Exam 3

After teaching a client who has had a Roux-en-Y gastric bypass, which client statement indicates the need for additional teaching? "I should pick cereals with less than 2 g of fiber per serving." "A total serving should amount to be less than 1 cup." "I need to chew my food slowly and thoroughly." "I need to drink 8 oz of water before eating."

"I need to drink 8 oz of water before eating."

After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching? "I'll have to catheterize my pouch every 2 hours." "I should eat foods from all the food groups." "I'll need to drink at least eight glasses of water a day." "I'll have to wear an external collection pouch for the rest of my life."

"I'll have to wear an external collection pouch for the rest of my life."

Question 15 of 56 The nurse administers a tube feeding to a client via the intermittent gravity drip method. The nurse should administer the feeding over at least which period of time? 60 minutes 30 minutes 15 minutes 80 minutes

30 minuets

A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use? 30-mL 20-mL 5-mL 10-mL

30-mL

The nurse is conducting a community education session on the prevention of oral cancers. The nurse includes which cancer as being a type of premalignant squamous cell skin cancer? Actinic cheilitis Herpes simplex 1 Chancre Erythroplakia

Actinic cheilitis

A nurse cares for a client who is postoperative bariatric surgery and has experienced frequent episodes of dumping syndrome. The client now reports anorexia. What is the primary reason for the client's report of anorexia? Taste of food Absorption of food Fear of eating Size of the stomach

Fear of eating

The nurse is caring for a client with a suspected megacolon. The nurse anticipates that one of the findings of assessment will be Hemorrhoids Dark, tarry stools Fecal incontinence Diarrhea

Fecal incontinence

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take? Provide oral hygiene. Flush with 10 mL of water. Withdraw the tube gently for 6 to 8 inches. Remove the tape from the nose of the client.

Flush with 10 mL of water.

A positive Rovsing's sign is indicative of appendicitis. A nurse knows to assess for this indicator by palpating the: Left upper quadrant. Right lower quadrant. Left lower quadrant. Right upper quadrant.

Left lower quadrant.

A nurse is preparing to discharge a client newly diagnosed with peptic ulcer disease. The client's diagnostic test results were positive for H. pylori bacteria. The health care provider has ordered the "triple therapy" regimen. Which medications will the nurse educate the client on? Proton-pump inhibitor, an antibiotic, and bismuth salts H2-receptor antagonist, proton-pump inhibitor, and an antibiotic Proton-pump inhibitor and two antibiotics H2-receptor antagonist and two antibiotics

Proton-pump inhibitor and two antibiotics

A client who is postoperative from bariatric surgery reports foul-smelling, fatty stools. What is the nurse's understanding of the primary reason for this finding? Excessive fat intake Decreased gastric size Decreased motility Rapid gastric dumping

Rapid gastric dumping

A client with peptic ulcer disease has been prescribed sucralfate. What health education should the nurse provide to this client? Take the medication at bedtime to accommodate sedative effects Take the medication 2 hours before or after other medications Blood levels will be evaluated after 1 week Ensure adequate potassium intake during therapy

Take the medication 2 hours before or after other medications

The client is receiving 50% dextrose parenteral nutrition with fat emulsion therapy through a peripherally inserted central catheter (PICC). The nurse has developed a care plan for the nursing diagnosis "Risk for infection related to contamination of the central catheter site or infusion line." The nurse includes the intervention Wear a face mask during dressing changes. Assess the PICC insertion site daily. Use clean gloves when providing site care. Change the transparent dressing every 3 days.

Wear a face mask during dressing changes.

A middle-aged obese female presents to the ED with severe radiating right-sided flank pain, nausea, vomiting, and fever. A likely cause of these symptoms is: hepatitis B hepatitis A pancreatitis acute cholecystitis

acute cholecystitis

The nurse is conducting a community education program on peptic ulcer disease prevention. The nurse includes that the most common cause of peptic ulcers is: stress and anxiety. alcohol and tobacco. ibuprofen and aspirin. gram-negative bacteria.

gram-negative bacteria.

A client has symptoms suggestive of peritonitis. Nursing management would not include: limiting analgesics to avoid the formation of paralytic ileus. accurate recording of input and output. inserting a nasogastric tube. inserting a urinary retention catheter.

limiting analgesics to avoid the formation of paralytic ileus.

The nurse inspects a client's tongue. Which finding would the nurse evaluate as an indication of potential oral cancer? thin, white coating on dorsum of tongue large, vallate papillae on dorsum of tongue V formation on dorsum of tongue red plaque on undersurface of tongue

red plaque on undersurface of tongue

The nurse is admitting a client whose medication regimen includes regular injections of vitamin B12. The nurse should question the client about a history of: diverticulitis. total gastrectomy. gastroesophageal reflux disease (GERD). bariatric surgery.

total gastrectomy.

A client had a central line inserted for parenteral nutrition and is awaiting transport to the radiology department for catheter placement verification. The client reports feeling anxious and has a respiratory rate of 28 breaths/minute. What is the next action of the nurse? Auscultate lung sounds Consult with the healthcare provider Apply nasal cannula oxygen Position client flat in bed

Auscultate lung sounds

The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease? Avoid eating or drinking 2 hours before bedtime. Eat a low-carbohydrate diet. Minimize intake of caffeine, beer, milk, and foods containing peppermint or spearmint. Elevate the foot of the bed on 6- to 8-inch blocks.

Avoid eating or drinking 2 hours before bedtime.

A patient is scheduled for a fiberoptic colonoscopy. What does the nurse know that fiberoptic colonoscopy is most frequently used to diagnose? Occult bleeding Bowel disease of unknown origin Cancer Inflammatory bowel disease

Cancer

A nurse is preparing to administer a client's scheduled parenteral nutrition (PN). Upon inspecting the bag, the nurse notices that small amounts of white precipitate are present in the bag. What is the nurse's best action? Contact the pharmacy to obtain a new bag of PN. Recognize this as an expected finding. Place the bag in a warm environment for 30 minutes. Shake the bag vigorously for 10 to 20 seconds.

Contact the pharmacy to obtain a new bag of PN.

A nurse is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply. Diaphoresis Diarrhea Decreased bowel sounds Tachycardia Hypertension

Diarrhea Tachycardia Diaphoresis

The nurse is caring for an older adult who reports xerostomia. The nurse evaluates for use of which medication? Diuretics Steroids Antibiotics Antiemetics

Diuretics

A nurse is assessing a client for GI dysfunction. What is the most common symptom in a client with GI dysfunction? Dyspepsia Constipation Diffuse pain Abdominal bleeding

Dyspepsia

The nurse advises the patient who has just been diagnosed with acute gastritis to: Refrain from food until the GI symptoms subside. Restrict food and fluids for 12 hours. Take an emetic to rid the stomach of the irritating products. Restrict all food for 72 hours to rest the stomach.

Refrain from food until the GI symptoms subside.

A client comes to the clinic reporting pain in the epigastric region. What statement by the client suggests the presence of a duodenal ulcer? "I know that my father and my grandfather both had ulcers." "I seem to have bowel movements more often than I usually do." "My pain resolves when I have something to eat." "The pain really interferes with my quality of life."

"My pain resolves when I have something to eat."

An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom? Gastroesophageal reflux disease Esophageal tumor Gastritis Hiatal hernia

Esophageal tumor

A nurse is assessing the abdomen of a client just admitted to the unit with a suspected GI disease. Inspection reveals several diverse lesions on the client's abdomen. How should the nurse best interpret this assessment finding? Abdominal lesions are usually due to age-related skin changes. The client needs to be assessed for self-harm. GI diseases often produce skin changes. Integumentary diseases often cause GI disorders.

GI diseases often produce skin changes.

A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply. Remove gas and fluids from the stomach Diagnose gastrointestinal motility disorders Evaluate for masses in the large colon Administer nutritional substances Flush ingested toxins from the stomach

Remove gas and fluids from the stomach Diagnose gastrointestinal motility disorders Flush ingested toxins from the stomach Administer nutritional substances

A nurse works in a bariatric clinic and cares for client with obesity who will or have undergone bariatric surgery. What is the nurse's understanding of how the procedure works? Impairs caloric absorption. Restricts the client's ability to digest fat. Impairs gastric motility. Restricts the client's ability to eat.

Restricts the client's ability to eat.

The nurse cares for a client after an endoscopic examination and prepares the client for discharge. The nurse includes which instruction? Resume regular diet. Increase fluid intake. Avoid driving for 24 hours. Continue a clear liquid diet.

Resume regular diet.

The nurse observes the physician palpating the abdomen of a client that is suspected of having acute appendicitis. When the abdomen is pressed in the left lower quadrant the client complains of pain on the right side. What does the nurse understand this assessment technique is referred to? Referred pain Rovsing sign Cremasteric reflex Rebound pain

Rovsing sign

The nurse should assess for an important early indicator of acute pancreatitis. What prolonged and elevated level would the nurse determine is an early indicator? Serum lipase Serum bilirubin Serum amylase Serum calcium

Serum lipase

Which nursing instruction is correct to provide the client following a barium enema? An enema will be used to clear the bowel. The stools may be a white or clay colored. Sips of fluid may be increased if tolerated. The client will maintain a low residue diet.

The stools may be a white or clay colored.

When preparing to insert a nasogastric tube, the nurse determines the length of the tube to be inserted. The nurse places the distal tip of the tube at which location? Tip of the xiphoid process Tragus of the ear Base of the neck Tip of patient's nose

Tip of patient's nose

A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms? Severe diarrhea An absence of blood in stool Involvement of the rectal mucosa A pattern of distinct exacerbations and remissions

An absence of blood in stool

A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond? "Your small intestine will adapt over time to the absence of your appendix." "Your appendix doesn't play a major role, so you won't notice any difference after your recovery from surgery." "Your body will absorb slightly fewer nutrients from the food you eat, but you won't be aware of this." "The surgeon will encourage you to limit your fat intake for a few weeks after the surgery, but your body will then begin to compensate."

"Your appendix doesn't play a major role, so you won't notice any difference after your recovery from surgery."

A patient reports an inflamed salivary gland below the right ear. The nurse documents probable inflammation of which gland? Submandibular Sublingual Buccal Parotid

Parotid

A client with diabetes begins to have digestive problems and is told by the physician that they are a complication of the diabetes. Which of the following explanations from the nurse is most accurate? Insulin has an adverse effect of constipation. The pancreas secretes digestive enzymes. Elevated glucose levels cause bacteria overgrowth in the large intestine. The nerve fibers of the intestinal lining are experiencing neuropathy.

The pancreas secretes digestive enzymes.

A nurse is creating a care plan for a client with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube? Auscultate the client's abdomen after injecting air through the tube. Assess the color and pH of aspirate. Locate the marking made after the initial x-ray confirming placement. Use a combination of at least two accepted methods for confirming placement.

Use a combination of at least two accepted methods for confirming placement.

A client with low back pain is being seen in the clinic. In planning care, which teaching point should the nurse include? Avoid twisting and flexion activities. A soft mattress is most supportive by conforming to the body. Sleep on the stomach to alleviate pressure on the back. Use the large muscles of the leg when lifting items.

Use the large muscles of the leg when lifting items.

A client is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate? Wash the area around the tube with soap and water daily. Irrigate the skin surrounding the insertion site with normal saline before each use. Administer antibiotics via the tube as prescribed. Cleanse the skin within 2 cm of the insertion site with hydrogen peroxide once per shift.

Wash the area around the tube with soap and water daily.

An elderly client comes into the emergency department reporting an earache. The client and has an oral temperature of 37.9° (100.2ºF) and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next? Assess the temporomandibular joint for evidence of a malocclusion. Inspect the client's gums for bleeding and hyperpigmentation. Palpate the client's parotid glands to detect swelling and tenderness. Test the integrity of cranial nerve XII by asking the client to protrude the tongue.

Palpate the client's parotid glands to detect swelling and tenderness.

A client has been taking a 10-day course of antibiotics for pneumonia. The client has been having white patches that look like milk curds in the mouth. What treatment will the nurse educate the client about? Cephalexin Fluocinolone acetonide oral base gel Acyclovir Nystatin

Nystatin

A client is being treated for prolonged diarrhea. Which foods should the nurse encourage the client to consume? Potassium-rich foods High-fat foods High-fiber foods Protein-rich foods

Potassium-rich foods

A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse? Administer prescribed morphine intravenously. Obtain consent for the esophagogastroscopy. Suction the oral cavity of the client. Assess lung sounds bilaterally.

Assess lung sounds bilaterally

A client is postoperative following a graft reconstruction of the neck. What intervention is the most important for the nurse to complete with the client? Cleanse around the drain using aseptic technique. Reinforce the neck dressing when blood is present on the dressing. Assess the graft for color and temperature. Administer prescribed intravenous vancomycin at the correct time.

Assess the graft for color and temperature.

A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate? Hang a solution of dextrose 10% and water until the new solution is available. Slow the current infusion rate so that it will last until the new solution arrives. Begin an infusion of normal saline in another site to maintain hydration. Have someone go to the pharmacy to obtain the new solution.

Hang a solution of dextrose 10% and water until the new solution is available.

The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon return to the nursing unit, what does the nurse identify as the client goal? Increase the amount of fluids Decrease nausea and vomiting Recover from the general anesthesia Ambulate independently

Increase the amount of fluids

The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly? Tape the tube to the head of the bed to avoid dislodgement. Keep the vent lumen above the patient's waist to prevent gastric content reflux. Irrigate only through the vent lumen. Maintain intermittent or continuous suction at a rate greater than 120 mm Hg.

Keep the vent lumen above the patient's waist to prevent gastric content reflux.

The health care provider orders the insertion of a single lumen nasogastric tube. When gathering the equipment for the insertion, what will the nurse select? Sengstaken-Blakemore tube Salem sump tube Levin tube Miller-Abbott tube

Levin tube

A client is treated for gastrointestinal problems related to chronic cholecystitis. What pathophysiological process related to cholecystitis does the nurse understand is the reason behind the client's GI problems? Increased bile as a result of inflammation leads to indigestion. Inflammation of the gallbladder causes pain and impacts gastric motility. Contractile spasms of the gallbladder decreases appetite and leads to malnutrition. Reduced or absent bile as a result of obstruction impacts digestion.

Reduced or absent bile as a result of obstruction impacts digestion.

A nurse cares for a client who is post op from bariatric surgery. Once able, the nurse encourages oral intake for what primary purpose? Stimulate GI peristalsis Assess for gastric perforation Assess for intact swallowing Stimulate digestive hormones

Stimulate GI peristalsis

The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length? The distance determined by measuring from the tragus of the ear to the xiphoid process The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process A length of 50 cm (20 in) A point that equals the distance from the nose to the xiphoid process

The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process

A nurse is admitting a client diagnosed with late-stage gastric cancer. The client's family is distraught and angry that she was not diagnosed earlier in the course of her disease. What factor most likely contributed to the client's late diagnosis? The early symptoms of gastric cancer are usually not alarming or highly unusual. Gastric cancer does not cause signs or symptoms until metastasis has occurred. Adherence to screening recommendations for gastric cancer is exceptionally low. Early symptoms of gastric cancer are usually attributed to constipation.

The early symptoms of gastric cancer are usually not alarming or highly unusual.