GI exam - MedSurg - Chap 43-48

c. 3 (Umbilicus region) The area around the umbilicus would be indicated. Cullen's sign consists of ecchymosis around the umbilicus. Cullen's sign occurs because of seepage of bloody exudates from the inflamed pancreas and indicates severe acute pancreatitis.

In reviewing the medical record for a patient admitted with acute pancreatitis, the nurse sees that the patient has a positive Cullen's sign. Indicate the area in the accompanying figure where the nurse will assess for this change. a. 1 (Epigastric region) b. 2 (Left hypochondriac region) c. 3 (Umbilicus region) d. 4 (Hypogastric region)

After a patient has had a hemorrhoidectomy at an outpatient surgical center, which instructions will the nurse include in discharge teaching? a. Maintain a low-residue diet until the area is healed. b. Avoid using any topical preparations on the surgical area. c. Take prescribed pain medications before you expect a bowel movement. d. Delay having a bowel movement for several days until you are well healed.

Take prescribed pain medications before you expect a bowel movement. Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. A high-residue diet will increase stool bulk and prevent constipation. Delay of bowel movements is likely to lead to constipation. Topical preparations that provide anesthesia or reduce internal sphincter spasms such as topical lidocaine, 2% diltiazem, and glyceryl trinitrate may be used. Warm Sitz baths are used to relieve pain and keep the surgical area clean.

b. 2 (LUQ) Rationale: The spleen is usually not palpable, but when palpated, it is located in left upper quadrant of abdomen.

Which area of the abdomen shown in the accompanying figure will the nurse palpate to assess for splenomegaly? a. 1 (RUQ) b. 2 (LUQ) c. 3 (RLQ) d. 4 (LLQ)

Which patient statement would indicate to the nurse that teaching after a laparoscopic cholecystectomy was effective? a. "I can take a shower and walk around the house tomorrow." b. "I need to limit my activities and not return to work for 4 weeks." c. "I can expect yellowish drainage from the incision for a few days." d. "I will follow a low-fat diet for life because I do not have a gallbladder."

a. "I can take a shower and walk around the house tomorrow." After a laparoscopic cholecystectomy, patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a lifelong requirement.

A 40-yr-old woman who is obese reports that she wants to lose weight. Which question would the nurse ask first? a. "What factors led to your weight gain?" b. "Which types of food do you like best?" c. "How long have you been overweight?" d. "What physical activities do you enjoy?"

a. "What factors led to your weight gain?" Rationale: The nurse should obtain information about the patient's perceptions of the reasons for the obesity to develop a plan individualized to the patient. The other information also will be obtained from the patient, but the patient is more likely to make changes when the patient's beliefs are considered in planning.

A patient with a new ileostomy asks how much it will drain after the bowel has adapted in a few months. How many cups of drainage per day would the nurse tell the patient to expect? a. 2 b. 3 c. 4 d. 5

a. 2 After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL daily. One cup is about 240 mL.

A healthy adult woman who weighs 145 lb (66 kg) asks the clinic nurse about the minimum daily requirement for protein. How many grams of protein will the nurse recommend? a. 53 b. 66 c. 79 d. 98

a. 53 Rationale: The recommended daily protein intake is 0.8 to 1 g/kg of body weight. Therefore, the minimum for this patient is 66 kg x 0.8 g = 52.8 or 53 g/day.

Which patient would the nurse assess first after receiving change-of-shift report? a. A 40-yr-old patient who has a distended abdomen and tachycardia b. A 60-yr-old patient whose ileostomy has drained 800 mL over 8 hours c. A 30-yr-old patient with ulcerative colitis who had six liquid stools in 4 hours d. A 50-yr-old patient with familial adenomatous polyposis who has occult blood in the stool

a. A 40-yr-old patient who has a distended abdomen and tachycardia The patient's abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients would be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses.

Which patient would the nurse assess first after receiving change-of-shift report? a. A patient with esophageal varices who has a rapid heart rate b. A patient with a history of gastrointestinal bleeding who has melena c. A patient with nausea who has a dose of metoclopramide (Reglan) due d. A patient who is crying after receiving a diagnosis of esophageal cancer

a. A patient with esophageal varices who has a rapid heart rate A patient with esophageal varices and a rapid heart rate indicate possible hemodynamic instability caused by GI bleeding. The other patients require interventions, but their findings do not indicate acutely life-threatening complications.

Which action would the nurse plan when admitting a patient with acute diverticulitis plan for initial care? a. Administer IV fluids. b. Prepare for colonoscopy. c. Encourage a high-fiber diet. d. Give stool softeners and enemas.

a. Administer IV fluids A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given. These will be implemented later in the hospitalization. The patient with acute diverticulitis will not have enemas or a colonoscopy because of the risk for perforation and peritonitis.

After an unimmunized person is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take? (Select all that apply.) a. Administer hepatitis B vaccine. b. Test for antibodies to hepatitis B. c. Teach about a-interferon therapy. d. Give hepatitis B immune globulin. e. Explain options for oral antiviral therapy.

a. Administer hepatitis B vaccine. b. Test for antibodies to hepatitis B. d. Give hepatitis B immune globulin. The recommendations for hepatitis B exposure include both vaccination and immune globulin administration. In addition, baseline testing for hepatitis B antibodies will be needed. Interferon and oral antivirals are not used for hepatitis B prophylaxis.

A patient has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider? a. Asterixis and lethargy b. Jaundiced sclera and skin c. Elevated total bilirubin level d. Liver 3 cm below costal margin

a. Asterixis and lethargy The patient's findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy. Patients with acute liver failure can deteriorate rapidly from grade 1 or 2 to grade 3 or 4 hepatic encephalopathy and need early transfer to a transplant center. The other findings are typical of patients with hepatic failure and would be reported but would not indicate a need for an immediate change in the therapeutic plan.

When teaching a patient about testing to diagnose metabolic syndrome, which topic would the nurse include? a. Blood glucose test b. Cardiac enzyme tests c. Postural blood pressures d. Resting electrocardiogram

a. Blood glucose test Rationale: A fasting blood glucose result greater than 100 mg/dL is one of the diagnostic criteria for metabolic syndrome. The other tests are not used to diagnose metabolic syndrome, but they may be used to check for cardiovascular complications of the disorder.

Which information obtained by the nurse interviewing a patient is most important to communicate to the health care provider? a. Blood in the stool b. History of constipation c. Appendectomy 3 years ago d. Smokes a pack/day of cigarettes

a. Blood in the stool Blood in the stool is a possible clinical manifestation of colorectal cancer and requires further assessment by the health care provider. The other patient information will also be communicated to the health care provider but does not indicate an urgent need for further testing or intervention.

A patient calls the clinic to report a severe diarrhea lasting 4 days. What would the nurse anticipate that the patient will need to do? a. Collect a stool specimen. b. Prepare for colonoscopy. c. Schedule a barium enema. d. Have blood cultures drawn.

a. Collect a stool specimen. Acute diarrhea is often caused by an infectious process, so stool specimens are obtained for culture and examined for parasites or white blood cells. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema.

The nurse is assessing a patient with abdominal pain. How will the nurse document ecchymosis around the area of umbilicus? a. Cullen's sign b. Rovsing sign c. McBurney's sign d. Grey-Turner's sign

a. Cullen's sign Cullen's sign is ecchymosis around the umbilicus. Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. Grey Turner's sign is bruising over the flanks. Deep tenderness at McBurney's point (halfway between the umbilicus and the right iliac crest), known as McBurney's sign, is a sign of acute appendicitis.

Which information would the nurse teach patients about self-management after gastric bypass surgery? a. Drink fluids between meals but not with meals. b. Choose high-fat foods for at least 30% of intake. c. Developing flabby skin can be prevented by exercise. d. Choose foods high in fiber to promote bowel function.

a. Drink fluids between meals but not with meals. Rationale: Intake of fluids with meals tends to cause dumping syndrome and diarrhea. Food choices should be low in fat and fiber. Exercise does not prevent the development of flabby skin.

A patient is admitted with possible botulism poisoning after eating home-canned green beans. Which intervention ordered by the health care provider would the nurse question? a. Encourage oral fluids to 3 L/day. b. Document neurologic symptoms. c. Position patient lying on the side. d. Observe respiratory status closely.

a. Encourage oral fluids to 3 L/day. The patient should not have oral fluids because neuromuscular weakness increases risk for aspiration. Side-lying position and assessment of neurologic and respiratory status are expected interventions.

Which action will the nurse include in the plan of care for a 25-yr-old male patient with a new diagnosis of irritable bowel syndrome (IBS)? a. Encourage the patient to express concerns and ask questions about IBS. b. Suggest that the patient increase the intake of milk and other dairy products. c. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs). d. Teach the patient about the use of alosetron (Lotronex) to reduce IBS symptoms.

a. Encourage the patient to express concerns and ask questions about IBS. Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS.

Which diagnostic test would the nurse anticipate for an older patient who is vomiting "coffee-ground" emesis? a. Endoscopy b. Angiography c. Barium studies d. Gastric analysis

a. Endoscopy Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy cannot be done because it is more invasive and has more possible complications. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding.

A patient with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider? a. Fever b. Nausea c. Joint pain d. Headache

a. Fever Since infliximab suppresses the immune response, rapid treatment of infection is essential. Nausea, joint pain, and headache are common side effects of the medication, but they do not indicate any potentially life-threatening complications.

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

a. Fistulas can form between the bowel and bladder. Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. Teaching for UTI prevention in general includes good hygiene, adequate fluid intake, and voiding before and after intercourse.

Which finding for a young adult who follows a vegan diet may indicate the need for cobalamin supplementation? a. Glossitis b. Ecchymoses c. Dry, scaly skin d. Gingival swelling

a. Glossitis Rationale: Cobalamin (vitamin B12) cannot be obtained from foods of plant origin, so the patient will be most at risk for signs of cobalamin deficiency, such as glossitis, anorexia, sore mouth and tongue, pallor, neurologic problems (e.g., depression, dizziness), weight loss, nausea, constipation, and anemia. The other symptoms listed are associated with other nutritional deficiencies but would not be associated with a vegan diet.

Which laboratory test result will the nurse monitor to evaluate the effects of therapy for a patient who has acute pancreatitis? a. Lipase b. Calcium c. Bilirubin d. Potassium

a. Lipase Lipase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effective.

After having frequent diarrhea and a weight loss of 10 lb (4.5 kg) over 2 months, a patient has a new diagnosis of Crohn's disease. What would the nurse plan to teach the patient? a. Medication use b. Fluid restriction c. Enteral nutrition d. Activity restrictions

a. Medication use Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings if the patient is able to eat.

Which menu choice by the patient with diverticulosis is best for preventing diverticulitis? a. Navy bean soup and vegetable salad b. Whole grain pasta with tomato sauce c. Baked potato with low-fat sour cream d. Roast beef sandwich on whole wheat bread

a. Navy bean soup and vegetable salad A diet high in fiber and low in fats and red meat is recommended to prevent diverticulitis. Although all the choices have some fiber, the bean soup and salad will be the highest in fiber and the lowest in fat.

A woman receiving chemotherapy for breast cancer develops a Candida albicans oral infection. Which intervention would the nurse anticipate? a. Nystatin tablets b. Antiviral agents c. Referral to a dentist d. Hydrogen peroxide rinses

a. Nystatin tablets C. albicans infections are treated with an antifungal such as nystatin. Peroxide rinses would be painful. Oral saltwater rinses may be used but will not cure the infection. Antiviral agents are used for viral infections such as herpes simplex. Referral to a dentist is indicated for gingivitis but not for Candida infection.

Which action would the nurse in the emergency department anticipate for a young adult patient who has had several acute episodes of bloody diarrhea? a. Obtain a stool specimen for culture. b. Administer antidiarrheal medication. c. Provide teaching about antibiotic therapy. d. Teach the adverse effects of acetaminophen (Tylenol).

a. Obtain a stool specimen for culture. Patients with bloody diarrhea should have a stool culture for Escherichia coli O157:H7. Antidiarrheal medications are usually avoided for possible infectious diarrhea to avoid prolonging the infection. Antibiotic therapy in the treatment of infectious diarrhea is controversial because it may precipitate kidney complications. Acetaminophen does not cause bloody diarrhea.

A patient has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which action by assistive personnel (AP) requires that the registered nurse (RN) intervene? a. Offering the patient a pitcher of water b. Positioning the patient on the right side c. Checking the vital signs every 30 minutes d. Swabbing the patient's mouth with a wet cloth

a. Offering the patient a pitcher of water Rationale: Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. Assessment for return of the gag reflex should be done by the RN. The other actions by the AP are appropriate.

A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which prescribed action would the nurse take first? a. Place the patient on NPO status. b. Administer sedative medications. c. Ensure the consent form is signed. d. Teach patient about the procedure.

a. Place the patient on NPO status. Rationale: The patient will need to be NPO for 8 hours before the ERCP is done, so the nurse's initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO.

A patient is awaiting surgery for acute peritonitis. Which action will the nurse plan to include in the preoperative care? a. Position patient with the knees flexed. b. Avoid use of opioids or sedative drugs. c. Offer frequent small sips of clear liquids. d. Assist patient to breathe deeply and cough.

a. Position patient with the knees flexed. There is less peritoneal irritation with the knees flexed, which will help decrease pain. Opioids and sedatives are typically given to control pain and anxiety. Preoperative patients with peritonitis are given IV fluids for hydration. Deep breathing and coughing will increase the patient's discomfort.

A patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action would the nurse take? a. Schedule the patient for HCV genotype testing. b. Administer the HCV vaccine and immune globulin. c. Teach the patient about direct-acting antiviral treatment. d. Explain that the infection will resolve over a few months.

a. Schedule the patient for HCV genotype testing. Genotyping of HCV has an important role in managing treatment and is done before drug therapy is initiated. Because most patients with acute HCV infection convert to the chronic state, the nurse should not teach the patient that the HCV will resolve in a few months. Immune globulin or vaccine is not available for HCV. Direct-acting antiviral drugs are used for chronic HCV infection.

Which prescribed intervention for a patient with chronic short bowel syndrome would the nurse question? a. Senna 1 tablet daily b. Ferrous sulfate 325 mg daily c. Psyllium (Metamucil) 3 times daily d. Diphenoxylate with atropine (Lomotil) PRN loose stools

a. Senna 1 tablet daily Patients with short bowel syndrome have diarrhea because of decreased nutrient and fluid absorption and would not need stimulant laxatives. Iron supplements are used to prevent iron-deficiency anemia, bulk-forming laxatives help make stools less watery, and opioid antidiarrheal drugs are helpful in slowing intestinal transit time.

A patient who has just been started on enteral nutrition of full-strength formula at 100 mL/hr has 6 liquid stools the first day. Which action would the nurse plan to take? a. Slow the infusion rate of the feeding. b. Check gastric residual volumes more often. c. Change the enteral feeding system and formula every 8 hours. d. Discontinue administration of water through the feeding tube.

a. Slow the infusion rate of the feeding. Rationale: Loose stools indicate poor absorption of nutrients and indicate a need to slow the feeding rate or decrease the concentration of the feeding. Water should be given when patients receive enteral feedings to prevent dehydration. When a closed enteral feeding system is used, the tubing and formula are changed every 24 hours. High residual volumes do not contribute to diarrhea.

The nurse receives the following information about a patient who is scheduled for a colonoscopy. Which information would the nurse communicate to the health care provider before preparing the patient for the procedure? a. The patient declined to drink the prescribed laxative solution. b. The patient has had an allergic reaction to shellfish and iodine. c. The patient has a permanent pacemaker to prevent bradycardia. d. The patient is worried about discomfort during the examination.

a. The patient declined to drink the prescribed laxative solution. Rationale: If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure would be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patient's anxiety about discomfort.

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.

a. The patient is alert and oriented. The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.

The nurse is coaching a community group for persons who are overweight. Which participant behavior is an example of the best exercise plan for weight loss? a. Walking for 40 minutes 6 or 7 days/week b. Playing soccer for an hour on the weekend c. Running for 10 to 15 minutes 3 times/week d. Lifting weights for 2 hours with friends 1 time/week

a. Walking for 40 minutes 6 or 7 days/week Rationale: Exercise should be at least 150 minutes of moderate-intensity aerobic activity (i.e., brisk walking) every week. Muscle-strengthening activities on 2 or more days a week is recommended. Exercising in highly aerobic activities for short bursts or only once a week is not helpful and may be dangerous in an individual who has not been exercising. Running may be appropriate, but patients should start with an exercise that is less stressful and can be done for a longer period.

Which information about dietary management would the nurse include when teaching a patient with peptic ulcer disease (PUD)? a. "You will need to remain on a bland diet." b. "Avoid foods that cause pain after you eat them." c. "High-protein foods are least likely to cause pain." d. "You should avoid eating raw fruits and vegetables."

b. "Avoid foods that cause pain after you eat them." The best information is that each person should choose foods that are not associated with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa but chewing well seems to decrease this problem and some patients tolerate these healthy foods well. High-protein foods help neutralize acid, but they also stimulate hydrochloric (HCl) acid secretion and may increase discomfort for some patients. Bland diets may be recommended during an acute exacerbation of PUD, but there is little evidence to support their ongoing use.

The nurse is assessing an alert and independent older adult patient for malnutrition risk. Which is the most useful initial question? a. "How do you get to the store to buy your food?" b. "Can you tell me the food that you ate yesterday?" c. "Do you have any difficulty in preparing or eating food?" d. "Are you taking any medications that alter your taste for food?"

b. "Can you tell me the food that you ate yesterday?" Rationale: This question is the most open-ended and will provide the best overall information about the patient's daily intake and risk for poor nutrition. The other questions may be asked, depending on the patient's response to the first question.

Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of famotidine (Pepcid)? a. "Famotidine absorbs the excess gastric acid." b. "Famotidine decreases gastric acid secretion." c. "Famotidine constricts the blood vessels near the ulcer." d. "Famotidine covers the ulcer with a protective material."

b. "Famotidine decreases gastric acid secretion." Famotidine is a histamine-2 (H2) receptor blocker that decreases the secretion of gastric acid. Famotidine does not constrict the blood vessels, absorb the gastric acid, or cover the ulcer.

The nurse is admitting a patient with new-onset steatorrhea. Which question is most important for the nurse to ask? a. "How much milk do you drink?" b. "Have you had a recent weight loss?" c. "What time of day do your bowels move?" d. "Do you eat meat or other animal products?"

b. "Have you had a recent weight loss?" Although all the questions provide useful information, it is most important to determine if the patient has an imbalance in nutrition because of the steatorrhea.

A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement to the nurse indicates a need for additional teaching about GERD? a. "I quit smoking years ago, but I chew gum." b. "I eat small meals and have a bedtime snack." c. "I take antacids between meals and at bedtime each night." d. "I sleep with the head of the bed elevated on 4-inch blocks."

b. "I eat small meals and have a bedtime snack." GERD is exacerbated by eating late at night, and the nurse would plan to teach the patient to avoid eating within 3 hours of bedtime. Smoking cessation, taking antacids, and elevating the head of the bed are appropriate actions to control symptoms of GERD.

A young adult patient is hospitalized with massive abdominal trauma from a motor vehicle crash. The patient asks about the purpose of receiving famotidine (Pepcid). Which information would the nurse explain about the action of the medication? a. "It decreases nausea and vomiting." b. "It inhibits development of stress ulcers." c. "It lowers the risk for H. pylori infection." d. "It prevents aspiration of gastric contents."

b. "It inhibits development of stress ulcers." Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent H. pylori infection.

Which information will the nurse provide for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a. "Peppermint tea may reduce your symptoms." b. "Keep the head of your bed elevated on blocks." c. "Avoid eating between meals to reduce acid secretion." d. "Vigorous exercise may increase the incidence of reflux."

b. "Keep the head of your bed elevated on blocks." Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will decrease lower esophageal sphincter (LES) pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD.

After bariatric surgery, a patient who is being discharged tells the nurse, "I prefer to be independent. I am not interested in any support groups." Which initial response would the nurse provide? a. "I hope you change your mind so that I can suggest a group for you." b. "Tell me what types of resources you think you might use after this surgery." c. "Support groups have been found to lead to more successful weight loss after surgery." d. "Because there are many lifestyle changes after surgery, we recommend support groups."

b. "Tell me what types of resources you think you might use after this surgery." Rationale: This statement allows the nurse to assess the individual patient's potential needs and preferences. The other statements offer the patient more information about the benefits of support groups but do not acknowledge the patient's preferences.

Which statement by a patient with chronic atrophic gastritis indicates that the nurse's teaching regarding cobalamin injections has been effective? a. "The cobalamin injections will prevent gastric inflammation." b. "The cobalamin injections will prevent me from becoming anemic." c. "These injections will increase the hydrochloric acid in my stomach." d. "These injections will decrease my risk for developing stomach cancer."

b. "The cobalamin injections will prevent me from becoming anemic." Cobalamin supplementation prevents the development of pernicious anemia. Chronic gastritis may cause achlorhydria, but cobalamin does not correct this. The loss of intrinsic factor secretion with chronic gastritis is permanent, and the patient will need lifelong supplementation with cobalamin. The incidence of stomach cancer is higher in patients with chronic gastritis, but cobalamin does not reduce the risk for stomach cancer.

Which statement by the nurse is most likely to help a 22-yr-old patient with extreme obesity in losing weight on a 1000-calorie diet? a. "It will be necessary to change lifestyle habits permanently to maintain weight loss." b. "You are likely to notice changes in how you feel after a few weeks of diet and exercise." c. "You will decrease your risk for future health problems such as diabetes by losing weight now." d. "Most of the weight that you lose during the first weeks of dieting is water weight rather than fat."

b. "You are likely to notice changes in how you feel after a few weeks of diet and exercise." Rationale: Motivation is a key factor in successful weight loss and a short-term outcome provides a higher motivation. Future health problems are unlikely to motivate a 22-yr-old patient. Telling a patient that the initial weight loss is water would be discouraging, although this may be correct. Changing lifestyle habits permanently is recommended, but this process occurs over time, and discussing this is not likely to motivate the patient.

After the nurse teaches about the recommended amounts of foods from animal and plant sources, which menu selections indicate that the patient understands the diet instructions? a. 3 oz of lean beef, 2 oz of low-fat cheese, and a sliced tomato b. 3 oz of roasted pork, a cup of broccoli, and a cup of carrot sticks c. Cup of tossed salad and nonfat dressing topped with a chicken breast d. Half cup of tuna mixed with nonfat mayonnaise and a half cup of celery

b. 3 oz of roasted pork, a cup of broccoli, and a cup of carrot sticks Rationale: This selection is most consistent with the recommendations to limit foods from animal sources and increase plant source foods. The other choices all have higher ratios of animal origin foods to plant source foods than would be recommended.

After change-of-shift report, which patient would the nurse assess first? a. A 40-yr-old male patient with celiac disease who has frequent frothy diarrhea b. A 30-yr-old female patient with a femoral hernia who has abdominal pain and vomiting c. A 30-yr-old male patient with ulcerative colitis who has severe perianal skin breakdown d. A 40-yr-old female patient with a colostomy bag that is pulling away from the adhesive wafer

b. A 30-yr-old female patient with a femoral hernia who has abdominal pain and vomiting Pain and vomiting with a femoral hernia suggest strangulation, which will require emergency surgery. All the other patients require assessment or care but have less urgent problems.

After change-of-shift report, which patient will the nurse assess first? a. A 40-yr-old woman whose parenteral nutrition infusion bag has 30 minutes of solution left b. A 40-yr-old man with continuous enteral feedings who has developed pulmonary crackles c. A 30-yr-old man with 4+ generalized pitting edema and severe protein-calorie malnutrition d. A 30-yr-old woman whose gastrostomy tube is plugged after crushed medications were administered

b. A 40-yr-old man with continuous enteral feedings who has developed pulmonary crackles Rationale: The patient data suggest aspiration may have occurred, and rapid assessment and intervention are needed. The other patients should also be assessed soon, but the data about them do not suggest any immediately life-threatening complications.

Which patients would the nurse refer to the dietitian for a complete nutritional assessment? (Select all that apply.) a. A 35-yr-old patient who reports intermittent nausea for the past 2 days b. A 48-yr-old patient with rheumatoid arthritis who takes prednisone daily c. A 23-yr-old patient who has a history of fluctuating weight gains and losses d. A 64-yr-old patient who is admitted for debridement of an infected surgical wound e. A 52-yr-old patient admitted with chest pain and possible myocardial infarction (MI)

b. A 48-yr-old patient with rheumatoid arthritis who takes prednisone daily c. A 23-yr-old patient who has a history of fluctuating weight gains and losses d. A 64-yr-old patient who is admitted for debridement of an infected surgical wound Rationale: Weight fluctuations, use of corticosteroids, and draining or infected wounds all suggest that the patient may be at risk for malnutrition. Patients with chest pain or MI are not usually poorly nourished. Although vomiting that lasts 5 days places a patient at risk, nausea that has persisted for 2 days does not always indicate poor nutritional status or risk for health problems caused by poor nutrition.

Which risk factor would the nurse specifically ask about when a patient is being admitted with acute pancreatitis? a. Diabetes b. Alcohol use c. High-protein diet d. Cigarette smoking

b. Alcohol use Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors.

Which result is most important for the nurse to monitor to detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices? a. Bilirubin levels b. Ammonia levels c. Potassium levels d. Prothrombin time

b. Ammonia levels The protein in the blood in the gastrointestinal tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but they will not be affected by the bleeding episode.

A severely malnourished patient reports that he is Jewish. Which initial action would the nurse take to meet his nutritional needs? a. Have family members bring in food. b. Ask the patient about food preferences. c. Teach the patient about nutritious Kosher foods. d. Order supplements that are manufactured Kosher.

b. Ask the patient about food preferences. Rationale: The nurse's first action would be further assessment of whether the patient follows any specific religious guidelines that impact nutrition. The other actions may also be appropriate, based on the information obtained during the assessment.

After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all this. I don't want to look at the stoma." Which action would the nurse take? a. Reassure the patient that ileostomy care will become easier. b. Ask the patient about the concerns with stoma management. c. Postpone any teaching until the patient adjusts to the ileostomy. d. Develop a detailed written list of ostomy care tasks for the patient.

b. Ask the patient about the concerns with stoma management. Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgment of the patient's feelings and concerns is important rather than offering false reassurance. Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy care plan will not improve the patient's ability to manage the ostomy. Although detailed ostomy teaching could be postponed, the nurse should begin to offer teaching about some aspects of living with an ostomy.

Which action would the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? a. Request that the patient stand on one foot. b. Ask the patient to extend both arms forward. c. Request that the patient walk with eyes closed. d. Ask the patient to perform the Valsalva maneuver.

b. Ask the patient to extend both arms forward. Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests might be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.

Which action would the nurse take when coaching adults who are obese in a behavior therapy program? a. Having the adults write down the caloric intake of each meal b. Asking the adults about situations that tend to increase appetite c. Suggesting that the adults plan rewards such as sugarless candy for achieving their goals d. Encouraging the adults to eat small amounts frequently rather than having scheduled meals

b. Asking the adults about situations that tend to increase appetite Rationale: Behavior therapy programs focus on how and when the person eats and de-emphasize aspects such as calorie counting. Nonfood rewards are recommended for achievement of weight-loss goals. Patients are often taught to restrict eating to designated meals when using behavior therapy.

Which information will the nurse include when teaching adults to decrease the risk for cancers of the tongue and buccal mucosa? a. Use sunscreen even on cloudy days. b. Avoid cigarettes and smokeless tobacco. c. Complete antibiotic courses used to treat throat infections. d. Use antivirals to treat herpes simplex virus (HSV) infections.

b. Avoid cigarettes and smokeless tobacco. Tobacco use greatly increases the risk for oral cancer. Acute throat infections do not increase the risk for oral cancer, although chronic irritation of the oral mucosa does increase risk. Sun exposure does not increase the risk for cancers of the buccal mucosa, although it increases risk for cancer of the lip. Human papillomavirus (HPV) infection is associated with an increased risk, but HSV infection is not a risk factor for oral cancer.

Which topic is most important for the nurse to include in teaching for a 41-yr-old patient diagnosed with early alcoholic cirrhosis? a. Taking lactulose b. Avoiding all alcohol use c. Maintaining good nutrition d. Using vitamin B supplements

b. Avoiding all alcohol use The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.

Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to assistive personnel (AP)? a. Auscultating for bowel sounds b. Brushing the teeth and tongue c. Assessing the nares for irritation d. Irrigating the nasogastric (NG) tube

b. Brushing the teeth and tongue AP education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN.

Which information will the nurse include when teaching a patient how to avoid chronic constipation? (Select all that apply.) a. Stimulant and saline laxatives can be used regularly. b. Bulk-forming laxatives are an excellent source of fiber. c. Walking or cycling frequently will help bowel motility. d. A good time for a bowel movement may be after breakfast. e. Some over-the-counter (OTC) medications cause constipation.

b. Bulk-forming laxatives are an excellent source of fiber. c. Walking or cycling frequently will help bowel motility. d. A good time for a bowel movement may be after breakfast. e. Some over-the-counter (OTC) medications cause constipation. Stimulant and saline laxatives should be used infrequently. Use of bulk-forming laxatives, regular early morning timing of defecation, regular exercise, and avoiding many OTC medications will help the patient avoid constipation.

Which assessment action would help the nurse determine if an obese patient has metabolic syndrome? a. Take the patient's apical pulse. b. Check the patient's blood pressure. c. Ask the patient about dietary intake. d. Dipstick the patient's urine for protein.

b. Check the patient's blood pressure. Rationale: Elevated blood pressure is one of the characteristics of metabolic syndrome. The other information will not assist with the diagnosis of metabolic syndrome.

A patient admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action would the nurse take? a. Irrigate the NG tube. b. Check the vital signs. c. Give the ordered antacid. d. Elevate the foot of the bed.

b. Check the vital signs. The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. Elevating the foot of the bed may increase abdominal pressure and discomfort, as well as making it more difficult for the patient to breathe.

Which screening test would the nurse plan to teach a 45-yr-old male about during an annual wellness exam? a. Endoscopy b. Colonoscopy c. Computerized tomography d. Carcinoembryonic antigen (CEA)

b. Colonoscopy At age 45 years, persons with an average risk for colorectal cancer (CRC) would begin screening for CRC. Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical exam at age 45 years.

A patient who underwent a gastroduodenostomy (Billroth I) 12 hours ago reports increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the past hour. Which nursing action is the highest priority? a. Monitor drainage. b. Contact the surgeon. c. Irrigate the NG tube. d. Give prescribed morphine.

b. Contact the surgeon. Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion or return to surgery are needed (or both). Because the NG is draining, there is no indication that irrigation is needed. Continuing to monitor the NG drainage is needed but not an adequate response to the findings. The patient may need morphine, but this is not the highest priority action.

The nurse is preparing to teach a frail 79-yr-old Hispanic man who lives with an adult daughter about ways to improve nutrition. Which action would the nurse take first? a. Ask the daughter about the patient's food preferences. b. Determine who shops for groceries and prepares the meals. c. Question the patient about how many meals per day are eaten. d. Assure the patient that culturally preferred foods will be included.

b. Determine who shops for groceries and prepares the meals. Rationale: The family member who shops for groceries and cooks will be in control of the patient's diet, so the nurse will need to ensure that this family member is involved in any teaching or discussion about the patient's nutritional needs. The other information will also be assessed and used but will not be useful in meeting the patient's nutritional needs unless nutritionally appropriate foods are purchased and prepared.

Which item would the nurse offer to the patient restarting oral intake after being NPO due to nausea and vomiting? a. Glass of orange juice b. Dish of lemon gelatin c. Cup of coffee with cream d. Bowl of hot chicken broth

b. Dish of lemon gelatin Clear cool liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated.

Which nursing action would be included in the postoperative plan of care for a patient after a laparoscopic esophagectomy? a. Reposition the NG tube if drainage stops. b. Elevate the head of the bed to at least 30 degrees. c. Start oral fluids when the patient has active bowel sounds. d. Notify the doctor for any bloody nasogastric (NG) drainage.

b. Elevate the head of the bed to at least 30 degrees. Elevation of the head of the bed decreases the risk for reflux and aspiration of gastric secretions. The NG tube would not be repositioned without consulting with the health care provider. Bloody NG drainage is expected for the first 8 to 12 hours. A swallowing study is needed before oral fluids are started.

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

b. Encourage the patient to ambulate. Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine is used as an antiemetic rather than to decrease gas pains or distention.

A young adult with extensive facial injuries from a motor vehicle crash is receiving continuous enteral nutrition through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include in the plan of care? a. Keep the patient positioned lying on the left side. b. Flush the tube with 30 mL of water every 4 hours. c. Crush and mix medications in with the feeding formula. d. Obtain a daily abdominal radiograph to verify tube placement.

b. Flush the tube with 30 mL of water every 4 hours. Rationale: The tube is flushed every 4 hours during continuous feedings to avoid tube obstruction. The patient should be positioned with the head of the bed elevated. Crushed medications mixed in with the formula are likely to clog the tube. An x-ray is obtained immediately after placement of the PEG tube to check position, but daily x-rays are not needed.

A malnourished patient is receiving a parenteral nutrition (PN) infusion containing amino acids and dextrose from a bag that was hung with a new tubing and filter 24 hours ago. The nurse observes that about 50 mL remain in the PN container. Which action would the nurse take? a. Add a new container of PN using the current tubing and filter. b. Hang a new container of PN and change the IV tubing and filter. c. Infuse the remaining 50 mL and then hang a new container of PN. d. Ask the health care provider to clarify the written PN prescription.

b. Hang a new container of PN and change the IV tubing and filter. Rationale: All PN solutions and tubings are changed at 24 hours. Infusion of the additional 50 mL will increase patient risk for infection. The nurse (not the health care provider) is responsible for knowing the indicated times for tubing and filter changes.

A patient's peripheral parenteral nutrition (PN) bag is nearly empty, and a new PN bag has not arrived yet from the pharmacy. Which action would the nurse take? a. Monitor the patient's capillary blood glucose every 6 hours. b. Infuse 5% dextrose in water until a new PN bag is delivered. c. Decrease the PN infusion rate to 10 mL/hr until a new bag arrives. d. Flush the peripheral line with saline until a new PN bag is available.

b. Infuse 5% dextrose in water until a new PN bag is delivered. Rationale: To prevent hypoglycemia, the nurse should infuse a 5% dextrose solution until the next peripheral PN bag can be started. Decreasing the rate of the ordered PN infusion is beyond the nurse's scope of practice. Flushing the line and then waiting for the next bag may lead to hypoglycemia. Monitoring the capillary blood glucose every 6 hours would not identify hypoglycemia while awaiting the new PN bag.

A patient has been admitted with hypotension and dehydration after 3 days of nausea and vomiting. Which prescribed action will the nurse implement first? a. Insert a nasogastric (NG) tube. b. Infuse normal saline at 250 mL/hr. c. Administer IV ondansetron (Zofran). d. Provide oral care with moistened swabs.

b. Infuse normal saline at 250 mL/hr. Because the patient has severe dehydration, rehydration with IV fluids is the priority. The other orders would be accomplished after the IV fluids are initiated.

A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 bloody stools a day. Which intervention would the nurse include in the patient's plan of care? a. Administer oral metoclopramide. b. Instruct the patient not to eat or drink. c. Administer cobalamin (vitamin B12) injections. d. Teach the patient about total colectomy surgery.

b. Instruct the patient not to eat or drink. An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate during this acute phase.

What action would the nurse take when caring for a patient with a soft, silicone nasogastric tube in place for enteral nutrition? a. Avoid giving medications through the feeding tube. b. Keep head of bed elevated to 30- to 45-degree angle. c. Replace the tube every 3 days to avoid mucosal damage.d. Administer medications mixed with enteral feeding formula.

b. Keep head of bed elevated to 30- to 45-degree angle. Rationale: Elevate the head of the bed to decrease the risk of aspiration. The tubes are less likely to cause mucosal damage than the stiffer polyvinyl chloride tubes used for nasogastric suction and do not need to be replaced at certain intervals. Medications can be given through these tubes but flushing before and after medication administration is important to avoid clogging. Do not mix medications with formula, as the combination can clog the tube.

Which information will the nurse plan to teach a patient who has lactose intolerance? a. Ice cream is relatively low in lactose. b. Live-culture yogurt is usually tolerated. c. Heating milk will break down the lactose. d. Nonfat milk is tolerated better than whole milk.

b. Live-culture yogurt is usually tolerated. Lactose-intolerant persons can usually eat yogurt without experiencing discomfort. Ice cream, nonfat milk, and milk that have been heated are all high in lactose.

An adult with a body mass index (BMI) of 22 kg/m2 is being admitted to the hospital for elective knee surgery. Which assessment finding would the nurse report to the health care provider? a. Tympany on percussion of the abdomen b. Liver edge 3 cm below the costal margin c. Bowel sounds of 20/min in each quadrant d. Aortic pulsations visible in the epigastric area

b. Liver edge 3 cm below the costal margin Rationale: Normally the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly. Visible aortic pulsations in the epigastrium, active bowel sounds, and abdominal tympany are within normal findings for an adult of normal weight.

A 26-yr-old patient who was admitted with viral hepatitis has severe anorexia and fatigue, and is homeless. Which goal has the highest priority in the plan of care? a. Increase activity level. b. Maintain adequate nutrition. c. Establish a stable place of residence. d. Identify source of hepatitis exposure.

b. Maintain adequate nutrition. The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis.

The nurse is planning care for a patient with acute severe pancreatitis. Which outcome would the nurse identify as the highest priority? a. Achieving fluid and electrolyte balance b. Maintaining normal respiratory function c. Expressing satisfaction with pain control d. Developing no ongoing pancreatic disease

b. Maintaining normal respiratory function Respiratory failure can occur as a complication of acute pancreatitis and maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

Which adult would the nurse plan to teach about risks associated with obesity? a. Man who has a BMI of 18 kg/m2 b. Man with a 42 inch waist and 44 inch hips c. Woman who has a body mass index (BMI) of 24 kg/m2 d. Woman with a waist circumference of 34 inches (86 cm)

b. Man with a 42 inch waist and 44 inch hips Rationale: The waist-to-hip ratio for this patient with a 42 inch waist and 44 inch hips is 0.95, which exceeds the recommended level of less than 0.80. A patient with a BMI of 18 kg/m2 is considered underweight. A BMI of 24 kg/m2 is normal. Health risks associated with obesity increase in women with a waist circumference larger than 35 in (89 cm) and men with a waist circumference larger than 40 in (102 cm).

Which scheduling would the nurse teach a patient with chronic pancreatitis to use for the prescribed pancrelipase (Viokase)? a. Bedtime b. Mealtime c. When needed for pain d. When feeling nauseated

b. Mealtime Pancreatic enzymes are used to help with digestion of nutrients and would be taken with every meal.

Which topic would the nurse plan to teach the patient diagnosed with acute hepatitis B? a. Administering a-interferon b. Measures for improving appetite c. Side effects of nucleotide analogs d. Ways to increase activity and exercise

b. Measures for improving appetite Maintaining adequate nutritional intake is important for regeneration of hepatocytes. Interferon and antivirals may be used for chronic hepatitis B, but they are not prescribed for acute hepatitis B infection. Rest is recommended.

A patient who recently had a colon resection for cancer of the colon asks about the purpose of the carcinoembryonic antigen (CEA) test. Which explanation would the nurse provide? a. Identify any metastasis of the cancer. b. Monitor for tumor growth after surgery. c. Confirm the diagnosis of a specific type of cancer. d. Determine the need for postoperative chemotherapy.

b. Monitor for tumor growth after surgery. CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help to determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made based on the biopsy. Chemotherapy use is based on factors other than CEA.

Which nursing action will the nurse include in the plan of care for a patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict IV fluid intake. b. Monitor stools for blood. c. Ambulate six times daily. d. Increase dietary fiber intake.

b. Monitor stools for blood. Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Dietary fiber may increase gastrointestinal motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.

A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. Instruct the patient to cough every hour. b. Monitor the patient for shortness of breath. c. Verify the position of the balloon every 4 hours. d. Deflate the gastric balloon if the patient reports nausea.

b. Monitor the patient for shortness of breath. The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. Balloons may be deflated briefly every 8 to 12 hours to avoid tissue necrosis, but if only the gastric balloon is deflated, the esophageal balloon may occlude the airway. Balloons are not deflated for nausea.

Which is the correct technique for the nurse to palpate the liver during a head-to-toe physical assessment? a. Place one hand on top of the other and use the upper fingers to apply pressure and the bottom fingers to feel for the liver edge. b. Place one hand on the patient's back and press upward and inward with the other hand below the patient's right costal margin. c. Press slowly and firmly over the right costal margin with one hand and withdraw the fingers quickly after the liver edge is felt. d. Place one hand under the patient's lower ribs and press the left lower rib cage forward, palpating below the costal margin with the other hand.

b. Place one hand on the patient's back and press upward and inward with the other hand below the patient's right costal margin. Rationale: The liver is normally not palpable below the costal margin. The nurse needs to push inward below the right costal margin while lifting the patient's back slightly with the left hand. The other methods will not allow palpation of the liver.

Which action would the nurse take after assisting with a needle biopsy of the liver at a patient's bedside? a. Elevate the head of the bed to facilitate breathing. b. Place the patient on the right side with the bed flat. c. Check the patient's postbiopsy coagulation studies. d. Position a sandbag over the liver to provide pressure.

b. Place the patient on the right side with the bed flat. Rationale: After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site. Coagulation studies are checked before the biopsy. A sandbag does not exert adequate pressure to splint the site.

A patient with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? a. Auscultate the bowel sounds. b. Prepare the patient for surgery. c. Check the patient's oral temperature. d. Obtain information about the accident.

b. Prepare the patient for surgery. Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery.

A patient has a body mass index (BMI) of 31 kg/m2, a normal C-reactive protein level, and low serum transferrin and albumin levels. What should the nurse encourage the patient to increase in the diet? a. Iron b. Protein c. Calories d. Carbohydrate

b. Protein Rationale: The patient's C-reactive protein and transferrin levels indicate low protein stores. The BMI is in the obese range, so increasing caloric intake is not indicated. The data do not indicate a need for increased carbohydrate or iron intake.

When caring for a patient who has cirrhosis, which nursing action could the registered nurse (RN) delegate to assistive personnel (AP)? a. Assessing the patient for jaundice b. Providing oral hygiene after a meal c. Palpating the abdomen for distention d. Teaching the patient the prescribed diet

b. Providing oral hygiene after a meal Providing oral hygiene is within the scope of AP. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher level nursing education and scope of practice and could be delegated to licensed practical/vocational nurses (LPNs/VNs) or RNs.

Which action for a patient receiving enteral nutrition through a percutaneous endoscopic gastrostomy (PEG) may be delegated to a licensed practical/vocational nurse (LPN/VN)? a. Assessing the patient's nutritional status weekly b. Providing skin care to the area around the tube site c. Teaching the patient how to administer the feedings d. Determining the need for adding water to the feedings

b. Providing skin care to the area around the tube site Rationale: LPN/VN education and scope of practice include actions such as dressing changes and wound care. Patient teaching and complex assessments (such as patient nutrition and hydration status) require registered nurse (RN)-level education and scope of practice.

A 74-yr-old male patient tells the nurse that growing old causes constipation, so he has been using a suppository to prevent constipation every morning. Which action would the nurse take first? a. Encourage the patient to increase oral fluid intake. b. Question the patient about risk factors for constipation. c. Suggest that the patient increase intake of high-fiber foods. d. Teach the patient that a daily bowel movement is unnecessary.

b. Question the patient about risk factors for constipation. The nurse's initial action should be further assessment of the patient for risk factors for constipation and for his usual bowel pattern. The other actions may be appropriate but will be based on the assessment.

Which action would the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B? a. Advise limiting alcohol intake to 1 drink daily. b. Schedule for liver cancer screening every 6 months. c. Initiate administration of the hepatitis C vaccine series. d. Monitor anti-hepatitis B surface antigen (anti-HBs) levels.

b. Schedule for liver cancer screening every 6 months. Patients with chronic hepatitis are at higher risk for development of liver cancer and should be screened for liver cancer every 6 to 12 months. Patients with chronic hepatitis are advised to completely avoid alcohol. There is no hepatitis C vaccine. Because anti-HBs is present whenever there has been a past hepatitis B infection or vaccination, there is no need to regularly monitor for this antibody.

A 19-yr-old patient has familial adenomatous polyposis (FAP). Which action will the nurse in the gastrointestinal clinic include in the plan of care? a. Obtain blood samples for DNA analysis. b. Schedule the patient for yearly colonoscopy. c. Provide preoperative teaching about total colectomy. d. Discuss lifestyle modifications to decrease cancer risk.

b. Schedule the patient for yearly colonoscopy. Patients with FAP should have annual colonoscopy starting at age 16 years and usually have total colectomy by age 25 years to avoid developing colorectal cancer. DNA analysis is used to make the diagnosis but is not needed now for this patient. Lifestyle modifications will not decrease cancer risk for this patient.

A patient hospitalized with chronic heart failure eats only about 50% of each meal and reports "feeling too tired to eat." Which action would the nurse take first? a. Teach the patient about the importance of good nutrition. b. Serve multiple small feedings of high-calorie, high-protein foods. c. Consult with the health care provider about parenteral nutrition (PN). d. Obtain an order for enteral feedings of liquid nutritional supplements.

b. Serve multiple small feedings of high-calorie, high-protein foods. Rationale: Eating small amounts of food frequently throughout the day is less fatiguing and will improve the patient's ability to take in more nutrients. Teaching the patient may be appropriate but will not address the patient's inability to eat more because of fatigue. Enteral nutrition or PN may be needed if the patient is unable to take in enough nutrients orally but increasing the oral intake should be attempted first.

A patient is receiving continuous enteral nutrition through a small-bore silicone feeding tube. What would the nurse plan for when this patient has a computed tomography (CT) scan ordered? a. Ask the health care provider to reschedule the scan. b. Shut the feeding off 30 to 60 minutes before the scan. c. Connect the feeding tube to continuous suction before and during the scan. d. Send a suction catheter with the patient in case of aspiration during the scan.

b. Shut the feeding off 30 to 60 minutes before the scan. Rationale: The feeding should be shut off 30 to 60 minutes before any procedure requiring the patient to lie flat. Because the CT scan is ordered for diagnosis of patient problems, rescheduling is not usually an option. Prevention, rather than treatment, of aspiration is needed. Small-bore feeding tubes are soft and collapse easily with aspiration or suction, making nasogastric suction of gastric contents unreliable.

A patient with a family history of stomach cancer asks the nurse about ways to decrease the risk for developing stomach cancer. What would the nurse teach the patient to avoid? a. Emotionally stressful situations b. Smoked foods such as ham and bacon c. Foods that cause distention or bloating d. Chronic use of H2 blocking medications

b. Smoked foods such as ham and bacon Smoked foods such as bacon, ham, and smoked sausage increase the risk for stomach cancer. Stressful situations, abdominal distention, and use of H2 blockers are not associated with an increased incidence of stomach cancer.

The nurse is caring for a patient with a biliary obstruction. Which condition would the nurse expect? a. Melena b. Steatorrhea c. Decreased serum cholesterol level d. Increased serum indirect bilirubin level

b. Steatorrhea Rationale: A common bile duct obstruction will reduce the absorption of fat in the small intestine, leading to fatty stools. Gastrointestinal bleeding is not caused by common bile duct obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin level is increased with biliary obstruction.

Which information will the nurse prioritize in planning preoperative education for a patient undergoing a Roux-en-Y gastric bypass? a. Explaining the nasogastric (NG) tube to the patient b. Teaching the patient coughing and breathing techniques c. Discussing necessary postoperative modifications in lifestyle d. Demonstrating passive range-of-motion exercises for the legs

b. Teaching the patient coughing and breathing techniques Rationale: Coughing and deep breathing can prevent major postoperative complications such as carbon monoxide retention and hypoxemia. Information about passive range of motion, the NG tube, and postoperative modifications in lifestyle will also be discussed, but avoidance of respiratory complications is the priority goal after surgery.

The nurse is assessing a patient who had a total gastrectomy 8 hours ago. Which information is most important to report to the health care provider? a. Hemoglobin (Hgb) 10.8 g/dL b. Temperature 102.1F (38.9C) c. Absent bowel sounds in all quadrants d. Scant nasogastric (NG) tube drainage

b. Temperature 102.1F (38.9C) An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery and do not require any urgent action.

The nurse and a licensed practical/vocational nurse (LPN/VN) are working together to care for a patient who had an esophagectomy 2 days ago. Which action by the LPN/VN requires that the nurse intervene? a. The LPN/VN uses soft swabs to provide oral care. b. The LPN/VN positions the head of the bed in the flat position. c. The LPN/VN includes the enteral feeding volume when calculating intake. d. The LPN/VN encourages the patient to use pain medications before coughing.

b. The LPN/VN positions the head of the bed in the flat position. The patient's bed would be in Fowler's position to prevent reflux and aspiration of gastric contents. The other actions by the LPN/LVN are appropriate.

A patient is admitted to the outpatient testing area for an ultrasound of the gallbladder. Which information obtained by the nurse indicates that the ultrasound may need to be rescheduled? a. The patient has a gastrostomy tube. b. The patient ate a bagel 4 hours ago. c. The patient took a laxative the day before. d. The patient had a high-fat meal the previous evening.

b. The patient ate a bagel 4 hours ago. Rationale: Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient would be NPO for 8 to 12 hours before the test. A high-fat meal the previous evening, laxative use, or a gastrostomy tube will not affect the results of the study.

Which finding for a patient who has been taking orlistat (Xenical) is most important to report to the health care provider? a. The patient has frequent liquid stools. b. The patient is pale and has many bruises. c. The patient feels very bloated after meals. d. The patient is having a weight loss plateau.

b. The patient is pale and has many bruises. Rationale: Because orlistat blocks the absorption of fat-soluble vitamins, the patient may not be receiving an adequate amount of vitamin K, resulting in a decrease in clotting factors. Abdominal bloating and liquid stools are common side effects of orlistat and indicate that the nurse should remind the patient that fat in the diet may increase these side effects. Weight loss plateaus are expected during weight reduction.

Which information from a 70-yr-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C? a. The patient had a blood transfusion in 2005. b. The patient used IV drugs about 30 years ago. c. The patient frequently eats in fast-food restaurants. d. The patient traveled to a country with poor sanitation.

b. The patient used IV drugs about 30 years ago. Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992 (when an antibody test for hepatitis C became available) do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries.

A 22-yr-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that the nurse's teaching about skin integrity has been effective? a. The patient uses incontinence briefs to contain loose stools. b. The patient uses witch hazel compresses to soothe irritation. c. The patient asks for antidiarrheal medication after each stool. d. The patient cleans the perianal area with soap after each stool.

b. The patient uses witch hazel compresses to soothe irritation. Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications cannot be given 15 to 20 times a day. The perianal area should be washed with plain water or pH balanced cleanser after each stool.

The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? a. The patient reports right upper-quadrant pain with palpation. b. The patient's hands flap back and forth when the arms are extended. c. The patient has ascites and a 2-kg weight gain from the previous day. d. The patient's abdominal skin has multiple spider-shaped blood vessels.

b. The patient's hands flap back and forth when the arms are extended. Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain indicate the need for treatment but not as urgently as the changes in neurologic status.

The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider? a. The bowel sounds are hyperactive in all four quadrants. b. The patient's lungs have crackles audible to the midchest. c. The nasogastric (NG) suction is returning coffee-ground material. d. The patient's blood pressure (BP) has increased to 142/84 mm Hg.

b. The patient's lungs have crackles audible to the midchest. The patient's lung sounds indicate that pulmonary edema may be developing because of the rapid infusion of IV fluid and that the fluid infusion rate would be slowed. The return of coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when a patient has GI bleeding.

Which assessment information will be most important for the nurse to report to the health care provider about a patient who has acute cholecystitis? a. The patient's urine is bright yellow. b. The patient's stools are tan colored. c. The patient reports chronic heartburn. d. The patient has increased pain after eating.

b. The patient's stools are tan colored. Tan or gray stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, and would be reported but do not require urgent intervention.

A 33-yr-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will the nurse include in patient teaching? a. Stool will be expelled from both stomas. b. This type of colostomy is usually temporary. c. Soft, formed stool can be expected as drainage. d. Irrigations can regulate drainage from the stomas.

b. This type of colostomy is usually temporary. A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible.

A critically ill patient with sepsis is frequently incontinent of watery stools. Which action by the nurse will prevent complications associated with ongoing incontinence? a. Apply incontinence briefs. b. Use a fecal management system. c. Insert a rectal tube with a drainage bag. d. Assist the patient to a commode frequently.

b. Use a fecal management system. Fecal management systems are designed to contain loose stools and can be in place for as long as 4 weeks without causing damage to the rectum or anal sphincters. Although incontinence briefs may be helpful, unless they are changed frequently, they are likely to increase the risk for skin breakdown. Rectal tubes are avoided because of possible damage to the anal sphincter and ulceration of the rectal mucosa. A critically ill patient will not be able to tolerate getting up frequently to use the commode or bathroom.

Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? a. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Use care when eating high-fiber foods to avoid obstruction of the ileum. c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d. Change the pouch every day to prevent leakage of contents onto the skin.

b. Use care when eating high-fiber foods to avoid obstruction of the ileum. High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies do not have a colon for the absorption of water; they need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible.

Which information in this male patient's electronic health record as shown in the accompanying figure will the nurse use to confirm that the patient has metabolic syndrome? (Select all that apply.) Vital Signs: Temp: 98.2F BP: 126.82 Pulse: 98 Respirations: 20 Assessment Data: Wt: 91 kg Ht: 68 in BMI: 30.4 kg/m2 Waist Circumference: 41 in. Lab Results: Fasting Blood Glucose: 124 mg/dL Total Cholesterol: 234 mg/dL HDL: 34 mg/dL LDL: 194 mg/dL Triglycerides: 130 mg/dL a. Weight b. Waist size c. Blood glucose d. Blood pressure e. Triglyceride level f. Total cholesterol level

b. Waist size c. Blood glucose Rationale: The patient's waist circumference, high-density lipoprotein level, and fasting blood glucose level indicate that he has metabolic syndrome. The other data are not used in making a metabolic syndrome diagnosis or do not meet the criteria for this diagnosis.

The nurse evaluates that administration of hepatitis B vaccine to a healthy patient was effective when the patient's later blood specimen reveals the presence of a. HBsAg. b. anti-HBs. c. anti-HBc IgG. d. anti-HBc IgM.

b. anti-HBs. The presence of surface antibody to hepatitis B (anti-HBs) is a marker of a positive response to the vaccine or previous illness with hepatitis B. The other laboratory values indicate current infection with hepatitis B.

A 26-yr-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient's symptoms? a. "What type of foods do you eat?" b. "Is it possible that you are pregnant?" c. "Can you tell me more about the pain?" d. "What is your usual elimination pattern?"

c. "Can you tell me more about the pain?" A complete description of the pain provides clues about the cause of the problem. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms.

A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies, but serologic testing is negative for viral causes of hepatitis. Which question would the nurse ask? a. "Have you taken corticosteroids?" b. "Do you have a history of IV drug use?" c. "Do you use any over-the-counter drugs?" d. "Have you recently traveled to another country?"

c. "Do you use any over-the-counter drugs?" The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause acute liver dysfunction.

A woman who was recently diagnosed with esophageal cancer tells the nurse, "I do not feel ready to die yet." Which response would the nurse provide? a. "You may have quite a few years still left to live." b. "Thinking about dying will only make you feel worse." c. "Having this new diagnosis must be very hard for you." d. "It is important that you be realistic about your prognosis."

c. "Having this new diagnosis must be very hard for you." This response is open ended and will encourage the patient to further discuss feelings of anxiety or sadness about the diagnosis. Patients with esophageal cancer have a low survival rate, so the response "You may have quite a few years still left to live" is misleading. The response beginning, "Thinking about dying" indicates that the nurse is not open to discussing the patient's fears of dying. The response beginning, "It is important that you be realistic" discourages the patient from feeling hopeful, which is important to patients with any life-threatening diagnosis.

Which patient statement indicates that the nurse's postoperative teaching after a gastroduodenostomy has been effective? a. "I will drink more liquids with my meals." b. "I should choose high carbohydrate foods." c. "Vitamin supplements may prevent anemia." d. "Persistent heartburn is expected after surgery."

c. "Vitamin supplements may prevent anemia." Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to receive cobalamin via injections or nasal spray. Although peptic ulcer disease may recur, persistent heartburn is not expected after surgery, and the patient should call the health care provider if this occurs. Ingestion of liquids with meals is avoided to prevent dumping syndrome. Foods that have moderate fat and low carbohydrate should be chosen to prevent dumping syndrome.

After change-of-shift report, which patient would the nurse assess first? a. A 42-yr-old patient who has acute gastritis and ongoing epigastric pain b. A 70-yr-old patient with a hiatal hernia who experiences frequent heartburn c. A 60-yr-old patient with nausea and vomiting who is lethargic with dry mucosa d. A 53-yr-old patient who has dumping syndrome after a recent partial gastrectomy

c. A 60-yr-old patient with nausea and vomiting who is lethargic with dry mucosa A patient with nausea and vomiting who is lethargic with dry mucosa is at high risk for problems such as aspiration, dehydration, and fluid and electrolyte disturbances. The other patients will also need to be assessed, but the information about them indicates symptoms that are typical for their diagnoses and are not life threatening.

After change-of-shift report, which patient would the nurse assess first? a. A 42-yr-old patient who has acute gastritis and ongoing epigastric pain b. A 70-yr-old patient with a hiatal hernia who experiences frequent heartburn c. A 60-yr-old patient with nausea and vomiting who is lethargic with dry mucosa d. A 53-yr-old patient who has dumping syndrome after a recent partial gastrectomy

c. A 60-yr-old patient with nausea and vomiting who is lethargic with dry mucosa A patient with nausea and vomiting who is lethargic with dry mucosa is at high risk for problems such as aspiration, dehydration, and fluid and electrolyte disturbances. The other patients will also need to be assessed, but the information about them indicates symptoms that are typical for their diagnoses and are not life threatening.

During change-of-shift report, the nurse learns about the following four patients. Which patient would the nurse assess first? a. A patient who has compensated cirrhosis and reports anorexia b. A patient with chronic pancreatitis who has gnawing abdominal pain c. A patient with cirrhosis and ascites who has a temperature of 102F (38.8C) d. A patient recovering from a laparoscopic cholecystectomy who has severe shoulder pain

c. A patient with cirrhosis and ascites who has a temperature of 102F (38.8C) This patient's history and fever suggest possible spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.

Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment? a. Loud gurgles b. High-pitched gurgles c. Absent bowel sounds d. Intermittent sounds

c. Absent bowel sounds Rationale: Absent bowel sounds are abnormal and require further assessment by the nurse. Normal sounds are relatively high pitched intermittent gurgling.

Which prescribed action will the nurse implement first for a patient who has vomited 1100 mL of blood? a. Give an IV H2 receptor antagonist. b. Draw blood for type and crossmatch. c. Administer 1 L of lactated Ringer's solution. d. Insert a nasogastric (NG) tube and connect to suction.

c. Administer 1 L of lactated Ringer's solution. Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions also are important to implement quickly but are not the highest priorities.

An adult with E. coli O157:H7 food poisoning is admitted to the hospital with bloody diarrhea and dehydration. Which prescribed action will the nurse question? a. Infuse lactated Ringer's solution at 250 mL/hr. b. Monitor blood urea nitrogen and creatinine daily. c. Administer loperamide (Imodium) after each stool. d. Provide a clear liquid diet and progress diet as tolerated.

c. Administer loperamide (Imodium) after each stool. Use of antidiarrheal agents is avoided with this type of food poisoning because the drugs slow GI motility and can prolong infection. IV fluids, clear oral fluids, and monitoring renal function are appropriate for dehydration.

The nurse is caring for a patient with pancreatic cancer. Which nursing action would be the highest priority? a. Offer psychologic support for depression. b. Offer high-calorie, high-protein dietary choices. c. Administer prescribed opioids to relieve pain as needed. d. Teach about the need to avoid scratching any pruritic areas.

c. Administer prescribed opioids to relieve pain as needed. Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to teaching, or manage anxiety or depression.

A patient has peptic ulcer disease associated with Helicobacter pylori. Which medications will the nurse plan to teach the patient? a. Sucralfate (Carafate), nystatin, and bismuth (Pepto-Bismol) b. Metoclopramide (Reglan), bethanechol, and promethazine c. Amoxicillin (Amoxil), clarithromycin, and omeprazole (Prilosec) d. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole

c. Amoxicillin (Amoxil), clarithromycin, and omeprazole (Prilosec) The drugs used in triple drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not included in the protocol for H. pylori infection.

To evaluate an obese patient for adverse effects of Plenity, which action will the nurse take? a. Measure the apical pulse. b. Check sclera for jaundice. c. Ask about bowel movements. d. Assess for agitation or restlessness.

c. Ask about bowel movements. Rationale: Constipation is a common side effect of Plenity, a gel substance taken to increase the volume of stomach and small intestine contents and induce satiety. The other assessments would be appropriate for other weight-loss medications.

A patient calls the clinic reporting diarrhea for 24 hours. Which action would the nurse take first? a. Inform the patient that testing of blood and stools will be needed. b. Suggest that the patient drink clear liquid fluids with electrolytes. c. Ask the patient to describe the stools and any associated symptoms. d. Advise the patient to use over-the-counter antidiarrheal medication.

c. Ask the patient to describe the stools and any associated symptoms. The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment.

How would the nurse prepare a patient with ascites for paracentesis? a. Place the patient on NPO status. b. Assist the patient to lie flat in bed. c. Ask the patient to empty the bladder. d. Position the patient on the right side.

c. Ask the patient to empty the bladder. The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Because no sedation is required for paracentesis, the patient does not need to be NPO.

After successfully losing a pound per week for several months, a patient at the clinic has not lost any weight for the past month. Which action should the nurse take first? a. Review the diet and exercise guidelines with the patient. b. Instruct the patient to weigh and record weights weekly. c. Ask the patient whether there have been any changes in exercise or diet patterns. d. Discuss the possibility that the patient has reached a temporary weight loss plateau.

c. Ask the patient whether there have been any changes in exercise or diet patterns. Rationale: The initial nursing action should be assessment of reasons for weight stability. The other actions may be needed, but further assessment is required before any interventions are planned or implemented.

A patient born in 1955 had hepatitis A infection 1 year ago. Which action would the nurse include in care when the patient is seen for a routine annual physical examination? a. Start the hepatitis B immunization series. b. Teach the patient about hepatitis A immune globulin. c. Ask whether the patient has been screened for hepatitis C. d. Test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM).

c. Ask whether the patient has been screened for hepatitis C. Current CDC guidelines indicate that all patients who were born between 1945 and 1965 should be screened for hepatitis C because many persons who are positive have not been diagnosed. Although routine hepatitis B immunization is recommended for infants, children, and adolescents, vaccination for hepatitis B is recommended only for adults at risk for blood-borne infections. Because the patient has already had hepatitis A, immunization, and anti-HAV IgM levels will not be needed.

A patient had an abdominal-perineal resection for colon cancer. Which action is most important for the nurse to include in the plan of care for the day after surgery? a. Teach about a low-residue diet. b. Monitor output from the stoma. c. Assess the drainage and incision. d. Encourage acceptance of the stoma.

c. Assess the drainage and incision. Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.

A young adult has been admitted to the emergency department with nausea and vomiting. Which action could the RN delegate to assistive personnel (AP)? a. Auscultate the bowel sounds. b. Assess for signs of dehydration. c. Assist the patient with oral care. d. Ask more questions about the nausea.

c. Assist the patient with oral care. Oral care is included in AP education and scope of practice. The other actions are all assessments that require more education and a higher scope of nursing practice.

A patient is being admitted for bariatric surgery. Which nursing action can the nurse delegate to assistive personnel (AP)? a. Demonstrate use of the incentive spirometer. b. Plan methods for turning the patient after surgery. c. Assist with IV insertion by holding adipose tissue out of the way. d. Develop strategies to provide privacy and decrease embarrassment.

c. Assist with IV insertion by holding adipose tissue out of the way. Rationale: AP can assist with IV placement by assisting with patient positioning or holding skinfolds aside. Planning for care and patient teaching require registered nurse (RN)-level education and scope of practice.

A patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), which assessment would the nurse plan to make more frequently than is routine? a. Apical pulse b. Bowel sounds c. Breath sounds d. Abdominal girth

c. Breath sounds Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine.

Which action would the nurse in the emergency department take first for a patient who arrives vomiting blood? a. Insert a large-gauge IV catheter. b. Draw blood for coagulation studies. c. Check blood pressure and heart rate. d. Place the patient in the supine position.

c. Check blood pressure and heart rate. The nurse's first action would be to determine the patient's hemodynamic status by assessing vital signs. Drawing blood for coagulation studies and inserting an IV catheter are also appropriate. However, the vital signs may indicate the need for more urgent actions. Because aspiration is a concern for this patient, the nurse will need to assess the patient's vital signs and neurologic status before placing the patient in a supine position.

A 19-yr-old woman is brought to the emergency department with a knife handle protruding from her abdomen. Which action would the nurse take during the initial assessment of the patient? a. Remove the knife and assess the wound. b. Determine the presence of Rovsing sign. c. Check for circulation and tissue perfusion. d. Insert a urinary catheter and assess for hematuria.

c. Check for circulation and tissue perfusion. The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. Assessment for bladder trauma is not part of the initial assessment.

Four hours after a bowel resection, a 74-yr-old male patient with a nasogastric tube to suction reports nausea and abdominal distention. Which action would the nurse take first? a. Auscultate for hypotonic bowel sounds. b. Notify the patient's health care provider. c. Check for tube placement and reposition it. d. Remove the tube and replace it with a new one.

c. Check for tube placement and reposition it. Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider unless other interventions do not resolve the problem. Information about the presence or absence of bowel sounds will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient, so that would only be done if the tube was completely occluded.

When taking the blood pressure (BP) on the right arm of a patient who has severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action would the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level in the health record. d. Notify the health care provider immediately.

c. Check the calcium level in the health record. The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider would be notified after the nurse checks the patient's calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain.

Which patient choice for a snack 3 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective? a. Chocolate pudding b. Glass of low-fat milk c. Cherry gelatin with fruit d. Peanut butter and jelly sandwich

c. Cherry gelatin with fruit Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods such as chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure.

A 72-yr-old patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider? a. Skin is dry with tenting and poor turgor. b. Patient has not voided for the last 2 hours. c. Crackles are heard halfway up the posterior chest. d. Patient has had 5 loose stools over the previous 6 hours.

c. Crackles are heard halfway up the posterior chest. The presence of crackles in an older patient receiving IV fluids at a high rate suggests volume overload and a need to reduce the rate of the IV infusion. The other data will be reported but are consistent with the patient's age and diagnosis and do not require a change in the prescribed treatment.

Which activity in the care of a patient with a new colostomy could the nurse delegate to assistive personnel (AP)? a. Document the appearance of the stoma. b. Place a pouching system over the ostomy. c. Drain and measure the output from the ostomy. d. Check the skin around the stoma for breakdown.

c. Drain and measure the output from the ostomy. Draining and measuring the output from the ostomy is included in AP education and scope of practice. The other actions should be implemented by LPNs or RNs.

A 19-yr-old woman admitted with anorexia nervosa is 5 ft, 6 in (163 cm) tall and weighs 88 lb (41 kg). Laboratory tests reveal hypokalemia and iron-deficiency anemia. Which patient problem has the highest priority? a. Difficulty coping b. Negative self-image c. Electrolyte imbalance d. Nutritionally compromised

c. Electrolyte imbalance Rationale: The patient's hypokalemia may lead to life-threatening cardiac dysrhythmias. The other diagnoses may also be appropriate for this patient but are not associated with immediate risk for fatal complications.

The nurse is caring for a patient on the first postoperative day after a Roux-en-Y gastric bypass procedure. Which assessment finding should be reported immediately to the provider? a. Bilateral crackles audible at both lung bases b. Redness, irritation, and skin breakdown in skinfolds c. Emesis of bile-colored fluid past the nasogastric (NG) tube d. Use of patient-controlled analgesia (PCA) several times an hour for pain

c. Emesis of bile-colored fluid past the nasogastric (NG) tube Rationale: Vomiting with an NG tube in place indicates that the NG tube needs to be repositioned by the provider to avoid putting stress on the gastric sutures. The nurse should implement actions to decrease skin irritation and have the patient cough and deep breathe, but these do not indicate a need for rapid notification of the provider. Frequent PCA use after bariatric surgery is expected.

An older patient reports chronic constipation. When would the nurse suggest that the patient regularly attempt defecation? a. Right after awakening in the morning b. Before eating breakfast c. Immediately after the first daily meal d. Right before bedtime

c. Immediately after the first daily meal Rationale: The gastrocolic reflex is most active after the first daily meal. Awakening, the anticipation of eating, and bedtime timing do not stimulate these reflexes.

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

c. Infuse a liter of lactated Ringer's solution over 30 minutes. The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.

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

c. Infuse metronidazole (Flagyl) 500 mg IV. Because peritonitis can be fatal if treatment is delayed, the initial action would be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated.

At his first postoperative checkup appointment after a gastrojejunostomy (Billroth II), a patient reports that dizziness, weakness, and palpitations occur about 20 minutes after each meal. Which action would the nurse teach the patient to take? a. Increase the amount of fluid with meals. b. Eat foods that are higher in carbohydrates. c. Lie down for about 30 minutes after eating. d. Drink sugared fluids or eat candy after meals.

c. Lie down for about 30 minutes after eating. The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down for a short rest after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome.

Which information will the nurse include in teaching for a 35-yr-old woman who is overweight and starting a weight-loss plan? a. Weigh yourself at the same time every morning and evening. b. Stick to a 600- to 800-calorie diet for the most rapid weight loss. c. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain. d. Weighing all foods on a scale is necessary to choose appropriate portion sizes.

c. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain. Rationale: The restrictive nature of fad diets makes the weight loss achieved by the patient more difficult to maintain. Portion size can be estimated in other ways besides weighing. Severely calorie-restricted diets are not necessary for patients in the overweight category and need to be closely supervised. Patients should weigh weekly rather than daily.

A 76-yr-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action would the nurse take first? a. Administer bulk-forming laxatives. b. Assist the patient to sit on the toilet. c. Manually remove the hard stool. d. Increase the patient's oral fluid intake.

c. Manually remove the hard stool. The initial action with a fecal impaction is manual disimpaction. The other actions will be used to prevent future constipation and impactions.

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient who has acute pancreatitis? a. Nausea and vomiting b. Hypotonic bowel sounds c. Muscle twitching and finger numbness d. Upper abdominal tenderness and guarding

c. Muscle twitching and finger numbness Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Although the other findings should also be reported to the health care provider, they do not indicate complications that require rapid action.

Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? a. Scrambled eggs b. White toast and jam c. Oatmeal with cream d. Pancakes with syrup

c. Oatmeal with cream During acute exacerbations of IBD, the patient would avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.

The nurse is planning care for a patient who is chronically malnourished. Which action would the nurse to delegate to assistive personnel (AP)? a. Assist the patient to choose high-nutrition items from the menu. b. Monitor the patient for skin breakdown over the bony prominences. c. Offer the patient the prescribed nutritional supplement between meals. d. Assess the patient's strength while ambulating the patient in the room.

c. Offer the patient the prescribed nutritional supplement between meals. Rationale: Feeding the patient and assisting with oral intake are included in AP education and scope of practice. Assessing the patient and assisting the patient in choosing high-nutrition foods require licensed practical/vocational nurse (LPN/VN)—or registered nurse (RN)—level education and scope of practice.

The nurse has completed teaching a patient with newly diagnosed eosinophilic esophagitis about the management of the disease. Which patient action indicates that the teaching has been effective? a. Patient orders nonfat milk for each meal. b. Patient uses the prescribed corticosteroid inhaler. c. Patient schedules an appointment for allergy testing. d. Patient takes ibuprofen (Advil) to control throat pain.

c. Patient schedules an appointment for allergy testing. Eosinophilic esophagitis is frequently associated with environmental allergens, so allergy testing is used to determine possible triggers. Corticosteroid therapy may be prescribed, but the medication will be swallowed, not inhaled. Milk is a frequent trigger for attacks. NSAIDs are not used for eosinophilic esophagitis.

A 76-yr-old woman with a body mass index (BMI) of 17 kg/m2 and a low serum albumin level is being admitted. Which assessment finding would the nurse expect? a. Restlessness b. Hypertension c. Pitting edema d. Food allergies

c. Pitting edema Rationale: Edema occurs when serum albumin levels and plasma oncotic pressure decrease. The blood pressure and level of consciousness are not directly affected by malnutrition. Food allergies are not an indicator of nutritional status.

Which action would the nurse include in the plan of care for a patient who is being admitted with a C. difficile infection? a. Teach the patient about proper food storage. b. Order a diet without dairy products for the patient. c. Place the patient in a private room on contact isolation. d. Teach the patient about why antibiotics will not be used.

c. Place the patient in a private room on contact isolation. Because C. difficile is highly contagious, the patient would be placed in a private room, and contact precautions would be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile infections. Improper food handling and storage do not cause C. difficile.

A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a parenteral nutrition (PN) infusion. Which action would the nurse take? a. Obtain a venous blood glucose specimen. b. Slow the infusion rate of the PN infusion. c. Recheck the blood glucose level in 4 to 6 hours. d. Contact the health care provider for infusion rate changes.

c. Recheck the blood glucose level in 4 to 6 hours. Rationale: Mild hyperglycemia is expected during the first few days after PN is started and requires ongoing monitoring. Because the glucose elevation is small and expected, infusion rate changes are not needed. There is no need to obtain a venous specimen for comparison. Slowing the rate of the infusion is beyond the nurse's scope of practice and will decrease the patient's nutritional intake.

Which finding in the mouth of a patient who uses smokeless tobacco is suggestive of oral cancer? a. Bleeding during tooth brushing b. Painful blisters at the lip border c. Red patches on the buccal mucosa d. Curdlike plaques on the posterior tongue

c. Red patches on the buccal mucosa A red, velvety patch suggests erythroplasia, which has a high incidence (>50%) of progression to squamous cell carcinoma. The other lesions are suggestive of acute processes (e.g., gingivitis, oral candidiasis, herpes simplex).

A 36-yr-old female patient is receiving treatment for chronic hepatitis B with pegylated interferon (Pegasys). Which finding is important to communicate to the health care provider to suggest a change in therapy? a. Nausea and anorexia b. Weight loss of 2 lb (1 kg) c. Report of severe depression d. Hemoglobin level of 10.4 g/dL

c. Report of severe depression Depression is a side effect of therapy. We must screen patients for depression and other mood disorders before starting treatment and monitor them frequently while on therapy. Anemia, weight loss, and nausea are common adverse effects of the prescribed regimen and may require actions such as patient teaching, but they would not require immediate cessation of the therapy.

While interviewing a young adult patient, the nurse learns that the patient has a family history of familial adenomatous polyposis (FAP). Which area of patient knowledge would the nurse plan to assess? a. Preventing noninfectious hepatitis b. Treating inflammatory bowel disease c. Risk for developing colorectal cancer d. Using antacids and proton pump inhibitors

c. Risk for developing colorectal cancer Rationale: FAP is a genetic condition that greatly increases the risk for colorectal cancer. Noninfectious hepatitis, use of medications that treat increased gastric pH, and inflammatory bowel disease are not related to FAP.

A patient who has cirrhosis and esophageal varices is being treated with propranolol. Which finding is the best indicator to the nurse that the medication has been effective? a. The patient reports no chest pain. b. Blood pressure is 130/80 mm Hg. c. Stools test negative for occult blood. d. The apical pulse rate is 68 beats/min.

c. Stools test negative for occult blood. Because the purpose of b-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices.

A young adult patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action would the nurse take? a. Assist the patient to cough and deep breathe. b. Palpate the abdomen for rebound tenderness. c. Suggest the patient lie on the side, flexing the right leg. d. Encourage the patient to sip clear, noncarbonated liquids.

c. Suggest the patient lie on the side, flexing the right leg. The patient's clinical manifestations are consistent with appendicitis. Lying still with the right leg flexed is often the most comfortable position. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient should be NPO in case immediate surgery is needed. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.

After abdominal surgery, a patient with protein calorie malnutrition is receiving parenteral nutrition (PN). Which data is the best indicator that the patient is receiving adequate nutrition? a. Serum albumin level is 3.5 mg/dL. b. Fluid intake and output are balanced. c. Surgical incision is healing normally. d. Blood glucose is less than 110 mg/dL.

c. Surgical incision is healing normally. Rationale: Because poor wound healing is a possible complication of malnutrition for this patient, normal healing of the incision is an indicator of the effectiveness of the PN in providing adequate nutrition. Blood glucose is monitored to prevent the complications of hyperglycemia and hypoglycemia, but it does not indicate that the patient's nutrition is adequate. The intake and output will be monitored, but do not indicate that the PN is effective. The albumin level is in the low-normal range but does not reflect adequate caloric intake, which is also important for the patient.

Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago? a. Dry palpebral and oral mucosa b. Crackles at bilateral lung bases c. Temperature 100.8F (38.2C) d. No bowel movement for 4 days

c. Temperature 100.8F (38.2C) The risk of infection is high in the first few months after liver transplant, and fever is frequently the only sign of infection. The other patient data indicate the need for further assessment or nursing actions and might be communicated to the health care provider, but they do not indicate a need for urgent action.

Which response by the nurse best explains the purpose of propranolol for a patient who was admitted with bleeding esophageal varices? a. The medication will reduce the risk for aspiration. b. The medication will inhibit development of gastric ulcers. c. The medication will prevent irritation of the enlarged veins. d. The medication will decrease nausea and improve the appetite.

c. The medication will prevent irritation of the enlarged veins. Esophageal varices are dilated submucosal veins. Patients with varices who are at risk for bleeding often receive a nonselective -blocker (nadolol, propranolol) to reduce bleeding risk. Beta-Blockers decrease high portal pressure, which decreases the risk for rupture. Propranolol does not decrease the risk for peptic ulcers, reduce nausea, or help prevent aspiration pneumonia.

A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours ago. Which assessment finding is most important for the nurse to address immediately? a. The patient reports 7/10 (0 to 10 scale) abdominal pain. b. The patient is experiencing intermittent waves of nausea. c. The patient has no breath sounds in the left anterior chest. d. The patient has hypoactive bowel sounds in all four quadrants.

c. The patient has no breath sounds in the left anterior chest. Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The nausea and abdominal pain would be addressed, but they are not as high priority as the patient's respiratory status. Decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action.

A patient has just been admitted to the emergency department with nausea and vomiting. Which information requires the most rapid intervention by the nurse? a. The patient has been vomiting for 4 days. b. The patient takes antacids 8 to 10 times a day. c. The patient is lethargic and difficult to arouse. d. The patient had a small intestinal resection 2 years ago.

c. The patient is lethargic and difficult to arouse. A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information is also important to collect, but it does not require as quick action as the risk for aspiration.

A 20-yr-old woman is being admitted with electrolyte disorders of unknown etiology. Which assessment finding is most important to report to the health care provider? a. The patient uses laxatives daily. b. The patient's knuckles are macerated. c. The patient's serum potassium level is 2.9 mEq/L. d. The patient has a history of extreme weight fluctuations.

c. The patient's serum potassium level is 2.9 mEq/L. Rationale: The low serum potassium level may cause life-threatening cardiac dysrhythmias, and potassium supplementation is needed rapidly. The other information will also be reported because it suggests that bulimia may be the etiology of the patient's electrolyte disturbances, but it does not suggest imminent life-threatening complications.

A patient has arrived in the recovery area after an upper endoscopy. Which information collected by the nurse is most important to communicate to the health care provider? a. The patient is very drowsy. b. The patient reports a sore throat. c. The patient's temperature is 101.4F. d. The patient's pulse rate is 100 beats/min.

c. The patient's temperature is 101.4F. Rationale: A temperature elevation may indicate that an acute perforation has occurred. The other assessment data are normal immediately after the procedure.

A patient had an incisional cholecystectomy 6 hours ago. Which action would the nurse identify as the highest priority for the patient to accomplish? a. Perform leg exercises hourly while awake. b. Ambulate the evening of the operative day. c. Turn, cough, and deep breathe every 2 hours. d. Choose preferred low-fat foods from the menu.

c. Turn, cough, and deep breathe every 2 hours. Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions are also important to implement but are not as high a priority as ensuring adequate ventilation.

Which information about an 80-year old male patient at he senior center is of most concern to the nurse? a. Decreased appetite b. Occasional indigestion c. Unintended weight loss d. Difficulty chewing foos

c. Unintended weight loss Rationale: Unintentional weight loss is not a normal finding and may indicate a problem such as cancer or depression. Poor appetite, difficulty in chewing, and indigestion are common in older patients. These will need to be addressed but are not of as much concern as the weight loss.

A patient vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. What would the nurse ask the patient about to determine possible risk factors for gastritis? a. The amount of saturated fat in the diet b. A family history of gastric or colon cancer c. Use of nonsteroidal antiinflammatory drugs d. A history of a large recent weight gain or loss

c. Use of nonsteroidal antiinflammatory drugs Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis.

Four months after bariatric surgery, a patient tells the nurse, "My skin is hanging off me. I think I might want to surgery to remove the skinfolds." Which response would the nurse provide? a. "The important thing now is that you are improving your health." b. "The skinfolds show everyone how much weight you have lost." c. "Perhaps you should talk to a counselor about your body image." d. "Cosmetic surgery may be possible once your weight has stabilized."

d. "Cosmetic surgery may be possible once your weight has stabilized." Rationale: passed since the surgery. The responses, "The important thing is that your weight loss is improving your health," and "The skinfolds show everyone how much weight you have lost," ignore the patient's concerns about appearance and implies that the nurse knows what is important. It may be helpful for the patient to talk to a counselor; however, there is no indication given that the concern about skinfolds is dysfunctional.

Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome (IBS)? a. "Have you been passing a lot of gas?" b. "What foods affect your bowel patterns?" c. "Do you have any abdominal distention?" d. "How long have you had abdominal pain?"

d. "How long have you had abdominal pain?" One criterion for the diagnosis of irritable bowel syndrome is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are associated with IBS but are not diagnostic criteria.

Which statement by a patient with jaundice indicates a need for teaching? a. "I used cough syrup several times a day last week." b. "I take a baby aspirin every day to prevent strokes." c. "I take an antacid for indigestion several times a week" d. "I use acetaminophen (Tylenol) every 4 hours for pain."

d. "I use acetaminophen (Tylenol) every 4 hours for pain." Rationale: Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the patient's jaundice. The other patient statements require further assessment by the nurse but do not indicate a need for patient education.

How would the nurse explain esomeprazole (Nexium) to a patient who has recurring heartburn? a. "It reduces gastroesophageal reflux by increasing the rate of gastric emptying." b. "It neutralizes stomach acid and provides relief of symptoms in a few minutes." c. "It coats and protects the lining of the stomach and esophagus from gastric acid." d. "It treats gastroesophageal reflux disease by decreasing stomach acid production."

d. "It treats gastroesophageal reflux disease by decreasing stomach acid production." The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly.

Which finding is likely in the nurse's assessment of a patient who has a large bowel obstruction? a. Referred back pain b. Metabolic alkalosis c. Projectile vomiting d. Abdominal distention

d. Abdominal distention Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction.

A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective? a. Bowel sounds are present. b. Grey Turner sign resolves. c. Electrolyte levels are normal. d. Abdominal pain is decreased.

d. Abdominal pain is decreased. NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status has been effective. Electrolyte levels may be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this to occur to determine whether treatment was effective.

A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action would the nurse take? a. Withhold both drugs. b. Administer both drugs. c. Administer the furosemide. d. Administer the spironolactone.

d. Administer the spironolactone. Spironolactone is a potassium-sparing diuretic and will help increase the patient's potassium level. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider.

A patient has cirrhosis and 4+ pitting edema. Which focused data would the nurse assess? a. Hemoglobin b. Temperature c. Activity level d. Albumin Level

d. Albumin Level The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters are not directly associated with the patient's edema.

The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. Which medication schedule would the nurse teach the patient? a. Sucralfate at bedtime and antacids before each meal b. Sucralfate and antacids together 0 minutes before meals c. Antacids 30 minutes before each dose of sucralfate is taken d. Antacids after meals and sucralfate 30 minutes before meals

d. Antacids after meals and sucralfate 30 minutes before meals Sucralfate is most effective when the pH is low and should not be given with or soon after antacids. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications.

A young adult contracts hepatitis from contaminated food. Which result would the nurse expect serologic testing to reveal during the acute (icteric) phase of the patient's illness? a. Antibody to hepatitis D (anti-HDV) b. Hepatitis B surface antigen (HBsAg) c. Anti-hepatitis A virus immunoglobulin G (anti-HAV IgG) d. Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)

d. Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM) Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.

A 40-yr-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia. Which patient teaching will the nurse provide before discharge? a. Soak in Sitz baths several times each day. b. Cough 5 times each hour for the next 48 hours. c. Avoid using acetaminophen (Tylenol) for pain. d. Apply a scrotal support and ice to reduce swelling.

d. Apply a scrotal support and ice to reduce swelling. A scrotal support and ice are used to reduce edema and pain. Coughing will increase pressure on the incision. Sitz baths will not relieve pain and would not be of use after this surgery. Acetaminophen can be used for postoperative pain.

A 60-yr-old man who is hospitalized with an abdominal wound infection has been eating very little and states, "Nothing on the menu sounds good." Which action by the nurse will be most effective in improving the patient's oral intake? a. Order six small meals daily. b. Make a referral to the dietitian. c. Teach the patient about high-calorie foods. d. Ask family members to bring favorite foods.

d. Ask family members to bring favorite foods. Rationale: The patient's statement that the hospital foods are unappealing indicates that favorite home-cooked foods might improve intake. The other interventions may also help improve the patient's intake, but the most effective action will be to offer the patient more appealing foods.

Which topic would the nurse plan to teach to a patient with Crohn's disease who has megaloblastic anemia? a. Iron dextran infusions b. Oral ferrous sulfate tablets c. Routine blood transfusions d. Cobalamin (B12) supplements

d. Cobalamin (B12) supplements Crohn's disease frequently affects the ileum, where absorption of cobalamin occurs. Cobalamin must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions.

Which condition would the nurse anticipate when caring for a patient with a history of a total gastrectomy? a. Constipation b. Dehydration c. Elevated total serum cholesterol d. Cobalamin (vitamin B12) deficiency

d. Cobalamin (vitamin B12) deficiency Rationale: The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for cobalamin (vitamin B12) absorption. Because the stomach absorbs only small amounts of water and nutrients, the patient is not at higher risk for dehydration, elevated cholesterol, or constipation.

Which breakfast choice indicates a patient's good understanding of information about a diet for celiac disease? a. Wheat toast with butter b. Oatmeal with nonfat milk c. Bagel with low-fat cream cheese d. Corn tortilla with scrambled eggs

d. Corn tortilla with scrambled eggs Avoidance of gluten-containing foods is the only treatment for celiac disease. Corn does not contain gluten, but oatmeal and wheat do.

A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. Which action would the nurse take? a. Place ice packs around the stoma. b. Notify the surgeon about the stoma. c. Monitor the stoma every 30 minutes. d. Document stoma assessment findings.

d. Document stoma assessment findings. The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery. An ice pack is not needed.

Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? a. Increased serum albumin level b. Decreased indirect bilirubin level c. Improved alertness and orientation d. Fewer episodes of bleeding varices

d. Fewer episodes of bleeding varices TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.

Which menu choice best indicates that the patient is implementing the nurse's suggestion to choose high-calorie, high-protein foods? a. Baked fish with applesauce b. Beef noodle soup and canned corn c. Fresh fruit salad with yogurt topping d. Fried chicken with potatoes and gravy

d. Fried chicken with potatoes and gravy Rationale: Foods that are high in calories include fried foods and those covered with sauces. High-protein foods include meat and dairy products. The other choices are lower in calories and protein.

A patient who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information would the nurse provide? a. Fiber-containing laxatives may reduce the absorption of fat-soluble vitamins. b. Dietary sources of fiber should be eliminated to prevent excessive gas formation. c. Use of this type of laxative to prevent constipation does not cause adverse effects. d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.

d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction. A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should gradually increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives.

An 80-yr-old patient who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration? a. Sucralfate (Carafate) b. Aluminum hydroxide c. Omeprazole (Prilosec) d. Metoclopramide (Reglan)

d. Metoclopramide (Reglan) Metoclopramide can cause central nervous system side effects ranging from anxiety to hallucinations. Hallucinations are not a side effect of proton pump inhibitors, mucosal protectants, or antacids.

A patient who takes a nonsteroidal antiinflammatory drug (NSAID) daily for the management of severe rheumatoid arthritis has recently developed melena. What would the nurse anticipate teaching the patient? a. Substitution of acetaminophen (Tylenol) for the NSAID b. Use of enteric-coated NSAIDs to reduce gastric irritation c. Reasons for using corticosteroids to treat the rheumatoid arthritis d. Misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa

d. Misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa bleeding associated with NSAID use. Enteric coating of NSAIDs does not reduce the risk for GI bleeding. Corticosteroids increase the risk for ulcer development and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating rheumatoid arthritis.

A patient is diagnosed with stomach cancer after an unintended 20-lb weight loss. Which action would the nurse include in the plan of care? a. Refer the patient for hospice services. b. Infuse IV fluids through a central line. c. Teach the patient about antiemetic therapy. d. Offer supplemental feedings between meals.

d. Offer supplemental feedings between meals. The patient data indicate a poor nutritional state and improvement in nutrition will be helpful in improving the response to therapies such as surgery, chemotherapy, or radiation. Nausea and vomiting are not common clinical manifestations of stomach cancer. There is no indication that the patient requires hospice or IV fluid infusions.

Which assessment finding is of most concern for a patient with acute pancreatitis? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass

d. Palpable abdominal mass A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications.

A nurse is considering which patient to admit to the same room as a patient who is hospitalized with acute rejection 3 weeks after a liver transplant. Which patient would be the best choice? a. Patient who is receiving chemotherapy for liver cancer b. Patient who is receiving treatment for acute hepatitis C c. Patient who has a wound infection after cholecystectomy d. Patient who requires pain management for chronic pancreatitis

d. Patient who requires pain management for chronic pancreatitis The patient with chronic pancreatitis does not present an infection risk to the immunosuppressed patient who had a liver transplant. The other patients either are at risk for infection or currently have an infection, which will place the immunosuppressed patient at risk for infection.

A patient with chronic hepatitis B infection declines to take any medication that requires an injection. Which medication, if prescribed, requires further discussion with the health care provider? a. Tenofovir (Viread) b. Adefovir (Hepsera) c. Lamivudine (Epivir) d. Pegylated a-interferon (Pegasys)

d. Pegylated a-interferon (Pegasys) Pegylated a-interferon is administered subcutaneously. Tenofovir (Viread), adefovir (Hepsera), and entecavir (Baraclude) are administered orally. The medications are all appropriate for a patient with chronic hepatitis B infection.

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? a. Restrict daily dietary protein intake. b. Reposition the patient every 4 hours. c. Perform passive range of motion twice daily. d. Place the patient on a pressure-relief mattress.

d. Place the patient on a pressure-relief mattress. The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take the pressure off areas such as the sacrum that are vulnerable to breakdown.

After several days of antibiotic therapy for pneumonia, an older hospitalized patient develops watery diarrhea. Which action would the nurse take first? a. Notify the health care provider. b. Obtain a stool specimen for analysis. c. Teach the patient about hand washing. d. Place the patient on contact precautions.

d. Place the patient on contact precautions. The patient's history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions are also appropriate but can be accomplished after contact precautions are implemented.

Which topic would the nurse anticipate teaching to a patient who has a new report of heartburn? a. Radionuclide tests b. Barium swallow exam c. Endoscopy procedures d. Proton pump inhibitors

d. Proton pump inhibitors Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.

Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)? a. Teach symptoms of variceal bleeding. b. Draw blood for hepatitis serology testing. c. Discuss the need to increase caloric intake. d. Review the patient's current medication list.

d. Review the patient's current medication list. Some medications can increase the risk for NAFLD, and they should be discontinued. NAFLD is not associated with hepatitis, weight loss is usually indicated, and variceal bleeding would not be expected in a patient with asymptomatic NAFLD.

After sleeve gastrectomy, a 42-yr-old male patient returns to the surgical nursing unit with a nasogastric tube to low, intermittent suction and a patient-controlled analgesia (PCA) machine for pain control. Which nursing action would be included in the postoperative plan of care? a. Offer sips of fruit juices at frequent intervals. b. Irrigate the nasogastric (NG) tube frequently. c. Remind the patient that PCA use may slow the return of bowel function. d. Support the surgical incision during patient coughing and turning in bed.

d. Support the surgical incision during patient coughing and turning in bed. Rationale: Protecting the incision from strain decreases the risk for wound dehiscence. The patient should be encouraged to use the PCA because pain control will improve the cough effort and patient mobility. NG irrigation may damage the suture line or overfill the stomach pouch. Sugar-free clear liquids are offered during the immediate postoperative time to decrease the risk for dumping syndrome.

Which assessment would the nurse perform first for a patient who just vomited bright red blood? a. Measuring the quantity of emesis b. Palpating the abdomen for distention c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse

d. Taking the blood pressure (BP) and pulse The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal bleeding. BP and pulse are the best indicators of these complications. The other information is important to obtain, but BP and pulse rate are the best indicators for assessing intravascular volume.

The nurse is providing preoperative teaching for a patient scheduled for an abdominal-perineal resection. Which information will the nurse include? a. The patient will need to be on bedrest for three days after surgery. b. An ileal-anal reservoir will be surgically created in 8 to 12 weeks. c. The patient will have a temporary colostomy for 6-12 months. d. The site for the stoma will be marked on the abdomen before surgery.

d. The site for the stoma will be marked on the abdomen before surgery. A wound, ostomy, continence nurse (WOCN) would select the site where the ostomy will be positioned and mark the abdomen preoperatively. The site would be within the rectus muscle, on a flat surface, and in a place that the patient is able to see. A permanent colostomy is created with this surgery and no further surgery would be planned. The patient will be encouraged to walk the day after surgery.

Which information will the nurse provide for a patient with achalasia? a. A liquid diet will be necessary. b. Avoid drinking fluids with meals. c. Lying down after meals is recommended. d. Treatment may include endoscopic procedures.

d. Treatment may include endoscopic procedures. Endoscopic and laparoscopic procedures are the most effective therapy for improving symptoms caused by achalasia. Keeping the head elevated after eating will improve esophageal emptying. A semisoft diet is recommended to improve esophageal emptying. Patients are advised to drink fluids with meals.