Medsurg CAQs assignment #1

After surgery for creation of an ileostomy, a client is to be discharged. Before discharge, what is the primary nursing intervention? 1 Emphasizing that it is essential that the client can care for the ileostomy without assistance 2 Evaluating the client's ability to care for the ileostomy 3 Ensuring that the client understands the dietary limitations that must be followed 4 Ensuring that the client is competent at changing the dry sterile dressing on the incision

2

A client is diagnosed with a peptic ulcer. What should the nurse expect when assessing the client's pain? 1 Intensifies after vomiting 2 Occurs one to three hours after meals 3 Increases when an excess of fatty foods is ingested 4 Begins in the epigastrium, then radiates to the abdomen

2

An underweight client has autoimmune hemolytic anemia that has been unresponsive to corticosteroids, and a splenectomy is scheduled. For what complication should the nurse assess the client in the immediate postoperative period? 1 Dehiscence 2 Hemorrhage 3 Wound infection 4 Abscess formation

2

The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump? 1 Checking for the last bowel movement 2 Checking for residual stomach contents 3 Checking to determine time of last medication for nausea 4 Checking to make sure the head of bed is elevated at least 15 degrees

2

A client is to have gastric lavage following an overdose of acetaminophen. In which position should the nurse place the client when the nasogastric tube is being inserted? 1 Supine 2 Mid-Fowler 3 High-Fowler 4 Trendelenburg

3

A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is most important for the nurse to determine when collecting information about the constipation? 1 Presence of distention 2 Extent of weight gained 3 Amount of high-fiber food consumed 4 Length of time this problem has existed

4

A client has surgery for an abdominal cholecystectomy and returns from surgery with a nasogastric tube to low continuous suction, a T-tube, and an indwelling catheter. Which intervention should the nurse perform first? 1 Fasten each tube to the bedsheets 2 Irrigate each tube with normal saline 3 Measure the drainage in the collection devices 4 Ensure that all tubes are attached to collection devices

4

A nurse is caring for a postoperative client who has a nasogastric tube attached to low continuous suction. Which assessment findings indicate that the client may be experiencing hypokalemia? 1 Tingling of the fingertips and toes 2 Dry and sticky mucous membranes 3 Abdominal cramping and irritability 4 Muscle weakness and cardiac dysrhythmias

4

A nurse is collecting a health history from a client who has a diagnosis of cancer of the tongue. Which risk factor commonly associated with cancer of the tongue should the nurse assess when collecting the client's history? 1 Nail biting 2 Poor dental habits 3 Frequent gum chewing 4 Large consumption of alcohol

4

A nurse is caring for a client who is having difficulty digesting fatty foods. To what deficiency does the nurse attribute this difficulty? 1 Bile 2 Lipase 3 Amylase 4 Cholesterol

1

A nurse is instructing a group of clients in the community about food preparation. Which statement indicates a client is at an increased risk for contracting botulism? 1 "I do not usually brush my teeth after I finish eating a meal." 2 "Sometimes I eat grapes before I have a chance to wash them." 3 "Utensils that I use to cut up chicken are put into the dishwasher." 4 "I save money when I buy the slightly damaged cans of vegetables."

4

A client is admitted to the hospital with slight jaundice and reports of pain on the left side and back. A diagnosis of acute pancreatitis is made. Which common response to acute pancreatitis should the nurse monitor in the client? 1 Crackles 2 Hypovolemia 3 Gastric reflux 4 Jugular vein distention

2

A client who is suspected of having salmonellosis asks the nurse how the diagnosis is confirmed. The nurse responds that the medical diagnosis is established with what laboratory test? 1 Urinalysis 2 Stool culture 3 Febrile agglutinin test 4 Complete blood count

2

A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the primary nursing concern? 1 Chronic pain 2 Risk for injury 3 Electrolyte imbalance 4 Inadequate gas exchange

3

A nurse is caring for a client with a new colostomy. Which client outcome is most important for achievement of long-range goals associated with adjusting to a new colostomy? 1 Mastery of techniques of colostomy care 2 Readiness to accept an altered body function 3 Awareness of available community resources 4 Knowledge of the necessary dietary modifications

2

When assessing a client's abdomen, the nurse palpates the area directly above the umbilicus. By what term is this area known? 1 Iliac area 2 Epigastric area 3 Hypogastric area 4 Suprasternal area

2

A client is diagnosed with cancer of the pancreas and is apprehensive and restless. Which nursing action should be included in the plan of care? 1 Encouraging expression of concerns 2 Administering antibiotics as prescribed 3 Teaching the importance of getting rest 4 Explaining that everything will be all right

1

A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results? 1 Sodium and chloride levels 2 Bicarbonate and sulfate levels 3 Magnesium and protein levels 4 Calcium and phosphate levels

1

A client who had previously signed a consent form for a liver biopsy reconsiders and decides not to have the procedure. What is the nurse's best initial response? 1 "Why did you sign the consent form originally?" 2 "I can understand why you changed your mind." 3 "Can you tell me your reasons for refusing the procedure?" 4 "You must be afraid about something concerning the procedure."

3

A client experiences occasional right upper quadrant pain attributed to cholecystitis. The nurse is providing discharge instructions, including a list of foods that cause dyspepsia. Which foods should be on the list the nurse provided the client? 1 Nuts and popcorn 2 Meatloaf and baked potato 3 Chocolate and boiled shrimp 4 Fried chicken and buttered corn

4

A nurse identifies a moderate amount of bright red blood in a client's gastric drainage four hours after a subtotal gastrectomy. What should the nurse do first? 1 Clamp the nasogastric tube. 2 Irrigate the tube gently with normal saline. 3 Record the observation and continue to monitor the drainage from the tube. 4 Reduce the pressure of the suction and record observations of the drainage characteristics.

3

A nurse instructs a client with viral hepatitis about the type of diet that should be ingested. Which lunch selected by the client indicates understanding about dietary principles associated with this diagnosis? 1 Turkey salad, french fries, sherbet 2 Cottage cheese, mixed fruit salad, milkshake 3 Salad, sliced chicken sandwich, gelatin dessert 4 Cheeseburger, tortilla chips, chocolate pudding

3

A nurse is caring for a client who is cachectic. What information about the function of adipose tissue in fat metabolism is necessary to better address the needs of this client? 1 Releases glucose for energy 2 Regulates cholesterol production 3 Uses lipoproteins for fat transport 4 Stores triglycerides for energy reserves

4

A nurse is caring for a client with cholelithiasis and obstructive jaundice. When assessing this client, the nurse should be alert for which findings that are consistent with these conditions? Select all that apply. 1 Ecchymosis 2 Yellow sclera 3 Dark brown stool 4 Straw-colored urine 5 Pain in right upper quadrant

1, 2, 5

A client who had an abdominoperineal resection and colostomy refuses to allow any family members to see the incision or stoma. The client is noncompliant with most of the dietary recommendations. The nurse concludes that the client is experiencing what response? 1 Reaction formation; this is related to the client's recent altered body image 2 Denial; the client is having difficulty accepting reality 3 Impotency resulting from the surgery; sexual counseling may be indicated 4 Suicidal thoughts; consultation with a psychiatrist should be prescribed

2

A nurse is caring for a client on the second day after an abdominoperineal resection. Which finding does the nurse document as normal in the stoma? 1 Dry, pale pink, and even with the skin 2 Moist, skin-colored, and flush with the skin 3 Moist, red, and raised above the skin surface 4 Dry, purple, and depressed below the skin surface

3

A client is experiencing an exacerbation of ulcerative colitis. A low-residue, high-protein diet and IV fluids with vitamins have been prescribed. When implementing these prescriptions, which goal is the nurse trying to achieve? 1 Reduce gastric acidity 2 Reduce colonic irritation 3 Reduce intestinal absorption 4 Reduce bowel infection rate

2

The nurse identifies that a client who had extensive abdominal surgery appears depressed. Which nursing action is the most appropriate? 1 Talking with the client and encouraging exploration of feelings 2 Asking the client's primary healthcare provider to prescribe an antidepressant medication 3 Understanding that the client's depression is an expected response to surgery 4 Reassuring the client that feelings of depression will lift after returning home

1

A nurse is teaching a client about prophylactic measures that minimize the risk of contracting hepatitis B. Which actions should be included in this teaching plan? Select all that apply. 1 Preventing constipation 2 Screening of blood donors 3 Avoiding shellfish in the diet 4 Limiting hepatotoxic drug therapy 5 Maintaining a monogamous sexual relationship

2,5

After abdominal surgery a client returns to the unit with a nasogastric (NG) tube to low intermittent wall suction. The primary healthcare provider prescribes an antiemetic every six hours as needed for nausea. When the client complains of nausea, what should the nurse do first? 1 Check for correct placement of the NG tube. 2 Administer the prescribed antiemetic. 3 Irrigate the NG tube with normal saline. 4 Notify the primary healthcare provider immediately.

1

A nurse is providing discharge teaching for a client who recently had surgery for an abdominal perineal resection of the colon and the creation of a colostomy. Which condition will the nurse share with the client for when to call the healthcare provider immediately? 1 Intestinal cramps during fluid inflow 2 Difficulty inserting the irrigation tube 3 Passage of flatus during expulsion of feces 4 An inability to complete the procedure in one hour

2

A client newly diagnosed with cancer of the pancreas is scheduled for surgery. The client says to the nurse, "Wouldn't I be better off with some other treatment instead of surgery?" What response by the nurse is the best? 1 "It's a good idea to explore other acceptable treatments for your cancer. There is information available for you." 2 "Surgery is the recommended approach. Why don't you discuss this further with the healthcare provider?" 3 "Maybe you will be more confident with a second opinion. I think you need a referral to another healthcare provider." 4 "With your disease your prognosis will improve if you follow the suggestion to have the recommended surgery."

2

An older adult is returned to the surgical unit after having a subtotal gastrectomy. Which dietary modification should the nurse anticipate that the healthcare provider will most likely prescribe? 1 Increase intake of dietary roughage quickly 2 Avoid oral feedings for a prolonged period 3 Resume small, easily digested feedings gradually 4 Limit intake to self-selection of personally preferred foods

3

During a client's paracentesis, 1500 mL of fluid is removed. The nurse monitors the client for which sign of a potentially severe response? 1 Abdominal girth decrease 2 Mucous membranes becoming drier 3 Heart rate increases from 80 to 135 4 Blood pressure rises from 130/70 to 190/80

3

A client had a bypass graft because of an abdominal aortic aneurysm. Postoperative prescriptions include measurements of the client's abdominal girth. Which serious problem may be indicated by an increasing abdominal girth? 1 Graft leakage 2 Bowel puncture 3 Abdominal infection 4 Postoperative flatulence

1

A client is admitted to the hospital with a history of cancer of the liver and jaundice. In relation to the jaundice, the nurse expects the client to report the presence of what symptom? 1 Pruritus 2 Diarrhea 3 Blurred vision 4 Bleeding gums

1

A client was diagnosed with ulcerative colitis. Two months after the diagnosis, the client is readmitted for an exacerbation of the illness. The client is weak, thin, and irritable. The client states, "I am now ready for surgery to create an ileostomy." Which nursing intervention will best meet the client's priority need? 1 Replace the client's fluids and electrolytes 2 Help the client gain weight 3 Teach the client how to use the ileostomy appliance 4 Encourage client interaction with other clients who have an ileostomy

1

A nurse is caring for a client who just had a liver biopsy. After the procedure, the nurse should monitor for which common complication associated with the biopsy? 1 Hemorrhage 2 Gastroparesis 3 Pulmonary embolism 4 Tension pneumothorax

1

A nurse is caring for a client with Addison disease. Which dietary instruction should the nurse teach the client to follow? 1 Add extra salt to food 2 Consume high-potassium foods 3 Omit protein foods at each meal 4 Restrict the daily intake of fluids to 1 L

1

After having a transverse colostomy, the client asks what physical effect the surgery will have on future sexual relationships. Which information should the nurse include in a teaching plan for this client? 1 "You will be able to resume usual sexual relationships." 2 "Surgery will temporarily decrease your sexual impulses." 3 "Your sexual activity must be curtailed for several weeks." 4 "Partners should be told about the surgery before any sexual activity."

1

A client has a new colostomy. The nurse has provided teaching related to when the client should irrigate the colostomy. Which client statement indicates correct understanding of the teaching? 1 "After it gets done healing in a few weeks, I will begin irrigating it just before going to bed each day." 2 "It will need to be irrigated each morning before I can eat any food." 3 "I plan to irrigate it in the late morning, the same time I had a bowel movement every day before I had my surgery." 4 "I can wait to start irrigating it until after I have gotten used to this bag and change in lifestyle."

3

A client with cirrhosis is scheduled for a liver biopsy. The client asks if there are any risks after the procedure. Which response by the nurse is the best? 1 "There are relatively no risks associated with this procedure." 2 "The major risk is infection at the biopsy site." 3 "The major risk is bleeding postprocedure." 4 "The major risk is liver failure postprocedure."

3

Which dietary selection by the client leads the nurse to determine that teaching about a low-residue diet is understood? 1 Baked fish, macaroni with cheese, strained carrots, fruit gelatin, milk 2 Stewed chicken, baked potato with butter, peas, white bread, plain cake, milk 3 Lean roast beef, buttered white rice with egg slices, white bread with jelly, tea with sugar 4 Creamed soup with crackers, omelet, mashed potatoes, bran muffin, orange juice, coffee with milk

3

Which represents appropriate nursing management of the client's nasogastric (NG) tube in the immediate postoperative period following gastroduodenostomy? 1 Advancing the tube to the original insertion depth if the tube becomes dislodged. 2 Obtaining a prescription to vigorously irrigate the nasogastric tube if clogging is noted. 3 Carefully monitoring the nasogastric tube to ensure that the tube is patent and the suction is working. 4 Reporting the presence of bright red gastric aspirant in the suction canister during the immediate postoperative period.

3

A client is diagnosed with cancer of the rectum and has surgery for an abdominoperineal resection and colostomy. Which nursing care should be implemented during the postoperative period? 1 Limiting fluid intake for several days 2 Withholding fluids for 72 hours 3 Having the client change the colostomy bag 4 Keeping the client's skin around the stoma clean

4

A client was diagnosed with cancer of the head of the pancreas two months ago. The client is admitted to the hospital with weight loss, severe epigastric pain, and jaundice. When performing the client's assessment, the nurse expects the client's stool to be what color? 1 Green 2 Brown 3 Red-tinged 4 Clay-colored

4

A client is admitted to the hospital with ascites. The client reports drinking a quart (liter) of vodka mixed in orange juice every day for the past three months. To assess the potential for withdrawal symptoms, which question would be appropriate for the nurse to ask the client? 1 "When was your last drink of vodka?" 2 "What prompts your drinking episodes?" 3 "Do you also eat when you drink?" 4 "Why do you mix the vodka with orange juice?"

1

A client with achalasia is scheduled to have a bougienage to dilate the lower esophagus and cardiac sphincter. After the procedure the nurse assesses the client for what complications related to esophageal perforation? 1 Tachycardia and abdominal pain 2 Faintness and feelings of fullness 3 Diaphoresis and cardiac palpitations 4 Increased blood pressure and urinary output

1

A nurse is caring for a client with a hiatal hernia. Which risk factor should the nurse assess for in this client? 1 Obesity 2 Alcoholism 3 Chronic bronchitis 4 Esophageal varices

1

After a partial gastrectomy is performed, a client is returned from the postanesthesia care unit to the surgical unit with an intravenous (IV) solution infusing and a nasogastric tube in place. The nurse identifies that there is no nasogastric drainage for 30 minutes. There is a prescription for instillation of the nasogastric tube as needed. What should the nurse instill, and what is the procedure that follows? 1 30 mL of normal saline, then continue the suction 2 20 mL of air, then clamp off the suction for 1 hour 3 50 mL of saline, then increase the pressure of the suction 4 15 mL of distilled water, then disconnect the suction for 30 minutes

1

A client with cancer of the colon is admitted to the hospital for a hemicolectomy. What does the nurse expect the preoperative plan of care to include? 1 Giving oil-retention enemas daily for two days preoperatively 2 Administering cleansing enemas and then neomycin 3 Having a Sengstaken-Blakemore tube at the bedside 4 A high-protein and high-carbohydrate regular diet for two days preoperatively

2

A client with a high cholesterol level says to the nurse, "Why can't the doctor just give me a medication to eliminate all the cholesterol in my body so it isn't a problem?" Which factor related to why cholesterol is important in the human body should the nurse include in a response to the client's question? 1 Blood clotting 2 Bone formation 3 Muscle contraction 4 Cellular membranes

4

After a subtotal gastrectomy for cancer of the stomach, a client develops dumping syndrome. The client says, "What does it mean when the healthcare provider says that I am experiencing dumping syndrome?" What information should the nurse include in a response to this question? 1 Nausea resulting from a full stomach 2 Reflux of gastric contents into the esophagus 3 Buildup of flatulence within the large intestine 4 Rapid passage of concentrated fluid into the small intestine

4

Surgery is performed on a client with a parotid tumor. Postoperative arterial blood gas values are pH 7.32, PCO2 53 mm Hg, and HCO3 25 mEq/L (25 mmol/L). Which action should the nurse take? 1 Administer a potent diuretic 2 Obtain a prescription for an alkalinizing agent 3 Have the client breathe into a rebreather bag at a slow rate 4 Encourage the client to cough and then take deep breaths between coughs

4

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What nursing intervention is the priority? 1 Weigh the client daily. 2 Restrict the client's oral fluid intake. 3 Measure the client's urine specific gravity. 4 Observe the client for increasing confusion.

4

Six weeks after discharge, a client with a jejunoileal bypass for morbid obesity returns to the outpatient clinic reporting palpitations, abdominal cramps, diarrhea, and dizziness 30 minutes after meals. What complication should the nurse consider that the client is most likely experiencing? 1 Gastric reflux 2 Reflux gastritis 3 Dumping syndrome 4 Abdominal peritonitis

3

A client had a colon resection and formation of a colostomy two days ago. Which color indicates to the nurse the stoma is viable? 1 Blue 2 Gray 3 Brick red 4 Dark purple

3

A client with esophageal varices has severe hematemesis, and a Sengstaken-Blakemore tube is inserted. What design and purpose does the tube have? 1 Single-lumen; for gastric lavage 2 Double-lumen; for intestinal decompression 3 Triple-lumen; for esophageal compression 4 Multilumen; for gastric and intestinal decompression

3

A client, experiencing an exacerbation of Crohn disease, is admitted to the hospital for intravenous steroid therapy. The nurse should not assign this client to a room with a roommate who has which illness? 1 Pancreatitis 2 Thrombophlebitis 3 Bacterial meningitis 4 Acute cholecystitis

3

A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome? 1 Low-residue, bland diet 2 Fluid intake below 500 mL 3 Small, frequent feeding schedule 4 Low-protein, high-carbohydrate diet

3

A nurse reviews the plan of care for a client with less than adequate nutritional intake. The nurse should question which prescription? 1 Have client sit in a chair for meals 2 Provide six small feedings in 24 hours 3 Give one can of diet supplement at 8:00 AM and 4:00 PM 4 Encourage the client's family members to bring food from home

3

A teenager is admitted with an acute onset of right lower quadrant pain at McBurney point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis? 1 Urinary retention 2 Gastric hyperacidity 3 Rebound tenderness 4 Increased lower bowel motility

3

A client is admitted to the hospital with a diagnosis of intestinal obstruction. The healthcare provider prescribes intestinal suction via a nasoenteric decompression tube. The loss of which constituents associated with intestinal suctioning is most important to consider when caring for this client? 1 Protein enzymes 2 Energy carbohydrates 3 Vitamins and minerals 4 Water and electrolytes

4

A client describes abdominal discomfort following ingestion of milk. Which enzyme, as a result of a genetic deficiency, should the nurse consider to be the cause of the client's discomfort? 1 Lactase 2 Sucrase 3 Maltase 4 Amylase

1

Immediately after a liver biopsy the nurse places the client onto the right side. Which reason explains the use of the right side-lying position? 1 Provides the greatest comfort 2 Restores circulating blood volume 3 Helps stop bleeding if any should occur 4 Reduces the fluid trapped in the biliary ducts

3

An older client's colonoscopy reveals the presence of extensive diverticulosis. Which type of diet should the nurse encourage the client to follow? 1 Low-fat 2 High-fiber 3 High-protein 4 Low-carbohydrate

2

A nurse is caring for a client who had major abdominal surgery one day ago. What factor increases the risk of this client developing a wound dehiscence? 1 Placement of a T-tube 2 Client being overweight 3 Presence of excessive flatus 4 Client receiving prophylactic antibiotics

2

A nurse is evaluating a client's response to receiving an intermittent gravity flow percutaneous endoscopic gastrostomy (PEG) tube feeding. Which clinical finding indicates that the client is unable to tolerate a continuation of the feeding? 1 Passage of flatus 2 Rise of formula in the tube 3 Rapid inflow of the feeding 4 Tenderness of epigastric area

2

A client is diagnosed with hepatitis A. The nurse provides the client with information about untoward signs and symptoms related to hepatitis. The nurse instructs the client to contact the primary healthcare provider if the client develops what symptom? 1 Fatigue 2 Anorexia 3 Yellow urine 4 Clay-colored stools

4

A client with gastroesophageal reflux disease reports having difficulty sleeping at night. What should the nurse instruct the client to do? 1 Drink a glass of milk before retiring. 2 Elevate the head of the bed on blocks. 3 Eliminate carbohydrates from the diet. 4 Take antacids, such as sodium bicarbonate.

2

A primary healthcare provider diagnoses a client with acute cholecystitis with biliary colic. Which clinical findings should the nurse expect when performing a health history and physical assessment? Select all that apply. 1 Diarrhea with black feces 2 Intolerance to foods high in fat 3 Vomiting of coffee-ground emesis 4 Gnawing pain when stomach is empty 5 Pain that radiates to the right shoulder

2, 5

A client with cancer of the stomach is admitted to the hospital and scheduled for a subtotal gastrectomy. The nurse is providing preoperative teaching. What should the nurse teach the client to do postoperatively to minimize the complication of dumping syndrome? 1 Ambulate after every meal. 2 Remain on a diet low in fat. 3 Eat 5 or 6 small meals a day. 4 Increase fluid intake when eating food.

3

A nurse is caring for a client who just had a gastrectomy. What should the nurse emphasize when teaching the client how to avoid dumping syndrome? 1 Increase activity after eating 2 Drink at least two to three glasses of fluid with each meal 3 Eat small meals with low carbohydrate and moderate fat content 4 Sit in a high-Fowler position for 30 minutes after eating

3

The nurse provides education related to the relationship between aerobic exercise and weight loss to an obese client. The nurse evaluates that teaching is effective when the client states which effect of exercise? 1 Decreases my appetite 2 Decreases my metabolic rate 3 Increases my lean body mass 4 Increases my resting heart rate

3

While receiving a blood transfusion, a client develops flank pain, chills, and fever. What type of transfusion reaction does the nurse conclude that the client probably is experiencing? 1 Allergic 2 Pyrogenic 3 Hemolytic 4 Anaphylactic

3