416 Exam 3- Practice Q's
The nurse is caring for a client who has possible acute pancreatitis. What serum laboratory findings would the nurse expect for this client? (Select all that apply.) a. Elevated amylase b. Elevated lipase c. Elevated glucose d. Decreased calcium e. Elevated bilirubin f. Elevated leukocyte count
ALL
The nurse is preparing to administer natalizumab for a client who has Crohn disease (CD). What is the most important client assessment for the nurse to perform before giving this drug? A.) Body temperature B.) Breath sounds C.) Peripheral pulses D.) Skin integrity
A.) Body temperature
A nurse is teaching a client with Crohn's disease about managing the disease with the drug adalimumab (Humira). Which instruction does the nurse emphasize to the client? A. "Avoid large crowds and anyone who is sick." B. "Do not take the medication if you are allergic to foods with fatty acids." C. "Expect difficulty with wound healing while you are taking this drug." D. "Monitor your blood pressure and report any significant decrease in it."
A. "Avoid large crowds and anyone who is sick."
While working in the outpatient procedure unit, the RN is assigned to these clients. Which client does the nurse assess first? A. A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) B. A 54-year-old who is ready for discharge following a colonoscopy C. A 58-year-old who has just arrived for basal gastric secretion and gastric acid stimulation testing D. A 60-year-old with questions about an endoscopic ultrasound examination
A. A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP)
The nurse is teaching a group of clients with irritable bowel syndrome (IBS) about complementary and alternative therapies. What does the nurse suggest as possible treatment modalities? (Select all that apply.) A. Acupuncture B. Decreasing physical activities C. Herbs (moxibustion) D. Meditation E. Peppermint oil capsules F. Yoga
A. Acupuncture C. Herbs (moxibustion) D. Meditation E. Peppermint oil capsules F. Yoga
The nurse is teaching a client who recently began taking sulfasalazine (Azulfidine) about the drug. What side effects does the nurse tell the client to report to the health care provider? (Select all that apply.) A. Anorexia B. Depression C. Drowsiness D. Frequent urination E. Headache F. Vomiting
A. Anorexia E. Headache F. Vomiting
What does the nurse advise a client diagnosed with irritable bowel syndrome (IBS) to take during periods of constipation? A. Bulk-forming laxatives B. Saline laxatives C. Stimulant laxatives D. Stool-softening agents
A. Bulk-forming laxatives
When performing an abdominal assessment on a patient diagnosed with pancreatitis, the nurse notes gray-blue discoloration around the periumbilical area, a dull sound on percussion, and normal bowel sounds. What action by the nurse is priority? A. Document the findings B. Prepare the patient for the operating room C. Contact the health care provider immediately D. Obtain a stat hemoglobin and hematocrit level
A. Document the findings
The nurse is caring for a client with a complete large bowel obstruction. What assessment findings would the nurse expect? Select all that apply. A. Obstipation B. Dehydration C. Metabolic alkalosis D. Abdominal distention E. Abdominal pain F. Profuse vomiting
A. Obstipation D. Abdominal distention E. Abdominal pain
In acute pancreatitis, what does elevated serum lipase indicate? A. Inflammation B. Pancreatic cell injury C. Hepatobiliary obstruction D. Hepatobiliary involvement
B. Pancreatic cell injury
What medications are administered to a patient with acute pancreatitis to decrease gastric acid secretion? Select all that apply. A. Imipenem B. Ranitidine C. Meperidine D. Omeprazole E. Ciprofloxacin
B. Ranitidine D. Omeprazole
The nurse is caring for a client diagnosed with peptic ulcer disease (PUD). For which potential complications will the nurse monitor? Select all that apply. A.) Pneumonia B.) Peritonitis C.) Anemia D.) Stroke E.) Hypotension F.) Cirrhosis
B.) Peritonitis C.) Anemia E.) Hypotension
A nurse cares for a middle-aged male client who has irritable bowel syndrome. The client states, "I have changed my diet and take bulk-forming laxatives, but my symptoms have not gotten better. I heard about a drug called Amitiza. Do you think it might help?" How should the nurse respond? A. "This drug is still in the research phase and is not available for public use yet." B. "Unfortunately, lubiprostone is approved only for use in women." C. "Lubiprostone works well. I will recommend this prescription to your provider." D. "This drug should not be used with bulk-forming laxatives."
B. "Unfortunately, lubiprostone is approved only for use in women."
The RN on the medical-surgical unit receives a shift report about four clients. Which client does the nurse assess first? A. A 34-year-old who has returned to the unit after a colon resection with a new colostomy stoma, which is dark pink B. A 36-year-old admitted after a motor vehicle crash with areas of ecchymoses on the abdomen in a "lap-belt" pattern C. A 40-year-old with pneumonia who has abdominal distention and decreased bowel sounds in all quadrants D. A 51-year-old with familial adenomatous polyposis (FAP) who is scheduled for a colonoscopy
B. A 36-year-old admitted after a motor vehicle crash with areas of ecchymoses on the abdomen in a "lap-belt" pattern
The nurse is caring for a patient with peritonitis. What assessment findings will the nurse observe? Select all that apply. A. Diarrhea B. Anorexia C. Low-grade fever D. Distended abdomen E. Increased urine output
B. Anorexia D. Distended abdomen
An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first? A. Measure the client's abdominal girth B. Assess for abdominal guarding or rigidity C. Check the client's hemoglobin and hematocrit D. Obtain the client's complete health history
B. Assess for abdominal guarding or rigidity
The nurse is caring for a client with peritonitis from a perforated appendix. Which abdominal assessment finding will the nurse most likely expect? A. Soft abdomen B. Board-like abdomen C. Slightly distended abdomen D. Absent bowel sounds
B. Board-like abdomen
A client is diagnosed with irritable bowel syndrome (IBS). What factors does the nurse suspect as possible causes of the client's problem? (Select all that apply.) A. Antihistamines B. Caffeinated drinks C. Stress D. Sleeping pills E. Anxiety
B. Caffeinated drinks C. Stress E. Anxiety
A client has vague symptoms that indicate an acute inflammatory bowel disorder. Which symptom is most indicative of Crohn's disease (CD)? A. Abdominal pain relieved by bending the knees B. Chronic diarrhea, abdominal pain, and fever C. Epigastric cramping D. Hypotension with vomiting
B. Chronic diarrhea, abdominal pain, and fever
What laboratory findings are consistent with ulcerative colitis (UC)? Select all that apply. A. Decreased erythrocyte sedimentation rate (ESR) B. Increased C-reactive protein C. Decreased white blood cell (WBC) count D. Increased sodium levels E. Decreased potassium levels
B. Increased C-reactive protein E. Decreased potassium levels
A client diagnosed with irritable bowel syndrome (IBS) is discharged home with a variety of medications for IBS symptoms. Upon returning to the clinic, the client states, "Most of my symptoms have improved, except for the diarrhea." What does the nurse anticipate will be prescribed for this client? A. Antidiarrheal agent B. Muscarinic receptor antagonist C. Serotonin antagonist D. Tricyclic antidepressant
B. Muscarinic receptor antagonist
A patient has been newly diagnosed with ulcerative colitis. Which statement by the patient indicates a need for further teaching about the complications of the disease? A. "I may have up to 20 liquid, bloody stools a day." B. "I should monitor closely for gastrointestinal hemorrhage." C. "I may have an increased risk of bladder infections caused by fistulas." D. "I will have an increased risk of colorectal cancer, especially after 10 years."
C. "I may have an increased risk of bladder infections caused by fistulas."
While assessing a patient with peritonitis, which finding would make the nurse suspect that the inflammation has progressed? A. Slow heart rate B. Sunken abdomen C. Absence of bowel sounds D. Increased intestinal motility
C. Absence of bowel sounds
A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? A. Measure intake and output every shift. B. Do not administer food or fluids by mouth. C. Administer opioid analgesic medication. D. Assist the client to assume a position of comfort.
C. Administer opioid analgesic medication.
A client with a bowel obstruction is ordered a nasogastric (NG) tube. After the nurse inserts the tube, which nursing intervention is the highest priority for this client? A. Attaching the tube to high continuous suction B. Auscultating for bowel sounds and peristalsis while the suction runs C. Connecting the tube to low intermittent suction D. Flushing the tube with 30 mL of normal saline every 24 hours
C. Connecting the tube to low intermittent suction
The nurse is caring for a client who is diagnosed with a perforated duodenal ulcer. Which assessment finding would the nurse expect?A.) Absent bowel sounds in all four quadrants B.) Nausea and profuse vomiting C.) Rigid, board-like and tender abdomen D.) Positive McBurney point
C.) Rigid, board-like and tender abdomen
The primary health care provider prescribes natalizumab to a patient with Crohn's disease. Which health teaching is most important before beginning the medication? A. "This drug masks the symptoms of infection." B. "A cold and a sore throat are common infections." C. "A headache and abdominal pain are common side effects." D. "Cognitive, motor, and sensory changes have very lethal effects."
D. "Cognitive, motor, and sensory changes have very lethal effects."
A client newly diagnosed with ulcerative colitis (UC) is started on sulfasalazine (Azulfidine). What does the nurse tell the client about why this therapy has been prescribed? A. "It is to stop the diarrhea and bloody stools." B. "This will minimize your GI discomfort." C. "With this medication, your cramping will be relieved." D. "Your intestinal inflammation will be reduced."
D. "Your intestinal inflammation will be reduced."
A client with an intestinal obstruction has pain that changes from a "colicky" intermittent type to constant discomfort. What does the nurse do first? A. Administers medication for pain B. Changes the nasogastric suction level from "intermittent" to "constant" C. Positions the client in high-Fowler's position D. Prepares the client for emergency surgery
D. Prepares the client for emergency surgery
A patient with an intestinal obstruction has pain that changes from a "colicky" intermittent type to constant discomfort. What does the nurse do first? A. Administers medication for pain B. Changes the nasogastric suction level from "intermittent" to "constant" C. Positions the patient in high-Fowler's position D. Prepares the patient for emergency surgery
D. Prepares the patient for emergency surgery
Which clinical findings in a patient indicate ulcerative colitis? A. Bowel fistulas B. Thickened bowel wall C. Inflammation of the ileum and colon D. Presence of blood and mucus in the stool
D. Presence of blood and mucus in the stool
Which set of assessment findings indicates to the nurse that a client may have acute pancreatitis? A. Absence of jaundice, pain of gradual onset B. Absence of jaundice, pain in right abdominal quadrant C. Presence of jaundice, pain worsening when sitting up D. Presence of jaundice, pain worsening when lying supine
D. Presence of jaundice, pain worsening when lying supine
Which patient assessment information is correlated with a diagnosis of chronic gastritis? A. Anorexia, nausea, and vomiting B. Frequent use of corticosteroids C. Hematemesis and anorexia D. Radiation therapy, smoking, and excessive alcohol use
D. Radiation therapy, smoking, and excessive alcohol use
A patient is diagnosed with acute pancreatitis. Which test is a sensitive indicator of biliary obstruction in this disorder? A. Serum amylase B. Serum bilirubin C. Alkaline phosphatase D. Serum alanine aminotransferase
D. Serum alanine aminotransferase
The nurse is attempting to position a client having an acute attack of pancreatitis in the most comfortable position possible. In which position does the nurse place this client? A. Supine, with a pillow supporting the abdomen B. Up in a chair between frequent periods of ambulation C. High-Fowler's position, with pillows used as needed D. Side-lying position, with knees drawn up to the chest
D. Side-lying position, with knees drawn up to the chest (Fetal)
A client is being evaluated in the emergency department for a possible small bowel obstruction. Which signs and/or symptoms does the nurse expect to assess? A. Cramping intermittently, metabolic acidosis, and minimal vomiting B. Intermittent lower abdominal cramping, obstipation, and metabolic alkalosis C. Metabolic acidosis, upper abdominal distention, and intermittent cramping D. Upper abdominal distention, metabolic alkalosis, and great amount of vomiting
D. Upper abdominal distention, metabolic alkalosis, and great amount of vomiting
The nurse is planning health teaching about omeprazole for a client who has acute gastritis. What would the nurse include in the health teaching? A.) Avoiding alcohol while taking this drug B.) Taking the drug when the client has gastric pain C.) Crushing the drug and mixing in applesauce D.) Taking the drug 30 minutes before a meal
D.) Taking the drug 30 minutes before a meal
A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge?
Do you have a one or a two story home?
A nurse cares for a client with acute pancreatitis. The client states, I am hungry. How should the nurse reply? a. Is your stomach rumbling or do you have bowel sounds? b. I need to check your gag reflex before you can eat. c. Have you passed any flatus or moved your bowels? d. You will not be able to eat until the pain subsides.
Have you passed gas or had a BM today?
The nurse is caring for a client with peptic ulcer disease. Which assessment finding indicates to the nurse that the client most likely has an ulcer in the stomach rather than in the duodenum? a. Body mass index (BMI) is 16.6. b. Stool is positive for occult blood. c. Client has had four ulcers in the last 5 years. d. Hemoglobin is 13 g/dL and hematocrit is 42%.
a. Body mass index (BMI) is 16.6.
The nurse is preparing a client who has chronic pancreatitis about how to prevent exacerbations of the disease. Which health teaching will the nurse include? (Select all that apply.) a. "Avoid alcohol ingestion." b. "Be sure and balance rest with activity." c. "Avoid caffeinated beverages." d. "Avoid green, leafy vegetables." e. "Eat small meals and high-calorie snacks."
a. "Avoid alcohol ingestion." b. "Be sure and balance rest with activity." c. "Avoid caffeinated beverages." e. "Eat small meals and high-calorie snacks."
A nurse assesses a client who is prescribed alosetron. Which assessment question would the nurse ask this client before starting the drug? a. "Have you been experiencing any constipation?" b. "Are you eating a diet high in fiber and fluids?" c. "Do you have a history of high blood pressure?" d. "What vitamins and supplements are you taking?"
a. "Have you been experiencing any constipation?"
A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find? a. Severe, steady right lower quadrant pain b. Abdominal pain associated with nausea and vomiting c. Marked peristalsis and hyperactive bowel sounds d. Abdominal pain that increases with knee flexion
a. Severe, steady right lower quadrant pain
A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this client's assessment? (Select all that apply.) a. "Which food types cause an exacerbation of symptoms?" b. "Where is your pain and what does it feel like?" c. "Have you lost a significant amount of weight lately?" d. "Are your stools soft, watery, and black in color?" e. "Do you experience nausea associated with defecation?"
a. "Which food types cause an exacerbation of symptoms?" b. "Where is your pain and what does it feel like?" e. "Do you experience nausea associated with defecation?"
A nurse assesses a client with irritable bowel syndrome (IBS). Which questions would the nurse include in this client's assessment? (Select all that apply.) a. "Which food types cause an exacerbation of symptoms?" b. "Where is your pain or discomfort and what does it feel like?" c. "Have you lost a significant amount of weight lately?" d. "Are your stools soft, watery, and black?" e. "Do you often experience nausea and vomiting"
a. "Which food types cause an exacerbation of symptoms?" b. "Where is your pain or discomfort and what does it feel like?"
A nurse cares for an older adult who is admitted to the hospital with complications of diverticulitis. Which actions would the nurse include in the client's plan of care? (Select all that apply.) a. Administer pain medications as prescribed. b. Palpate the abdomen for distention. c. Assess for sudden changes in mental status. d. Provide the client with a high-fiber diet. e. Evaluate stools for occult blood.
a. Administer pain medications as prescribed. b. Palpate the abdomen for distention. c. Assess for sudden changes in mental status. e. Evaluate stools for occult blood.
The nurse assesses a client who has chronic pancreatitis. What assessment findings would the nurse expect for this client? (Select all that apply.) a. Ascites b. Weight gain c. Steatorrhea d. Jaundice e. Polydipsia f. Polyuria
a. Ascites c. Steatorrhea d. Jaundice e. Polydipsia f. Polyuria
A client has a gastrointestinal hemorrhage and is prescribed two units of packed red blood cells. What actions should the nurse perform prior to hanging the blood? (Select all that apply.) a. Ask a second nurse to double-check the blood. b. Prime the IV tubing with normal saline. c. Prime the IV tubing with dextrose in water. d. Take and record a set of vital signs. e. Teach the client about reaction manifestations.
a. Ask a second nurse to double-check the blood. b. Prime the IV tubing with normal saline. d. Take and record a set of vital signs. e. Teach the client about reaction manifestations.
A nurse cares for a client who has a nasogastric (NG) tube. Which actions should the nurse take? (Select all that apply.) a. Assess for proper placement of the tube every 4 hours. b. Flush the tube with water every hour to ensure patency. c. Secure the NG tube to the client's upper lip. d. Disconnect suction when auscultating bowel peristalsis. e. Monitor the client's skin around the tube site for irritation.
a. Assess for proper placement of the tube every 4 hours. d. Disconnect suction when auscultating bowel peristalsis. e. Monitor the client's skin around the tube site for irritation.
An older client is admitted to the hospital with acute gastritis. The health care provider orders magnesium hydroxide (Mylanta) 1 hour and 3 hours after meals and at bedtime. Which action by the nurse is most appropriate? a. Check the clients renal function studies before giving the drug. b. Call the health care provider and ask for a different antacid for the client. c. Assess the clients pain and treat pain if present. d. Assist the client in ordering bland food from the menu.
a. Check the clients renal function studies before giving the drug. kidneys excrete magnesium
A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse teaches the client and family about the signs of potential complications which include what problems? (Select all that apply.) a. Cholangitis b. Pancreatitis c. Perforation d. Renal lithiasis e. Sepsis
a. Cholangitis b. Pancreatitis c. Perforation e. Sepsis
A nurse assesses a client with Crohn's disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Distended abdomen b. Temperature of 100.0° F (37.8° C) c. Loose and bloody stool d. Lower abdominal cramps
a. Distended abdomen
A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Distended abdomen b. Inability to pass flatus c. Bradycardia d. Hyperactive bowel sounds e. Decreased urine output
a. Distended abdomen b. Inability to pass flatus e. Decreased urine output
A nurse prepares to discharge a client who is newly diagnosed with a chronic inflammatory bowel disease. Which questions would the nurse ask in preparation for discharge? (Select all that apply.) a. Does your gym provide yoga classes? b. When should you contact your provider? c. What do you plan to eat for dinner? d. Do you have a scale for daily weights? e. How many bathrooms are in your home?
a. Does your gym provide yoga classes? b. When should you contact your provider? c. What do you plan to eat for dinner? e. How many bathrooms are in your home?
The nurse is caring for a client who has received multiple serious injuries in a motor vehicle accident. The client asks the nurse why ranitidine (Zantac) is prescribed because she does not have any abdominal pain. Which is the nurses best response? a. It will help prevent the development of a stomach ulcer from the stress of your injuries. b. It will help prevent aspiration pneumonia when you are anesthetized during surgery tomorrow. c. It will help your throat heal after it was irritated from the nasogastric tube. d. It will help prevent nausea and vomiting from the narcotic pain medications that you are taking.
a. It will help prevent the development of a stomach ulcer from the stress of your injuries.
The nurse is caring for a client with chronic gastritis. The client asks the nurse how to prevent another flare-up of gastritis. Which is the nurses best response? a. Join a support group to help you stop smoking. b. Take a multivitamin with iron and folic acid every day. c. Make sure to include plenty of fresh vegetables in your diet. d. Make sure that your weight stays within normal limits.
a. Join a support group to help you stop smoking.
The nurse is caring for a client with peritonitis. What assessment findings would the nurse expect? (Select all that apply.) a. Nausea and vomiting b. Distended rigid abdomen c. Abdominal pain d. Bradycardia e. Decreased urinary output f. Fever
a. Nausea and vomiting b. Distended rigid abdomen c. Abdominal pain e. Decreased urinary output f. Fever
A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.) a. Performs hand hygiene and positions the client in high-Fowlers position, with pillows behind the head and shoulders b. Instructs the client to extend the neck against the pillow once the NG tube has reached the oropharynx c. Checks for correct placement by checking the pH of the fluid aspirated from the tube d. Secures the NG tube by taping it to the clients nose and pinning the end to the pillowcase e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent
a. Performs hand hygiene and positions the client in high-Fowlers position, with pillows behind the head and shoulders c. Checks for correct placement by checking the pH of the fluid aspirated from the tube e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent
A nurse is caring for a client who has been diagnosed with a small bowel obstruction. Which assessment findings would the nurse correlate with this diagnosis? (Select all that apply.) a. Serum potassium of 2.8 b. Loss of 15 lb without dieting c. Abdominal pain in upper quadrants d. Low-pitched bowel sounds e. Serum sodium of 121
a. Serum potassium of 2.8 c. Abdominal pain in upper quadrants e. Serum sodium of 121
A nurse plans care for a client who has chronic diarrhea. Which actions should the nurse include in this clients plan of care? (Select all that apply.) a. Using premoistened disposable wipes for perineal care b. Turning the client from right to left every 2 hours c. Using an antibacterial soap to clean after each stool d. Applying a barrier cream to the skin after cleaning e. Keeping broken skin areas open to air to promote healing
a. Using premoistened disposable wipes for perineal care b. Turning the client from right to left every 2 hours d. Applying a barrier cream to the skin after cleaning
When a client is admitted to the hospital for treatment of acute cholecystitis, the nurse would anticipate that the immediate medical management will be a. antibiotic therapy. b. provided by a medical nutritionist. c. systemic corticosteroid administration. d. total parenteral nutrition.
a. antibiotic therapy.
Health promotion activities a nurse could recommend to a client in order to prevent pancreatitis include (Select all that apply) a. avoiding alcohol abuse. b. eating a high-protein diet. c. getting regular exercise. d. losing weight if needed.
a. avoiding alcohol abuse. d. losing weight if needed.
A client with a history of cholelithiasis presents at the hospital with nausea and vomiting, abdominal pain, and jaundice. The nurse would assess the client for a. common bile duct obstruction. b. infarct of the hepatic vein. c. perforation of the gallbladder. d. spasm of the biliary tree.
a. common bile duct obstruction.
The nurse is caring for a client who has been prescribed lubiprostone for irritable bowel syndrome (IBS-C). What health teaching will the nurse include about taking this drug? a. "This drug will make you very dry because it will decrease your diarrhea." b. "Be sure to take this drug with food and water to help manage constipation." c. "Avoid people who have infection as this drug will suppress your immune system." d. "Include high-fiber foods in your diet to help produce more solid stools."
b. "Be sure to take this drug with food and water to help manage constipation."
A client who has peptic ulcer disease is prescribed quadruple drug therapy for Helicobacter pylori infection. What health teaching related to bismuth would the nurse include? a. "Report stool changes to your primary health care provider immediately." b. "Do not take aspirin or aspirin products of any kind while on bismuth." c. "Take bismuth about 30 minutes before each meal and at bedtime." d. "Be aware that bismuth can cause frequent vomiting and diarrhea."
b. "Do not take aspirin or aspirin products of any kind while on bismuth."
A client is admitted with acute pancreatitis. The orders are for pancreatic rest. The nurse would implement which of the following? (Select all that apply.) a. Administering pancreatic enzymes with meals b. Bed rest with appropriate positioning c. Immediate insertion of an NG tube d. Withholding foods and liquids
b. Bed rest with appropriate positioning d. Withholding foods and liquids
After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, carbonated beverage b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk
b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice
The nurse is caring for a client with a long history of peptic ulcer disease. What assessment findings would the nurse anticipate if the client experiences upper gastrointestinal (GI) bleeding? (Select all that apply.) a. Decreased heart rate b. Decreased blood pressure c. Bounding radial pulse d. Dizziness e. Hematemesis f. Decreased urinary output
b. Decreased blood pressure d. Dizziness e. Hematemesis f. Decreased urinary output
The nurse is caring for a client with acute pancreatitis. Which nursing intervention best reduces discomfort for the client? a. Administering morphine sulfate IV every 4 to 6 hours as needed b. Maintaining NPO status for the client with IV fluids c. Providing small, frequent feedings, with no concentrated sweets d. Placing the client in semi-Fowler's position at elevation of 30 degrees
b. Maintaining NPO status for the client with IV fluids
The nurse is caring for a client with a nasogastric (NG) tube after an episode of GI bleeding. Which interventions are included in the nursing care plan? (Select all that apply.) a. Monitor and record intake and output every 8 hours. b. Monitor hemoglobin and hematocrit laboratory values. c. Ensure that suction is set on high continuous for Levin tubes. d. Measure the clients girth and/or assess for distention daily. e. Pin the tube to the clients gown, so it cannot be dislodged. f. Check vital signs and orthostatic blood pressure every 4 hours and PRN.
b. Monitor hemoglobin and hematocrit laboratory values. e. Pin the tube to the clients gown, so it cannot be dislodged. f. Check vital signs and orthostatic blood pressure every 4 hours and PRN.
The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the client's abdomen is tense and rigid. What action takes priority? a. Administer the prescribed pain medication. b. Notify the health care provider immediately. c. Percuss all four abdominal quadrants. d. Take and document a set of vital signs.
b. Notify the health care provider immediately.
A client has a pyloric obstruction and reports sudden muscle weakness. What action by the nurse takes priority? a. Document the findings in the chart. b. Request an electrocardiogram (ECG). c. Facilitate a serum potassium test. d. Place the client on bedrest.
b. Request an electrocardiogram (ECG).
A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report? a. Nausea and vomiting b. Severe boring abdominal pain c. Jaundice and itching d. Elevated temperature
b. Severe boring abdominal pain
A nurse cares for a patient who has a chronic inflammatory bowel disease. Which actions would the nurse take to prevent skin excoriation? (Select all that apply.) a. Cleanse the perineum with an antibacterial soap. b. Use medicated wipes instead of toilet paper. c. Identify foods that decrease constipation. d. Apply a thin coat of aloe cream to the perineum. e. Gently pat the perineum dry after cleansing.
b. Use medicated wipes instead of toilet paper. d. Apply a thin coat of aloe cream to the perineum. e. Gently pat the perineum dry after cleansing.
A client is being admitted for the eighth exacerbation of chronic pancreatitis in 2 years. The client is frail and emaciated and becomes agitated when the nurse asks about pain medication. Which referral can the nurse make to best meet this clients needs and address potential complications of the condition? The nurse should request a referral to a a. chaplain for spiritual distress related to the chronic nature of the disease. b. chemical dependency counselor to assess and treat substance abuse. c. medical nutritionist to assess and treat the clients malnutrition. d. surgeon to assess whether or not this client can be treated surgically
b. chemical dependency counselor to assess and treat substance abuse.
A nurse is teaching a client about magnesium hydroxide with aluminum hydroxide (Maalox). What instruction is most appropriate? a. "Aspirin must be avoided." b. "Do not worry about black stools." c. "Report diarrhea to your provider." d. "Take 1 hour before meals."
c. "Report diarrhea to your provider."
The nurse is caring for a client with cholecystitis. Which assessment finding indicates to the nurse that the condition is chronic rather than acute? a. Abdomen that is hyperresonant to percussion b. Hyperactive bowel sounds and diarrhea c. Clay-colored stools and dark amber urine d. Rebound tenderness in the right upper quadrant
c. Clay-colored stools and dark amber urine
The nurse is caring for a client who is diagnosed with a complete small bowel obstruction. For what priority problem is this client most likely at risk? a. Abdominal distention b. Nausea c. Electrolyte imbalance d. Obstipation
c. Electrolyte imbalance
The nurse reviews the laboratory results for a client who has possible appendicitis. Which laboratory test finding would the nurse expect? a. Decreased potassium level b. Increased sodium level c. Elevated leukocyte count d. Decreased thrombocyte count
c. Elevated leukocyte count
A nurse assesses a client who is hospitalized with an exacerbation of Crohn's disease. Which clinical manifestation should the nurse expect to find? a. Positive Murphy's sign with rebound tenderness to palpitation b. Dull, hypoactive bowel sounds in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Reports of abdominal cramping that is worse at night
c. High-pitched, rushing bowel sounds in the right lower quadrant
In evaluating a client for the presence of gallbladder disease, the nurse would recognize that the clients statement most suggestive of this problem is a. I am having difficulty swallowing. b. I get a sharp, stabbing pain every time I take a deep breath or cough. c. I have a terrible pain in my stomach; it is so bad I can feel it in my shoulder. d. I have a very strong craving for fatty foods like bacon and eggs fried in butter.
c. I have a terrible pain in my stomach; it is so bad I can feel it in my shoulder.
The nurse assesses a client who has possible gastritis. Which assessment finding(s) indicate(s) that the client has chronic gastritis? (Select all that apply.) a. Anorexia b. Dyspepsia c. Intolerance of fatty foods d. Pernicious anemia e. Nausea and vomiting
c. Intolerance of fatty foods d. Pernicious anemia
The nurse is caring for a client with cholecystitis. The client is a poor historian and is unable to tell the nurse when the symptoms started. Which assessment finding indicates to the nurse that the condition is chronic rather than acute? a. Temperature of 100.1° F (37.8° C) b. Positive Murphy's sign c. Light-colored stools d. Upper abdominal pain after eating
c. Light-colored stools
During an interview, the client tells the nurse that the client has a duodenal ulcer. Which assessment finding would the nurse expect? a. Hematemesis b. Pain when eating c. Melena d. Weight loss
c. Melena
The nurse planning the care of a client admitted with severe pancreatitis would anticipate the diet order of a. clear liquids. b. enteral feedings. c. NPO with TPN. d. soft, low fat.
c. NPO with TPN.
A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride. The client's respiratory rate is 8 breaths/min. What action by the nurse is appropriate? a. Administer naloxone. b. Call the Rapid Response Team. c. Provide physical stimulation. d. Ventilate with a bag-valve-mask
c. Provide physical stimulation.
The nurse is to insert a nasogastric (NG) tube for a client with upper GI bleeding. Which instruction does the nurse give to the client before starting the procedure? a. You may take some sips of water when I begin to insert the tube into your nose. b. Please hold your breath when I insert the tube through your nose. c. Tilt your head down to your chest when the tube gets to the back of your throat. d. The distance from the end of your nose to your navel tells me which size tube to use.
c. Tilt your head down to your chest when the tube gets to the back of your throat.
The nurse is caring for a female client who has just received a prescription for misoprostol (Cytotec). Which instructions does the nurse provide to the client regarding this medication? a. You may dissolve the contents of the capsule in warm water if it is difficult for you to swallow. b. Take this medication on an empty stomach just before going to bed every evening. c. You will need to stop taking your magnesium hydroxide (Mylanta) now that you are on this drug. d. You should add extra fiber to your diet because this medication may cause constipation.
c. You will need to stop taking your magnesium hydroxide (Mylanta) now that you are on this drug.
The morning after admission, a client being treated for gallstones begins to vomit about every 15 minutes and is complaining of abdominal pain. The most appropriate action by the nurse would be to a. encourage the client to ambulate. b. offer clear fluids. c. prepare to insert a nasogastric tube. d. turn the client to the right side.
c. prepare to insert a nasogastric tube.
To attempt to alleviate the pain of a client with acute pancreatitis, the nurse would place the client in the a. prone position with a pillow under the abdomen. b. semi-Fowler position with a small pillow under the knees. c. side-lying position with a pillow splinting the abdomen. d. supine position with a cold pack to the abdomen.
c. side-lying position with a pillow splinting the abdomen.
An emergency room nurse cares for a client who has been shot in the abdomen and is hemorrhaging heavily. Which action should the nurse take first? a. Send a blood sample for a type and crossmatch. b. Insert a large intravenous line for fluid resuscitation. c. Obtain the heart rate and blood pressure. d. Assess and maintain a patent airway.
d. Assess and maintain a patent airway.
A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? a. Administer intravenous opioid medications. b. Position the client with knees to chest. c. Insert a nasogastric tube for decompression. d. Assess the clients bowel sounds.
d. Assess the clients bowel sounds.
A client has returned to the nursing unit after esophagogastroduodenoscopy (EGD). Which action by the nurse takes priority? a. Keep the client on strict bedrest for 8 hours. b. Delegate taking vital signs to the nursing assistant. c. Increase the IV rate to flush the kidneys. d. Assess the clients gag reflex.
d. Assess the clients gag reflex.
The nurse is caring for a client who is at risk for developing gastritis. Which finding from the clients history leads the nurse to this conclusion? a. Client is lactose intolerant and cannot drink milk. b. Client recently traveled to Mexico and South America. c. Client works at least 60 hours per week in a stressful job. d. Client takes naproxen sodium (Naprosyn) 500 mg daily for arthritis pain.
d. Client takes naproxen sodium (Naprosyn) 500 mg daily for arthritis pain.
The nurse is caring for a client with acute pancreatitis. During the physical assessment, the nurse notes a grayish-blue discoloration of the client's flanks. Which is the nurse's priority action? a. Prepare the client for emergency surgery. b. Place the client in high Fowler's position. c. Insert a nasogastric (NG) tube to low intermittent suction. d. Ensure that the client has a patent large-bore IV site.
d. Ensure that the client has a patent large-bore IV site.
The nurse is teaching a client how to avoid the formation of hemorrhoids. What lifestyle change would the nurse include? a. Avoiding alcohol b. Quitting smoking c. Decreasing fluid intake d. Increasing dietary fiber
d. Increasing dietary fiber
The nurse caring for clients with gastrointestinal disorders would recall that omeprazole is a drug in which classification? a. Gastric acid inhibitor b. Histamine receptor blocker c. Mucosal barrier fortifier d. Proton pump inhibitor
d. Proton pump inhibitor
The nurse is caring for a client with a large bowel obstruction due to fecal impaction. What position would be appropriate for the client while in bed? a. Prone b. Supine c. Recumbent d. Semi-Fowler
d. Semi-Fowler
A client who had pancreatic surgery has been started on medication therapy with pancrelipase (Pancrease). The manifestation that the nurse would report as an indication that the dosage may be insufficient is a. black, tarry stools. b. clay-colored stools. c. constipation. d. steatorrhea.
d. steatorrhea.
