GI/GU Practice Exam

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

increase intake of raw vegetables

a nurse is caring for four clients. which of the following clients should the nurse identify as having the highest risk for aspiration

a client receiving continuous enteral feeding through NG tube

A charge nurse is observing a nurse performing a Mantoux tuberculin skin test for a client. Which of the following should prompt the charge nurse to intervene?

Withdrawing the needle and massaging the site gently

While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following?

a systolic murmur

A nurse withdraws morphine 2 mg from a 4-mg/mL vial to inject IM for a client. Which of the following actions should the nurse take for wasting the excess medication?

have a second nurse witness the disposal of the excess medication

A nurse is administering an oral medication to an older adult client. The client states, "The pill I always take is green. I don't take an orange pill." Which of the following responses should the nurse make?

"I will check your medication order again."

A nurse is assessing a client for pitting edema and notes indentation of 6mm (0.25in) at point of pressure. Which of the following is the appropriate doc of edema?

3+

A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following foods should the nurse allow the client to have?

grape juice

A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure?

"I'll use the cleansing wipe to wipe from front to back."

A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client's partner indicates the teaching was effective?

"My partner should tilt their head forward when swallowing."

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk of aspiration while eating?

A client who has had a CVA., A client who is 4 h post op following a leg amputation with general anesthesia, A client who has had radiation therapy for head and neck cancer.

A provider prescribes a sublingual medication for a client who has an NG tube in place. Which of the following actions should the nurse take?

administer the medication under the client's tongue

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation?

Excessive laxative use, Ignoring the urge to defecate, Inadequate fluid intake

a nurse arrives for her shift and is preparing to count the controlled substances in the secure cabinet, which of the following actions should the nurse take?

verify that the amounts of each medication she counts match the amounts on the inventory record

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

wash the area of the puncture thoroughly with soap and water

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?

urinary tract infection

A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

"They improve your circulation to keep blood from pooling in your legs."

a nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment

1. Ask the client if they have a history of stomach pain 2. inspect the abdomen for skin integrity 3. Auscultate the abdomen for bowel sounds 4. Percuss the abdomen in each of the four quadrants 5. Palpate the abdomen lightly for tenderness

a nurse is preparing to administer penicillin IM to an adult client. Which angle should the nurse use for injection in the ventrogluteal muscle?

90 degrees

A nurse is preparing to administer an ophthalmic solution to a client. Which of the following actions should the nurse take?

Hold the ophthalmic solution 2 cm (3/4 in) above the lower conjunctival sac

A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

I will clean and dry the area before applying the patch

A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle?

Place one finger across the acromion process and measure 3 finger breadths below to the midpoint and center of the lateral aspect of the upper arm

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

albumin

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

ask the client's full name and date of birth

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

assess the apical pulse for a full minute

A client receives the wrong medication. The nurse who made the medication error should take which of the following actions first?

assess the patient

A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check?

at the client's bedside before administration

A nurse is caring for a client who has an indwelling urinary catheter and notes blood tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

bladder infection

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?

blood

a nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client?

broth, grape juice, lemon gelatin

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?

call the dietary department and ask for a kosher tray

A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

carotid

A nurse is having difficulty reading the providers writing one transcribing a prescription for a client's medication. Which of the following actions should the nurse take?

contact the provider to clarify the prescription

When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?

contact the provider to question the dosage

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the clients lunch tray?

cranberry juice

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

determine the location of the pain

A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?

discard the tablet and obtain another dose of medication

A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following?

dysrhythmias

A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?

ecchymosis

A nurse is planning to administer an IM injection into a client's deltoid muscle. Which of the following actions should the nurse take?

inject the medication at a 90 degree angle

A nurse is assessing a client's abdomen who reports "stomach pain". which of the following actions should the nurse do first?

inspect

A nurse is preparing medication for a client when another client has an emergency. Which of the following actions should the nurse take?

lock the medication in a room and finish preparing it after returning

A nurse is measuring a client for knee-high anti-embolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

measure from the heel to the popliteal space

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

obtain a pair of slipper socks for the client

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?

palpates the abdomen prior to performing auscultation

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. what would the nurse expect to find

poor skin turgor, hypotension, flat neck veins

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

prior to percussing the abdomen

A nurse is developing a plan of care for a client who practices Islam. Which of the following actions should the nurse include in the plan?

request a meal tray without pork

a nurse is caring for a client who needs a stool specimen collected. Which of the following actions should the nurse do when obtaining the specimen?

send specimen container immediately to the lab

A nurse is providing discharge teaching to a client who has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching?

shake the inhaler for 3 to 5 seconds

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior?

take the client to the bathroom every two hours

A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?

tell the client to blow her nose gently before the instillation

A nurse in a long term care facility is assisting a client with eating during meal time and recognizes another client indicating he is choking. Which of the following situations requires immediate intervention by the nurse?

the client is not making any sounds

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

the clients hand is cool and pale

a nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

the left second intercostal space