ATI questions (Exam 3)

A nurse is completing a history and physical assessment for a client who has a chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? - High-calorie diet - Prior gastrointestinal illness - Tobacco use - Alcohol use

Alcohol use Rationale: Alcohol consumption is one of the major causes of chronic pancreatitis in the U.S. Long-term alcohol use disorder produces hypersecretion of protein in pancreatic secretions. The result is protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage to these cells is more likely to occur and to be more severe in clients whose diets are poor in protein content and either very high or very low in fat.

A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should the nurse anticipate returning to the expected reference range within 72 hr after treatment begins? - Aldolase - Lipase - Amylase - Lactic dehydrogenase

Amylase Rationale: Amylase MY ANSWER Pancreatitis is the most common diagnosis for marked elevations in serum amylase. Serum amylase begins to increase about 3 to 6 hr following the onset of acute pancreatitis. The amylase level peaks in 20 to 30 hr and returns to the expected reference range within 2 to 3 days.

A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect? - Jaundice - Anorexia - Dark urine - Pale feces

Anorexia Rationale: Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product.

A nurse is a checking the client's nasogastric tube for placement. Which of the following procedures should the nurse implement?

Aspirate stomach contents and check the pH

A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend? - Foods high in vitamin C - Foods low in fat - Foods high in fiber - Foods low in calories

Foods high in fiber Rationale: The result of long-term, low-fiber eating habits along with increased intracolonic pressure lead to straining during bowel movements, causing the development of diverticula. High-fiber foods help strengthen and maintain active motility of the gastrointestinal tract.

A nurse is reinforcing teaching with a client who has color cancer and is scheduled for a procedure to remove their entire large intestine and return. The nurse should reinforce with the client that they are scheduled for which of the following types of ostomy procedure?

Ileostomy

A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipates for this client? - Endoscopic sclerotherapy - Liver lobectomy - Liver transplant - Transjugular intrahepatic portal-systemic shunt placement

Liver transplant Rationale: Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients.

A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? - Flush the tube with water. - Place the client in semi-Fowlers's position. - Cleanse the skin around the tube site. - Aspirate the tube for residual contents.

Place the client in semi-Fowlers's position. Rationale: The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second priority in the ABC priority-setting framework because adequate ventilatory effort is essential for oxygen exchange to occur. Circulation is the third priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. A client who is receiving PEG tube feedings should be positioned with the head of the bed elevated at least 30° during and after feedings to decrease the risk of aspiration. Therefore, this is the priority action by the nurse.

A nurse is reinforcing teaching with a client about replacing an ostomy pouching system. The client reports that they occasionally experience pain when removing the skin barrier. Which of the following techniques should the nurse suggest?

Push the skin away from the barrier while removing it.

A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate ti the nurse that a possible bowel perforation has occurred? - Elevated blood pressure - Bowel sounds increased in frequency and pitch - Rigid abdomen - Emesis of undigested food

Regid abdomen Rationale: Abdominal tenderness and rigidity occur with a bowel perforation. As fluid escapes into the peritoneal cavity, there is a reduction in circulating blood volume and a lowered blood pressure, or hypotension, results.

A nurse is informed during shift report that a client has a nasogastric tube connected to continuous suction. The nurse should identify that this client must have which of the following types of tubes.

Salem sump tube

A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings requires intervention by the nurse? - A full pitcher of water is sitting on the client's bedside table within the client's reach. - The disposable feeding bag is from the previous day at 1000 and contains 200 mL of feeding. - The client is lying on the right side with a visible dependent loop in the feeding tube. - The head of the bed is elevated 20°.

The head of the bed is elevated 20°. Rationale: The head of the bed should be elevated at least 30° (semi-Fowler's position) while the tube feeding is administered. This position uses gravity to help the feeding move down through the digestive system and lessens the possibility of regurgitation.

A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is used to do which of the following? - To visualize polyps in the colon - To detect an ulceration in the stomach - To identify an obstruction in the biliary tract - To determine the presence of free air in the abdomen

To detect an ulceration in the stomach Rationale: An EGD is used to visualize the esophagus, stomach, and duodenum with a lighted tube to detect a tumor, ulceration, or obstruction.

A nurse is providing preoperative teaching for a client who is scheduled for creation of a sigmoid colostomy. Which of the following information should the nurse include in the teaching?

Use irrigation to help establish a regular bowel pattern.

A nurse in the emergency department is caring for a client who has bleeding esophageal varices. The nurse should anticipate a prescription of which of the following medications? - Famotidine - Esomeprazole - Vasopressin - Omeprazole

Vasopressin Rationale: Vasopressin constricts the splanchnic bed and decreases portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varices.

A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove from the client's meal tray? - Wheat toast - Tapioca pudding - Hard-boiled egg - Mash potatoes

Wheat toast Rationale: Celiac disease is an autoimmune disorder characterized by a permanent intolerance to wheat, barley, and rye. Wheat toast contains gluten and should be removed from the client's tray.

A nurse is teaching a client who has Barrett's esophagus and is scheduled to undergo an esophagogastroduidenoscopy (EGD). Which of the following statements should the nurse include in the teaching? - "This procedure is performed to measure the presence of acid in your esophagus." - "This procedure can determine how well the lower part of your esophagus works." - "This procedure is performed while you are under general anesthesia." - "This procedure can determine if you have colon cancer."

"This procedure can determine how well the lower part of your esophagus works." Rationale: An EGD is useful in determining the function of the esophageal lining and the extent of inflammation, potential scarring, and strictures.

A nurse is preparing a community education program about hepatitis B. Which of the following statements should the nurse include in the teaching? - "A hepatitis B immunization is recommended for those who travel, especially military personnel." - "A hepatitis B immunization is given to infants and children." - "Hepatitis B is acquired by eating foods that are contaminated during handling." - "Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation."

"A hepatitis B immunization is given to infants and children." Rationale: Hepatitis B immune globulin is given as part of the standard childhood immunizations. It can be administered as early as birth, especially in infants born to hepatitis B surface antigen (HBsAg) negative mothers. These infants should receive the second dose between 1 and 4 months of age.

A nurse is tacking a group of unit nurses about clients who have a need for gastric decompression. The nurse should identify that which of the following clients needs nasogastric tube intubation for gastric decompression.

A 40-year-old client who has a postoperative bowel obstruction.

A nurse is inserting a nasogastric tube for a pt & asks the pt to flex their head toward their chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by achieving which of the following? A. Closing off the glottis B. Preventing curling of the tube in the mouth C. Allowing the client to breathe through the mouth D. Opening the lower esophageal sphincter

A. Closing off the glottis Rationale: This action prohibits the tube from entering the trachea by closing it off and opening the esophagus.

A client who lives in a LTC facility is receiving intermittent enteral feedings & is experiencing social isolation. Which of the following interventions should the nurse recommend? A. Encourage the client to go to the dining room at meal times to talk with other clients B. Suggest that the client watch television while feedings are being administered C. Remind the client that they can have visitors after feeding administration times D. Ask the facility chaplain to speak with the client

A. Encourage the client to go to the dining room at meal times to talk with other clients Rationale: By encouraging the resident to maintain a normal schedule and social interactions, the nurse is helping to promote socialization and reverse patterns of isolation.

A nurse is preparing to administer a continuous enteral tube feeding to a client. The nurse should take which of the following actions to prevent a complication of the tube feeding? A. Limit the time the formula hangs to 8 hr. B. Flush the tube every 8 hr. C. Deliver the formula at a brisk rate D. Allow the feeding bag to empty before refilling it

A. Limit the time the formula hangs to 8 hr. Rationale: Formula that hangs longer than 12 hr for an open system and 48 hr for a closed system is at risk for spoilage of the formula or bacterial contamination, typically manifested as diarrhea.

A nurse is caring for a client who has a dysfunctional gastrointestinal tract and requires enteral feeding. Which of the following formulas should the nurse administer to the client? A. Modular B. Elemental C. Polymeric D. Specialty

B. Elemental Rationale: Elemental formulas contain predigested nutrients that are easy for a partially functional gastrointestinal tract to absorb.

A nurse is caring for a client who has a paralytic ileus and requires nutritional support for approximately 2 weeks. Which of the following types of feeding tubes should the nurse anticipate the provider to prescribe? A. Nasogastric tube B. Nasointestinal tube C. Percutaneous endoscopic gastrostomy tube D. Percutaneous endoscopic jejunostomy tube

B. Nasointestinal tube Rationale: A nasointestinal tube allows post-pyloric feeding by depositing enteral formula directly into the intestines. This is an appropriate choice for a pt who lacks stomach motility (paralytic ileus) & requires short-term (less than 4 weeks) enteral feeding.

A nurse is providing teaching about risk for aspiration w/ a client who is receiving intermittent bolus nasogastric feedings. Which of the following findings should the nurse instruct the client to report? A. A feeling of fullness B. Persistent coughing C. Discomfort in the naris D. Post-feeding belching

B. Persistent coughing Rationale: A persistent cough can indicate that the distal end of the NG tube has moved into the respiratory tract. The pt should report this finding to nurse immediately because this is a risk for aspiration

A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect? - Increased blood pressure - Decreased heart rate - Yellowing of the skin - Boardlike abdomen

Boardlike abdomen Rationale: The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of a boardlike abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation causes hemorrhaging.

A nurse is caring for a group of clients. The nurse should identify that which of the following clients requires an enteral tube feeding? A. A client who has a paralytic ileus B. A client who has recently experienced facial trauma C. A client who has dysphagia D. A client who has a decreased appetite

C. A client who has dysphagia Rationale: The nurse should identify that a client who is unable to swallow oral nutrition can benefit from enteral feedings.

A nurse is inserting a small-bore feeding tube. Before initiating the feeding, the nurse should take which of the following actions to verify placement? A. Measure the pH of gastric aspirate. B. Auscultate the epigastric area while injecting air. C. Obtain an x-ray. D. Place the open end of the tube in a cup of water.

C. Obtain an x-ray. Rationale: Obtaining an x-ray is the only reliable method for verifying initial placement of a small-bore feeding tube.

A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is at risk for developing hepatitis A? - Children - Older adults - Women who are pregnant - Middle-aged men

Children Rationale: The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The hepatitis A virus can be contracted from the feces, bile, and blood of infected clients. The usual mode of transmission is the fecal-oral route. Children and young adults are the two groups most often affected by the hepatitis A virus. Typically, a child or young adult acquires the infection at school, through poor hygiene, hand-to-mouth contact, or another form of close contact.

A nurse is replacing the ostomy appliance for a client whose newly created colostomy is functioning. After removing the pouch, which of the following actions should the nurse take first?

Cleanse the stoma and peristomal skin.

A nurse is caring for a client who is postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? - Vanilla pudding - Apple juice - Diet ginger ale - Clear liquids

Clear liquids Rationale: Clear liquids, such as water or broth, can be given for the first oral feedings, but should be limited to only 30 mL (1 oz) per feeding. Water does not contain sugar, which could cause diarrhea due to hyperosmolarity.

A nurse is obtaining health history from a client who has a colostomy. The client reports frequent episodes of loose stools over the last month but has no signs of infection of bowel obstruction. The client tells the nurse that they have avoided participation in social activities because they are concerned about leakage. Which of the following should the nurse recommend?

Consume foods that are low in fiber content.

A nurse is administering an enteral tube feeding to a client. Which of the following actions should the nurse take to prevent aspiration? A. Flush the feeding tube with 30 mL of water. B. Add blue food coloring to the enteral formula. C. Ensure the formula is at room temperature. D. Place the client in Fowler's position.

D. Place the client in Fowler's position. Rationale: Positioning a client in Fowler's position during a tube feeding can reduce the risk of regurgitation, which can lead to aspiration. If Fowler's is uncomfortable or contraindicated for the client, elevate the head of the client's bed to at least 30°.

To determine the length of a nasointestinal tube to insert, a nurse should measure the distance from the tip of the client's nose to the earlobe & from the earlobe to the... A. Umbilicus B. Xiphoid process C. Manubrium plus 10 to 20 cm more D. Xiphoid process plus 20 to 30 cm more

D. Xiphoid process plus 20 to 30 cm more Rationale: Measuring from the tip of nose to earlobe to xiphoid process approximates the distance from nose to stomach for 98% of clients. For duodenal or jejunal placement, an additional 20 to 30 cm is required.

A nurse is teaching a client who has a new ileostomy about preventing the excoriation and breakdown of the peristomal skin after they have returned home. Which of the following instructions should the nurse include?

Empty the pouch when it is less than half full.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? - Hypertension - Excessive thirst - Fever - Diaphoresis

Diaphoresis Rationale: The nurse should recognize that the client has the potential for the development of hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger.

A nurse is caring for a client who has a history of cirrhosis and is admitted with a manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? - Gamma-glutamyl transferase (GGT) - Alkaline phosphatase (ALP) - Serum bilirubin - Alanine aminotransferase (ALT)

Gamma-glutamyl transferase (GGT) Rationale: The GGT laboratory test is specific to the hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. Therefore, it is useful for monitoring drug toxicity and excessive alcohol use.

A nurse is caring for a client who has a nasogastric tube connected to suction. Which of the following findings indicates that the tube has become occluded.

Increased abdominal distention

A nurse is performing a nasogastric intubation on a client and has reached the tube's predetermined length. Which of the following actions should the nurse take?

Inspect the oropharynx with a penlight and a tongue blade.

A nurse is teaching a client who has bladder cancer about urinary diversion options. The nurse should inform the client that which of the following options will allow them to have some control over urinary elimination?

Kock's pouch

A nurse is caring for a client who has a newly inserted nasogastric tube. Which of the following actions should the nurse use to verify the initial placement of the tube?

Obtain an x-ray

A nurse is teaching a client about extended-wear skin barriers. Which of the following strategies should the nurse instruct the client to use for maximal adherence?

Press gently around the barrier for 30 seconds to 1 min.

A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following laboratory findings should the nurse monitor prior to the procedure? - Prothrombin time - Serum lipase - Bilirubin - Calcium

Prothrombin time Rationale: A major complication following a liver biopsy is hemorrhage. Many clients who have liver disease have clotting defects and are at risk for bleeding. Along with the prothrombin time (PT), the activated partial thromboplastin time (aPTT) and the platelet count should be monitored. Liver dysfunction causes the production of blood clotting factors to be reduced, which leads to an increased incidence of bruising, nosebleeds, bleeding from wounds, and gastrointestinal bleeding. This is due to a deficient absorption of vitamin K from the gastrointestinal tract caused by the inability of liver cells to use vitamin K to make prothrombin.

A nurse is caring for a client who is recovering from gastric surgery, is NPO, and has a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membranes.

Provide frequent mouth care.

A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? - Right shoulder pain - Urine output 20mL/hr - Temperature 38.4° C (101.1° F) - Oxygen saturation 92%

Right shoulder pain Rationale: The client can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1 to 2 days. Mild analgesics and a recumbent position can help with client comfort.