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40. The nurse is planning the care of a client who has had an abdominal perineal resection for cancer of the colon. Which interventions should the nurse implement? Select all that apply. 1. Provide meticulous skin care to stoma. 2. Assess the flank incision. 3. Maintain the indwelling catheter. 4. Irrigate the J-P drains every shift. 5. Position the client semi-recumbent

. 1. Colostomy stomas are portions of the large intestines pulled through the abdominal wall through which feces exits the body. Feces can be irritating to the abdominal skin, so careful and thorough skin care is needed. 3. Because of the perineal wound, the client will have an indwelling catheter to keep urine out of the incision 5. The client should not sit upright because this would cause pressure on the perineum.

112. The client has a large abdominal wound that has eviscerated. Which intervention should the nurse implement? 1. Apply sterile normal saline dressing. 2. Use sterile gloves to replace protruding parts. 3. Place the client in the reverse Trendelenburg position. 4. Administer intravenous antibiotic stat.

. 1. Evisceration is a life-threatening condition in which the abdominal contents have protruded through the ruptured incision. The nurse must protect the bowel from the environment by placing a sterile normal saline dressing on it. The saline prevents the intestines from drying out and necrosing.

92. The nurse writes the client problem "imbalanced nutrition: less than body requirements" for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care? 1. Provide a high-calorie intake diet. 2. Discuss total parenteral nutrition (TPN). 3. Instruct the client to decrease salt intake. 4. Encourage the client to increase water intake.

. 1. Sufficient energy is required for healing. Adequate carbohydrate intake can spare protein. The client should eat approximately 16 carbohydrate kilocalories for each kilogram of ideal body weight daily

24. Which nursing diagnosis would be appropriate for the nurse to identify for the client with diarrhea? 1. Alteration in skin integrity. 2. Chronic pain perception. 3. Fluid volume excess. 4. Ineffective coping.

. 1. When clients have multiple liquid stools, the rectal area can become irritated. The integrity of the skin can be impaired.

66. Which assessment data should the nurse expect to find for the client who had an upper gastrointestinal (UGI) series? 1. Chalky white stools. 2. Increased heart rate. 3. A firm hard abdomen. 4. Hyperactive bowel sounds.

1. A UGI requires the client to swallow barium, which passes through the intestines, making the stools a chalky white color

27. The nurse is assessing the client in end-stage liver failure who has been diagnosed with portal hypertension. Which intervention should the nurse include in the plan of care? 1. Assess the abdomen for a tympanic wave. 2. Monitor the client's blood pressure. 3. Percuss the liver for size and location. 4. Weigh the client twice each week.

1. A client who has been diagnosed with portal hypertension should be assessed for a fluid wave to check for ascites.

62. The client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement? 1. Apply a heating pad to the abdomen for 15 to 20 minutes. 2. Administer morphine sulfate intravenously after diluting with saline. 3. Contact the surgeon for an order to x-ray the right shoulder. 4. Apply a sling to the right arm that was injured in surgery.

1. A heating pad should be applied for 15 to 20 minutes to assist the migration of the CO2 used to insufflate the abdomen

58. The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis? Select all that apply. 1. Eat a high-fiber diet. 2. Increase fluid intake. 3. Elevate the HOB after eating. 4. Walk 30 minutes a day. 5. Take an antacid every two (2) hours

1. A high-fiber diet will help to prevent constipation, which is the primary reason for diverticulitis. 2. Increased fluids will help keep the stool soft and prevent constipation. 4. Exercise will help prevent constipation

39. The 85-year-old male client diagnosed with cancer of the colon asks the nurse, "Why did I get this cancer?" Which statement is the nurse's best response? 1. Cancer of the colon is associated with a lack of fiber in the diet. 2. Cancer of the colon has a greater incidence among those younger than age 50 years. 3. Cancer of the colon has no known risk factors. 4. Cancer of the colon is rare among male clients

1. A long history of low-fiber, high-fat, highprotein diets results in a prolonged transit time. This allows the carcinogenic agents in the waste products to have a greater exposure to the lumen of the colon

4. When assessing the oral cavity of an elderly client, which data should the nurse report to the health-care provider? 1. The client's tongue is rough and beefy red. 2. The client's tonsils are at a !1 on a grading scale. 3. The client's mucosa is pink and moist. 4. The client's uvula rises with the mouth open.

1. A rough, beefy-red tongue may indicate that the client has pernicious anemia and should be evaluated by the health-care provider

28. When assessing the client with the diagnosis of peptic ulcer disease, which physical examination should the nurse implement first? 1. Auscultate the client's bowel sounds in all four quadrants. 2. Palpate the abdominal area for tenderness. 3. Percuss the abdominal borders to identify organs. 4. Assess the tender area progressing to nontender.

1. Auscultation should be used prior to palpation or percussion when assessing the abdomen. If the nurse manipulates the abdomen, the bowel sounds can be altered and give false information.

82. The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy? 1. Gastrointestinal bleeding. 2. Hypoalbuminemia. 3. Splenomegaly. 4. Hyperaldosteronism.

1. Blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy.

2. The client receiving antibiotic therapy complains of white, cheesy plaques in the mouth that bleed when removed. Which action should the nurse implement? 1. Notify the health-care provider to obtain an antifungal medication. 2. Explain that the patches will go away naturally in about two (2) weeks. 3. Instruct the client to rinse the mouth with diluted hydrogen peroxide and water daily. 4. Allow the client to verbalize feelings about having the plaques.

1. Candidiasis, or thrush, presents as white, cheesy plaques that bleed if rubbed and is a side effect of antibiotic therapy. Candidiasis is treated with antifungal solution, which is swished around the mouth, held for at least one (1) minute, and then swallowed. Candidiasis can be prevented if acidophilus is administered concurrently with antibiotic therapy.

64. When assessing the client recovering from an open cholecystectomy, which signs and symptoms should the nurse report to the health-care provider? Select all that apply. 1. Clay-colored stools. 2. Yellow-tinted sclera. 3. Dark yellow urine. 4. Feverish chills. 5. Abdominal pain.

1. Clay-colored stools are caused by recurring stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome. 2. Yellow-tinted sclera and skin indicate residual effects of stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome. 3. Dark yellow urine indicates a residual effect of a stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome. 4. Fever and chills indicate residual or recurring calculi, inflammation, or stricture of common bile duct, which is a sign of postcholecystectomy syndrome. 5. Abdominal pain indicates a residual effect of a stricture of common bile duct, inflammation, or calculi, which is a sign of postcholecystectomy syndrome

49. The nurse at the scene of a knife fight is caring for a young man who has a knife stuck in his abdomen. Which action should the nurse implement? 1. Stabilize the knife. 2. Remove the knife gently. 3. Turn the client on the side. 4. Apply pressure to the insertion site.

1. Do not remove any penetrating object in the abdomen; removal could cause further internal damage.

103. Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning? 1. Fluid volume deficit. 2. Nausea. 3. Risk for aspiration. 4. Impaired urinary elimination.

1. Fluid volume deficit secondary to diarrhea is the priority because of the potential for metabolic acidosis and hypokalemia, which are both life threatening, especially in the elderly.

57. The client with acute diverticulitis has a nasogastric tube draining green liquid bile. Which action should the nurse implement? 1. Document the findings as normal. 2. Assess the client's bowel sounds. 3. Determine the client's last bowel movement. 4. Insert the N/G tube at least 2 more inches

1. Green bile contains hydrochloric acid and should be draining from the N/G tube; therefore the nurse should take no action and should document the findings.

90. The public health nurse is discussing hepatitis B with a group in the community. Which health promotion activities should the nurse discuss with the group? Select all that apply. 1. Do not share needles or equipment. 2. Use barrier protection during sex. 3. Get the hepatitis B vaccines. 4. Obtain immune globulin injections. 5. Avoid any type of hepatotoxic medications.

1. Hepatitis B can be transmitted by sharing any type of needles, especially those used by drug abusers. 2. Hepatitis B can be transmitted through sexual activity; therefore the nurse should recommend abstinence, mutual monogamy, or barrier protection 3. Three doses of hepatitis B vaccine provide immunity in 90% of healthy adults

77. The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the unlicensed assistant warrants intervention by the primary nurse? 1. Assisting the client to take a hot soapy shower. 2. Applying an emollient to the client's legs and back. 3. Putting mittens on both hands of the client. 4. Patting the client's skin dry with a clean towel

1. Hot water increases pruritus, and soap will cause dry skin, which increases pruritus; therefore, the nurse should discuss this with the assistant.

16. The client diagnosed with a hiatal hernia has been scheduled for a laparoscopic Nissen fundoplication. Which statement indicates that the nurse's teaching has been effective? 1. "I will have three (3) or four (4) small incisions." 2. "I will be able to go home the same day of surgery." 3. "I will not have any pain because this is laparoscopic surgery." 4. "I will be returning to work the day after my surgery

1. In a laparoscopic Nissen fundoplication, there are four (4) to five (5) incisions approximately one (1) inch apart that allow for the passage of equipment to visualize the abdominal organs and perform the operation.

50. The nurse writes the problem "risk for impaired skin integrity" for a client with a sigmoid colostomy. Which expected outcome would be appropriate for this client? 1. The client will have intact skin around the stoma. 2. The client will be able to change the ostomy bag. 3. The client will express anxiety about the body changes. 4. The client will maintain fluid balance.

1. Intact skin around the stoma is the most appropriate outcome for the problem of "impaired skin integrity."

139. The client diagnosed with AIDS is experiencing voluminous diarrhea. Which interventions should the nurse implement? Select all that apply. 1. Monitor diarrhea, charting amount, character, and consistency. 2. Assess the client's tissue turgor every day. 3. Encourage the client to drink carbonated soft drinks. 4. Weigh the client daily in the same clothes and at the same time. 5. Assist the client with a warm sitz bath PRN

1. It is important to keep track of the amounts, color, and other characteristics of all body fluids lost. 4. Daily weights are the best method of determining fluid loss and gain. 5. Sitz baths will assist in keeping the client's perianal area clean without having to rub. The warm water is soothing, providing comfort

37. The nurse working in a skilled nursing facility is collaborating with the dietician concerning the meals of a client who is immobile. Which foods would be most appropriate for this client? 1. Oatmeal and wheat toast. 2. Cream of wheat and biscuits. 3. Cottage cheese and canned peaches. 4. Tuna on croissant and applesauce.

1. Oatmeal and wheat toast are high-fiber foods that are recommended for clients who are immobile to help prevent constipation.

13. The nurse in an outpatient clinic is caring for a client who is 67 inches tall and weighs 100 kg. The client complains of occasional pyrosis that resolves with standing or with taking antacids. What treatment should the nurse expect the HCP to order? 1. Place the client on a weight loss program. 2. Instruct the client to eat three (3) balanced meals. 3. Tell the client to take an antiemetic before each meal. 4. Discuss the importance of decreasing alcohol intake.

1. Obesity increases the risk of pyrosis (heartburn); therefore losing weight could help decrease the incidents.

6. The nurse is caring for an adult client diagnosed with gastroesophageal reflux disease (GERD). Which condition is the most common comorbid disease associated with GERD? 1. Adult-onset asthma. 2. Pancreatitis. 3. Peptic ulcer disease. 4. Increased gastric emptying.

1. Of adult-onset asthma cases, 80%-90% are caused by gastroesophageal reflux disease (GERD).

34. The elderly client has been diagnosed with acute gastritis. Which client problem would be priority for this client? 1. Fluid volume deficit. 2. Altered nutrition: less than body requirements. 3. Impaired tissue perfusion. 4. Alteration in comfort.

1. Pediatric and geriatric clients are the most at risk for fluid volume and electrolyte imbalances, and the nurse should always be alert to this possible complication.

11. The nurse is performing an admission assessment on a client diagnosed with gastroesophageal reflux disease (GERD). Which signs and symptoms would indicate GERD? 1. Pyrosis, water brash, and flatulence. 2. Weight loss, dysarthria, and diarrhea. 3. Decreased abdominal fat, proteinuria, and constipation. 4. Mid-epigastric pain, positive H. pylori test, and melena.

1. Pyrosis is heartburn, water brash is the feeling of saliva secretion as a result of reflux, and flatulence is gas—all symptoms of GERD.

99. The client is diagnosed with salmonellosis secondary to eating some slightly cooked hamburger meat. Which clinical manifestations would the nurse expect the client to report? 1. Abdominal cramping, nausea, and vomiting. 2. Neuromuscular paralysis and dysphagia. 3. Gross amounts of explosive bloody diarrhea. 4. Frequent "rice water stool" with no fecal odor.

1. Symptoms develop 8-48 hours after ingesting the Salmonella bacteria and include diarrhea, abdominal cramping, nausea, and vomiting, along with low-grade fever, chills, and weakness.

17. The client diagnosed with IBD is prescribed total parental nutrition (TPN). Which intervention should the nurse implement? 1. Check the client's glucose level. 2. Administer an oral hypoglycemic. 3. Assess the peripheral intravenous site. 4. Monitor the client's oral food intake.

1. TPN is high in dextrose, which is glucose; therefore the client's blood glucose level must be monitored closely.

26. The client has been seen by the health-care provider and the suspected diagnosis is peptic ulcer disease. Which diagnostic test would confirm this diagnosis? 1. Esophagogastroduodenoscopy (EGD). 2. Magnetic resonance imaging (MRI). 3. Occult blood test. 4. Gastric acid stimulation.

1. The EGD is an invasive diagnostic test that visualizes the esophagus and stomach to accurately diagnose an ulcer and evaluate the effectiveness of the client's treatment

115. The client who has had an abdominal surgery has a Jackson Pratt (JP) drainage tube. Which assessment data would warrant immediate intervention by the nurse? 1. The bulb is round and has 40 mL of fluid. 2. The drainage tube is pinned to the dressing. 3. The JP insertion site is pink and has no drainage. 4. The JP bulb has suction and is sunken in.

1. The JP bulb should be depressed, which indicates suction is being applied. A round bulb indicates that the bulb is full and needs to be emptied and suction reapplied.

7. Which expected outcome would be appropriate for the client diagnosed with aphthous stomatitis? 1. The client will be able to cope with perceived stress. 2. The client will consume a balanced diet. 3. The client will deny any difficulty swallowing. 4. The client will take antacids as prescribed.

1. The cause of canker sores, aphthous stomatitis, is unknown. The small ulcerations of the soft oral tissue are linked to stress, trauma, allergies, viral infections, and metabolic disorders. Therefore, being able to cope with stress would be a desired outcome.

2 The nurse caring for a client diagnosed with gastroesophageal reflux disease (GERD) writes the nursing problem of "behavior modification." Which intervention should be included for this problem? 1. Teach the client to sleep with a foam wedge under the head. 2. Encourage the client to decrease the amount of smoking. 3. Instruct the client to take over-the-counter medication for relief of pain. 4. Discuss the need to attend Alcoholics Anonymous to quit drinking.

1. The client should elevate the head of the bed on blocks or use a foam wedge to use gravity to help keep the gastric acid in the stomach and prevent reflux into the esophagus. Behavior modification is changing one's behavior.

13. The client is diagnosed with ulcerative colitis. When assessing this client, which sign/ symptom would the nurse expect to find? 1. Twenty bloody stools a day. 2. Oral temperature of 102!F. 3. Hard, rigid abdomen. 4. Urinary stress incontinence.

1. The colon is ulcerated and unable to absorb water, resulting in bloody diarrhea. Ten (10) to twenty bloody diarrhea stools is the most common symptom of ulcerative colitis.

86. Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? 1. Hepatitis A. 2. Hepatitis B. 3. Hepatitis C. 4. Hepatitis D.

1. The hepatitis A virus is in the stool of infected people up to two (2) weeks before symptoms develop.

20 Which intervention should the nurse implement specifically for the client in end-stage liver failure who is experiencing hepatic encephalopathy? 1. Assess the client's neurological status. 2. Prepare to administer a loop diuretic. 3. Check the client's stool for bleeding. 4. Assess the abdominal fluid wave.

1. The increased serum ammonia level associated with liver failure causes the hepatic encephalopathy, which, in turn, leads to neurological deficit.

42. The nurse caring for a client one (1) day postoperative sigmoid resection notes a moderate amount of dark reddish brown drainage on the midline abdominal incision. Which intervention should the nurse implement first? 1. Mark the drainage on the dressing with the time and date. 2. Change the dressing immediately using sterile technique. 3. Notify the health-care provider immediately. 4. Reinforce the dressing with a sterile gauze pad.

1. The nurse should mark the drainage on the dressing to determine if active bleeding is occurring because dark reddish-brown drainage indicates old blood. This allows the nurse to assess what is actually happening.

40. The nurse is caring for the client that is one (1)-day post-upper gastrointestinal series (UGI). Which assessment data warrant immediate intervention? 1. No bowel movement. 2. Oxygen saturation 96%. 3. Vital signs within normal baseline. 4. Intact gag reflex.

1. The nurse should monitor the client for the first bowel movement to document elimination of barium that should be eliminated within two (2) days. If the client does not have a bowel movement, a laxative may be needed to help the client to eliminate the barium before it becomes too hard to pass.

43. The nurse is teaching the client diagnosed with colon cancer who is scheduled for a colostomy the next day. Which behavior indicates the best method of applying adult teaching principles? 1. The nurse repeats the information as indicated by the client's questions. 2. The nurse teaches in one session all the information that the client needs. 3. The nurse uses a video so that the client can hear the medical terms. 4. The nurse waits until the client asks questions about the surgery.

1. The nurse should realize the client is anxious about the diagnosis of cancer and the impending surgery. Therefore the nurse should be prepared to repeat information as necessary. The teaching principle that the nurse needs to consider is that anxiety decreases learning.

31. The nurse is speaking to a support group for clients diagnosed with Crohn's disease. Which information would be most important for the nurse to discuss with the clients? 1. Discuss coping skills that assist with adaptation to lifestyle modifications. 2. Teach about drug administration, dosages, and scheduled times. 3. Teach dietary changes necessary to control symptoms. 4. Explain the care of the colostomy and necessary equipment.

1. The objectives for support groups are to help members cope with chronic diseases and help manage symptom control.

47. The nurse is preparing the postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement? 1. Establish a rapport with the client to decrease embarrassment of assessing site. 2. Encourage the client to lie in the lithotomy position twice a day. 3. Milk the tube inserted during surgery to allow the passage of flatus. 4. Digitally dilate the rectal sphincter to express old blood.

1. The site of the surgery can cause embarrassment when the nurse assesses the site; therefore, the nurse should establish a positive relationship.

22. The client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client would support this diagnosis? 1. "My pain goes away when I have a bowel movement." 2. "I have bright red blood in my stool all the time." 3. "I have episodes of diarrhea and constipation." 4. "My abdomen is hard and rigid and I have a fever."

1. The terminal ileum is the most common site for regional enteritis and causes right lower quadrant pain that is relieved by defecation

55. The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and T 102!F. Which intervention should the nurse implement? 1. Notify the health-care provider. 2. Prepare to administer a Fleet's enema. 3. Administer an antipyretic suppository. 4. Continue to monitor the client closely.

1. These are signs of peritonitis, which is life threatening. The health-care provider should be notified immediately

142. The client presents to the emergency department experiencing frequent watery, bloody stools after eating some undercooked meat at a fast food restaurant. Which intervention should be implemented first? 1. Provide the client with a specimen collection hat to collect a stool sample. 2. Initiate antibiotic therapy intravenously. 3. Have the laboratory draw a complete blood count. 4. Administer the antidiarrheal medication Lomotil.

1. This client may have developed an infection from the undercooked meat. The nurse should try to get a specimen for the laboratory to analyze and for the nurse to be able to assess. The client's complaint of "bloody diarrhea" needs to be investigated by the nurse, who should observe the amount, color, and characteristics of the stool.

136. The client has had a stool that is dark, watery, and shiny in appearance. Which intervention should be the nurse's first action? 1. Check for a fecal impaction. 2. Encourage the client to drink fluids. 3. Check the chart for sodium and potassium levels. 4. Apply a protective barrier cream to the perianal area.

1. This is a symptom of diarrhea moving around an impaction higher up in the colon. The nurse should assess for an impaction when observing this finding.

8. The nurse is administering a proton pump inhibitor to the client diagnosed with peptic ulcer disease. Which statement supports the rationale for administering this medication? 1. It prevents the final transport of hydrogen ions into the gastric lumen. 2. It blocks receptors that control hydrochloric acid secretion by the parietal cells. 3. It protects the ulcer from the destructive action of the digestive enzyme pepsin. 4. It neutralizes the hydrochloric acid secreted by the stomach.

1. This is the rationale for proton pump inhibitors.

70. Which laboratory value would the nurse expect to find indicating a chronic inflammation in the client with cholecystitis? 1. An elevated white blood cell (WBC) count. 2. A decreased lactate dehydrogenase (LDH) 3. An elevated alkaline phosphatase. 4. A decreased direct bilirubin level.

1. This value would be elevated in clients with chronic inflammation.

48. The client has recently been diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms? 1. Instruct the client to avoid drinking fluids with meals. 2. Explain the need to decrease intake of flatus-forming foods. 3. Teach the client how to perform gentle perianal care. 4. Encourage the client to see a psychologist.

1. This will help prevent abdominal distention, which causes symptoms of IBS. Do not confuse inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS).

79. The client is in end-stage liver failure and has vitamin K deficiency. Which interventions should the nurse implement? Select all that apply. 1. Avoid rectal temperatures. 2. Use only a soft toothbrush. 3. Monitor the platelet count. 4. Use small-gauge needles. 5. Assess for asterixis.

1. Vitamin K deficiency causes impaired coagulation; therefore rectal thermometers should be avoided to prevent bleeding. 2. Soft toothbrushes will help prevent bleeding of the gums. 3. Platelet count, PTT/PT, and INR should be monitored to assess coagulation status. 4. Injections should be avoided, if at all possible, because the client is unable to clot, but if they are absolutely necessarily, the nurse should use small-gauge needles.

116. The post-anesthesia care nurse is caring for a client who has had abdominal surgery. The client is complaining of nausea. Which intervention should the nurse implement first? 1. Medicate the client with a narcotic analgesic IVP. 2. Assess the nasogastric tube for patency. 3. Check the temperature for elevation. 4. Hyperextend the neck to prevent stridor.

2. A client who has had abdominal surgery usually has a nasogastric tube (NGT) in place. If the NGT is not patent, this will cause nausea. Irrigating the NGT may relieve nausea.

35. Which assessment data would indicate to the nurse that the client's gastric ulcer has perforated? 1. Complaints of sudden, sharp, substernal pain. 2. Rigid, boardlike abdomen with rebound tenderness. 3. Frequent, clay-colored, liquid stool. 4. Complaints of vague abdominal pain in the right upper quadrant

2. A rigid boardlike abdomen with rebound tenderness is the classic sign and symptom of peritonitis, which is a complication of a perforated gastric ulcer.

89. Which instruction should the nurse discuss with the client who is in the icteric phase of hepatitis C? 1. Decrease alcohol intake. 2. Encourage rest periods. 3. Eat a large evening meal. 4. Drink diet drinks and juices.

2. Adequate rest is needed for maintaining optimal immune function.

111. The client is one (1) day postoperative major abdominal surgery. Which client problem is priority? 1. Impaired skin integrity. 2. Fluid and electrolyte imbalance. 3. Altered bowel elimination. 4. Altered body image.

2. After abdominal surgery, the body distributes fluids to the affected area as part of the healing process. These fluids are shifted from the intravascular compartment to the interstitial space, which causes potential fluid and electrolyte imbalance.

63. The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching was effective? 1. "I will take my lipid-lowering medicine at the same time each night." 2. "I may experience some discomfort when I eat a high-fat meal." 3. "I need someone to stay with me for about a week after surgery." 4. "I should not splint my incision when I deep breathe and cough."

2. After removal of the gallbladder, some clients experience abdominal discomfort when eating fatty foods.

20. The client diagnosed with ulcerative colitis has had an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy? 1. "My stoma should be pink and moist." 2. "I will irrigate my ileostomy every morning." 3. "If I get a red, bumpy, itchy rash I will call my HCP." 4. "I will change my pouch if it starts leaking."

2. An ileostomy will drain liquid all the time and should not routinely be irrigated; only specially trained nurses are allowed to irrigate an ileostomy. A sigmoid colostomy may need daily irrigation to evacuate feces.

94. The client diagnosed with liver problems asks the nurse, "Why are my stools claycolored?" On which scientific rationale should the nurse base the response? 1. There is an increase in serum ammonia level. 2. The liver is unable to excrete bilirubin. 3. The liver is unable to metabolize fatty foods. 4. A damaged liver cannot detoxify vitamins.

2. Bilirubin, the byproduct of red blood cell destruction, is metabolized in the liver and excreted via the feces, which is what gives the feces the dark color. If the liver is damaged, the bilirubin is excreted via the urine and skin.

138. The dietician and nurse in a long-term care facility are planning the menu for the day. Which foods would be recommended for the immobile clients for whom swallowing is not an issue? 1. Cheeseburger and milk shake. 2. Canned peaches and a sandwich on whole-wheat bread. 3. Mashed potatoes and mechanically ground red meat. 4. Biscuits and gravy with bacon

2. Canned peaches are soft and can be chewed and swallowed easily while providing some fiber, and whole-wheat bread is higher in fiber than white bread. These foods will be helpful for clients whose gastric motility is slowed as a result of lack of exercise or immobility.

38. Which intervention should the nurse implement when administering a potassium supplement? 1. Determine the client's allergies. 2. Assess the client's apical heart rate. 3. Monitor the client's blood pressure. 4. Monitor the client's complete blood count.

2. Cardiac dysrhythmias occur when serum potassium levels are too low or too high. Many dysrhythmias can be detected by assessing the regularity of the heart rate.

35. The nurse is caring for the client diagnosed with chronic gastritis. Which symptom(s) would support this diagnosis? 1. Rapid onset of mid-sternal discomfort. 2. Epigastric pain relieved by eating food. 3. Dyspepsia and hematemesis. 4. Nausea and projectile vomiting

2. Chronic pain in the epigastric area that is relieved by ingesting food is a sign of chronic gastritis.

1. The nurse is caring for the client with active herpes simplex 1 lesions. Which intervention should the nurse implement to prevent the spread of the virus? 1. Wash hands completely only before providing care. 2. Wear clean gloves to prevent transfer of the virus. 3. Scrub the lesions with soap and water twice daily. 4. Apply 1% Lidocaine (hydrocortisone) cream to the lesions.

2. Clean gloves should be worn when providing care to prevent the transfer of the herpes simplex 1 virus.

69. Which assessment data indicate that the client recovering from an open cholecystectomy requires pain medication? 1. The client's pulse is 65 beats per minute. 2. The client has shallow respirations. 3. The client's bowel sounds are 20 per minute. 4. The client uses a pillow to splint when coughing.

2. Clients having abdominal pain frequently have shallow respirations. When assessing clients for pain, the nurse should discuss pain medication with any client who has shallow respirations

37. The occupational health nurse is preparing a presentation to a group of factory workers about preventing colon cancer. Which information should be included in the presentation? 1. Wear a high filtration mask when around chemicals. 2. Eat several servings of cruciferous vegetables daily. 3. Take a multiple vitamin every day. 4. Do not engage in high-risk sexual behaviors.

2. Cruciferous vegetables, such as broccoli, cauliflower, and cabbage, are high in fiber. One of the risks for cancer of the colon is a high-fat, low-fiber, and high-protein diet. The longer the transit time (the time from ingestion of the food to the elimination of the waste products) the greater the chance of developing cancer of the colon

44. The nurse is caring for the client one (1) day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement? 1. Change the infusion rate of the intravenous fluid. 2. Encourage the client to discuss his or her feelings. 3. Administer opioid narcotic medications for pain management. 4. Assist the client out of bed to sit in the chair twice daily.

2. Encouraging the client to verbalize feelings about body changes assists the client to accept these changes.

78. The nurse identifies the client problem as "excess fluid volume" for the client in liver failure. Which short-term goal would be most appropriate for this problem? 1. The client will not gain more that two (2) kg a day. 2. The client will have no increase in abdominal girth. 3. The client's vital signs will remain within normal limits (WNL). 4. The client will receive a low-sodium diet.

2. Excess fluid volume could be secondary to portal hypertension. Therefore, no increase in abdominal girth would be an appropriate short-term goal, indicating no excess of fluid volume.

10. Which statement made by the client would alert the nurse that the client may be experiencing GERD? 1. "My chest hurts when I walk up the stairs in my home." 2. "I take antacid tablets with me wherever I go." 3. "My spouse tells me I snore very loudly at night." 4. "I drink six (6) to seven (7) soft drinks every day."

2. Frequent use of antacids indicates an acidreflux problem.

12. The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulitis? Select all that apply. 1. Eat a low-fiber diet. 2. Drink 2500 mL of water daily. 3. Avoid eating foods with seeds. 4. Walk 30 minutes a day. 5. Take an antacid every two (2) hours.

2. Increased fluids will help keep the stool soft and prevent constipation. 3. It is controversial if seeds cause an exacerbation of diverticulosis, but this is an appropriate intervention to teach until proved otherwise. 4. Exercise will help prevent constipation, which causes an exacerbation of diverticulitis.

36. The client with a history of peptic ulcer disease has been admitted into the hospital intensive care unit with frank gastric bleeding. Which priority intervention should the nurse implement? 1. Maintain a strict record of intake and output. 2. Insert a nasogastric tube and begin saline lavage. 3. Assist the client with keeping a detailed calorie count. 4. Provide a quite environment to promote rest.

2. Inserting a nasogastric tube and lavaging the stomach with saline is the most important intervention because this directly stops the bleeding.

134. Which statement made by the client admitted with electrolyte imbalance from frequent cathartic use demonstrates an understanding of the discharge teaching? 1. "In the future I will eat a banana every time I take the medication." 2. "I don't have to have a bowel movement every day." 3. "I should limit the fluids I drink with my meals." 4. "If I feel sluggish, I will eat a lot of cheese and dairy products."

2. It is not necessary to have a bowel movement every day to have normal bowel functioning.

15. The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first? 1. Notify the health-care provider. 2. Assess the client for leg cramps. 3. Request telemetry for the client. 4. Prepare to administer potassium IV

2. Leg cramps are a sign of hypokalemia; hypokalemia can lead to cardiac dysrhythmias and can be life threatening. Assessment is priority for a potassium level that is just below normal level, which is 3.5 to 5.5 mEq/L.

.31. When planning the care for a client diagnosed with peptic ulcer disease, which expected outcome should the nurse include? 1. The client's pain is controlled with the use of NSAIDs. 2. The client maintains lifestyle modifications. 3. The client has no signs and symptoms of hemoptysis. 4. The client takes antacids with each meal.

2. Maintaining lifestyle changes such as following an appropriate diet and reducing stress indicates that the client is complying with the medical teachings. Such compliance is the goal of treatment to prevent complications.

91. The client with hepatitis asks the nurse, "I went to an herbalist, who recommended I take milk thistle. What do you think about that?" Which statement is the nurse's best response? 1. "You are concerned about taking an herb." 2. "The herb has been used to treat liver disease." 3. "I would not take anything that is not prescribed." 4. "Why would you want to take any herbs?"

2. Milk thistle has an active ingredient, silymarin, which has been used to treat liver disease for more than 2000 years. It is a powerful oxidant and promotes liver cell growth.

1 The male client in a health-care provider's office tells the nurse that he has been experiencing "heartburn" at night that awakens him. Which assessment question should the nurse ask? 1. "How much weight have you gained recently?" 2. "What have you done to alleviate the heartburn?" 3. "Do you consume many milk and dairy products?" 4. "Have you been around anyone with a stomach virus?"

2. Most clients with GERD have been selfmedicating with over-the-counter medications prior to seeking advice from a health-care provider. It is important to know what the client has been using to treat the problem.

107. Which nursing interventions should be included in the care plan for the 84-year-old client diagnosed with acute gastroenteritis? Select all that apply. 1. Assess the skin turgor on the back of the client's hands. 2. Monitor the client for orthostatic hypotension. 3. Record the frequency and characteristics of sputum. 4. Use standard precautions when caring for the client. 5. Institute safety precautions when ambulating the client

2. Orthostatic hypotension indicates fluid volume deficit, which can occur in an elderly client who is having many episodes of diarrhea, which occurs with acute gastroenteritis 4. Standard precautions, including wearing gloves and hand washing, help prevent the spread of the infection to others. 5. The elderly client is at risk for orthostatic hypotension; therefore safety precautions should be instituted to ensure the client doesn't fall as a result of a decrease in blood pressure.

87. Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? 1. Airborne precautions. 2. Standard precautions. 3. Droplet precautions. 4. Exposure precautions.

2. Standard Precautions apply to blood, all body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood.

105. The 79-year-old client diagnosed with acute gastroenteritis is admitted to the medical unit. Which nursing task would be most appropriate for the nurse to delegate to the unlicensed nursing assistant? 1. Evaluate the client's intake and output. 2. Take the client's vital signs. 3. Change the client's intravenous solution. 4. Assess the client's perianal area

2. The assistant can take the vital signs for a client who is stable; the nurse must interpret and evaluate the vital signs.

60. The client is admitted to the medical floor with acute diverticulitis. Which collaborative intervention would the nurse anticipate the health-care provider ordering? 1. Administer total parenteral nutrition. 2. Maintain NPO and nasogastric tube. 3. Maintain on a high-fiber diet and increase fluids. 4. Obtain consent for abdominal surgery

2. The bowel must be put at rest. Therefore, the nurse should anticipate orders for maintaining NPO and a nasogastric tube.

97. The female client came to the clinic complaining of abdominal cramping and has had at least 10 episodes of diarrhea every day for the last 2 days. The client reported that she had been in Mexico on a mission trip and just returned yesterday. Which intervention should the nurse implement? 1. Instruct the client to take a cathartic laxative daily. 2. Encourage the client to drink lots of Gatorade. 3. Discuss the need to increase protein in the diet. 4. Explain that the client should weigh herself daily.

2. The client probably has traveler's diarrhea, and oral rehydration is the preferred choice for replacing fluids lost as a result of diarrhea. An oral glucose electrolyte solution, such as Gatorade, All-Sport, or Pedialyte, is recommended

16. The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement? 1. Provide a low-residue diet. 2. Monitor intravenous fluids. 3. Assess vital signs daily. 4. Administer antacids orally.

2. The client requires fluids to help prevent dehydration from diarrhea and to replace the fluid lost through normal body functioning

44. The client with a new colostomy is being discharged. Which statement made by the client indicates the need for further teaching? 1. "If I notice any skin breakdown I will call the HCP." 2. "I should drink only liquids until the colostomy starts to work." 3. "I should not take a tub bath until the HCP okays it." 4. "I should not drive or lift more than five (5) pounds."

2. The client should be on a regular diet, and the colostomy will have been working for several days prior to discharge. The client's statement indicates the need for further teaching.

17. The client has been diagnosed with esophageal diverticula. Which lifestyle modification should be taught by the nurse? 1. Raise the foot of the bed to 45 degrees to increase peristalsis. 2. Eat the evening meal at least two (2) hours prior to bed. 3. Eat a low-fat, low-cholesterol, high-fiber diet. 4. Wear an abdominal binder to strengthen the abdominal muscles.

2. The evening meal should be eaten at least two (2) hours prior to retiring. Small, frequent meals and semi-soft foods ease the passage of food, which can decrease signs and symptoms of the disease process.

21. Which priority teaching information should the nurse discuss with the client to help prevent contracting hepatitis B? 1. Explain the importance of good hand washing. 2. Tell the client to take the hepatitis B vaccine in three (3) doses. 3. Tell the client not to ingest unsanitary food or water. 4. Discuss how to implement standard precautions.

2. The hepatitis B vaccine will prevent the client from contracting this disease.

29. The nurse is caring for the client diagnosed with hepatic encephalopathy. Which sign and symptom would indicate that the disease is progressing? 1. The client has a decrease in serum ammonia level. 2. The client is not able to circle choices on the menu. 3. The client is able to take deep breaths as directed. 4. The client is now able to eat previously restricted food items

2. The inability to circle food items on the menu indicates deterioration in the client's cognitive status

54. The nurse is preparing to administer an aminoglycoside antibiotic to the client just admitted with a diagnosis of acute diverticulitis. Which intervention should the nurse implement? 1. Obtain a serum trough level. 2. Ask about drug allergies. 3. Monitor the peak level. 4. Assess the vital signs.

2. The nurse should always ask about allergies to medication when administering medications, but especially when administering antibiotics, which are notorious for allergic reactions.

43. The client complains to the nurse of unhappiness with the health-care provider. Which intervention should the nurse implement next? 1. Call the HCP and suggest he or she talk with the client. 2. Determine what about the HCP is bothering the client. 3. Notify the nursing supervisor to arrange a new HCP to take over. 4. Explain to the client that until discharge, the client will have to keep the HCP

2. The nurse should determine what is concerning the client. It could be a misunderstanding or a real situation where the client's care is unsafe or inadequate.

93. The female nurse sticks herself with a dirty needle. Which action should the nurse implement first? 1. Notify the infection control nurse. 2. Cleanse the area with soap and water. 3. Request post-exposure prophylaxis. 4. Check the hepatitis status of the client.

2. The nurse should first clean the needle stick with soap and water to help remove any virus that is on the skin.

26. The nurse is caring for the client scheduled for an abdominal perineal resection for Stage IV colon cancer. When preparing the plan of care during surgery, which client problem should the nurse include in the plan? 1. Fluid volume deficit. 2. Impaired tissue perfusion. 3. Infection of surgical site. 4. Immunosuppression.

2. The perfusion of the surgical site is compromised as a result of the surgical incision, especially when a graft is used.

84. The client is admitted with end-stage liver failure and is prescribed the laxative lactulose (Chronulac). Which statement indicates the client needs more teaching concerning this medication? 1. "I should have two to three soft stools a day." 2. "I must check my ammonia level daily." 3. "If I have diarrhea, I will call my doctor." 4. "I should check my stool for any blood.

2. There is no instrument that can be used at home to test daily ammonia levels. The ammonia level is a serum level that requires venipuncture and laboratory diagnostic equipment.

137. The charge nurse has completed report. Which client should be seen first? 1. The client diagnosed with Crohn's disease who had two (2) semi-formed stools on the previous shift. 2. The elderly client admitted from another facility who is complaining of constipation. 3. The client diagnosed with AIDS who had a 200-mL diarrhea stool and has elastic skin tissue turgor. 4. The client diagnosed with hemorrhoids who had some spotting of bright red blood on the toilet tissue.

2. This client has just arrived so the nurse does not know if the complaint is valid and needs intervention unless this client is seen and assessed. The elderly have difficulty with constipation as a result of decreased gastric motility, medications, poor diet, and immobility.

119. The nurse is caring for the following clients on a surgical unit. Which client would the nurse assess first? 1. The client who had an inguinal hernia repair and has not voided in four (4) hours. 2. The client who was admitted with abdominal pain who suddenly has no pain. 3. The client four (4) hours postoperative abdominal surgery with no bowel sounds. 4. The client who is one (1) day postoperative appendectomy who is being discharged.

2. This could indicate a ruptured appendix, which could lead to peritonitis, a lifethreatening complication; therefore, the nurse should assess this client first

101. The client diagnosed with gastroenteritis is being discharged from the emergency department. Which intervention should the nurse include in the discharge teaching? 1. If diarrhea persists for more than 96 hours, contact the physician. 2. Instruct the client to wash hands thoroughly before handling any type of food. 3. Explain the importance of decreasing steroids gradually as instructed. 4. Discuss how to collect all stool samples for the next 24 hours.

2. This should be done by the client at all times, but especially when the client has gastroenteritis. The bacteria in feces may be transferred to other people via food if hands are not washed properly.

27. When the nurse is conducting the initial interview, which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease? 1. History of side effects experienced from all medication. 2. Use of nonsteroidal anti-inflammatory drugs (NSAIDs). 3. Any known allergies to drugs and environmental factors. 4. Medical histories of at least three (3) generations.

2. Use of NSAIDs places the client at risk for peptic ulcer disease and hemorrhage. Any client suspected of having peptic ulcer disease should be questioned specifically about the use of NSAIDs.

73. The client diagnosed with end-stage liver failure is admitted to the medical unit diagnosed with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (Sengstaken-Blakemore). Which nursing action should the nurse implement for this treatment? 1. Assess the gag reflex every shift. 2. Stay with the client at all times. 3. Administer the laxative lactulose (Chronulac). 4. Monitor the client's ammonia level.

2. While the balloons are inflated, the client must not be left unattended in case they become dislodged and occlude the airway. This is a safety issue.

102. Which medication would the nurse expect the health-care provider to order to treat the client diagnosed with botulism secondary to eating contaminated canned goods? 1. An antidiarrheal medication. 2. An aminoglycoside antibiotic. 3. An antitoxin medication. 4. An ACE inhibitor medication

3. A botulism antitoxin neutralizes the circulating toxin and is prescribed for a client with botulism

32. The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. When the nurse is evaluating care, which assessment data require further intervention? 1. Bowel sounds auscultated fifteen (15) times in one (1) minute. 2. Belching after eating a heavy and fatty meal late at night. 3. A decrease in systolic BP of 20 mm Hg from lying to sitting. 4. A decreased frequency of distress located in the epigastric region.

3. A decrease of 20 mm Hg in blood pressure after changing position from lying, to sitting, to standing is orthostatic hypotension. This could indicate that the client is bleeding.

108. The nurse has received the A.M. shift report. Which client should the nurse assess first? 1. The 44-year-old client diagnosed with peptic ulcer disease who is complaining of acute epigastric pain. 2. The 74-year-old client diagnosed with acute gastroenteritis who has had four (4) diarrhea stools during the night. 3. The 65-year-old client diagnosed with inflammatory bowel disease who has a hard, rigid abdomen and elevated temperature. 4. The 15-year-old client diagnosed with food poisoning who has vomited several times during the night shift.

3. A hard, rigid abdomen and an elevated temperature are abnormal in any circumstance and the nurse should assess this client first. These are clinical manifestations of peritonitis, a potentially lifethreatening condition.

6. The female client is diagnosed with ulcerative colitis. Which sign/symptom would warrant immediate intervention by the nurse? 1. The client has 20 bloody stools a day. 2. The client's oral temperature is 99.8"F. 3. The client's abdomen is hard and rigid. 4. The client complains of urinating when she coughs.

3. A hard, rigid abdomen indicates peritonitis, which is a complication of ulcerative colitis and warrants immediate intervention.

14. The client is one (1) hour postoperative laparoscopic cholecystectomy. Which intervention should the nurse implement? 1. Assess the client's abdominal dressing for bleeding. 2. Monitor the client's T-tube output every one (1) hour. 3. Discuss discharge teaching with the significant other. 4. Check the client's upper right quadrant stoma site.

3. A laparoscopic cholecystectomy is done in day surgery. The nurse must make sure the significant others taking care of the client are knowledgeable of postoperative care.

23. The client diagnosed with ulcerative colitis is prescribed a low-residue diet. Which meal selection indicates the client understands the diet teaching? 1. Grilled hamburger on a wheat bun and fried potatoes. 2. A chicken salad sandwich and lettuce and tomato salad. 3. Roast pork, white rice, and plain custard. 4. Fried fish, whole grain pasta, and fruit salad.

3. A low-residue diet is a low-fiber diet. Products made of refined flour or finely milled grains, along with roasted, baked, or broiled meats, are recommended.

28. The nurse is caring for the client diagnosed with ascites from hepatic cirrhosis. What information should the nurse report to the health-care provider? 1. A decrease in the client's daily weight of one (1) pound. 2. An increase in urine output after administration of a diuretic. 3. An increase in abdominal girth of two (2) inches. 4. A decrease in the serum direct bilirubin to 0.6 mg/dL.

3. An increase in abdominal girth would indicate that the ascites is increasing, meaning that the client's condition is becoming more serious and should be reported to the health-care provider

110. The client has had abdominal surgery and tells the nurse, "I felt as something just gave way in my stomach." Which action should the nurse implement first? 1. Notify the surgeon immediately. 2. Instruct the client to splint the incision. 3. Assess for serosanguineous wound drainage. 4. Administer pain medication intravenously.

3. Assessing the surgical incision is the first intervention because this may indicate the client has wound dehiscence.

12. The client diagnosed with gastroesophageal reflux disease (GERD) is at greater risk for which disease? 1. Hiatal hernia. 2. Gastroenteritis. 3. Esophageal cancer. 4. Gastric cancer.

3. Barrett's esophagitis results from longterm erosion of the esophagus as a result of reflux of stomach contents secondary to GERD. This is a precursor to esophageal cancer

113. The client is diagnosed with peritonitis. Which assessment data indicate the client's condition is improving? 1. The client is using more pain medication on a daily basis. 2. The client's nasogastric tube is draining coffee-ground material. 3. The client has a decrease in temperature and a soft abdomen. 4. The client has had two (2) soft, formed bowel movements.

3. Because the signs of peritonitis are elevated temperature and rigid abdomen, a reversal of these signs would indicate the client is getting better.

52. The nurse is discussing the therapeutic diet for the client diagnosed with diverticulosis. Which meal indicates the client understands the discharge teaching? 1. Fried fish, mashed potatoes, and iced tea. 2. Ham sandwich, applesauce, and whole milk. 3. Chicken salad on whole-wheat bread and water. 4. Lettuce, tomato, and cucumber salad and coffee.

3. Chicken and whole-wheat bread are high in fiber, which is the therapeutic diet prescribed for clients with diverticulosis. An adequate intake of water helps prevent constipation.

80. The client is in end-stage liver failure. Which gastrointestinal assessment data would the nurse expect to find when assessing the client? 1. Hypoalbuminemia and muscle wasting. 2. Oligomenorrhea and decreased body hair. 3. Clay-colored stools and hemorrhoids. 4. Dyspnea and caput medusae.

3. Clay-colored stools and hemorrhoids are gastrointestinal effects of liver failure.

32. The nurse is caring for a client diagnosed with ulcerative colitis. Which symptom(s) supports this diagnosis? 1. Increased appetite and thirst. 2. Elevated hemoglobin. 3. Multiple bloody, liquid stools. 4. Exacerbations unrelated to stress

3. Clients report as many as 10 to 20 liquid bloody stools in a day.

4. The nurse is planning the care of a client diagnosed with lower esophageal sphincter dysfunction. Which dietary modifications should be included in the plan of care? 1. Allow any of the client's favorite foods as long as the amount of the food is limited. 2. Have the client perform eructation exercises several times a day. 3. Eat four (4) to six (6) small meals a day and limit fluids during mealtimes. 4. Encourage the client to consume a glass of red wine with one (1) meal a day

3. Clients should eat small, frequent meals and limit fluids with the meals to prevent reflux into the esophagus from a distended stomach.

74. The client has had a liver biopsy. Which post-procedure intervention should the nurse implement? 1. Instruct the client to void immediately. 2. Keep the client NPO for eight (8) hours. 3. Place the client on the right side. 4. Monitor blood urea nitrogen (BUN) and creatinine level.

3. Direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure.

22. The nurse is working in an emergency department of a community hospital. During the past 2 hours, 15 clients have been diagnosed with Salmonella food poisoning. Which information should the nurse discuss with clients? 1. Explain that the incubation period is 48 to 72 hours. 2. Explain that the source of this poisoning is contaminated water. 3. Explain that one (1) source of potential contamination is eggs. 4. Explain that the bacterial contaminant is from canned food

3. Eggs, poultry, pet turtles, and chickens are sources of the Salmonellae bacteria, which cause food poisoning

120. The 84-year-old client comes to the clinic complaining of right lower abdominal pain. Which question would be most appropriate for the nurse to ask the client? 1. "When was your last bowel movement?" 2. "Did you have a high-fat meal last night?" 3. "How long have you had this pain?" 4. "Have you been experiencing any gas?"

3. Elderly clients usually display a high tolerance to pain and frequently may have a ruptured appendix with minimal pain, therefore the nurse should assess the characteristic and etiology of the pain

23. Which intervention should the nurse include when discussing ways to prevent food poisoning? 1. Wash hands for ten (10) seconds after handling raw meat. 2. Clean all cutting boards between meats and fruits. 3. Maintain food temperatures at 140%F during extended servings. 4. Explain that fruits do not require washing prior to eating or preparing.

3. Foods that are being served for an extended time should be kept at 140$F.

59. Which client would be most likely to have the diagnosis of diverticulosis? 1. A 60-year-old male with a sedentary lifestyle. 2. A 72-year-old female with multiple childbirths. 3. A 63-year-old female with hemorrhoids. 4. A 40-year-old male with a family history of diverticulosis.

3. Hemorrhoids would indicate the client has chronic constipation, which is a strong risk factor for diverticulosis. Constipation increases the intraluminal pressure in the sigmoid colon, leading to weakness in the intestinal lining, which, in turn, causes outpouchings, or diverticula

100. The client is diagnosed with gastroenteritis. Which laboratory data would warrant immediate intervention by the nurse? 1. A serum sodium level of 137 mEq/L. 2. An arterial blood gas of pH 7.37, PaO2 95, PaCO2 43, HCO3 24. 3. A serum potassium level of 3.3 mEq/L. 4. A stool sample that is positive for fecal leukocytes

3. In gastroenteritis, diarrhea often results in metabolic acidosis and loss of potassium. The normal serum potassium level is 3.5-5.5 mEq/L; therefore a 3.3 mEq/L would require immediate intervention. Hypokalemia (a low potassium level) can lead to life-threatening cardiac dysrhythmias.

46. The client has been diagnosed with hemorrhoids. Which statement from the client indicates that further teaching is needed? 1. "I should increase fruits, bran, and fluids in my diet." 2. "I will use warm compresses and take sitz baths daily." 3. "I must take a laxative every night and have a stool daily." 4. "I can use an analgesic ointment or suppository for pain."

3. Laxatives can be harsh to the bowel and are habit-forming, so they should not be taken daily. Stool softeners that soften stool can be taken daily

144. The nurse is caring for clients on a medical unit. Which client information should be brought to the attention of the HCP immediately? 1. A serum sodium of 139 mEq/L in a client diagnosed with obstipation. 2. The client diagnosed with fecal impaction who had two (2) hard formed stools. 3. A serum potassium level of 3.0 mEq/L in a client diagnosed with diarrhea. 4. The client with diarrhea who had two (2) semi-liquid stools totaling 300 mL.

3. Normal potassium levels are 3.5-5.5 mEq/L. The level stated in this option is below normal. Imbalances in potassium levels can be caused by diarrhea and can cause cardiac dysrhythmias.

133. The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented? 1. Administer an antidiarrheal medication, every day and PRN. 2. Perform bowel training every two (2) hours. 3. Administer oil retention enemas. 4. Prepare for an upper gastrointestinal (UGI) series x-ray

3. Oil retention enemas will help to soften the feces and evacuate the stool.

5. Which complaint would be significant for the nurse to assess in the adolescent male client who uses oral tobacco? 1. The client complains of clear to white sputum. 2. The client has an episodic blister on the upper lip. 3. The client complains of a nonhealing sore in the mouth. 4. The client has bilateral ducts at the second molars.

3. Presence of any nonhealing sore on the lips or mouth may be oral cancer, the risk for which is increased by using oral tobacco.

106. The emergency department nurse knows the client diagnosed with acute gastroenteritis understands the discharge teaching when the client makes which statement? 1. "I will probably have some leg cramps while I have gastroenteritis." 2. "I should decrease my fluid intake until the diarrhea subsides." 3. "I should reintroduce solid foods very slowly into my diet." 4. "I should only drink bottled water until the abdominal cramping stops."

3. Reintroducing solid foods slowly, in small amounts, will allow the bowel to rest and the mucosa to return to health after acute gastroenteritis states

117. The nurse is completing the shift assessment on the client recovering from abdominal surgery who has a PCA pump. The client has shallow respirations and refuses to deep breathe. Which intervention should the nurse implement? 1. Insist that the client take deep breaths. 2. Notify the surgeon to request a chest x-ray. 3. Determine the last time the client used the PCA pump. 4. Administer oxygen 2 L/min via nasal cannula.

3. Shallow respirations and refusal to deep breathe could be the result of abdominal pain. The nurse should assess the client for pain and determine the last time the PCA pump was used.

46. The nurse is caring for clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society's recommendations for the early detection of colon cancer? 1. Beginning at age 60, a digital rectal exam should be done yearly. 2. After the client reaches middle age, a yearly fecal occult test should be done. 3. At age 50, a colonoscopy and then once every five (5) to ten (10) years. 4. A flexible sigmoidoscopy should be done yearly after age 40.

3. The American Cancer Society recommends a colonoscopy at age 50 and every five (5) to ten (10) years thereafter and a flexible sigmoidoscopy and barium enema every five (5) years.

9. Which task can the nurse delegate to the unlicensed nursing assistant to improve the desire to eat in a client diagnosed with anorexia? 1. Administer an antiemetic 30 minutes before the meal. 2. Provide mouth care with lemon glycerin swabs prior to the meal. 3. Create a social atmosphere by interacting with the client. 4. Encourage the client's parents to sit with the client during meals.

3. The NA assisting the client with meals needs to increase interaction to improve the client's appetite and make it an enjoyable occasion.

76. The client diagnosed with end-stage renal failure with ascites is scheduled for a paracentesis. Which client teaching should the nurse discuss with the client? 1. Explain that the procedure will be done in the operating room. 2. Instruct the client that a Foley catheter will have to be inserted. 3. Tell the client that vital signs will be taken frequently after the procedure. 4. Provide instructions on holding the breath when the HCP inserts the catheter.

3. The client is at risk for hypovolemia; therefore, vital signs will be assessed frequently to monitor for signs of hemorrhaging.

19. The client diagnosed with Crohn's disease is crying and tells the nurse, "I can't take it anymore. I never know when I will get sick and end up here in the hospital." Which statement would be the nurse's best response? 1. "I understand how frustrating this must be for you." 2. "You must keep thinking about the good things in your life." 3. "I can see you are very upset. I'll sit down and we can talk." 4. "Are you thinking about doing anything like committing suicide?"

3. The client is crying and is expressing feelings of powerlessness; therefore the nurse should allow the client to talk.

3. Which instruction should be discussed with the client diagnosed with gastroesophageal reflux disease (GERD)? 1. Eat a low-carbohydrate, low-sodium diet. 2. Lie down for 30 minutes after eating. 3. Do not eat spicy foods or acidic foods. 4. Drink two (2) glasses of water before bedtime.

3. The client should avoid irritants, such as spicy foods or acidic foods, as well as alcohol, caffeine, and tobacco, because they increase gastric secretions.

8. The nurse is preparing a client diagnosed with gastroesophageal reflux disease (GERD) for surgery. Which information should be brought to the attention of the health-care provider? 1. The client's Bernstein esophageal test was positive. 2. The client's abdominal x-ray shows a hiatal hernia. 3. The client's WBC count is 14,000 mg/dL. 4. The client's hemoglobin is 13.8 mg/dL.

3. The client's WBC is elevated, indicating a possible infection, which warrants notifying the HCP

67. The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care? 1. Instruct the client to cough forcefully. 2. Encourage early ambulation. 3. Assess for return of a gag reflex. 4. Administer held medications.

3. The endoscopic retrograde cholangiopancreatogram (ERCP) requires that an anesthetic spray be used prior to insertion of the endoscope. If medications, food, or fluid is given orally prior to the return of the gag reflex, the client may aspirate, causing pneumonia that could be fatal.

140. The nurse, a licensed practical nurse, and an unlicensed nursing assistant are caring for clients on a medical floor. Which nursing task would be most appropriate to assign to the licensed practical nurse? 1. Assist the unlicensed nursing assistant to learn to perform blood glucose checks. 2. Monitor the potassium levels of a client with diarrhea. 3. Administer a bulk laxative to a client diagnosed with constipation. 4. Assess the abdomen of a client who has had complaints of pain

3. The licensed practical nurse could administer a laxative

38. The nurse is admitting a male client to a medical floor with a diagnosis of adenocarcinoma of the rectosigmoid colon. Which assessment data support this diagnosis? 1. The client reports up to 20 bloody stools per day. 2. The client states that he has a feeling of fullness after a heavy meal. 3. The client has diarrhea alternating with constipation. 4. The client complains of right lower quadrant pain with rebound tenderness.

3. The most common symptom of colon cancer is a change in bowel habits, specifically diarrhea alternating with constipation.

81. Which assessment question would be priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis? 1. How many years have you been drinking alcohol? 2. Have you completed an advanced directive? 3. When did you have your last alcoholic drink? 4. What foods did you eat at your last meal?

3. The nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol

15. Which information should the nurse teach the client post-barium enema procedure? 1. The client should not eat or drink anything for four (4) hours. 2. The client should remain on bed rest until the sedative wears off. 3. The client should take a mild laxative to help expel the barium. 4. The client will have normal elimination color and pattern immediately.

3. The nurse needs to teach the client to take a mild laxative to help evacuate the barium and return to the client's normal bowel routine. Failure to pass the barium could cause constipation when the barium hardens.

51. The client is admitted to the medical unit with a diagnosis of acute diverticulitis. Which health-care provider's order should the nurse question? 1. Insert a nasogastric tube. 2. Start IV D5W at 125 mL/hr. 3. Put client on a clear liquid diet. 4. Place client on bed rest with bathroom privileges.

3. The nurse should question a clear liquid diet because the bowel must be put on total rest, which means NPO.

96. Which task would be most appropriate for the nurse to delegate to the unlicensed nursing assistant? 1. Draw the serum liver function test. 2. Evaluate the client's intake and output. 3. Assist the client to the bedside commode. 4. Help the ward clerk transcribe orders.

3. The nursing assistant can assist a client to the bedside commode.

18. The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement first? 1. Weigh the client daily and document it in the client's chart. 2. Teach coping strategies such as dietary modifications. 3. Record the frequency, amount, and color of stools. 4. Monitor the client's oral fluid intake every shift.

3. The severity of the diarrhea helps determine the need for fluid replacement. The liquid stool should be measured as part of the total output.

143. The nurse is planning the care of a client diagnosed with infectious diarrhea. Which independent problem should be included in the plan of care? 1. Risk for hypovolemic shock. 2. Bacteremia. 3. Fluid volume deficit. 4. Increased knowledge of transmission.

3. The treatment of a fluid volume deficit is an independent nursing problem; the nurse can assess and intervene with oral fluids.

48. The client presents with a complete blockage of the large intestine from a large tumor. Which health-care provider's order would the nurse question? 1. Obtain consent for a colonoscopy and biopsy. 2. Start an IV of 0.9% saline at 125 mL/hour. 3. Administer 3 liters of Go-LYTELY. 4. Give tap water enemas until it is clear.

3. This client has an intestinal blockage from a solid tumor blocking the colon. Although the client needs to be cleaned out for the colonoscopy, this would cause severe cramping without a reasonable benefit to the client and could cause a medical emergency

9. The charge nurse is making assignments. Staffing includes a registered nurse with five (5) years of medical-surgical experience, a newly graduated registered nurse, and two (2) unlicensed nursing assistants. Which client should be assigned to the most experienced nurse? 1. The 39-year-old client diagnosed with lower esophageal dysfunction who is complaining of pyrosis. 2. The 54-year-old client diagnosed with Barrett's esophagitis who is scheduled to have an endoscopy this morning. 3. The 46-year-old client diagnosed with gastroesophageal reflux disease who has wheezes in all five (5) lobes. 4. The 68-year-old client who is three (3) days post-op hiatal hernia and needs to be ambulated four (4) times today

3. This client is exhibiting symptoms of asthma, a complication of GERD; therefore, the client should be assigned to the most experienced nurse.

65. The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed nursing assistant? 1. Check the abdominal dressings for bleeding. 2. Increase the IV fluid if the blood pressure is low. 3. Document the amount of output on the I & O sheet. 4. Listen to the breath sounds in all lobes.

3. This intervention would be appropriate for the nursing assistant to implement.

30. The client has been admitted to the hospital with hemorrhaging from a duodenal ulcer. Which collaborative interventions should the nurse implement? Select all that apply. 1. Perform a complete pain assessment. 2. Evaluate BP lying, sitting, and standing 3. Administer antibiotics intravenously. 4. Administer blood products. 5. Monitor intake of a soft, bland diet.

3. This is a collaborative intervention that the nurse should implement. It requires an order from the HCP. 4. Administering blood products is collaborative, requiring an order from the HCP.

83. The client is diagnosed with end-stage liver failure. The client asks the nurse, "Why is my doctor decreasing the doses of my medications?" Which statement is the nurse's best response? 1. "You are worried that your doctor has decreased the dosage." 2. "You really should ask your doctor. I am sure there is a good reason." 3. "You may have an overdose of the medication because your liver is damaged." 4. "The half-life is altered because the liver is damaged."

3. This is the main reason the HCP decreases the client's medication dose, and it is an explanation appropriate for the client.

14. The client is prescribed prednisone, a steroid, for an acute episode of inflammatory bowel disease. Which intervention should the nurse discuss with the client? 1. Take this medication on an empty stomach. 2. Notify the HCP if you experience a moon face. 3. Be sure to take this medication as prescribed. 4. Take the medication in the morning only

3. This medication must be tapered off to prevent adrenal insufficiency; therefore, the client must take this medication as prescribed

72. The client is six (6) hours postoperative open cholecystectomy and the nurse finds a large amount of red drainage on the dressing. Which intervention should the nurse implement? 1. Measure the abdominal girth. 2. Palpate the lower abdomen for a mass. 3. Turn client onto side to assess for further drainage. 4. Remove the dressing to determine the source.

3. Turning the client to the side to assess the amount of drainage and possible bleeding is important prior to contacting the surgeon.

85. The client is in the preicteric phase of hepatitis. Which signs/symptoms would the nurse expect the client to exhibit during this phase? 1. Clay-colored stools and jaundice. 2. Normal appetite and pruritus. 3. Being afebrile and left upper quadrant pain. 4. Complaints of fatigue and diarrhea

4. "Flu-like" symptoms are the first complaints of the client in the preicteric phase of hepatitis, which is the initial phase and may begin abruptly or insidiously.

109. The male client has had abdominal surgery and is now diagnosed with peritonitis. Which assessment data support the client's diagnosis of peritonitis? 1. Absent bowel sounds and potassium level of 3.9 mEq/L. 2. Abdominal cramping and hemoglobin of 14 gm/dL. 3. Profuse diarrhea and stool specimen shows Campylobacter. 4. Hard, rigid abdomen and white blood cell count 22,000 mm.

4. A hard, rigid abdomen indicates an inflamed peritoneum (abdominal wall cavity) resulting from an infection, which results in an elevated WBC level.

135. The client has been experiencing difficulty and straining when expelling feces. Which intervention should be taught to the client? 1. Explain that some blood in the stool will be normal for the client. 2. Instruct the client in manual removal of feces. 3. Encourage the client to use a cathartic laxative on a daily basis. 4. Place the client on a high-residue diet

4. A high-residue diet provides bulk for the colon to use in removing the waste products Bulk laxatives and fiber from vegetables and bran assist the colon to work more effectively.

7. The nurse is administering morning medications at 0730. Which medication would have priority? 1. A proton pump inhibitor. 2. A nonnarcotic analgesic. 3. A histamine receptor antagonist. 4. A mucosal barrier agent.

4. A mucosal barrier agent must be administered on an empty stomach for the medication to coat the stomach

114. The client has developed a paralytic ileus after abdominal surgery. Which intervention should the nurse include in the plan of care? 1. Administer a laxative of choice. 2. Encourage client to increase oral fluids. 3. Encourage the client to take deep breaths. 4. Maintain a patent nasogastric tube

4. A paralytic ileus is the absence of peristalsis; therefore the bowel will be unable to process any oral intake. A nasogastric tube is inserted to decompress the bowel until there is surgical intervention or bowel sounds return spontaneously

47. The nurse writes a psychosocial problem of "risk for altered sexual functioning related to new colostomy." Which intervention should the nurse implement? 1. Tell the client that there should be no intimacy for at least three (3) months. 2. Ensure that the client and significant other are able to change the ostomy pouch. 3. Demonstrate with charts possible sexual positions for the client to assume. 4. Teach the client to protect the pouch from becoming dislodged during sex.

4. A pouch that becomes dislodged during the sexual act would cause embarrassment for the client whose body image has already been dealt a blow.

71. Which nursing diagnosis would be highest priority for the client who had an open cholecystectomy surgery? 1. Alteration in nutrition. 2. Alteration in skin integrity. 3. Alteration in urinary pattern. 4. Alteration in comfort.

4. Acute pain management is the highest priority client problem after surgery because pain may indicate a life-threatening problem.

75. The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication? 1. Restrict sodium intake to 2 g/day. 2. Limit oral fluids to 1500 mL/day. 3. Decrease the daily fat intake. 4. Reduce protein intake to 60 to 80 g/day

4. Ammonia is a byproduct of protein metabolism and contributes to hepatic encephalopathy. Reducing protein intake should decrease ammonia levels.

34. The nurse has administered an antibiotic, a proton pump inhibitor, and Pepto-Bismol for peptic ulcer disease secondary to H. pylori. Which data would indicate to the nurse that the medications are effective? 1. A decrease in alcohol intake. 2. Maintaining a bland diet. 3. A return to previous activities. 4. A decrease in gastric distress.

4. Antibiotics, proton pump inhibitors, and Pepto-Bismol are administered to decrease the irritation of the ulcerative area and cure the ulcer. A decrease in gastric distress indicates the medication is effective.

98. Which intervention should the nurse include when discussing ways to help prevent potential episodes of gastroenteritis from Clostridium botulism? 1. Make sure that all hamburger meat is well cooked. 2. Ensure that all dairy products are refrigerated. 3. Discuss that campers should drink only bottled water. 4. Discard all canned goods that are damaged.

4. Any food that is discolored or comes from a can or jar that has been damaged or does not have a tight seal should be destroyed without tasting or touching it

104. Which assessment data would the nurse expect to find in the client diagnosed with acute gastroenteritis? 1. Decreased gurgling sounds on auscultation of the abdominal wall. 2. A hard, firm edematous abdomen on palpation. 3. Frequent, small melena-type liquid bowel movements. 4. Bowel assessment reveals loud, rushing bowel sounds.

4. Borborygmi, or loud, rushing bowel sounds, indicates increased peristalsis, which occurs in clients with diarrhea and is the primary clinical manifestation in a client diagnosed with acute gastroenteritis.

53. The client is two (2) hours post-colonoscopy. Which assessment data would warrant intermediate intervention by the nurse? 1. The client has a soft, nontender abdomen. 2. The client has a loose, watery stool. 3. The client has hyperactive bowel sounds. 4. The client's pulse is 104 and BP is 98/60.

4. Bowel perforation is a potential complication of a colonoscopy. Therefore signs of hypotension—decreased BP and increased pulse—would warrant immediate intervention from the nurse.

45. The nurse is caring for the client recovering from intestinal surgery. Which assessment finding would require immediate intervention? 1. Presence of thin pink drainage in the Jackson Pratt. 2. Guarding when the nurse touches the abdomen. 3. Tenderness around the surgical site during palpation. 4. Complaints of chills and feeling feverish.

4. Complaints of chills, sudden onset of fever, tachycardia, nausea, and hiccups are symptoms of peritonitis,

88. The school nurse is discussing ways to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the most important intervention that the school nurse must explain to the school teachers? 1. Do not allow students to eat or drink after each other. 2. Drink bottled water as much as possible. 3. Encourage protected sexual activity. 4. Thoroughly wash hands.

4. Hepatitis A is transmitted via the fecal-oral route. Good hand washing helps to prevent its spread

25. Which assessment data support the client's diagnosis of gastric ulcer? 1. Presence of blood in the client's stool for the past month. 2. Complaints of a burning sensation that moves like a wave. 3. Sharp pain in the upper abdomen after eating a heavy meal. 4. Comparison of complaints of pain with ingestion of food and sleep.

4. In a client diagnosed with a gastric ulcer, pain usually occurs 30-60 minutes after eating, but not at night. In contrast, a client with a duodenal ulcer has pain during the night that is often relieved by eating food. Pain occurs 1-3 hours after meals.

25. The nurse is assessing a client complaining of abdominal pain. Which data would support the diagnosis of a bowel obstruction? 1. Steady, aching pain in one specific area. 2. Sharp back pain radiating to the flank. 3. Sharp pain that increases with deep breaths. 4. Intermittent colicky pain near the umbilicus.

4. Intermittent and colicky pain located near the umbilicus is indicative of a small bowel obstruction; lumbar pain is indicative of colon involvement.

33. The nurse is teaching the client diagnosed with inflammatory bowel disease (IBD) about the therapeutic diet. Which food selection would be the best choice for a meal? 1. Roast beef on wheat bread and a milk shake. 2. Hamburger, French fries, and a Coke. 3. Pepper steak, brown rice, and iced tea. 4. Roasted turkey, asparagus, and water.

4. Meats can be eaten if prepared by roasting, baking, or broiling. Vegetables should be cooked, not raw, and skins should be removed. A low-residue diet should be eaten.

3 The nurse is preparing a client diagnosed with GERD for discharge following an esophagogastroduodenoscopy. Which statement indicates the client understands the discharge instructions? 1. "I should not eat for twenty-four (24) hours following this procedure." 2. "I can lie down whenever I want after a meal. It won't make a difference." 3. "The stomach contents won't bother my esophagus but will make me nauseous." 4. "I should avoid drinking orange juice and eating tomatoes until my esophagus heals."

4. Orange and tomato juices are acidic, and the client diagnosed with GERD should avoid acidic foods until the esophagus has had a chance to heal.

29. The client diagnosed with peptic ulcer disease is admitted into the hospital. Which nursing diagnosis should the nurse include in the plan of care to observe for physiological complications? 1. Alteration in bowel elimination patterns. 2. Knowledge deficit in the causes of ulcers. 3. Inability to cope with changing family roles. 4. Potential for alteration in gastric emptying.

4. Potential for alteration in gastric emptying is caused by edema or scarring associated with peptic ulcer disease, which may cause a feeling of "fullness," vomiting of undigested food, or abdominal distention

61. The client is four (4) hours postoperative open cholecystectomy. Which data would warrant immediate intervention by the nurse? 1. Absent bowel sounds in all four (4) quadrants. 2. The T-tube with 60 mL of green drainage. 3. Urine output of 100 mL in the past three (3) hours. 4. Refusal to turn, deep breathe, and cough

4. Refusing to turn, deep breathe, and cough puts the client at risk for pneumonia. This client needs immediate intervention to prevent complications.

41. The client is complaining of painful swallowing secondary to mouth ulcers. Which statement indicates the nurse's teaching has been effective? 1. "I will brush my teeth with a soft-bristle toothbrush." 2. "I will rinse my mouth with Listerine mouth wash." 3. "I will swish with antifungal solution and then swallow." 4. "I will avoid spicy foods, tobacco, and alcohol."

4. Substances that are irritating should be avoided during the outbreaks of ulcers in the mouth. Spicy foods, alcohol, and tobacco are common irritants that the client should avoid.

39. The nurse is preparing the client for a fiberoptic colonoscopy for colon polyps. Which task can be delegated to the unlicensed nursing assistant? 1. Administer the polyethylene glycol electrolyte lavage solution. 2. Explain to the client why that morning's breakfast is withheld. 3. Start an intravenous site with 0.9% normal saline fluid. 4. Administer a cleansing enema until the return is clear.

4. The administration of enemas can be delegated to the unlicensed nursing assistant.

95. Which statement by the client diagnosed with hepatitis would warrant immediate intervention by the clinic nurse? 1. "I will not drink any type of beer or mixed drink." 2. "I will get adequate rest so that I don't get exhausted." 3. "I had a big hearty breakfast this morning." 4. "I took some cough syrup for this nasty head cold."

4. The client needs to understand that some types of cough syrup have alcohol and all alcohol must be avoided to prevent further injury to the liver; therefore this statement requires intervention.

50. The nurse is teaching the client diagnosed with diverticulosis. Which instruction should the nurse include in the teaching session? 1. Discuss the importance of drinking 1000 mL of water daily. 2. Instruct the client to exercise at least three (3) times a week. 3. Teach the client about a eating a low-residue diet. 4. Explain the need to have daily bowel movements.

4. The client should have regular bowel movements, preferably daily. Constipation may cause diverticulitis, which is a potentially life-threatening complication of diverticulosis.

5. The nurse is caring for a client diagnosed with gastroesophageal reflux disease (GERD). Which nursing interventions should be implemented? 1. Place the client prone in bed and administer nonsteroidal anti-inflammatory medications. 2. Have the client remain upright at all times and walk for 30 minutes three (3) times a week. 3. Instruct the client to maintain a right lateral side-lying position and take antacids before meals. 4. Elevate the head of the bed 30 degrees and discuss lifestyle modifications with the client.

4. The head of the bed should be elevated to allow gravity to help in preventing reflux. Lifestyle modifications of losing weight, making dietary modifications, attempting smoking cessation, discontinuing the use of alcohol, and not stooping or bending at the waist all help to decrease reflux.

49. The client admitted to the medical unit with diverticulitis is complaining of severe pain in the left lower quadrant and has an oral temperature of 100.6!F. Which action should the nurse implement first? 1. Notify the health-care provider. 2. Document the findings in the chart. 3. Administer an oral antipyretic. 4. Assess the client's abdomen.

4. The nurse should assess the client to determine if the abdomen is soft and nontender. A rigid tender abdomen may indicate peritonitis.

41. The client who has had an abdominal perineal resection is being discharged. Which discharge information should the nurse teach? 1. The stoma should be a white, blue, or purple color. 2. Limit ambulation to prevent the pouch from coming off. 3. Take pain medication when the pain level is at an "8." 4. Empty the pouch when it is one-third to one-half full.

4. The pouch should be emptied when it is one-third to one-half full to prevent the contents from becoming too heavy for the seal to hold and to prevent leakage from occurring.

10. The male client with rule out colon cancer is two (2) hours post-sigmoidoscopy procedure. Which intervention would warrant immediate intervention by the nurse? 1. The client has hyperactive bowel sounds. 2. The client is eating a hamburger that his family brought. 3. The client is sleepy and wants to sleep. 4. The client's BP is 96/60 and apical pulse is 108.

4. These are signs/symptoms of hypovolemic shock that require immediate intervention by the nurse.

42. When assessing the integumentary system of the client with anorexia nervosa, which finding would support the diagnosis? 1. Preoccupation with calories. 2. Thick body hair. 3. Sore tongue. 4. Dry, brittle hair.

4. Thin, brittle hair occurs in clients with anorexia.

21. The client diagnosed with IBD is prescribed sulfasalazine (Asulfidine), a sulfonamide antibiotic. Which statement best describes the rationale for administering this medication? 1. It is administered rectally to help decrease colon inflammation. 2. This medication slows gastrointestinal motility and reduces diarrhea. 3. This medication kills the bacteria that cause the exacerbation. 4. It acts topically on the colon mucosa to decreases inflammation

4. This antibiotic is poorly absorbed from the gastrointestinal tract and acts topically on the colonic mucosa to inhibit the inflammatory process.

141. The client is placed on percutaneous gastrostomy (PEG) tube feedings. Which occurrence would warrant immediate intervention by the nurse? 1. The client tolerates the feedings being infused at 50 mL/hour. 2. The client pulls the nasogastric feeding tube out. 3. The client complains of being thirsty. 4. The client has green, watery stool.

4. This client needs to be cleaned immediately; the abdomen must be assessed; and a determination must be made regarding the type of feeding and the additives and medications being administered and skin damage occurring. This client is priority.

68. Which expected outcome would be appropriate for the client scheduled to have a cholecystectomy? 1. Decreased pain management. 2. Ambulate first day postoperative. 3. No break in skin integrity. 4. Knowledge of postoperative care

4. This would be an expected outcome for the client scheduled for surgery. This indicates that preoperative teaching has been effective.

36. The nurse identifies the client problem of "fluid volume deficit" for a client diagnosed with gastritis. Which intervention should be included in the plan of care? 1. Obtain permission for a blood transfusion. 2. Prepare the client for total parenteral nutrition. 3. Monitor the client's lung sounds every shift. 4. Assess the client's intravenous site.

4. This would be the most appropriate intervention to implement because fluid infusion is the treatment of choice for this problem. The effectiveness of the client's treatment would be altered if the intravenous site becomes infected or infiltrated.

11. The nurse identifies the client problem "alteration in gastrointestinal system" for the elderly client. Which statement reflects the most appropriate rationale for this diagnosis? 1. Elderly clients have a better mechanical handling of food with dentures. 2. Elderly clients have an increase in digestive enzymes, which helps with digestion. 3. Elderly clients have an increased need for laxatives because of a decrease in bile. 4. Elderly clients have an increase in bacteria in the GI system, resulting in diarrhea.

4. When the motility of the gastrointestinal tract decreases, bacteria remain in the gut longer and multiply, which results in diarrhea.

51. The client is admitted into the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright-red blood at home. Which interventions should the nurse implement? List in order of priority. 1. Assess the client's vital signs. 2. Insert a nasogastric tube. 3. Begin iced saline lavage. 4. Start an IV with an 18-gauge needle. 5. Type and crossmatch for a blood transfusion.

In order of priority: 1, 4, 5, 2, and 3 1. The nurse should assess the vital signs to determine if the client is in hypovolemic shock. 4. The nurse should start the IV line to replace fluid volume. 5. While the nurse is starting the IV, a blood sample for typing and cross-matching should be obtained and sent to the laboratory. 2. An N/G tube should be inserted so that direct iced saline can be instilled to cause constriction, which will decrease the bleeding. 3. The iced saline lavage will help decrease bleeding