pain that improves when lying flat. B. Constant gnawing mid-abdomen pain that is worse while lying supine C. Right upper quadrant pain accompanied by severe nausea D. Retro peritoneal pain in the lower back and flanks
B. Constant gnawing mid-abdomen pain that is worse while lying supine- Pancreatic pain is described as gnawing or boring pain in the mid-abdomen that worsens when lying supine or stretching abdominal muscles.
The nurse is assessing an older client who has had frequent vomiting and diarrhea for the last 24 hours. Which vital sign change would be of most concern to the nurse? A. Increased oxygen saturation B. Decreased blood pressure C. Increased temperature D. Decreased pulse rate
B. Decreased Blood Pressure- Failing blood pressure indicates decreased tissue perfusion
The nurse is notifying the provider about complications following gastric bypass. Which of the following assessment findings does NOT support the suspicion of dumping syndrome? A. Diarrhea B. Headache C. Tachycardia D. Nausea and Vomiting E. Severe abdominal discomfort
B. Headache
The nurse is considering potential complications for a client with a history of chronic gastritis and diagnosed as having a peptic ulcer. Which of the following complications might be common to both gastric problems? A. Hypertension B. Hematemesis C. Left shoulder pain D. Bradycardia
B. Hematemesis- Hematemesis is the term for vomiting blood. Patients with gastritis and those with peptic ulcer are at risk for gastric bleeding.
Which of the following anastomosis is not included in the Whippie procedure? A. Choledochojejunostomy B. Hepaticojejunostomy C. Pancreatojejunostomy D. Gastrojejunostomy
B. Hepaticojejunostomy- is not included in the whipple procedure
The preceptor explains that a patient is experiencing intravascular dehydration because the hypertonic tube feeding is causing osmotic dehydration. Which of the following explains this finding? A. The patient is not receiving enough free water B. Highly concentrated feeding is causing fluids to shift to the area of higher concentration in the gut C. The tube feeding is inadequate to meet hydration needs D. Tube feeding in the GI tract does not affect serum osmolality
B. Highly concentrated feeding is causing fluids to shift to the area of higher concentration in the gut.- the hyperosmolar tube feeding draws fluid across membranes to the area of higher concentration
Which statement by the client best indicates his understanding of his diagnosis of colon cancer that has metastasized to the liver and lung? A. "I have lung cancer and liver cancer" B. "I have colon cancer in my lungs and liver as well as my gut." C. "I have three different types of cancer." D. "After my colon is removed, I will be rid of this cancer."
B. I have colon cancer in my lungs and liver as well as my gut. - Metastatic cancer is named for the cancer of origin (because that's what it is, no matter where it travels.) This client has colon cancer that has metastasized to his lung and liver.
The nurse is caring for a client who had a liver transplant last week. For which complication will the nurse teach the client and family to monitor? A. Hypertension B. Infection C. Pulmonary edema D. Acute kidney injury
B. Infection- In addition to transplant rejection, transplant patients are at significant risk for infection.
A client developed gastroenteritis while traveling outside the country. What is the most likely cause of the client's symptoms? A. Bacteria on the patient's hands B. Ingestion of parasites in the water C. Insufficient vaccinations D. Overcooked food
B. Ingestion of parasites in the water - The most common cause of traveler's diarrhea is parasites ingested with drinking water.
While sharing her medical history with the nurse, the patient describes a bariatric surgery in which a portion of the stomach was removed and a sleeve was applied to decrease stomach capacity. Which procedure does the nurse expect to find in the patient record? A. Adjustable gastric banding B. Laparoscopic sleeve gastrectomy C. Roux-en-Y D. Gastric banding
B. Laparoscopic Sleeve Gastrectomy- only the laparoscopic sleeve gastrectomy involves both banding and removal of a portion of the stomach
The nurse is caring for a client postop a partial gastrectomy. After consuming a full liquid diet tray, the client becomes pale and diaphoretic, and complains of dizziness. What should be the nurse's initial response? A. Assess the client's vital signs B. Lower the patient to a supine position. C. Notify the provider immediately D. Call for a STAT ECG
B. Lower the patient to a supine position.-The client is exhibiting symptoms of dumping syndrome which may be relieved by lying flat to slow gastric emptying. Further assessment can be done after repositioning to relieve the symptoms.
While performing a patient assessment, the nurse notes a large area of erythema beneath a large apron-like fold of abdominal fatty tissue. What is the correct term for this area of inflammation? A. Panniculus B. Panniculitis C. Yeast rash D. Fungal rash
B. Panniculitis- the panniculus is the fold of tissue itself. The inflammation is referred to a panniculitis. No indication is given as to the irritant.
A nurse is evaluating the adequacy of a patient's protein intake. Which of the following is the most sensitive indicator of this patient's nutritional status? A. Serum Albumin B. Pre-Albumin C. Serum Cholesterol D. Transferrin
B. Pre- Albumin- Both albumin and pre-albumin help evaluate protein. However, due to the short half-life, pre-albumin is a more sensitive indicator.
A client had an open partial colectomy and colostomy placement 6 hours ago. Which assessment would concern the nurse? A. Stoma edema B. Purple, moist stoma C. Liquid stool in the appliance D. Serosanguineous fluid
B. Purple, moist stoma- Immediate postoperatively the stoma is expected to be swollen, but reddish-pink and moist, not purple (which may indicate lack of blood flow to the stoma). The stool is expected to be liquid at first and serosanguinous drainage is expected. post-op.
On a study abroad, a nursing student assesses a child to find normal hair, thin limbs, wasted fat and decreased muscle mass. Which laboratory finding might the student expect? A. a thin or wizened appearance B. serum protein within normal limits C. decreased serum protein D. low blood glucose
B. Serum protein within normal limits- Marasmus is caloric malnutrition and associated with normal hair, old man/ wizened appearance (not a lab finding), low body weight with thin limbs with little muscle or fat, and serum proteins WNL.
The community nurse is discussing risk factors for esophageal cancer with a group of clients. Which client behavior requires further teaching? A. Elevates pillows at night. B. Smokes 1/3 of a pack of cigarettes daily. C. Walks at the shopping mall three times weekly. D. Eats a small snack each night before bedtime.
B. Smokes 1/3 of a pack of cigarettes daily
When the client with cirrhosis refuses her evening dose of lactulose, what is the nurse's best response? A. I will ask pharmacy to reschedule this dose for 9am B. Tell me what you know about this medication. C. "I know it causes diarrhea; but it is for your own good D. You have every right to refuse. I'll return the dose to pharmacy
B. Tell me what you know about this medication- Lactulose prevents encephalopathy. We must assess understanding and educate to increase compliance.
The nurse is teaching a client how to maintain effective oral health. Which comment requires additional teaching? A. Regular dental checkups B. Use of mouthwashes containing alcohol. C. Ensuring that dentures fit properly D. Eating a balanced diet.
B. Use of mouthwashes containing alcohol - Alcohol containing mouthwashes can harm mucosa and cause pain.
A hospitalized client with ongoing abdominal tenderness reports an increase in generalized abdominal pain today. Which assessment technique will the nurse perform first? A. Auscultate beginning in the RLQ. B. Visually observe for contour and symmetry C. Percuss to determine size of liver and spleen. D. Deeply palpate the area of tenderness.
B. Visually observe for contour and symmetry - Review assessment sequence. Inspect and auscultate, then palpate. (Look, listen, and feel)
