ATI GI Practice
A nurse is caring for a client who is 3 days postoperative following abdominal surgery. The client states, "Something just popped when I coughed." Which of the following actions should the nurse take first? A. Cover the client's wound with a sterile, moist dressing B. Flex the client's knees C. Reassure the client D. Instruct the client to avoid coughing
A. Cover the client's wound with a sterile, moist dressing
A nurse in a provider's office is assessing a client with GERD. The nurse should expect the client to report which of the following manifestations? Select all that apply. A. Regurgitation B. Nausea C. Belching D. Heartburn E. Weight loss
A. Regurgitation B. Nausea C. Belching D. Heartburn
A nurse is teaching a client with Barrett's esophagus who is scheduled to undergo an EGD. Which of the following statements should the nurse include in the teaching? A. "This procedure is performed to measure the presence of acid in your esophagus." B. "This procedure can determine how well the lower part of your esophagus works." C. "This procedure is performed while you are under general anesthesia." D. "This procedure can determine if you have colon cancer."
B. "This procedure can determine how well the lower part of your esophagus works."
A nurse is presenting an in-service training session about nutrition. How many of the amino acids must be obtained from dietary intake? A. 6 B. 9 C. 11 D. 15
B. 9
A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect? A. Jaundice B. Anorexia C. Dark urine D. Pale feces
B. Anorexia
When checking for nasogastric tube placement, the nurse should conduct which of the following procedures? A. Instill 20mL of air into the tube and listen for a whooshing sound B. Aspirate stomach contents and check the pH. C. Aspirate stomach contents and check their color D. Auscultate lung sounds
B. Aspirate stomach contents and check the pH.
A nurse is caring for a client who has recovered from acute diverticulitis. The nurse should instruct the client to increase his intake of which of the following foods when the inflammation subsides? A. Cucumbers and tomatoes B. Cabbage and peaches C. Strawberries and corn D. Figs and nuts
B. Cabbage and peaches
A nurse is teaching a client who has diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include? Select all that apply. A. Bradycardia B. Diaphoresis C. Deep, rapid respirations D. Palpitations E. Shakiness
B. Diaphoresis D. Palpitations E. Shakiness
A patient with a gastric ileus postoperatively requires nutritional support for approximately 2 weeks. Which of the following types of feeding tubes is appropriate for this patient? A. Nasogastric tube B. Nasointestinal tube C. Percutaneous endoscopic gastrostomy tube D. Percutaneous endoscopic jejunostomy tube
B. Nasointestinal tube
A nurse is providing teaching to a patient who is receiving intermittent nasogastric feedings. Which of the following should the nurse instruct the patient to report immediately? A. A feeling of fullness B. Persistent coughing C. Discomfort in the naris D. Postfeeding belching
B. Persistent coughing
A patient who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should anticipate receiving an order from the provider for which of the following types of enemas? A. Cleansing B. Return-flow C. Medicated D. Oil-retention
B. Return-flow
A nurse is caring for a client who is scheduled to undergo an EGD. The nurse should identify that this procedure is for which of the following reasons? A. To visualize polyps in the colon B. To detect an ulceration in the stomach C. To identify an obstruction in the biliary tract D. To determine the presence of free air in the abdomen.
B. To detect an ulceration in the stomach
A nurse is completing a history and physical assessment for a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? A. High-calorie diet B. Prior gastrointestinal illness C. Tobacco use D. Alcohol use
D. Alcohol use
A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect? A. Increased BP B. Decreased HR C. Yellowing of the skin D. Boardlike abdomen
D. Boardlike abdomen
A nurse is caring for a client who has gastrointestinal bleeding. The provider suspects a bleeding lesion in the colon. The initial approach to treatment will likely involve which of the following procedures? A. Exploratory laparotomy B. Double-contrast barium enema C. MRI D. Colonoscopy
D. Colonoscopy
A nurse is recommending dietary modifications for a client who has GERD. The nurse should suggest eliminating which of the following foods from the client's diet? A. Oranges and tomatoes B. Carrots and bananas C. Potatoes and squash D. Whole wheat and beans
A. Oranges and tomatoes
A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following laboratory findings should the nurse monitor prior to the procedure? A. Prothrombin time B. Serum lipase C. Bilirubin D. Calcium
A. Prothrombin time
A nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a patient in preparation for a diagnostic procedure. Which of the following is an appropriate step in this procedure? A. Warm the enema solution prior to instillation B. Prepare 1,500 mL of enema fluid C. Use tap water as the enema fluid D. Hang the enema container 24 inches above the anus
A. Warm the enema solution prior to instillation.
A nurse is providing discharge teaching to the partner of a client who has a new diagnosis of hepatitis A. Which of the following instructions should the nurse include in the teaching? A. "During this illness, she may take acetaminophen for fevers or discomfort." B. "Encourage her to eat foods that are high in carbohydrates." C. "The provider will prescribe a medication that will help her liver heal faster." D. "Have her perform moderate exercise to restore her strength more quickly."
B. "Encourage her to eat foods that are high in carbohydrates."
A nurse is caring for a client who has ulcerative colitis. The provider prescribes bed rest with bathroom privileges. When the client asks why he has to stay in bed, which of the following responses should the nurse provide? A. "You need to conserve energy at this time." B. "Lying quietly in bed helps slow down the activity in your intestines." C. "Staying in bed promotes the rest and comfort you need." D. "Staying in bed will help prevent injury and minimize your fall risk."
B. "Lying quietly in bed helps slow down the activity in your intestines."
A nurse in a provider's office is assessing a client who has GERD. When documenting the client's history, the nurse should expect the client to report that symptoms worsen with which of the following actions? A. Stair-climbing B. Bending over C. Sitting D. Walking
B. Bending over
A nurse is obtaining a guaiac test from a client. This test is performed to detect which of the following? A. Fecal material in vomit B. Blood in stool C. Infestation of parasites D. Mircroorganisms in urine
B. Blood in stool
A nurse who is administering a return flow enema to a patient should instill 100 mL of enema fluid and then A. Instruct the patient to retain the fluid. B. Lower the container to allow the solution to flow back out. C. Help the patient to the toilet or bedside commode D. Wait 5 min and instill another 100mL of fluid
B. Lower the container to allow the solution to flow back out
A patient recovering from gastric surgery remains NPO and has a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membranes? A. Allow the patient to suck on ice chips B. Provide frequent mouth care C. Apply petroleum jelly to the patient's naris D. Offer throat lozenges
B. Provide frequent mouth care
A nurse is providing teaching to a client who has ulcerative colitis. Which of the following food selections by the client indicates an understanding of the teaching? A. Raw vegetable salad with low-fat dressing B. Roast chicken and white rice C. Fresh fruit salad and milk D. Peanut butter on whole wheat bread
B. Roast chicken and white rice
A nurse is administering an enema medicated with sodium polystyrene sulfonate (Kayexalate) to an older adult patient who has hyperkalemia. The nurse should insert the tip of the rectal tube A. 2.5-3.75 cm (1-1.5 in) B. 5-7.5 cm (2-3 in) C. 7.5-10 cm (3-4 in) D. 10-12.5 cm (4-5 in)
C. 7.5-10 cm (3-4 in)
A nurse is planning care for a client who has cholelithiasis. Which of the following interventions should the nurse include in the plan? A. Restrict the client's fluid intake B. Restrict the client's calcium intake C. Decrease the client's fat intake D. Decrease the client's potassium intake
C. Decrease the client's fat intake
A nurse is caring for a client who has abdominal pain and possible pancreatitis. Which of the following laboratory results should the nurse identify as an indication of pancreatitis? A. Decreased WBC count B. Increased albumin level C. Increased serum lipase level D. Decreased blood glucose level
C. Increased serum lipase level
A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? A. Vanilla pudding B. Apple juice C. Diet ginger ale D. Clear liquids
D. Clear liquids
A nurse is caring for a client who has diverticulitis and a new prescription for a low-fiber diet. Which of the following food items should the nurse remove from the client's meal tray? A. Canned fruit B. White bread C. Broiled hamburger D. Coleslaw
D. Coleslaw
A nurse is teaching a client who has cirrhosis of the liver and history of alcohol consumption. The nurse should explain that alcohol can cause liver cirrhosis through which of the following actions? A. Increasing the workload of the liver by releasing stored glycogen B. Causing ulceration of liver tissue that can lead to bleeding C. Dilating veins in the portal circulation D. Destroying liver cells that are later replaced with scar tissue
D. Destroying liver cells that are later replaced with scar tissue
A nurse is monitoring the laboratory results of a client who has end-stage liver failure. Which of the following results should the nurse expect? A. Decreased lactate dehydrogenase B. Increased serum albumin C. Decreased serum ammonia D. Increased prothrombin time
D. Increased prothrombin time
A nurse is preparing an older adult patient for an enema. The nurse should assist the patient to which of the following positions? A. Prone B. Dorsal recumbent C. Right lateral with both knees at chest D. Left lateral with the right leg flexed
D. Left lateral with the right leg flexed.
To determine how much of the length of a nasoenteric tube to insert, a nurse should measure the distance from the tip of the patient's nose to the earlobe and from the earlobe to the A. Umbilicus B. Xiphoid process C. Manubrium plus 10-20 cm more. D. Xiphoid process plus 20-30 cm more
D. Xiphoid process plus 20-30 cm more
A nurse is preparing to administer a cleansing enema to a patient who is prone to fecal incontinence due to poor sphincter control and is unlikely to retain the enema solution. Which of the following interventions is appropriate for this patient? A. Place the patient in the dorsal recumbent position B. Administer the enema while the patient sits on the toilet. C. Administer an antidiarrheal medication 3 hours prior to the enema D. Instill 200mL of fluid at 15-minute intervals times four
A. Place the patient in the dorsal recumbent position on a bed pain.
A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube serves which of the following purposes? A. Prevents excessive pressure on suture lines B. Allows gastric lavage after surgery C. Allows early postoperative feeding D. Facilitates obtaining gastric specimens for testing
A. Prevents excessive pressure on suture lines
A nurse should recognize that nasogastric intubation is indicated to relieve gastric distention for which of the following patients? A. A 6-year old child who drank a toxic substance B. A 60-year old patient admitted with gastrointestinal hemorrhage C. A 40-year old patient with a postoperative bowel obstruction D. A 20-year old patient with malabsorption syndrome
C. A 40-year old patient with a postoperative bowel obstruction
A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should return to the expected range within 72 hours of treatment beginning? A. Aldolase B. Lipase C. Amylase D. Lactic dehydrogenase
C. Amylase
A nurse is planning discharge teaching for a client who is postoperative following a traditional open cholecystectomy. Which of the following learning needs of the client is the nurse's priority. A. Dietary recommendations B. Incision care C. Coughing and deep-breathing exercises D. Pain management
C. Coughing and deep-breathing exercises
Nasogastric tube feedings are an appropriate choice for a patient who A. Has a paralytic ileus B. Has recently experienced facial trauma C. Is postoperative following laryngectomy D. Has pancreatitis
C. Is postoperative following laryngectomy.
A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? A. Endoscopic sclerotherapy B. Liver lobectomy C. Liver transplant D. Transjugular intrahepatic portal-systemic shunt placement
C. Liver transplant
While a nurse is administering a cleansing enema, the patient reports abdominal cramping. Which of the following is the appropriate intervention? A. Measure the patient's vital signs. B. Notify the PCP C. Lower the enema fluid container D. Stop the enema instillation
C. Lower the enema fluid container
A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching? A. "Because most of my colon is still intact and functioning, my stool will be formed." B. "My stoma will appear large at first, but will shrink over the next several weeks." C. "My colostomy will begin to function in 2 to 6 days after surgery. D. "I'll have to consume a soft diet after surgery."
D. "I'll have to consume a soft diet after surgery."
A nurse is caring for a client who has colitis and reported increased exacerbations due to stress at work. Which of the following responses should the nurse make? A. "I will contact the social worker so you can discuss career alternatives." B. "Have you thought about discussing the possibility of a part-time assignment with your employer?' C. "Why don't you ask your employer to relieve you of some work until you are stronger?" D. "Perhaps we should review your coping mechanisms and talk about other alternatives."
D. "Perhaps we should review your coping mechanisms and talk about other alternatives."
A nurse is preparing to administer an oil-retaining enema to a patient who has constipation. The nurse explains that the patient should try to retain the instilled for A. As long as it takes to complete the procedure B. About 10-15 minutes C. Until the next time he feels the urge to defecate D. At least 30 min, but preferably as long as he can.
D. At least 30 min, but preferably as long as he can.
A nurse is preparing to administer an oil-retention enema who has constipation. The nurse explains that the pt. should try to retain the instilled oil for A. As long as it takes to complete the procedure B. About 10-15 min C. Until the next time he feels he needs to defecate D. At least 30 min., but preferably as long as he can.
D. At least 30 min., but preferably as long as he can.
A nurse is providing dietary teaching to a client who has dumping syndrome following gastric bypass surgery 4 days ago. Which of the following recommendations should the nurse include in the teaching? A. Avoid foods containing protein B. Drink liquids during each meal C. Eat foods that contain simple sugars D. Maintain a supine position after meals
D. Maintain a supine position after meals
A nurse is caring for a patient who has a nasogastric tube connected to suction. Which of the following should indicate to the nurse that the tube has become occluded? A. Active bowel sounds B. Passing flatus C. Increase in gastric secretions D. Patient's report of nausea
D. Patient's report of nausea
A nurse is planning an in-service training session for a group of nurses regarding the role of enzymes in digestion. Which of the following enzymes plays a role in the digestion of protein? A. Amylase B. Lipase C. Steapsin D. Pepsin
D. Pepsin
To prevent aspiration during the administration of an enteral tube feeding, a nurse should A. Flush the feeding tube with 30 mL of water B. Add blue food coloring to the enteral formula C. Ensure the formula is at room temperature D. Place the patient in Fowler's position
D. Place the patient in Fowler's position
A nurse is performing a gastrointestinal assessment of a client who has liver cirrhosis with abdominal distention. Which of the following actions should the nurse take to assess for changes in the client's abdominal distention? A. Percuss the abdomen for tympanic sounds B. Inspect the contour of the abdominal wall C. Instruct the client to report increased abdominal discomfort D. Take serial measurements of the abdomen with a tape measure
D. Take serial measurements of the abdomen with a tape measure
A nurse is caring for a client who is dehydrated and receiving continuous tube feeding through a pump at 75mL/hr. When the nurse assess the client at 0800, which of the following findings requires intervention? A. A full pitcher is sitting on the client's bedside table within the client's reach. B. The disposable feeding bag is from the previous day at 1000 and contains 200mL of feeding. C. The client is lying on the right side with a visible dependent loop in the feeding tube. D. The head of the bed is elevated 20 degrees.
D. The head of the bed is elevated 20 degree.
A nurse enters a client's room and notes smoke coming from a wastebasket in the adjacent bathroom. Which of the following actions should the nurse take first? A. Close the door to the client's room B. Attempt to extinguish the fire C. Activate the facility's fire alarm system D. Transport the client to an area away from the smoke
D. Transport the client to an area away from the smoke
A nurse is performing discharge teaching about ostomy care while at home for a client who has a newly placed ileostomy. Which of the following instructions should the nurse include in the teaching? A. "Empty your ostomy pouch when it becomes half full." B. "Place an aspirin in the ostomy pouch to eliminate odor." C. "Change the ostomy appliance every week." D. "Cleanse the site around the stoma with hydrogen peroxide and water."
A. "Empty your ostomy pouch when it becomes full."
A nurse is teaching a group of clients about the functions of the liver and gallbladder. Which of the following should the nurse include in the teaching as the purpose of bile? A. Digesting fats B. Producing chyme C. Stimulating gastric acid secretion D. Providing energy
A. Digesting fats
A nurse is assisting a provider with performing a paracentesis on a client. Which of the following actions should the nurse take? A. Ask the client to empty his bladder before the procedure B. Place the client leaning forward over the bedside table for the procedure C. Inform the client he will be sedated during the procedure D. Instruct the client to fast for 6 hr prior to the procedure
A. Ask the client to empty his bladder before the procedure.
A nurse is developing a plan of care for a client who has GERD. The nurse should plan to monitor the client for which of the following complications? A. Aspiration B. Infection C. Anemia D. Weight loss
A. Aspiration
To assess a stroke patient for complications secondary to inadequate swallowing, the nurse should do which of the following? A. Auscultate the patient's lungs B. Place the tip of a tongue depressor on the patients posterior tongue C. With a penlight, inspect the patient's uvula an the soft palate D. Place fingers on the patient's throat at the level of the larynx and ask him to swallow
A. Auscultate the patient's lungs
A nurse is assessing a client who has cholecystitis. Which of the following findings should the nurse expect? A. Blumberg's sign B. Ascites C. Gastrointestinal bleeding D. Kehr's sign
A. Blumberg's sign
A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? A. Children B. Older adults C. Women who are pregnant D. Middle-aged men
A. Children
A nurse inserting a nasogastric tube asks the patient to flex her head toward her chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by A. Closing off the glottis B. Preventing curling of the tube in the mouth C. Allowing the patient to breathe through her mouth D. Opening the lower esophageal sphincter
A. Closing off the glottis
A nurse is teaching a client who has a colostomy about ways to reduce flatus and odor. Which of the following strategies should the nurse include? A. Eat crackers and yogurt regularly B. Chew minty gum throughout the day C. Drink orange juice every day D. Put an aspirin in the pouch
A. Eat crackers and yogurt regularly
A nurse is assessing a client who has a bleeding duodenal ulcer. Which of the following findings should the nurse expect? A. Emesis with a coffee-ground appearance B. Increased BP C. Decreased HR D. Bright green stools
A. Emesis with a coffee-ground appearance
An older adult patient in a long term care facility is receiving intermittent enteral feedings in his room. His affect is flat, and the nurse suspects that he is feeling isolated. Which of the following interventions is appropriate for this patient? A. Encourage him to go to the dining room at meal times to talk with other patients. B. Suggest that he watch television while his feedings are being administered C. Remind him that he can have visitors after his feeding administration times D. Ask the facility chaplain to speak with the patient
A. Encourage him to go to the dining room at meal times to talk with other patients.
A nurse is caring for a client who has an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take first? A. Ensure bowel rest B. Offer sparkling water frequently C. Administer a stool softener D. Offer plain warm tea frequently
A. Ensure bowel rest
A nurse is caring for a client with a history of cirrhosis who has been admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? A. Gamma-glutamyl transferase (GGT) B. Alkaline phosphatase (ALP) C. Serum bilirubin D. Alanine aminotransferase (ALT)
A. Gamma-glutamyl transferase (GGT)
A nurse is teaching dietary modification strategies to a client who has been newly diagnosed with cirrhosis. Which of the following foods should the nurse recommend? A. Grilled chicken B. Potato soup C. Fish sticks D. Baked ham
A. Grilled chicken
A nurse is performing a nasogastric intubation. Which of the following actions should the nurse take immediately after inserting the tube to the predetermined length? A. Inspect the oropharnx with a penlight and a tongueblade B. Obtain an x-ray examination of the chest and abdomen C. Tape the tube securely in place with a tube holder device D. Aspirate gastric contents
A. Inspect the oropharynx with a penlight and a tongueblade
A nurse is caring for a client who is NPO and has an NG tube to suction. When the client reports nausea, which of the following actions should the nurse take? A. Irrigate the tube with normal saline solution B. Provide oral hygiene C. Clamp the tube for 30 min D. Increase the amount of suction
A. Irrigate the tube with normal saline solution
To prevent a common complication of continuous enteral feedings, a nurse should A. Limit the time the formula hangs to 4 hr. B. Chill the formula prior to administration C. Deliver the formula at a brisk rate D. Allow the feeding bag to empty before refilling it
A. Limit the time the formula hangs to 4 hr.
A nurse is admitting a client who has cirrhosis. Which of the following prescriptions should the nurse anticipate? Select all that apply. A. Obtain the client's PT and INR measurements B. Administer lactulose 30mL PO 4 times daily C. Obtain daily weight and abdominal girth measurements D. Administer a daily multivitamin E. Place the client on high protein diet
A. Obtain the client's PT and INR measurements B. Administer lactulose 30mL PO 4 times daily C. Obtain daily weight and abdominal girth measurements D. Administer a daily multivitamin
A nurse is caring for a client who is 4 hour postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? A. Right shoulder pain B. Urine output 20 mL/hr C. Temperature 38.4 (101.1) D. Oxygen saturation 92%
A. Right shoulder pain
The nurse is teaching a newly licensed nurse about caring for a client who is scheduled for an esophagogatric balloon tamponade tube to treat esophageal varices. Which of the following pieces of information should the nurse include in the teaching? A. The client will be placed on mechanical ventilation prior to this procedure. B. The tube will be inserted into the client's trachea C. The client will receive a bowel preparation with cathartics prior to this procedure. D. The tube allows the application of a ligation band to the bleeding varices.
A. The client will be placed on mechanical ventilation prior to this procedure.
A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove from the client's meal tray? A. Wheat toast B. Tapioca pudding C. Hard-boiled egg D. Mashed potatoes
A. Wheat toast
A nurse is caring for a client who has acute diverticulitis. While the client has active inflammation, the nurse should instruct the client to include which of the following foods in her diet? A. White bread and plain yogurt B. Shredded wheat cereal and blueberries C. Broccoli and kidney beans D. Oatmeal and fresh pears
A. White bread and plain yogurt
A nurse is caring for a patient who has a newly inserted nasogastric tube. Which of the following methods is appropriate for verifying initial placement? A. X-ray examination of the chest and abdomen B. Auscultation of injected air C. pH measurement of gastric aspartate D. Color of gastric contents
A. X-ray examination of chest and abdomen
A nurse is preparing a community education program about hepatitis B. Which of the following statements should the nurse include in the teaching? A. "A hepatitis B immunization is recommended for those who travel, especially military personnel." B. "A hepatitis B immunization is given to infants and children." C. "Hepatitis B is acquired by eating foods that are contaminated during handling." D. "Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation."
B. "A hepatitis B immunization is given to infants and children."
Which of the following dietary modifications should an adolescent engaging in sports implement? A. Increase fats to 30% to 40% of daily kilocalories B. Drink water before and after sports activities C. Keep protein intake at same level D. Decrease carbohydrates to 30% to 40% of daily kilocalories
B. Drink water before and after sports activities
Which of the following formulas is appropriate to administer to a patient who has a dysfunctional GI tract? A. Modular B. Elemental C. Polymeric D. Specialty
B. Elemental
A nurse is demonstrating colostomy care to a client who has a new colostomy. Which of the following actions should the nurse teach the client to perform? Select all that apply. A. Use antimicrobial ointment on the peristomal skin B. Empty the bag when it is 1/3-1/2 full C. Cut the skin barrier opening a little larger than the ostomy D. Wash the peristomal skin with mild soap and water E. Apply the skin barrier while the skin is slightly moist
B. Empty the bag when it is 1/3-1/2 full C. Cut the skin barrier opening a little larger than the ostomy D. Wash the peristomal skin with mild soap and water
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? A. Place the drainage bag on the client's abdomen when transferring from a bed to a cart B. Empty the drainage bag when half-full of urine C. Rest the drainage bag on the floor when closing the drainage spigot during emptying D. Disconnect the drainage bag when obtaining a urine specimen.
B. Empty the drainage bag when half-full of urine
A nurse is assessing a client who is 12 hours postoperative following an open cholecystectomy. Which of the following findings should the nurse report to the provider? A. Hypoactive bowel sounds B. Indwelling urinary catheter output of 25mL/hr C. Heart rate of 96/min D. Serous drainage at the surgical incision site
B. Indwelling urinary catheter output of 25 mL/hr
A nurse is planning an in-service training session regarding nutrition. Which of the following minerals should the nurse identify as involved in oxygen transport? A. Zinc B. Iron C. Phosphorus D. Magnesium
B. Iron
A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? A. Flush the tube with water B. Place the client in the semi-Fowler's position C. Cleanse the skin around tube site D. Aspirate the tube for residual contents
B. Place the client in the semi-Fowler's position
A nurse is providing preoperative teaching to a client who will undergo surgery to create a temporary colostomy. The client asks the nurse about the difference between colostomies and ileostomies. Which of the following responses should the nurse make? A. "A colostomy drains stool, and an ileostomy drains urine." B. "A colostomy is temporary, and an ileostomy is permanent." C. "A colostomy is from the large intestine, and an ileostomy is from the small intestine." D. "An ileostomy requires dietary restrictions, while a colostomy does not."
C. "A colostomy is from the large intestine, and an ileostomy is from the small intestine."
A nurse is providing teaching about nutrients to a client. Which of the following statements should the nurse include? A. "Carbohydrates transport nutrients throughout the body." B. "Fats prevent ketosis." C. "Protein builds and repairs body tissue." D. "Carbohydrates help regulate body temperature."
C. "Protein builds and repairs body tissue."
A nurse is caring for a client who is 2 days postoperative following gastric surgery and has an NG tube inserted. Which of the following findings should the nurse report to the provider? A. Dryness of mucous membranes B. Hypoactive bowel sounds in all 4 quadrants C. 200 mL of bright red drainage from NG tube D. Suction set at a continuous low suction
C. 200mL of bright red drainage from NG tube
A nurse is caring for a client who had her spleen removed following a bicycle accident. The child's parent asks the nurse about the role of the spleen in the body. The nurse should explain that the spleen performs which of the following functions? A. Maintains fluid balance B. Regulates calcium in the blood C. Destroys old blood cells D. Produce prothrombin
C. Destroys old blood cells
A nurse is caring for a client from the Middle East who has celiac disease. Which of the following actions should the nurse perform regarding the client's diet? A. Provide foods prepared according to kosher dietary law B. Ask the kitchen to prepare grits to meet the client's dietary need for grains C. Determine the client's dietary preferences D. Prepare a diet tray that includes vegetable and barley soup.
C. Determine the client's dietary preferences
A nurse is providing teaching a client who has constipation. Which of the following instructions should the nurse include? A. Use bismuth subsalicylate regularly B. Consume a low-fiber diet C. Eat yogurt with live cultures D. Use bisacodyl suppositories regularly
C. Eat yogurt with live cultures
A nurse is caring for a patient who has impaired swallowing due to a CVA. Which of the following interventions should the nurse use to assist the patient with feeding? A. Provide the patient with a straw. B. Offer the patient thin fluids C. Elevate the head of the bed 45 to 90 degrees D. Place food in the weaker side of the mouth
C. Elevate the head of the bed 45 to 90 degrees
A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend? A. Foods high in vitamin C B. Foods low in fat C. Foods high in fiber D. Foods low in calories
C. Foods high in fiber
Which of the following strategies for enhancing the intake of healthful foods is appropriate for an adolescent? A. Encouraging the adolescent to consume snack foods from the grains food group. B. Permitting the adolescent to skip breakfast to enhance appetite at later meals C. Making healthful food choices more convenient and available for the adolescent D. Allowing the adolescent complete autonomy in making food choices
C. Making healthful food choices more convenient and available for the adolescent
The most reliable method for verifying initial placement of a small-bore feeding tube is by A. Measuring the pH of gastric aspartate B. Auscultating the epigastric area while injecting air. C. Obtaining an abdominal x-ray D. Placing the open end of the tube in a cup of water
C. Obtaining an abdominal x-ray
A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings indicates that a possible bowel perforation has occurred? A. Elevated BP B. Bowel sounds increased in frequency and pitch C. Rigid abdomen D. Emesis of undigested food
C. Rigid abdomen
During report, a nurse is informed that the patient has a nasogastric tube connected to continuous suction. The nurse should recognize that this patient must have which of the following types of tube? A. Levin B. Sengstaken-Blakemore C. Salem pump D. Ewald
C. Salem pump
A nurse is caring for a client who has cholelithiasis and will undergo a cholecystectomy. The client states that she does not understand how she will be alright without her gallbladder. The nurse should explain to the client that which of the following is the main function of the gallbladder? A. Producing bile B. Adding digestive enzymes to bile C. Storing bile D. Eliminating bile
C. Storing bile
A nurse in the emergency department is caring for a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? A. Famotidine B. Esomeprazole C. Vasopressin D. Omeprazole
C. Vasopressin
A nurse is providing postoperative teaching about the management of dumping syndrome to a client who had a partial gastrectomy. Which of the following instructions should the nurse include in the teaching? A. "Consume at least 4 oz. of fluid with meals." B. "Take a short walk after each meal." C. "Use honey to flavor foods such as cereal." D. "Eat protein with each meal."
D. "Eat protein with each meal."
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? A. Hypertension B. Excessive thirst C. Fever D. Diaphoresis
D. Diaphoresis
When teaching the parents of a toddler about feeding and eating, the nurse should include which of the following safety measures? A. Do not give the child peanut butter B. Have the child drink 28 to 32 oz. of milk daily C. Give the child 8 to 12 oz. of fruit juice daily D. Do not offer the child raw vegetables
D. Do not offer the child raw vegetables
A nurse is assessing a client who has a complete intestinal obstruction. Which of the following findings will the nurse expect? A. Absence of bowel sounds in all four quadrants B. Passage of blood-tinged liquid stool C. Presence of flatus D. Hyperactive bowel sounds above the obstruction
D. Hyperactive bowel sounds above the obstruction
A nurse is teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse include? A. Smoking cessation B. Benefits of a diet high in cruciferous vegetables C. New types of ostomy appliances D. Importance of colonoscopy screening starting at age 50 years old
D. Importance of colonoscopy screening starting at age 50 years old
A nurse is caring for a client who is postoperative following a laparotomy. The client has an indwelling catheter and a Jackson-Pratt drain in place. Which of the following findings indicates that the client is developing a postoperative complication? A. Pain scale score of 5 out of 10 B. Urine output of 65mL/hr C. 20 mL of bright red drainage from the drain D. Pulse oximetry of 85%
D. Pulse oximetry of 85%
Which of the following are appropriate choices for a patient prescribed a full liquid diet? Select all that apply. A. Plain yogurt B. Custard C. Ice cream D. Mashed potatoes E. Pureed meat F. Gelatin
A. Plain yogurt B. Custard C. Ice cream F. Gelatin
A nurse is caring for a patient who has sustained a head injury and whose level of consciousness fluctuates. The provider prescribes full liquid diet progressing to pureed diet as tolerated. Before initial feedings, it is essential that this patient undergo which of the following? A. Chest x-ray B. Swallowing examination C. Nasogastric tube insertion D. Olfactory nerve evaluation
B. Swallowing examination
