Endo/GI practice questions

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. 1.Respirations that are shallow 2.Respirations that are increased in rate 3.Respirations that are abnormally slow 4.Respirations that are abnormally deep 5.Respirations that cease for several seconds

respirations that are abnormally deep respirations that are increased in rate rationale: Kussmaul's respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs. In bradypnea, respirations are regular but abnormally slow. Apnea is described as respirations that cease for several seconds.

The nurse is performing an assessment on a client with suspected acute pancreatitis. Which complaint made by the client supports the diagnosis? 1."I have epigastric pain radiating to my neck." 2."I have severe abdominal pain that is relieved after vomiting." 3."My temperature has been running between 96º F (35.5º C) and 97º F (36.1º C)." 4."I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting."

"I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting." Rationale:Nausea and vomiting are common presenting manifestations of acute pancreatitis. A hallmark symptom is severe abdominal pain that is not relieved by vomiting. The vomitus characteristically consists of gastric and duodenal contents. Fever also is a common sign. Epigastric pain radiating to the neck area is not a characteristic symptom

The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which assessment question would most specifically elicit information regarding the pain that is associated with acute pancreatitis? 1."Does the pain in your stomach radiate to your back?" 2."Does the pain in your lower abdomen radiate to your hip?" 3."Does the pain in your lower abdomen radiate to your groin?" 4."Does the pain in your stomach radiate to your lower middle abdomen?"

1."Does the pain in your stomach radiate to your back?" Rationale:The pain that is associated with acute pancreatitis is often severe, is located in the epigastric region, and radiates to the back. The remaining options are incorrect because they are not specific for the pain experienced by the client with pancreatitis.

The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client reports a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? 1."I need to stop my insulin." 2."I need to increase my fluid intake." 3."I need to monitor my blood glucose every 3 to 4 hours." 4."I need to call my primary health care provider (PHCP) because of these symptoms."

1."I need to stop my insulin." rationale: Patients with diabetes type I are in risk of DKA, during sick days patient should not stop insulin. Stress/surgery/Illness increases the demand for insulin. Patient should increase fluid intake, and contact PCP and monitor blood glucose level every 3-4 hours. Client should also monitor the urine for ketones during illness.

A prescription reads levothyroxine, 150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg/tablet. The nurse administers how many tablet(s) to the client? Fill in the blank.

1.5 tablets Rationale:You must convert 150 mcg to milligrams. In the metric system, to convert smaller to larger, divide by 1000 or move the decimal 3 places to the left. Therefore, 150 mcg equals 0.15 mg. Next, use the formula to calculate the correct dose.Desired--------- × Tablet(s) = Tablet(s) per doseAvailable

The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply 1.Jaundice 2.Flu-like symptoms 3.Clay-colored stools 4.Elevated bilirubin levels 5.Dark or tea-colored urine

1.Jaundice 3.Clay-colored stools 4.Elevated bilirubin levels 5.Dark or tea-colored urine Rationale:There are 3 stages associated with viral hepatitis. The first (preicteric) stage includes flu-like symptoms only. The second (icteric) stage includes the appearance of jaundice and associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay-colored stools. The third (posticteric) stage occurs when the jaundice decreases and the colors of the urine and stool return to normal

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1.Maintain NPO (nothing by mouth) status. 2.Encourage coughing and deep breathing. 3.Give small, frequent high-calorie feedings. 4.Maintain the client in a supine and flat position. 5.Give hydromorphone intravenously as prescribed for pain. 6.Maintain intravenous fluids at 10 mL/hr to keep the vein open.

1.Maintain NPO (nothing by mouth) status. 2.Encourage coughing and deep breathing. 5.Give hydromorphone intravenously as prescribed for pain. Rationale:The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions, so adequate intravenous hydration is necessary. Because abdominal pain is a prominent symptom of pancreatitis, pain medications such as morphine or hydromorphone are prescribed. Meperidine is avoided, as it may cause seizures. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted.

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding

1.Malaise 2.Dark stools 3.Weight gain 4.Left upper quadrant discomfort Rationale:Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts

The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions should be included in the care plan for this client? Select all that apply 1.Monitor daily weight. 2.Measure abdominal girth. 3.Monitor respiratory status. 4.Place the client in a supine position. 5.Assist the client with care as needed.

1.Monitor daily weight. 2.Measure abdominal girth. 3.Monitor respiratory status 5.Assist the client with care as needed Rationale:Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby impairing the client's breathing patterns. The client should be placed in a semi-Fowler's position with the arms supported on a pillow to allow for free diaphragm movement. The correct options identify appropriate nursing interventions to be included in the plan of care for the client with ascites.

The primary health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis? 1."I have had unprotected sex with multiple partners." 2."I ate shellfish about 2 weeks ago at a local restaurant." 3."I was an intravenous drug abuser in the past and shared needles." 4."I had a blood transfusion 30 years ago after major abdominal surgery."

2."I ate shellfish about 2 weeks ago at a local restaurant." rationale:Hep A is spread through fecal-oral route via contaminated water or food or infected food handlers. Hep B, D,C are spready via blood or body fluids such as IV drug abuse, hx of blood transfusion or unprotected sex.

A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching 1."I should avoid drinking alcohol." 2."I can go back to work right away." 3."My partner should get the vaccine." 4."A condom should be used for sexual intercourse.

2."I can go back to work right away." Rationale:To prevent transmission of hepatitis, vaccination of the partner is advised. In addition, a condom is advised during sexual intercourse. Alcohol should be avoided because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that liver function has returned to normal. The client's activity is increased gradually, and the client should not return to work right away.

The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which finding should the nurse interpret as a sign or symptom of portal hypertension? 1.Flat neck veins 2.Abdominal distention 3.Hemoglobin of 14.2 g/dL (142 mmol/L) 4.Platelet count of 600,000 mm3 (600 × 109/L)

2.Abdominal distention Rationale:With portal hypertension, proteins shift from the blood vessels via the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, they leak through the liver capsule into the peritoneal cavity. This is called ascites, and abdominal distention would be the consequence. Increased portal pressure can lead to findings associated with right-sided heart failure, such as distended jugular veins. Thrombocytopenia, leukopenia, and anemia are caused by the splenomegaly that results from backup of blood from the portal vein into the spleen (portal hypertension)

The nurse is giving instructions to a client with cholecystitis about food to exclude from the diet. Which food item identified by the client indicates that the educational session was successful?' 1.Fresh fruit 2.Brown gravy 3.Fresh vegetables 4.Poultry without skin

2.Brown gravy Rationale:The client with cholecystitis should decrease overall intake of dietary fat. Foods that should be avoided include sausage, gravies, fatty meats, fried foods, products made with cream, and desserts. Appropriate food choices include fruits and vegetables, fish, and poultry without skin.

A client with viral hepatitis is having difficulty coping with the disorder. Which question by the nurse is the most appropriate in identifying the client's coping problem? 1."Do you have a fever?" 2."Are you losing weight?" 3."Have you enjoyed having visitors?" 4."Do you rest sometime during the day?

3."Have you enjoyed having visitors?" Rationale:Clients with hepatitis may experience anxiety because of an anticipated change in lifestyle or fear of prognosis. They also may have a disturbance in body image related to the stigma of having a communicable disease or a change in appearance because of jaundice. The correct option relates to the client's possible feelings of not wanting to be seen by others because of altered appearance. Remember that the client with hepatitis is jaundiced.

The nurse is developing a teaching plan for a client with viral hepatitis. The nurse should plan to include which information in the teaching session? 1.The diet should be low in calories. 2.Meals should be large to conserve energy. 3.Activity should be limited to prevent fatigue. 4.Alcohol intake should be limited to 2 ounces per day.

3.Activity should be limited to prevent fatigue. Rationale:Rest is necessary for the client with hepatitis, and the client with viral hepatitis should limit activity to avoid fatigue. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per day. Alcohol is strictly forbidden.

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence 1.Dorsiflex the client's foot. 2.Measure the abdominal girth. 3.Ask the client to extend the arms. 4.Instruct the client to lean forward.

3.Ask the client to extend the arms. Rationale:Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect.

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? 1.Clamp the T-tube. 2.Irrigate the T-tube. 3.Document the findings. 4.Notify the primary health care provider.

3.Document the findings. Rationale:Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output.

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (52.9 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.3 mmol/L). The nurse would next prepare to administer which medication? 1.An ampule of 50% dextrose 2.NPH insulin subcutaneously 3.IV fluids containing dextrose 4.Phenytoin for the prevention of seizure

3.IV fluids containing dextrose Rationale:Emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema, can occur. During management of DKA, when the blood glucose level falls to 250 to 300 mg/dL (13.9 to 16.7 mmol/L), the IV infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL (13.9 mmol/L), or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin is not a usual treatment measure for DKA.

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated primary health care provider's prescription? 1.Endotracheal intubation 2.100 units of NPH insulin 3.Intravenous infusion of normal saline 4.Intravenous infusion of sodium bicarbonate

3.Intravenous infusion of normal saline Rationale:The primary goal of treatment in hyperosmolar hyperglycemic syndrome (HHS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous (IV) fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHS

The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? 1."I will stop taking my insulin if I'm too sick to eat." 2."I will decrease my insulin dose during times of illness." 3."I will adjust my insulin dose according to the level of glucose in my urine." 4."I will notify my primary health care provider (PHCP) if my blood glucose level is higher than 250 mmol/L.

4."I will notify my primary health care provider (PHCP) if my blood glucose level is higher than 250 mmol/L. Rationale:During illness, the client with type 1 diabetes mellitus is at increased risk of diabetic ketoacidosis, due to hyperglycemia associated with the stress response and due to a typically decreased caloric intake. As part of sick day management, the client with diabetes should monitor blood glucose levels and should notify the PHCP if the level is higher than 250 mg/dL (13.9 mmol/L). Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the PHCP's advice and are usually adjusted on the basis of blood glucose levels, not urinary glucose readings

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? 1.Avoiding infection 2.Taking in adequate fluids 3.Preventing and recognizing hypoglycemia 4.Preventing and recognizing hyperglycemia

4.Preventing and recognizing hyperglycemia Rationale:The normal reference range for the glycosylated hemoglobin A1c is less than 6.0%. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Erythrocytes live for about 120 days, giving feedback about blood glucose for the past 120 days. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus, the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. The estimated average glucose for a glycosylated hemoglobin A1c of 8% is 205 mg/dL (11.42 mmol/L). Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes.

A prescription reads regular insulin, 8 units/hr by continuous intravenous (IV) infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 100 units of regular insulin in 100 mL normal saline (NS). An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters (mL) per hour to deliver 8 units/hr? Fill in the blank

8mL/hr Calculation of this problem can be done using a 2-step process. First, you need to determine the amount of regular insulin in 1 mL. The next step is to determine the infusion rate, or milliliters per hour.Step 1:Known amount of medication-------------------------- = Medication/mLTotal volume of diluent100 units--------- = 1 units/mL100 mLStep 2:Dose per hour desired--------------------- = mL/hrConcentration per mL8 units---------- = 8 mL/hr1 units/mL

The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which primary health care provider prescriptions should the nurse anticipate receiving? Select all that apply. 1.Initiate an infusion of 3% NaCl. 2.Administer intravenous furosemide. 3.Restrict fluids to 800 mL over 24 hours. 4.Elevate the head of the bed to high-Fowler's. 5.Administer a vasopressin antagonist as prescribed.

Initiate an infusion of 3% NaCl( hypertonic ) restrict fluids 800mL over 24 hours ( prevent more fluid volume overload) Administer vasopressin antagonist as prescribed Rationale:Clients with SIADH experience excess secretion of antidiuretic hormone (ADH), which leads to excess intravascular volume, a declining serum osmolarity, and dilutional hyponatremia.Management is directed at correcting the hyponatremia and preventing cerebral edema. Hypertonic saline is prescribed when the hyponatremia is severe, less than 120 mEq/L (120 mmol/L). When furosemide is used, potassium supplementation should also occur and serum potassium levels should be monitored. To promote venous return, the head of the bed should not be raised more than 10 degrees for the client with SIADH. Maximizing venous return helps avoid stimulating stretch receptors in the heart that signal to the pituitary that more ADH is needed.

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply 1.Increase in pH 2.Comatose state 3.Deep, rapid breathing 4.Decreased urine output 5.Elevated blood glucose level

comatose state deep rapid breathing elevated blood glucose level Rationale:Because of the profound deficiency of insulin associated with DKA, glucose cannot be used for energy and the body breaks down fat as a secondary source of energy. Ketones, which are acid by-products of fat metabolism, build up, and the client experiences a metabolic ketoacidosis. High serum glucose contributes to an osmotic diuresis and the client becomes severely dehydrated. If untreated, the client will become comatose due to severe dehydration, acidosis, and electrolyte imbalance. Kussmaul's respirations, the deep rapid breathing associated with DKA, is a compensatory mechanism by the body. The body attempts to correct the acidotic state by blowing off carbon dioxide (CO2), which is an acid. In the absence of insulin, the client will experience severe hyperglycemia. Option 1 is incorrect, because in acidosis the pH would be low. Option 4 is incorrect because a high serum glucose will result in an osmotic diuresis and the client will experience polyuria.

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply 1.Polyuria 2.Shakiness 3.Palpitations 4.Blurred vision 5.Lightheadedness 6.Fruity breath odor

shakiness, palpitations, lightheadneded Rationale:Shakiness, palpitations, and lightheadedness are signs/symptoms of hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and a fruity breath odor are manifestations of hyperglycemia.