Exam 1

The pancreas performs which functions?

-Secretes enzymes for digestion from exocrine part of the organ. - produces glucagon from the endocrine part of the organ. - Produces enzymes that digest carbohydrates, fats, and proteins.

The community nurses talking with a group of individuals about colorectal cancer CRC risk factors. Which community participant is at the highest risk for development of CRC?

30 Year old with Crohn's disease

A client with rectal bleeding who is preparing to undergo a colonoscopy tells the nurse, I'm very afraid of having polyps and cancer. What is the appropriate nursing response?

It's understandable that you were fearful. Tell me what friends you the most.

Which gastrointestinal problem is related to anorexia?

Loss of appetite

Which facial assessment finding in a client with a salivary gland tumor prompts the nurse to notify the healthcare provider?

Loss of sensation in tongue

The nurse is auscultating a patient's abdomen. Which technique should the nurse use?

Place the diaphragm of the stethoscope lightly on the abdominal wall.

A charge nurse is teaching a group of nurses about a client who has chronic gastritis and is scheduled for a selective vagotomy. Which of the following statements by unit nurse indicates understanding of the purpose of the procedure?

The client will have a reduction of gastric acid secretion

The nurse auscultates a patient's abdomen and hears high-pitched, loud, musical sounds in a air-filled abdomen. How does the nurse best describe the findings?

Tympanic

A nurse is providing discharge teaching to a client who has a new prescription for aluminum hydroxide. Which of the following information should the nurse include in the teaching?

Wait one hour before taking other oral medications

A patient has been diagnosed with mild gastroesophageal reflux disease (GERD) and asks the nurse about nonpharmacologic treatments to prevent symptoms. What does the nurse tell this patient? a. "Avoid caffeine-containing foods and beverages." b. "Eat three meals each day and avoid snacking between meals." c. "Peppermint lozenges help to reduce stomach upset." d. "Sleep on your left side with a pillow between your knees."

a. "Avoid caffeine-containing foods and beverages." The nurse tells the patient to avoid caffeine-containing foods and beverages. The nurse also teaches the patient to limit or eliminate foods that decrease lower esophageal sphincter (LES) pressure and that irritate inflamed tissue, causing heartburn. These foods include peppermint, chocolate, alcohol, fatty foods (especially fried), caffeine, and carbonated beverages.The nurse also needs to remind the patient to eat four to six small meals each day rather than three large ones and avoid snacking between meals. Large meals increase the volume of and pressure in the stomach and delay gastric emptying. Peppermint decreases LES pressure and increases the risk of symptoms. Patients need to be taught to elevate the head by 6 to 12 inches (30 cm) for sleep to prevent nighttime reflux.

The nurse admits an immunocompromised client who has contracted herpes simplex stomatitis. The nurse anticipates that the health care provider will request which medication? a. Acyclovir (Zovirax) b. Diphenhydramine (Benadryl) c. Nystatin (Mycostatin) d. Tetracycline syrup (Sumycin syrup)

a. Acyclovir (Zovirax) Acyclovir (Zovirax) is an antiviral agent that is prescribed for immunocompromised clients who contract herpes simplex stomatitis. Diphenhydramine is an antihistamine that is not indicated for treating this condition. Nystatin is indicated for treatment of fungal infection. Tetracycline syrup is indicated for treatment of recurrent aphthous ulcers.

The nurse is performing a physical assessment on a client's abdomen. The nurse inspects the abdomen and finds it a symmetrical, with a non-pulsating mass in the RUA. What is the priority nursing intervention?

Auscultate for bowel sounds in bruits.

When examining the abdomen, which technique for abdominal assessment is used second?

Auscultation

A client reports ongoing episodes of heartburn. The nurse educated the client on prevention and control of reflux by recommending dietary elimination of which food item?

Chocolate candy

when beginning an abdominal assessment, the nurse would begin in which quadrant?

Right upper quadrant (RUQ)

The community clinic nurse is discussing risk factors for a Soffa Gille cancer with a group of clients. Which client behavior requires further teaching?

Smokes one pack of cigarettes daily

On assessment of a client with GERD, which statement requires nursing intervention?

Sometimes I wake up gasping for air in the middle of the night

A nurse is planning care for a client who has acute gastritis. Which of the following nursing intervention should the nurse include in the plan of care? Select all that apply

Evaluate intake and output Monitor laboratory reports of electrolyte observe stool characteristics

A nurse is teaching about pernicious Anemia with a client who has chronic gastritis. Which of the following information should the nurse include in the teaching?

Expecting monthly injection vitamin of B12

The nurse is caring for a client who is concerned about developing oral tumors. Which client statement requires immediate nursing intervention?

I don't have dental insurance so I can't get dental check ups.

Anders is teaching a client who has a new prescription for famotidine. Which of the following statements by the client indicates an understanding of the teaching?

I will take my pill at bedtime

Adequate nutrition is required for healing after treatment for recurrent aphthous ulcers (RAU). Which client response indicates that nursing teaching has been effective?

I'd like scrambled eggs in a banana for breakfast

The nurse is assessing a patient with gastroesophageal reflux disease (GERD). Which findings does the nurse expect to observe? (Select All That Apply) a. Blood-tinged sputum b. Dyspepsia c. Excessive salivation d. Flatulence e. Regurgitation

b. Dyspepsia c. Excessive salivation d. Flatulence e. Regurgitation When assessing a patient for GERD, the nurse expects to find dyspepsia (heartburn), excessive salivation, flatulence which is common after eating, and regurgitation (backward flow of food and fluid into the throat).Blood-tinged sputum and excessive salivation are not symptoms of GERD.

The nurse is observing a coworker who is caring for a patient with a nasogastric tube following esophageal surgery. Which actions by the coworker require the nurse to intervene? (Select All That Apply) a. Checking tube placement every 12 hours b. Keeping the bed flat c. Placing the patient upright when taking sips of water d. Providing mouth care every 8 hours e. Securing the tube

a. Checking tube placement every 12 hours b. Keeping the bed flat d. Providing mouth care every 8 hours The nurse would intervene to make sure the nasogastric tube is checked every 4 to 8 hours and not every 12 hours. Also, the head of the bed needs to be elevated at least 30 degrees and not kept flat. Oral hygiene would be provided every 2 to 4 hours and not every 8 hours.The patient should be placed upright when taking sips or small amounts of water to prevent choking and to allow observation of the patient for dysphagia. The tube should be secured to prevent dislodgment.

As a result of being treated with radiation for oral cancer, a client is experiencing xerostomia. What collaborative resource does the nurse suggest for this client's care? a. Dentist b. Occupational therapist c. Psychiatrist d. Speech therapist

a. Dentist Xerostomia is a long-term effect of radiation therapy and requires ongoing oral care such as the use of saliva substitutes and follow-up dental visits. Occupational therapists, psychiatrists, and speech therapists are not the appropriate resource for a client with xerostomia.

dyspepsia is characterized by which factors?

- Indigestion associated with eating - heartburn associated with eating

The nurse is caring for a patient with abdominal pain. While assessing a patient, which questions will the nurse asked the patient?

- Is the pain burning, nine, or stabbing? - Can you point to where you feel the pain? - When did you first notice the pain? - Does the pain spread everywhere?

Which statements about in centric factor are correct?

- It produced by the parietal cells - it aids in the absorption of vitamin B 12 - it causes the stomach to secrete hydrochloric acid

Which statements about Kupffer cells are true?

- They are found in the liver - They phagocytize harmful bacteria - They are part of the body's reticuloendothelial system

Which substances predispose a patient to peptic ulcer disease and gastrointestinal (G.I.) bleeding?

- nonsteroidal anti-inflammatory drugs - anticoagulants - aspirin - caffeine

While performing an abdominal assessment on a patient with abdominal pain, the nurse performed inspection of the abdomen. Which inspection findings should the nurse be sure to document?

- overall shape of the abdomen - presence of discoloration or scarring - symmetry or asymmetry of the abdominal contour - distention of the abdomen

The nurse is caring for four clients. Which is at the highest risk for development of oral cancer?

41-year-old with human papilloma virus (HPV) infection

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) ERCP requires conscious sedation, so the client needs immediate assessment of respiratory and cardiovascular status. The endoscopic procedure and nursing care for a client having an ERCP are similar to those for the EGD procedure, except that the endoscope is advanced farther into the duodenum and into the biliary tractA 54-year old client being discharged after a colonoscopy, a 58-year old client who is going to have a gastric acid test, and a 60-year old client with questions about an endoscopic ultrasound examination are not at risk for depressed respiratory status.

A nurse in a providers office is preparing to auscultate in Perkasie clients abdomen as part of the comprehensive physical examination. Which of the following findings should the nurse expect select all that apply A. Tympany B. High-pitched clicks C. Borborygmi D. Friction rubs E. Bruits

A, B A. Correct: Tympany is the expected drumlike percussion sound over the abdomen. It indicates air in the stomach. B. Correct: Typical bowel sounds are high-pitched clicks and gurgles occurring about 35 times/min. C. Incorrect: Borborygmi are unexpected loud, growling sounds that indicate increased gastrointestinal motility. Possible causes include diarrhea, anxiety, bowel inflammation, and reactions to some foods. D. Incorrect: Friction rubs result from the rubbing together of inflamed layers of the peritoneum and are unexpected findings. E. Incorrect: Bruits indicate narrowed blood vessels and are unexpected findings.

A nurse in a provider's office is documenting his findings following an examination he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? (Select all that apply.) A. Posture B. Skin lesions C. Speech D. Allergies. E. immunization status

A, B, C Rationale: A. Posture is part of the body structure or general appearance portion of the general survey. B. Skin lesions are part of the body structure or general appearance portion of the general survey. C. Speech is part of the behavior portion of the general survey

A nurse is talking with an older adult client about improving nutritional status. Which of the following intervention should the nurse recommend? Select all that apply A. Increase protein intake to increase muscle mass. B. Decrease fluid intake to prevent urinary incontinence. C. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation.

A. Increase protein intake to increase muscle mass. C. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation.

A nurse in a providers office is preparing to perform a breast examination for an older adult client who is post menopausal. Which of the following findings should the nurse expect? Select all that apply A. Smaller nipples B. Less adipose tissue C. Nipple discharge D. More pendulous E. Nipple inversion

A,D,E A. Correct: In older adulthood, the nipples become smaller and flatter. B. Incorrect: Older adults have more adipose tissue and less glandular tissue in their breasts. C. Incorrect: Older adults have no nipple discharge, unless there is some underlying pathophysiology. D. Correct: In older adulthood, the breasts become softer and more pendulous. E. Correct: Nipple inversion is common among older adults, due to fibrotic changes and shrinkage.

A client is scheduled for a colonoscopy. What does the nurse tell the client to do before the procedure is performed? A. "Begin a clear liquid diet at least 24 hours before the test." B. "Do not eat or drink anything for 12 hours before the test." C. "Give yourself tap water enemas until the fluid returns are clear." D. "Be sure to take all currently prescribed medications prior to the procedure."

A. "Begin a clear liquid diet at least 24 hours before the test." The nurse tells the client to be on a clear liquid diet for at least 24 hours to cleanse the bowel before a colonoscopy.The client must be NPO (except for water) 4 to 6 hours before a colonoscopy, not 12 hours. Also, the client needs to avoid aspirin, anticoagulants, and antiplatelet drugs for several days before the procedure. Diabetic clients need to check with their health care provider about drug therapy requirements on the day of the test because they are NPO. The client would not give him/herself a tap water enema. Clients must not take all currently prescribed medications without first checking with their doctor.

Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit? A. A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis B. A 36-year-old who needs teaching about an endoscopic retrograde cholangiopancreatography C. A 40-year-old who will need administration of IV midazolam hydrochloride (Versed) during an upper endoscopy D. A 46-year-old who was recently admitted with abdominal cramping and diarrhea of unknown causes

A. A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis Nasogastric tube insertion is included in LPN/LVN education and is an appropriate task for an experienced LPN/LVN.Assessment and client teaching would be done by an RN. IV hypnotic medications would be administered by an RN.

The nurse is assessing an alert client who had abdominal surgery yesterday. What method provides the most accurate data about resumption of peristalsis in the client? A. Asking the client whether he or she has passed flatus (gas) within the previous 12 to 24 hours. (p. 17) B. Auscultating bowel sounds in all abdominal quadrants C. Counting the number of bowel sounds in each abdominal quadrant over one minute. D. Observing the abdomen for symmetry and distention

A. Asking the client whether he or she has passed flatus (gas) within the previous 12 to 24 hours. (p. 17) The best and most reliable method for assessing the return of peristalsis following abdominal surgery is the client's report of passing flatus within the past 8 hours or stool within the past 12 hours.Although auscultation and counting the number of sounds was once a method of assessing for bowel activity, it is no longer considered the most effective method. Observing the abdomen is one method of examining a client's abdomen, but it is not a reliable way to assess for resumption of activity after surgery.

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? Select all that apply A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. D. Warm the formula to body temperature. E. Discard any residual gastric contents.

A. Auscultate bowel sounds: If the nurse cannot hear bowel sounds, the client's gastrointestinal tract might not be able to absorb nutrients. The nurse should then withhold feedings and notify the provider. B. Assist the client to an upright position: The optimal position for enteral feeding is upright, and never lower than 30° of elevation of the head of the bed. Upright positioning helps prevent aspiration. C. Test the pH of gastric aspirate: Before administering enteral feedings, the nurse should verify the placement of the NG tube. The only reliable method is x-ray confirmation, which is impractical prior to every feeding. Testing the pH of gastric aspirate is an acceptable method between x-ray confirmations.

A client completing radiation treatment has developed dysphasia and stomatitis. What teaching will the nurse provide? Select all that apply. A. Brush teeth twice daily with chemo brush. B. Thin liquids will make it easier to swallow. C. Limit alcohol consumption to three drinks per day. D. Rinse mouth with mild Celine and water mix before and after eating. E. Refrain from using liquid dietary supplements because these will irritate mucosal membranes. F. Plan to eat soft foods such as cheese, well cooked lagoons, peanut butter, and pudding.

A. Brush teeth twice daily with chemo brush. D. Rinse mouth with mild Celine and water mix before and after eating. F. Plan to eat soft foods such as cheese, well cooked lagoons, peanut butter, and pudding.

What is a common gastrointestinal problem that older adults experience more frequently as they age? A. Decreased hydrochloric acid levels B. Excess lipase production C. Increased liver size D. Increased peristalsis

A. Decreased hydrochloric acid levels In older adults, decreased hydrochloric acid levels (hypochlorhydria) results from atrophy of the gastric mucosa.A decrease in lipase production results from calcification of pancreatic vessels. A decrease in the number and size of hepatic cells leads to decreased liver weight and mass. Peristalsis decreases, and nerve impulses are dulled.

A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? Select all that apply A. Review a signal the client can use if feeling any distress. B. Lay a towel across the client's chest. C. Administer oral pain medication. D. Obtain a Dobhoff tube for insertion. E. Have a petroleum-based lubricant available.

A. Review a Signal the client can use if feeling any distress: Before inserting an NG tube, it is important to establish a means for the client to communicate that she wants to stop the procedure. B. Play towel across the client's chest: Placing a disposable towel across the client's chest provides for a clean environment.

A nurse is delivering an internal feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asked the nurse why the water is necessary. Which of the following responses should the nurse make? A. "Water helps clear the tube so it doesn't get clogged." B. "Flushing helps make sure the tube stays in place." C. "This will help you get enough fluids." D. "Adding water makes the formula less concentrated."l help you get enough fluids." D. "Adding water makes the formula less concentrated."

A. Water helps clear the tube so it doesn't get clogged. Flushing the tube after instilling the feeding helps keep the NG tube patent by clearing any excess formula from the tube so that it doesn't clump and clog the tube.

A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? Select all that apply A. eye examination every 1-3 years B. decrease intake of calcium supplements C. DXA screening for osteoporosis D. increase intake of carbohydrate in the diet E. screening for depressive disorders

A. eye examination every 1-3 years C. DXA screening for osteoporosis D. increase intake of carbohydrate in the diet E. screening for depressive disorders

A nurse is collecting history and physical examination data from a middle adult the nurse should expect to find decreases in which of the following physiologic functions? (select all that apply) A. metabolism B. ability to hear low pitched sounds C. gastric secretions D. Far vision E. Glomerular filtration

A. metabolism C. gastric secretions E. Glomerular filtration

The patient is a 21-year-old who has recently been diagnosed with ulcerative colitis (UC). In the ED, she tells the nurse that she has been having 7 to 8 bloody stools daily. Upon assessment, the nurse finds that her heart rate is 120/min, and she has abdominal pain upon palpation. Laboratory results show a hemoglobin level of 9 g/dL.The patient is admitted to the acute medical unit. Which medication would the nurse question? A. Ibuprofen (Motrin) B. Mesalamine (Asacol) C. Prednisone (Deltasone) D. Loperamide (Imodium)

Answer: A Ibuprofen is a nonsteroidal antiinflammatory drug (NSAID); NSAIDs increase the risk for bleeding.

An older patient diagnosed with bacterial gastroenteritis reports abdominal cramping, diarrhea, nausea and vomiting, and fatigue for the past 24 hours. The nurse should monitor the patient for what priority assessment? A.Dehydration B. Hypokalemia C. Hypernatremia D. Perineal skin breakdown

Answer: A Rationale: In older adults, dehydration occurs with viral and bacterial gastroenteritis and may require hospitalization. Electrolyte imbalances are also common, especially hypokalemia and hypernatremia. The aging skin is also at risk of compromise from frequent exposure to enzymes in the stool.

Later in the afternoon, the patient states that the abdominal pain is getting worse. Which nursing interventions are appropriate? (Select all that apply.) A. Providing sitz baths as needed B. Administering analgesics as ordered C. Teaching music therapy or guided imagery D. Evaluating the diet for foods that cause pain E. Providing antidiarrheal medications if ordered

Answer: A, B, C Sitz baths will help prevent skin excoriation or irritation. Complementary therapies used in conjunction with analgesics can be very helpful in controlling pain. Antidiarrheal medications may provide symptomatic relief. Evaluating offending foods would not address the patient's immediate symptom of pain.

What priority laboratory analysis should the nurse review when caring for a patient with Crohn's disease? A. Potassium B. Hemoglobin C. Serum albumin D. C-reactive protein

Answer: B Rationale: Crohn's disease presents as transmural inflammation that causes a thickened bowel wall, strictures, and deep ulcerations that result in severe diarrhea and malabsorption of vital nutrients. Anemia is common, usually from iron deficiency or malabsorption issues. C-reactive protein may be monitored as a marker of inflammation, albumin to assess nutritional status, and potassium related to losses from diarrhea.

The patient is a 21-year-old who has recently been diagnosed with ulcerative colitis (UC). In the ED, she tells the nurse that she has been having 7 to 8 bloody stools daily. Upon assessment, the nurse finds that her heart rate is 120/min, and she has abdominal pain upon palpation. Laboratory results show a hemoglobin level of 9 g/dL. How is the severity of the patient's ulcerative colitis categorized? A. Mild B. Severe C. Moderate D. Fulminant

Answer: B Severe UC presents with greater than 6 bloody stools daily and may include fever, tachycardia, anemia, abdominal pain, and an elevated C-reactive protein and/or erythrocyte sedimentation rate (ESR).

What symptom does the nurse expect the patient with intussusception to exhibit? A. Decrease in pulse B. Singultus (hiccups) C. Frequent bloody stools D. Extremely elevated body temperature

Answer: B Rationale: Intussusception is a telescoping of the intestine within itself. Singultus (hiccups) is common with all types of intestinal obstruction. The vagus and phrenic nerves stimulate the hiccup reflex. Intestinal obstruction can increase the intraabdominal pressure, causing pressure on the phrenic nerve and the symptom of singultus (hiccups).

The patient is preparing for discharge. She asks what is the best way to keep her skin from breaking down. What is the appropriate teaching the nurse will provide? A. "Add high-fiber or high-cellulose foods to your diet." B. "Apply a pectin-based skin barrier after each bowel movement." C. "Wash with mild soap and warm water after each bowel movement." D. "Take a laxative daily at bedtime to facilitate morning bowel movements."

Answer: C Good skin care after each bowel movement is the best way to protect from excoriation or irritation due to frequent bowel movements. Pectin skin barriers should only be used with ostomies. High-fiber or high-cellulose foods should be avoided, as should laxatives.

A patient has recently been placed on corticosteroids as treatment for ulcerative colitis. The nurse should monitor the patient's laboratory results for evidence of which condition? A. Hyperkalemia B. Hypernatremia C. Hypercalcemia D. Hyperglycemia

Answer: D Rationale: Long-term adverse effects that commonly occur with steroid therapy include hyperglycemia, osteoporosis, peptic ulcer disease, and increased risk for infection.

The patient states, "I am afraid I'll never get to go out with my friends again because I can't be away from the toilet." Which is the appropriate nursing response? A. "What makes you say that?" B. "Your friends will understand." C. "I wouldn't worry about it if I were you." D. "It sounds like you are concerned about managing this disorder when you are out."

Answer: D This response verbalizes the implied concern. Response A does not address the concern and requires the patient to give an answer that defends her feelings. Responses B and C minimize the patient's feelings and do not address her concerns.

The nurse recognizes that which ethnic group has a higher incidence of colorectal cancer? A. Asian B. Caucasian C. Hispanic/Latino D. African-American

Answer: D Rationale: African-American men and women are diagnosed with and die from colorectal cancer at higher rates than men and women of any other United States racial or ethnic group. The reason for this is not yet understood.

A nurse is preparing to perform a comprehensive physical examination of an older adult. Which of the following intervention should the nurse use in consideration of the clients age? Select all that apply a.Collect the data in one continuous session. B.Plan to allow plenty of time for position changes. C.Make sure the client has any essential sensory aids in place. D. tell the client to take her time answering questions. E. invite the client to use the bathroom before beginning the examination

B, C, D, E Rationale: B. Because many older adults have mobility challenges, the nurse should plan to allow extra time for position changes. C. the nurse should make sure clients who use sensory aids have them available for use. the client has to be able to hear the nurse and see well enough to avoid injury. D. Some older clients need more time to collect their thoughts and answer questions, but most are reliable historians. Feeling rushed can hinder communication. E. This is a courtesy for all clients, to avoid discomfort during palpation of the lower abdomen for example, but this is especially important for older clients who have a smaller bladder capacity.

A nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (select all that apply) A. Address the client with the appropriate title and her last name. B. Use a mix of open- and close-ended questions. C. Reduce environmental noise. D. Have the client complete a health history form. E. Perform the general survey before the examination.

B, C, E Rationale: B. Open‑ended questions help the client tell her story in her own way. Closed‑ended questions are useful for clarifying and verifying information the nurse gathers from the client's story C. quiet, comfortable environment eliminates distractions and helps the client focus on the important aspects of the interview. E. The general survey is noninvasive and, along with the health history and vital sign measurement, can help put the client at ease before the more sensitive parts of the process, such as the examination

During a cardiovascular examination, a nurse in a providers office place is the diaphragm of the stethoscope on the left midclavicular line At the fifth intercostal space. Which of the following data is the nurse attempting to auscultate select all that apply A. Ventricular gallop B. Closure of the mitral valve C. Closure of the pulmonic valve D. Closure of the tricuspid valve E. Murmur

B, D A. Incorrect: To auscultate a ventricular gallop (an S3 sound), the nurse places the bell of the stethoscope at ech of the auscultatory sites. B. Correct: To auscultate the closure of the mitral valve, the nurse places the diaphragm of the stethoscope over the apex, or apical/mitral site, which is on the left midclavicular line at the fifth intercostal space. C. Incorrect: To auscultate the closure of the pulmonic valve, the nurse places the diaphragm of the stethoscope over the aortic area, which is just to the right of the sternum at the second intercostal space. D. Correct: To auscultate the closure of the tricuspid valve, the nurse places the diaphragm of the stethoscope over the apex, or apical/mitral site, which is on the left midclavicular line at the fifth intercostal space. E. Incorrect: To auscultate a murmur, the nurse places the bell of the stethoscope at various auscultatory sites.

The nurse is educating a group of older adults about screening for colorectal cancer. Which statement by a group member indicates the need for further clarification about these guidelines? A. "A barium enema every 5 years is a screening option." B. "I will need to have a routine colonoscopy every 5 years." C. "My routine flexible sigmoidoscopy every 5 years is OK." D. "The 'virtual' colonoscopy every 5 years is acceptable."

B. "I will need to have a routine colonoscopy every 5 years." The 2015 guidelines indicate that routine screening with colonoscopy is performed every 10 years, not every 5 years.Other options are performed at 5-year intervals. A barium enema every 5 years is a screening option. A flexible sigmoidoscopy and a "virtual" colonoscopy every 5 years are also acceptable for screening. A "virtual" colonoscopy or CT colonography is a noninvasive imaging procedure that takes multidimensional views of the entire colon.

A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as a priority to assess further. A. "i am struggling to accept that my parents are aging and need so much help." B. "Its been so stressful for me to think about having intimate relationships." C. "i know i should volunteer my time for a good cause, but maybe I am just selfish." D. "i love my grandchildren, but my child expects me to relive my parenting days."

B. "Its been so stressful for me to think about having intimate relationships."

hich client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) clinic? A. A 38-year-old who needs discharge instructions after having an endoscopic retrograde cholangiopancreatography (ERCP) B. A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy C. A 43-year-old recently admitted with nausea, abdominal pain, and abdominal distention D. A 50-year-old with epigastric pain who needs conscious sedation during a scheduled endoscopy procedure

B. A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy is the least complicated client. This client would be assigned to the float nurse who would have the experience and training to adequately care for this client. A clinic nurse typically cares for clients with chronic conditions.Discharge instructions following an ERCP, assessment of an admitted acutely ill client, and monitoring a client who is receiving conscious sedation would be accomplished best by nurses with experience in caring for adults with acute GI problems.

A nurse is collecting data from an older adult client as part of the comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? Select all that apply A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity

B. Decreased height D. Nail thickening E. Decreased bladder capacity

A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client? A. Assesses the abdomen in the following sequence: inspection, palpation, percussion, auscultation B. Examines the RUQ of the abdomen last following all other assessment techniques. C. Have the client lie in a supine position with legs straight and arms at the sides D. Gently palpates any bulging mass and documents findings.

B. Examines the RUQ of the abdomen last following all other assessment techniques. B. If the client reports pain in the RUQ, the nurse would examine this area last in the examination sequence. This sequence prevents the client from tensing abdominal muscles because of the pain, which would make the examination difficult.The sequence for examining the abdomen is inspection, auscultation, percussion, and then palpation. This sequence prevents the increase in intestinal activity and bowel sounds caused by palpation and percussion. The client would be positioned supine with the knees bent, while keeping the arms at the sides to prevent tensing of the abdominal muscles. If a bulging, pulsating mass is present during assessment of the abdomen, do not touch the area because the client may have an abdominal aortic aneurysm, a life-threatening problem. Notify the health care provider of this finding immediately!

A client had a routine sigmoidoscopy with a tissue biopsy. What post procedure complication would the nurse report to the health care provider? A. Gas and flatulence B. Excessive bleeding C. Nausea and vomiting D. Severe rectal pain

B. Excessive bleeding Excessive or heavy bleeding is a possible complication following a sigmoidoscopy. It must be reported immediately to the health care provider.Nausea, vomiting, and severe rectal pain are not common complications of sigmoidoscopy. Gas and flatulence are expected assessment findings post-sigmoidoscopy (p. 36)

The nurse practitioner is performing an abdominal assessment on a newly admitted client. In which order should the nurse proceed with assessment technique? A. Auscultation, percussion, palpation, inspection B. Inspection, auscultation, percussion, palpation C. Palpation, percussion, inspection, auscultation D. Percussion, auscultation, palpation, inspection

B. Inspection, auscultation, percussion, palpation The assessment technique proceeds as inspection, auscultation, percussion, palpation. This sequence is different from that used for other body systems. It is used so that palpation and percussion do not increase intestinal activity and bowel sounds. Nurse generalists may perform inspection, auscultation, and light palpation; percussion and deep palpation may be done by advanced practice nurses.Inspection must be the first assessment technique. Options beginning with auscultation, palpation, or percussion are incorrect.

The nurse is assessing a client who comes to the emergency department with acute abdominal pain. The nurse notes a bulging, pulsating mass when inspecting the abdomen. Which action by the nurse is correct? A. Auscultate the abdomen to determine the presence of bowel sounds. B. Notify the provider about this finding immediately. C. Palpate the client's abdomen to determine the outlines of the mass. C. Question the client about recent stool habits.

B. Notify the provider about this finding immediately. The nurse needs to immediately notify the health care provider because a bulging, pulsating mass may indicate an abdominal aortic aneurysm requiring emergency actions.Palpating the abdomen or even touching the abdomen with a stethoscope may cause this to rupture, which would be a life-threatening emergency. Because this is a potential life-threatening situation, questioning the client about stool habits is not appropriate.

A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following intervention should the nurse plan to recommend? Select all that apply A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test

B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. Auscultate breath sounds. B. Stop the feeding. C. Obtain a chest x-ray. D. Initiate oxygen therapy.

B. Stop the feeding The greatest risk to the client is aspiration pneumonia. Therefore, the first action the nurse should take is to stop the feeding so that no more formula can enter the lungs.

A nurse is preparing to instill and enteral feeding for a client who has an NG tube in place which of the following actions is the nurses hi assessment priority before performing this procedure? A. Check how long the feeding container has been open. B. Verify the placement of the NG tube. C. Confirm that the client does not have diarrhea. D. Make sure the client is alert and oriented.

B. Verify the placement of the NG tube The greatest risk to the client receiving enteral feedings is injury from aspiration. Therefore, the priority nursing assessment before initiating an enteral feeding is to verify proper placement of the NG tube.

A nurse is collecting data for a clients comprehensive physical examination after inspecting the client's abdomen which of the following skills of the physical examination process should the nurse perform? A.olfaction B.auscultation C.Palpation D.Percussion

B. auscultation Rationale: B. Because palpation and percussion can alter the frequency and intensity of bowel sounds, the nurse should auscultate the abdomen next and before using those two techniques

A nurse is collecting data to evaluate a middle adults psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental task select all that apply A. develop an acceptance of diminished strength and increased dependence on others. B. spend time focusing on improving job performance C. welcome opportunities to be creative and productive D. commit to finding friendship and companionship E. become involved with community issues and activities

B. spend time focusing on improving job performance C. welcome opportunities to be creative and productive E. become involved with community issues and activities

Which factors place a client at risk for gastrointestinal (GI) problems? Select all that apply. A. Eating a high-fiber diet B. Smoking a half-pack of cigarettes per day C. Socioeconomic status D. Some herbal preparations E. Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

B.Smoking a half-pack of cigarettes per day C.Socioeconomic status D.Some herbal preparations E.Use of nonsteroidal anti-inflammatory drugs (NSAIDs) Smoking or any tobacco use places a client in a higher-risk category for GI problems. Socioeconomic status can also influence the risk for GI problems; clients may not be able to afford to seek care or treatment and may put off seeking help. Some herbal preparations contribute to GI problems, such as Ayurvedic herbs, which can affect appetite, absorption, and elimination. NSAIDs can predispose clients to peptic ulcer disease or GI bleeding.High-fiber diets are generally believed to be healthy for most clients.

A nurse in a providers office is preparing to auscultate and percussive clients thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all that apply A. Rhonchi B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds

C, E A. Incorrect: Rhonchi are coarse sounds that result from fluid or mucus in the airways. B. Incorrect: Crackles are fine to coarse popping sounds that result from air passing through fluid or re-expanding collapsed small airways. C. Correct: Resonance is the expected percussion sound over the the thorax. It is a hollow sound that indicates air inside the lungs. D. Incorrect: Tactile fremitus is an expected vibration the nurse can expect to feel as the client vocalized. Speech creates sound waves, the vibrations of which travel from the vocal cords through the lungs and to the chest wall. E. Correct: Bronchovesicular sounds are expected breath sounds of medium pitch and intensity and of equal inspiration and expiration time. The nurse can expect to hear them over the larger airways.

The outpatient clinic nurse is caring for a recovering client who had a colonoscopy. The client asks for a drink. How does the nurse respond to this request? A."After I hear bowel sounds, you can have a drink." B."Twenty minutes after the procedure was completed, you may have some liquids." C."When you are able to pass flatus (gas), you can have a drink." D."You can have fluids when you get home and are settled."

C. "When you are able to pass flatus (gas), you can have a drink." Fluids are permitted after the client's peristalsis has returned, which is validated by the client's passing flatus (p. 34).Ability to pass flatus (gas) is more reliable than auscultation of bowel sounds when assessing a client's status to drink after a colonoscopy. There is no set time period after the procedure that is considered safe for the client to have something to drink. The client will not be discharged home without the nurse determining that peristalsis has returned. The client must report that he or she is passing flatus to go home; therefore, the client should be given a drink before being sent home.

A nurse in a providers office is performing a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature? A.Palmar surface B.Fingertips C.Dorsal surface D.Base of the fingers

C. Dorsal surface Rationale: C. The dorsal surface of the hand is the most sensitive to temperature.

During an abdominal examination a nurse in a providers office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is Todd, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias

C. Flatus A. Incorrect: With fat, there are rolls of adipose tissue along the sides, and the skin does not look taut. B. Incorrect: With fluid, the flans also protrude, and when the client turns onto one side, the protrusion moves to the dependent side. C. Correct: With flatus, the protrusion is mainly midline, and there is no change in flanks. D. Incorrect: With hernias, protrusions through the abdominal muscle wall are visible, especially when the client raises her head.

The nurse is assessing a client who has come to the emergency department with acute abdominal pain. The client is very thin and the nurse observes visible peristaltic movements when inspecting the abdomen. What does the nurse suspect? A. Acute diarrhea B. Aortic aneurysm C. Intestinal obstruction D. Pancreatitis

C. Intestinal obstruction The nurse would suspect an intestinal obstruction related to peristaltic movements. Peristaltic movements are rarely seen except in thin clients. This needs to be reported to the HCP.Acute diarrhea does not cause visible peristaltic movements. Aortic aneurysm may cause a bulging, pulsatile mass. Pancreatitis is characterized by severe pain.

Which substance, produced in the stomach, facilitates the absorption of vitamin B12? A. Glucagon B. Hydrochloric acid C. Intrinsic factor C. Pepsinogen

C. Intrinsic factor Intrinsic cells are produced by the parietal cells in the stomach. This substance facilitates the absorption of vitamin B12. Absence of intrinsic factor causes pernicious anemia.Glucagon, which is produced by the alpha cells in the pancreas, is essential for the regulation of metabolism. Parietal cells secrete hydrochloric acid, but this does not facilitate the absorption of vitamin B12. Pepsinogen is secreted by the chief cells; pepsinogen is a precursor to pepsin, a digestive enzyme.

And nurses providing teaching for an older adult client who has lost 4.5 kg (9.9lb) since the last admission six months ago. Which of the following instruction should the nurse include in the teaching? A. "Eat three large meals a day." B. "Eat your meals in front of the television." C."Eat foods that are easy to eat, such as finger foods." D."Invite family members to eat meals with you." E. "Exercise every day to increase appetite."

C."Eat foods that are easy to eat, such as finger foods." D."Invite family members to eat meals with you." E. "Exercise every day to increase appetite."

After a colonoscopy, a client reports severe abdominal pain. The nurse obtains these data: temperature 100.2°F (37.9°C), pulse 122 beats/min, blood pressure 100/45 mm Hg, respirations 44 breaths/min, and O2 saturation 89%. Which request from the health care provider does the nurse implement first? A. Give cefazolin (Ancef) 500 mg IV. B. Infuse normal saline at 200 mL/hr. C. Give morphine sulfate 2 mg IV. D. Provide oxygen at 6 L/min per nasal cannula.

D. Provide oxygen at 6 L/min per nasal cannula. The first request the nurse complies with is to place the client on oxygen. This is the most immediate concern because it involves the client's respiratory status. Based on the data given, the client may be experiencing complications of colonoscopy such as bleeding or perforation.An antibiotic request is important but is not the first priority. Fluid supplementation is important, but the client's oxygen saturation level places the client's respiratory status as the priority. The client's need for analgesia should be delayed until respiratory status is addressed. Morphine depresses respiratory status and therefore might not be the right choice for this client.

A client arrives at the emergency department with acute abdominal pain in the left lower quadrant. In which order does the nurse examine and assess the client's abdomen? (left lower quadrant (LLQ), left upper quadrant (LUQ), right lower quadrant (RLQ), and right upper quadrant (RUQ))? A. LLQ, RLQ, LUQ, RUQ B. LUQ, LLQ, RUQ, RLQ C. RLQ, LLQ, RUQ, LUQ D. RUQ, LUQ, RLQ, LLQ

D. RUQ, LUQ, RLQ, LLQ The LLQ would be the last area assessed for this client. Abdominal examination usually begins at the client's right side and proceeds in a systematic fashion: RUQ, LUQ, RLQ, LLQ. However, if the client is experiencing pain in a specific quadrant, that area should be assessed last in the examination sequence. This action prevents the client from tensing abdominal muscles because of the pain, which would make the examination difficult.The options that do not assess the quadrant where the pain presents last are incorrect.

A charge nurse is explaining the various stages of the life span to a group of newly licensed nurses. Which of the following examples should the nurse include as a developmental task for middle adulthood? A. the client evaluates their behavior after a social interaction B. the client states they are learning to trust others C. the client wishes to find meaningful friendships D. the client expresses concerns about the next generation.

D. the client expresses concerns about the next generation.

A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as a priority? A. "I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my son to help around the house." C."I just heard my friend Al died. That's the third one in 3 months." D."I keep forgetting which medications I have taken during the day."

D."I keep forgetting which medications I have taken during the day."

What is the name of the first 12 inches of the small intestine?

Duodenum

The nurse is caring for a patient diagnosed with esophageal cancer who is experiencing diarrhea after conventional esophageal surgery. The nurse anticipates that the primary health care provider will request which medication to manage diarrhea? a. Loperamide (Imodium) b. Mesalamine (Pentasa) c. Minocycline (Minocin) d. Pantoprazole (Protonix)

a. Loperamide (Imodium) The nurse anticipates that the primary health care provider will order Loperamide to manage the diarrhea. Diarrhea is thought to be the result of vagotomy syndrome, which develops as a result of interruption of vagal fibers to the abdominal viscera during surgery. It can occur 20 minutes to 2 hours after eating and can be symptomatically managed with loperamide.Mesalamine is used to treat patients with mild to moderate ulcerative colitis. Minocycline is an antibiotic used for treatment of infection. Pantoprazole is used to treat gastroesophageal reflux disease.

Which practice does the nurse include when teaching a client about proper oral care? a. Perform self-examination of the mouth every week, and report any unusual findings. b. Brush the teeth daily and floss as needed. c. Use drugs that reduce the flow of saliva unless lesions are present. d. Regularly rinse mouth with alcohol-based agent.

a. Perform self-examination of the mouth every week, and report any unusual findings. Clients must be taught to perform self-examination of the mouth every week and to report any unusual findings. Clients should brush teeth and floss every day. Clients should be instructed to avoid, if possible, drugs that can cause inflammation of the mouth or that can reduce the flow of saliva. Clients must be instructed to avoid or limit sun exposure, which is a risk factor for skin cancer.

The nurse is reinforcing the instructions on swallowing provided by the speech-language pathologist to a patient diagnosed with esophageal cancer. Which of the following instructions should be included in the teaching? a. Place food at the back of the mouth as you eat. b. Do not be overly concerned with tongue or lip movements. c. Before swallowing, tilt the head back to straighten the esophagus. d. Do not attempt to reach food particles that are on the lips or around the mouth.

a. Place food at the back of the mouth as you eat. The nurse should instruct the patient to place food at the back of the mouth when eating. This will help the patient avoid aspiration of food. Food aspiration can cause airway obstruction, pneumonia, or both, especially in older adults.Both tongue movements and sealing of the lips should be monitored in this patient. The patient's head should be tilted forward in the chin-tuck position and not back. The patient needs to be able to reach food particles on her or his lips and around the mouth with the tongue.

When caring for a client with oral cancer who has developed stomatitis as a complication of radiation and chemotherapy, which action does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Provide oral care using disposable foam swabs. b. Inspect the oral mucosa for evidence of oral candidiasis. c. Instruct the client on how to use nystatin (Mycostatin) oral rinses. d. Teach the client how to make appropriate dietary choices.

a. Provide oral care using disposable foam swabs. Providing oral care for a client with oral lesions is an appropriate assignment for a home health aide or UAP. Assessments, client teaching, and assisting clients with oral problems in making appropriate dietary choices are the responsibilities of licensed nursing staff.

The nurse is instructing a client on measures to maintain effective oral health. Which measures does the nurse include in the client's teaching plan? (Select All That Apply) a. Regular dental checkups b. Use of mouthwashes containing alcohol c. Ensuring that dentures are slightly loose-fitting d. Managing stress as much as possible e. Eating a balanced diet

a. Regular dental checkups d. Managing stress as much as possible e. Eating a balanced diet Regular dental checkups are important so potential problems can be prevented or attended to promptly. Stress suppresses the immune system, which can increase the client's risk for infections such as Candida albicans. Eating a balanced diet can reduce the risk for dental caries and infections such as C. albicans or stomatitis. Mouthwashes that contain alcohol may cause inflammation and should be avoided. Dentures should be in good repair and should fit properly.

A client who has undergone surgery and completed radiation therapy to treat oral cancer reports persistent dry mouth. What will the nurse teach this client about managing this symptom? a. Use saliva substitutes, especially when eating dry foods. b. This condition is common but is temporary. c. Use lozenges and hard candies to prevent dry mouth. d. This indicates a complication of therapy.

a. Use saliva substitutes, especially when eating dry foods. Xerostomia is a common effect of oral irradiation and may be permanent. Clients should be advised to use saliva substitutes. The condition is common, but often permanent. Lozenges and hard candies are not as effective as saliva substitutes. Dry mouth is a side effect of therapy, not a symptom of complications.

A nurse is preparing a health teaching session about early detection of colorectal cancer. Which test should the nurse include? Select all that apply? a. colonoscopy every 10 years b. Single sample fecal immunochemical test (FIT) c. flexible sigmoidoscopy every 5 years d. stool DNA test (sDNA) every 3 years e. double contrast-Barium enema every 5 years f. take home yearly guaiac fecal occult blood test (gFOBT)

a. colonoscopy every 10 years c. flexible sigmoidoscopy every 5 years d. stool DNA test (sDNA) every 3 years e. double contrast-Barium enema every 5 years f. take home yearly guaiac fecal occult blood test (gFOBT)

A patient with gastroesophageal reflux disease has undergone a laparoscopic Nissen fundoplication (LNF). What will the nurse include in postoperative home care instructions? a. "Consume carbonated beverages if you experience stomach upset." b. "Remain on a soft diet for about a week and avoid raw vegetables that are difficult to swallow." c. "You may resume running and weight lifting if you wish." d. "You may stop taking your antireflux medications after 1 week."

b. "Remain on a soft diet for about a week and avoid raw vegetables that are difficult to swallow." After LNF, patients need to be taught to remain on a soft diet for 1 week and to avoid raw vegetables that are difficult to swallow.Carbonated beverages should be avoided. Patients may walk but need to avoid heavy lifting. Antireflux medications need to be taken for 1 month after the procedure.

A patient who has been diagnosed recently with esophageal cancer states, "I'm not comfortable going to my father's birthday lunch at our family-owned restaurant because I'm afraid I'll choke in public." What is the nurse's best response? a. "I understand your concerns, but you can't give up your normal activities. You should go anyway and try not to worry about it." b. "Tell me more about the lunch, what will be served and who is going with you." c. "Why not take one of your antianxiety pills before going? That will keep you from worrying about everything so much." d. "You need to talk to your doctor about your concerns. The doctor may recommend that you join a support group for cancer survivors."

b. "Tell me more about the lunch, what will be served and who is going with you." The nurse's best response is to ask the patient for more information to help determine the specific fear and discuss possible alternatives so choking and/or fear of choking can be minimized or avoided in public.Telling the patient not to worry about it or to call the provider is evasive and unhelpful; it is used to placate the patient and does not address the patient's concerns. The patient should use problem-solving and coping skills before resorting to the use of medication.

A patient has been diagnosed with terminal esophageal cancer. The patient is interested in obtaining support from hospice, but expresses concern that pain management will not be adequate. What is the nurse's best response? a. "Haven't you received adequate pain management in the hospital?" b. "Would you like me to get a nurse from hospice to come talk with you?" c. "Do you want me to call the hospital chaplain to explain hospice to you?" d. "Talk to your primary health care provider about hospice services."

b. "Would you like me to get a nurse from hospice to come talk with you?" The best way to alleviate the patient's concerns would be to have a hospice nurse talk with the patient and answer any questions.Suggesting that the patient has had adequate pain management sounds defensive. Referring the patient to the chaplain or the primary health care provider is evasive and attempts to shift responsibility away from the nurse.

A client has undergone a partial glossectomy for cancer. What community resource does the nurse refer the client to when dressing supplies will be needed at home? a. Oral Cancer Foundation b. American Cancer Society (ACS) c. Client Advocate Foundation d. American Medical Supply Foundation

b. American Cancer Society (ACS) The ACS supplies dressings and transportation to and from follow-up visits or medical treatments for clients with cancer. The Oral Cancer Foundation is an organization for local support groups and resources. The Client Advocate Foundation provides education, legal counseling, and referrals to clients with cancer and survivors concerning managed care, insurance, financial issues, job discrimination, and debt crisis matters. The American Medical Supply Foundation does not exist.

A patient in the outpatient clinic tells the nurse about experiencing heartburn and nighttime coughing episodes. Which action does the nurse take first? a. Teach the patient about antacid effects and side effects. b. Ask the patient about oral intake, current medications and description of episodes. c. Suggest that the patient sleep with the head elevated 6 inches (15 cm). d. Tell the patient to avoid drinking alcohol late in the evening.

b. Ask the patient about oral intake, current medications and description of episodes. The nurse's first action would be further assessment of the patient's risk factors for gastroesophageal reflux disease (GERD). Before suggesting interventions or beginning patient teaching, the nurse must elicit more information about the patient's symptoms.The nurse needs additional data before telling the patient about antacid effects, sleeping with the head elevated, or not drinking alcohol late in the evening.

The nurse is caring for a patient with esophageal cancer who has received photodynamic therapy using porfimer sodium (Photofrin). What instructions does the nurse include in teaching the patient about porfimer sodium? (Select All That Apply) a. Avoid sunlight for 2 weeks. b. Cover or shield all exposed body areas from sunlight. c. Follow a clear liquid diet for 3 to 5 days after the procedure. d. Monitor for hypertension. e. Tissue particles may be found in the sputum.

b. Cover or shield all exposed body areas from sunlight. c. Follow a clear liquid diet for 3 to 5 days after the procedure. e. Tissue particles may be found in the sputum. The nurse teaches the patient that porfimer sodium causes photosensitivity, and sunglasses and protective clothing covering all exposed body areas are essential. Also, a clear liquid diet would be followed for 3 to 5 days after the procedure and then advanced to full liquids as tolerated. In addition, the patient would be warned that tissue particles may be released from the tumor site and may be present in the sputum.Sunlight needs to be avoided for 1 to 3 months, and not for 2 weeks. Side effects are rare and may include nausea, fever, and constipation. Hypertension is not a side effect of porfimer sodium.

The nurse is caring for a client who has been diagnosed with his esophageal cancer. The client appears anxious and ask the nurse, "does this mean I'm going to die?" which nursing responses are appropriate? Select all that apply. a. no surgery can cure you b. It sounds like death frightens you c. Let me call the hospital chaplain to talk with you d. You can beat this disease if you just put your mind to it e. Let me sit with you for a while and we can discuss how you're feeling about this

b. It sounds like death frightens you e. Let me sit with you for a while and we can discuss how you're feeling about this

When taking a history for a patient with G.I. problems, which daily behavior requires further nursing assessment? Select all that apply a. It's multiple servings of vegetables b. Takes 800 mg of ibuprofen for arthritic pain c. Walks 30 minutes d. Choose tobacco e. Takes senna to assist with bowel movements f. Listens to music to promote relaxation

b. Takes 800 mg of ibuprofen for arthritic pain d. Choose tobacco e. Takes senna to assist with bowel movements

A client had an open partial colectomy and ascending colostomy three days ago. Which assessment finding does the nurse expect? Select all that apply. a. Black, moist stoma b. gas inside the pouch c. pain controlled with analgesics d. small amount of form stool from the colostomy e. serosanguineous fluid draining from to Jackson Pratt drains

b. gas inside the pouch c. pain controlled with analgesics e. serosanguineous fluid draining from to Jackson Pratt drains

The nurse is performing an abdominal assessment on a patient. For which finding does the nurse alert the health care provider immediately?

bulging, pulsating mass

The nurse is reviewing the medication history for a patient diagnosed with gastroesophageal reflux disease (GERD) who has been prescribed esomeprazole (Nexium) once daily. The patient reports that this proton pump inhibitor medication doesn't completely control the symptoms. The nurse contacts the primary health care provider to discuss which intervention? a. Adding a second proton pump inhibitor medication b. Increasing the dose of esomeprazole c. Changing to a twice-daily dosing regimen d. Switching to omeprazole (Prilosec)

c. Changing to a twice-daily dosing regimen The nurse contacts the primary health care provider about changing the Proton pump inhibitor to twice daily. These medications are usually effective when given once daily but can be given twice daily if symptoms are not well controlled.Adding a second medication, increasing the dose, or switching to another proton pump inhibitor is not recommended.

The nurse is caring for a client diagnosed with aphthous ulcers. The nurse instructs the client to avoid which foods? (Select All That Apply) a. Apples b. Bananas c. Cheese d. Nuts e. Potatoes

c. Cheese d. Nuts e. Potatoes Certain foods such as cheese, nuts, and potatoes may trigger allergic responses that cause aphthous ulcers. Apples and bananas are not acidic and do not trigger allergic responses that cause aphthous ulcers.

client has recently developed acute sialadenitis. Which intervention does the nurse include in this client's care? a. Applying cold compresses b. Avoiding the use of fruit or citrus-flavored candy c. Massaging the salivary gland d. Restrict fluids

c. Massaging the salivary gland The salivary gland is massaged to stimulate the flow of saliva. This is done by milking the edematous gland with the fingertips toward the ductal opening. To promote the flow of saliva, warm compresses are applied to the affected salivary gland. Sialagogues such as lemon slices and fruit- or citrus-flavored candy are used to stimulate the flow of saliva. Elevation of the head of the bed promotes gravity drainage of the edematous gland.

Which of these assigned patients does the nurse assess first after receiving the change-of-shift report? a. Young adult admitted the previous day with abdominal pain who is scheduled for a computed tomography (CT) scan in 30 minutes b. Adult with gastroesophageal reflux disease (GERD) who is describing epigastric pain at a level of 6 (0-to-10 pain scale) c. Middle-aged adult with an esophagectomy done 2 days earlier who has bright-red drainage from the nasogastric (NG) tube d. Older adult admitted with an ileus who has absent bowel sounds and a prescription for metoclopramide (Reglan) on an as-needed (PRN) basis

c. Middle-aged adult with an esophagectomy done 2 days earlier who has bright-red drainage from the nasogastric (NG) tube The nurse must first assess the postoperative esophagectomy patient with bright red NG tube drainage. The presence of blood in NG drainage is an unexpected finding 2 days after esophagectomy and requires immediate investigation.The young adult scheduled for a CT scan, the adult with GERD, and the older adult with an ileus are all stable and do not require the nurse's immediate attention.

The nurse is caring for a postoperative client who had an extensive oral and neck surgery. The client is now describing throbbing pain in the head. The nurse anticipates that the health care provider will request which medication for this client? a. Diphenhydramine (Benadryl) b. Midazolam (Versed) intravenously c. Morphine sulfate intravenously d. Oxycodone plus acetaminophen (Percocet, Tylox)

c. Morphine sulfate intravenously Clients undergoing surgery for oral cancer describe their pain as throbbing or pounding. Intravenous morphine sulfate is indicated for severe pain and is given initially. Diphenhydramine is an anti-inflammatory agent and is not indicated for treatment of pain. Midazolam is used for conscious sedation and is not indicated for pain. Oxycodone/acetaminophen is given for systematic relief of moderate pain.

A patient with an inoperable esophageal tumor is receiving swallowing therapy. Which task does the home health nurse delegate to an experienced home health aide? a. Teaching family members how to determine whether the patient is obtaining adequate nutrition b. Assessing lung sounds for possible aspiration when the patient is swallowing clear liquids c. Reminding the patient to use the chin-tuck technique each time the patient attempts to swallow d. Instructing family members about symptoms that may indicate

c. Reminding the patient to use the chin-tuck technique each time the patient attempts to swallow The role of a home health aide when caring for a patient with swallowing difficulty includes reinforcement of previously taught swallowing techniques.Teaching and providing instructions to family members are not within the scope of practice of a home health aide and would be done by the home health nurse. Likewise, assessing lung sounds is part of the nursing process and would be done by the nurse.

The nurse is providing instructions to a client who has a history of stomatitis. Which instructions does the nurse include in the client's teaching plan? a. Encourage the client to eat acidic foods to decrease bacteria. b. Mouth care should be performed twice daily. c. Rinse the mouth with warm saline or sodium bicarbonate. d. Use a medium-bristled toothbrush for oral care.

c. Rinse the mouth with warm saline or sodium bicarbonate Rinsing the mouth with warm saline or sodium bicarbonate or a combination of the two decreases inflammation and pain. Acidic foods increase inflammation and should be avoided. Mouth care should be done after each meal and as often as needed. If stomatitis is not controlled, mouth care may have to be done every 2 hours or more frequently. A soft toothbrush should be used for oral care.

Which food does the nurse instruct a client undergoing chemotherapy for oral cancer with secondary stomatitis to avoid? a. Broiled fish b. Ice cream c. Salted pretzels d. Scrambled eggs

c. Salted pretzels Salty foods like pretzels can further irritate ulcers in the client's mouth, causing pain. Foods high in protein, such as fish, eggs, and ice cream, may be included in the diet of the client with stomatitis.

A client with oral carcinoma has a priority problem of risk for airway blockage related to obstruction by the tumor. At the beginning of the shift, which action will the nurse take first? a. Suction the client's oral secretions to clear the airway. b. Place the client on humidified oxygen per nasal cannula. c. Assist the client to an upright position to facilitate breathing. d. Assess the respiratory effort and quantities and types of oral secretions.

d. Assess the respiratory effort and quantities and types of oral secretions. Assessment is the first step of the nursing process; the nurse should assess the client's respiratory effort and quantities and types of oral secretions first. Suctioning the client, placing the client on humidified oxygen, and assisting the client to an upright position are not the first steps in the nursing process. These interventions may or may not be necessary if the nurse follows the nursing process.

The nurse prepares a teaching session regarding lifestyle changes needed to decrease the discomfort associated with a patient's gastroesophageal reflux disease (GERD). Which change does the nurse recommend to this patient? a. Eat only two or three meals daily. b. Sleep flat in a left side-lying position. c. Drink tea instead of coffee. d. Avoid working while bent over the computer.

d. Avoid working while bent over the computer. The patient should avoid working while bent over because this position presses on the diaphragm, causing discomfort.The patient with GERD needs to eat four to six meals a day. The head of the patient's bed would be elevated approximately 6 inches (15 cm). Both tea and coffee need to be eliminated from this patient's diet because of the caffeine content.

The nurse is working with the dietitian to plan a menu for a patient who has persistent difficulty swallowing. What is a suitable breakfast selection for this patient? a. Scrambled eggs and toast b. Oatmeal and orange juice c. Puréed fruit and English muffin d. Cream of wheat and applesauce

d. Cream of wheat and applesauce A breakfast selection of both cream of wheat and applesauce are foods of semisolid consistency and are appropriate for this patient. The patient who is having difficulty swallowing would be given semisolid foods and thickened liquids.Toast would not be appropriate, and orange juice would have to be thickened before it is given to this patient. An English muffin would be inappropriate for this patient because it is not a semisolid food.

The nurse is reviewing orders for a patient with possible esophageal trauma after a car crash. Which request does the nurse implement first? a. Give total parenteral nutrition (TPN) through a central venous catheter. b. Administer cefazolin (Kefzol) 1 g intravenously. c. Obtain a computed tomography (CT) scan of the chest and abdomen. d. Keep the patient nothing by mouth (NPO) to prevent further leakage of esophageal contents.

d. Keep the patient nothing by mouth (NPO) to prevent further leakage of esophageal contents. The nurse first implements the request to keep the patient NPO, because patients with possible esophageal tears need to be NPO until diagnostic testing is completed. Leakage of anything taken orally into the sterile mediastinum could occur. In addition, esophageal rest is maintained for about 10 days after esophageal trauma to allow time for mucosal healing.TPN is prescribed to provide calories and protein for wound healing. Although TPN is important, it is not a priority for the nurse to implement first. Antibiotics may be requested to prevent possible infection, but this is not the priority. A CT of the chest and abdomen will be needed but is not the nurse's initial action.

A client with oral cancer is depressed over the diagnosis and tells the nurse of plans to have a radical neck dissection. What is the nurse's best reaction? a. Listen to the client and then explain that it is normal to feel depressed about the diagnosis. b. Explain the grieving process and listen to what the client has to say. c. Suggest that the client talk with friends and family and seek their support. d. Listen to the client's concerns and feelings and then suggest that the client join a community group of cancer survivors.

d. Listen to the client's concerns and feelings and then suggest that the client join a community group of cancer survivors. The nurse should listen to the client and suggest a community support group of those with similar diagnoses who can offer support to the client. Telling the client that his or her feelings are normal or explaining the grieving process to the client are not helpful or therapeutic; the client needs more guidance. The nurse should not assume that the client's family and friends are an appropriate support group, because this may not be the case.

"A patient is being discharged, 8 days postoperatively following a total esophagectomy." Which teaching point does the nurse consider to be of the highest priority during the transition to home? a. Instruct the patient to eat three meals daily. b. Emphasize the importance of lying down after meals. c. Encourage the patient to ask his or her health care provider for antidepressant medication. d. Stress the importance of notifying the primary health care provider if leaking is noted at the incision site.

d. Stress the importance of notifying the primary health care provider if leaking is noted at the incision site. The teaching point with the highest priority is to notify the primary health care provider (PHCP) immediately if leaking is noted at the incision site. Leakage from the site of anastomosis is a dreaded complication that can appear 2 to 10 days after surgery. Wound management and prevention of infection are major concerns because the patient who has had an esophagectomy typically has multiple drains and incisions.The patient should eat six to eight small meals daily, and should sit up after meals to encourage satisfactory swallowing. The patient's coping skills should be assessed, as well as his or her level of anxiety and/or depression, before antidepressant medication is prescribed.

Which structure is involved in a protective function of the liver?

kupffer cells