Gastro
A nurse is admitting a client who has cirrhosis. Which of the following prescriptions should the nurse anticipate? (Select all that apply.) • A. Obtain the client's PT and INR measurements • B. Administer lactulose 30 mL PO 4 times daily • C. Obtain daily weight and abdominal girth measurements • D.Administer a daily multivitamin • E. Place the client on a low-protein diet
A. B. C. D.
A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following laboratory findings should the nurse monitor prior to the procedure? • A. Prothrombin time • B. Serum lipase C. Bilirubin D. Calcium
A. CORRECT: A major complication following a liver biopsy is hemorrhage. Many clients who have liver disease have clotting defects and are at risk for bleeding. Along with the prothrombin time (PT), the activated partial thromboplastin time (aPTT) and the platelet count should be monitored. Liver dysfunction causes the production of blood clotting factors to be reduced, which leads to an increased incidence of bruising nosebleeds, bleeding from wounds, and gastrointestinal bleeding. This is due to a deficient absorption of vitamin K from the gastrointestinal tract caused by the inability of liver cells to use vitamin K to make prothrombin.
A nurse in a provider's office is assessing a client who has GERD. The nurse should expect the client to report which of the following manifestations? (Select all that apply.) A. Regurgitation B. Nausea C. Belching D. Heartburn E. Weight loss
A. Regurgitation B. Nausea C. Belching D. Heartburn
A nurse is planning an in-service training session regarding nutrition. Which of the following minerals should the nurse identify as involved in oxygen transportation? • A. Zinc B. Iron • C. Phosphorus • D. Magnesium
Answer: B. Iron Iron transports oxygen by means of hemoglobin and myoglobin. It is also a component of enzyme systems
A nurse is demonstrating colostomy care to a client who has a new colostomy. Which of the following actions should the nurse teach the client to perform? (Select all that apply.) • A. Use antimicrobial ointment on the peristomal skin B. Empty the bag when it is one-third to one-half full C. Cut the skin barrier opening a little larger than the ostomy D. Wash the peristomal skin with mild soap and water • E. Apply the skin barrier while the skin is slightly moist
B, C, D
A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect? A. Jaundice • B. Anorexia • c. Dark urine • D. Pale feces
B. Anorexia
A nurse is teaching a client who has diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include? (Select all that apply.) • A. Bradycardia B. Diaphoresis C. Deep, rapid respirations • D. Palpitations E. Shakiness
B. Diaphoresis D. Palpitations E. Shakiness---Diaphoresis, palpitations, and shakiness are sympathetic nervous system responses to hypoglycemia.
A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should return to the expected reference range within 72 hr of treatment beginning? • A. Aldolase • B. Lipase • C. Amylase • D. Lactic dehydrogenase
C. Amylase
A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? • A. Endoscopic sclerotherapy • B. Liver lobectomy • C. Liver transplant • D. Transjugular intrahepatic portal-systemic shunt placement
C. Liver transplant
A nurse is performing discharge teaching about ostomy care while at home for a client who has a newly placed ileostomy. Which of the following instructions should the nurse include in the teaching? •A. "Empty your ostomy pouch when it becomes half full." B. "Place an aspirin in the ostomy pouch to eliminate odor." c. "Change the ostomy appliance every week." • D. "Cleanse the site around the stoma with hydrogen peroxide and water."
Correct Answer: A. "Empty your ostomy pouch when it becomes half full." The nurse should instruct the client to empty the ostomy pouch when it is one-third to one-half full. This prevents the ostomy from becoming too full of stool and gas and exploding.
A nurse is assisting a provider with performing a paracentesis on a client. Which of the following actions should the nurse take? •A. Ask the client to empty his bladder before the procedure • B. Place the client leaning forward over the bedside table for the procedure • C. Inform the client he will be sedated during the procedure • D. Instruct the client to fast for 6 hr prior to the procedure
Correct Answer: A. Ask the client to empty his bladder before the procedure The nurse should ask the client to empty his bladder before the procedure to prevent injury to the bladder.
A nurse is developing a plan of care for a client who has gastroesophageal reflux disease (GERD). The nurse should plan to monitor the client for which of the following complications? A. Aspiration B. Infection C. Anemia D. Weight loss
Correct Answer: A. Aspiration Aspiration is a common complication of GERD, which results when the esophageal sphincter malfunctions and allows gastric acid and undigested food to back up into the esophagus. This places the client at risk of aspiration. GERD causes effortless, uncontrolled regurgitation whether the client is in an upright position or reclining. The most common results of regurgitation are heartburn and indigestion; however, aspiration is also possible. Therefore, the nurse should monitor the client for crackles in the lung fields, which are an indication of aspiration.
A nurse is assessing a client who has cholecystitis. Which of the following findings should the nurse expect? • A. Blumberg's sign • B. Ascites •C. Gastrointestinal bleeding • D. Kehr's sign
Correct Answer: A. Blumberg's sign The nurse should expect to find rebound tenderness (Blumberg's sign) in a client who has cholecystitis. This response can be an indication of peritoneal inflammation.
A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? • A. Children • B. Older adults • c. Women who are pregnant • D. Middle-aged men
Correct Answer: A. Children The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The hepatitis A virus can be contracted from the feces, bile, and blood of infected clients. The usual mode of transmission is the fecal-oral route. Children and young adults are most often affected by the hepatitis A virus. Typically, a child or young adult acquires the infection at school, through poor hygiene, through hand-to-mouth contact, or via another form of close contact.
A nurse is caring for a client who is 3 days postoperative following abdominal surgery. The client states, "Something just popped when I coughed." Which of the following actions should the nurse take first? • A. Cover the client's wound with a sterile, moist dressing • B. Flex the client's knees • C. Reassure the client • D. Instruct the client to avoid coughing
Correct Answer: A. Cover the client's wound with a sterile, moist dressing The greatest risk to this client is an injury from infection due to wound exposure. Therefore, the first action the nurse should take is to cover the wound with a sterile, moist dressing.
A nurse is teaching a group of clients about the functions of the liver and gallbladder. Which of the following should the nurse include in the teaching as the purpose of bile? A. Digesting fats B. Producing chyme C. Stimulating gastric acid secretion D. Providing energy
Correct Answer: A. Digesting fats Bile is a product of the liver and aids in the digestion of fats.
A nurse is teaching a client who has a colostomy about ways to reduce flatus and odor. Which of the following strategies should the nurse include? • A. Eat crackers and yogurt regularly •B. Chew minty gum throughout the day • c. Drink orange juice every day • D. Put an aspirin in the pouch
Correct Answer: A. Eat crackers and yogurt regularly Crackers, toast, and yogurt can help reduce flatus, which contributes to odor.
A nurse is assessing a client who has a bleeding duodenal ulcer. Which of the following findings should the nurse expect? • A. Emesis with a coffee-ground appearance •B. Increased blood pressure • C. Decreased heart rate • D. Bright green stools
Correct Answer: A. Emesis with a coffee-ground appearance The nurse should expect a client who has a bleeding duodenal ulcer to have emesis that resembles coffee-grounds or is bright red in color. Hematemesis indicates upper gastrointestinal bleeding, occurring at or above the duodenojejunal junction.
A nurse is caring for a client who has an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take? • A. Ensure bowel rest •B. Offer sparkling water frequently • C. Administer a stool softener • D. Offer plain warm tea frequently
Correct Answer: A. Ensure bowel rest Clients who have an exacerbation of Crohn's disease usually require NPO status to ensure bowel rest and promote healing and recovery.
A nurse is caring for a client with a history of cirrhosis who has been admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? • A. Gamma-glutamyl transferase (GGT) • B. Alkaline phosphatase (ALP) • C. Serum bilirubin • D. Alanine aminotransferase (ALT)
Correct Answer: A. Gamma-glutamyl transferase (GGT) The GGT laboratory test is specific to the hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. Therefore, it is useful for monitoring drug toxicity and excessive alcohol use.
A nurse is teaching dietary-modification strategies to a client who has been newly diagnosed with cirrhosis. Which of the following foods should the nurse recommend? • A. Grilled chicken •B. Potato soup • C. Fish sticks • D. Baked ham
Correct Answer: A. Grilled chicken The nurse should identify that a client who has cirrhosis requires protein to compensate for disease-related weight loss. Increasing protein intake from animal or plant sources will also provide the client with more energy.
A nurse is caring for a client who is NPO and has an NG tube to suction. When the client reports nausea, which of the following actions should the nurse take? A. Irrigate the tube with normal saline solution • B. Provide oral hygiene • C. Clamp the tube for 30 min • D. Increase the amount of suction
Correct Answer: A. Irrigate the tube with normal saline solution When a client with an NG tube develops nausea, the nurse should first attempt to irrigate the tube to determine patency. If the tube is not patent, gastric pressure cannot decrease, and the steady or increasing pressure can cause nausea.
A nurse is recommending dietary modifications for a client who has GERD. The nurse should suggest eliminating which of the following foods from the client's diet? • A. Oranges and tomatoes • B. Carrots and bananas C. Potatoes and squash • D. Whole wheat and beans
Correct Answer: A. Oranges and tomatoes Symptoms of GERD worsen following the oral intake of substances that decrease lower esophageal stricture (LES) pressure. These include alcohol, caffeine, nicotine, chocolate, fatty foods, citrus fruits, tomatoes, and peppermint.
A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube serves which of the following purposes? • A. Prevents excessive pressure on suture lines • B. Allows gastric lavage after surgery • C. Allows early postoperative feeding • D. Facilitates obtaining gastric specimens for testing
Correct Answer: A. Prevents excessive pressure on suture lines The NG tube remains in place after surgery to prevent excessive pressure on suture lines postoperatively. It drains the air and fluid that can cause pressure from inside the gastrointestinal (GI) tract. In doing so, it also prevents vomiting and GI distention.
A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? • A. Right shoulder pain • B. Urine output 20 mL/hr • C. Temperature 38.4°C (101.1°F) • D. Oxygen saturation 92%
Correct Answer: A. Right shoulder pain The client can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1 to 2 days. Mild analgesics and a recumbent position can promote client comfort.
A nurse is teaching a newly licensed nurse about caring for a client who is scheduled for an esophagogastric balloon tamponade tube to treat bleeding esophageal varices. Which of the following pieces of information should the nurse include in the teaching? • A. The client will be placed on mechanical ventilation prior to this procedure. • B. The tube will be inserted into the client's trachea. • C. The client will receive a bowel preparation with cathartics prior to this procedure. • D. The tube allows the application of a ligation band to the bleeding varices.
Correct Answer: A. The client will be placed on mechanical ventilation prior to this procedure. The client will require intubation and mechanical ventilation prior to this procedure to protect the airway.
A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove from the client's meal tray? • A. Wheat toast B. Tapioca pudding C. Hard-boiled egg • D. Mashed potatoes
Correct Answer: A. Wheat toast Celiac disease is an autoimmune disorder characterized by a permanent intolerance to wheat, barley, and rye. Wheat toast contains gluten and should be removed from the client's tray.
A nurse is caring for a client who has acute diverticulitis. While the client has active inflammation, the nurse should instruct the client to include which of the following foods in her diet? •A. White bread and plain yogurt • B. Shredded wheat cereal and blueberries • C. Broccoli and kidney beans • D. Oatmeal and fresh pears
Correct Answer: A. White bread and plain yogurt Because of the acute inflammation of diverticulitis, the client should maintain a diet very low in fiber. The client can consume low-fiber foods like white bread, low-fat milk, yogurt with active cultures, poached eggs, and canned soft fruit.
A nurse is preparing a community education program about hepatitis B. Which of the following statements should the nurse include in the teaching? A. "A hepatitis B immunization is recommended for those who travel, especially military personnel." B. "A hepatitis B immunization is given to infants and children." c. "Hepatitis B is acquired by eating foods that are contaminated during handling." D. "Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation."
Correct Answer: B. "A hepatitis B immunization is given to infants and children." Hepatitis B immune globulin is given as part of the standard childhood immunizations. It can be administered as early as birth, especially in infants born to mothers that are negative for hepatitis B surface antigen (HBsAg). These infants should receive the second dose between 1 and 4 months of age.
A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is for which of the following reasons? •A. To visualize polyps in the colon •B. To detect an ulceration in the stomach •c. To identify an obstruction in the biliary tract • D. To determine the presence of free air in the abdomen
Correct Answer: B. To detect an ulceration in the stomach An EGD is used to visualize the esophagus, stomach, and duodenum with a lighted tube to detect a tumor, ulceration, or obstruction.
A nurse is providing discharge teaching to the partner of a client who has a new diagnosis of hepatitis A. Which of the following instructions should the nurse include in the teaching? •A. "During this illness, she may take acetaminophen for fevers or discomfort." •B. "Encourage her to eat foods that are high in carbohydrates." •c. "The provider will prescribe a medication to help her liver heal faster." D. "Have her perform moderate exercise to restore her strength more quickly."
Correct Answer: B. "Encourage her to eat foods that are high in carbohydrates." The client's diet should be high in carbohydrates and calories with only moderate amounts of protein and fat, especially if nausea is present.
A nurse is caring for a client who has ulcerative colitis. The provider prescribes bed rest with bathroom privileges. When the client asks the nurse why he has to stay in bed, which of the following responses should the nurse provide? A. "You need to conserve energy at this time." B. "Lying quietly in bed helps slow down the activity in your intestines." C. "Staying in bed promotes the rest and comfort you need." D. "Staying in bed will help prevent injury and minimize your fall risk."
Correct Answer: B. "Lying quietly in bed helps slow down the activity in your intestines." The greatest risk to the client is complications from severe diarrhea such as dehydration, electrolyte imbalances, and gastrointestinal bleeding and trauma. Activity restriction can help reduce intestinal peristalsis and diarrhea.
A nurse is teaching a client with Barrett's esophagus who is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? •A. "This procedure is performed to measure the presence of acid in your esophagus." •B. "This procedure can determine how well the lower part of your esophagus works." C. "This procedure is performed while you are under general anesthesia." • D. "This procedure can determine if you have colon cancer."
Correct Answer: B. "This procedure can determine how well the lower part of your esophagus works." An EGD is useful in determining the function of the esophageal lining and the extent of inflammation, potential scarring, and strictures.
A nurse is presenting an in-service training session about nutrition. How many of the amino acids must be obtained from dietary intake? A. 6 B. 9 C. 11 D. 15
Correct Answer: B. 9 Proteins are made up of chains of amino acids, which are composed of carbon, hydrogen, oxygen, and nitrogen. Nine amino acids are considered essential for the human body and must be obtained from diet. These include histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine.
A nurse in a provider's office is assessing a client who has GERD. When documenting the client's history, the nurse should expect the client to report that symptoms worsen with which of the following actions? A. Stair-climbing • B. Bending over • C. Sitting • D. Walking
Correct Answer: B. Bending over Gastroesophageal reflux symptoms are most evident with activities that increase intraabdominal pressure (e.g. bending over, straining, lifting, and lying down).
A nurse is obtaining a guaiac test from a client. This test is performed to detect which of the following? • A. Fecal material in vomit • B. Blood in stool • C. Infestation of parasites • D. Microorganisms in urine
Correct Answer: B. Blood in stool A guaiac test detects the presence of blood in the stool. It is a commonly used point-of-care test for fecal occult blood.
A nurse is caring for a client who has recovered from acute diverticulitis. The nurse should instruct the client to increase his intake of which of the following foods when the inflammation subsides? A. Cucumbers and tomatoes B. Cabbage and peaches C. Strawberries and corn D. Figs and nuts
Correct Answer: B. Cabbage and peaches When the acute inflammation has subsided, the client should increase his intake of foods that are high in fiber, such as wheat bran, whole-grain bread, and fresh fruits and vegetables that do not contain seeds.
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? •A. Place the drainage bag on the client's abdomen when transferring from a bed to cart • B. Empty the drainage bag when half-full of urine • C. Rest the drainage bag on the floor when closing the drainage spigot during emptying • D. Disconnect the drainage bag when obtaining a urine specimen
Correct Answer: B. Empty the drainage bag when half-full of urine The nurse should empty the drainage bag when half-full of urine. A drainage bag that is too full can place tension on the catheter tubing, resulting in trauma to the urethra and urinary meatus.
A nurse is assessing a client who is 12 hr postoperative following an open cholecystectomy. Which of the following findings should the nurse report to the provider? • A. Hypoactive bowel sounds •B. Indwelling urinary catheter output of 25 mL/hr C. Heart rate of 96/min D. Serous drainage at the surgical incision site
Correct Answer: B. Indwelling urinary catheter output of 25 mL/hr The nurse should report a urinary output of <30 mL/hr to the provider, as this can indicate hypovolemia or renal complication.
A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? • A. Flush the tube with water •B. Place the client in the semi-Fowler's position • C. Cleanse the skin around the tube site D. Aspirate the tube for residual contents
Correct Answer: B. Place the client in the semi-Fowler's position A client who is receiving PEG tube feedings should be positioned with the head of the bed elevated at least 30° during and after feedings to decrease the risk of aspiration. Therefore, this is the priority action by the nurse.
A nurse is providing dietary teaching to a client who has ulcerative colitis. Which of the following food selections by the client indicates an understanding of the teaching? A. Raw vegetable salad with low-fat dressing B. Roast chicken and white rice C. Fresh fruit salad and milk D. Peanut butter on whole wheat bread
Correct Answer: B. Roast chicken and white rice Clients who have ulcerative colitis are restricted to a low-fiber diet, which omits whole grains and raw fruits and vegetables. Roast chicken with white rice is the best choice.
A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? • A. Vanilla pudding • B. Apple juice • C. Diet ginger ale • D. Clear liquids
D. Clear liquids
A nurse is providing preoperative teaching to a client who will undergo surgery to create a temporary colostomy. The client asks the nurse about the difference between colostomies and ileostomies. Which of the following responses should the nurse make? •A. "A colostomy drains stool, and an ileostomy drains urine." •B. "A colostomy is temporary, and an ileostomy is permanent." •c. "A colostomy is from the large intestine, and an ileostomy is from the small intestine." • D. "An ileostomy requires dietary restrictions, while a colostomy does not."
Correct Answer: C. "A colostomy is from the large intestine, and an ileostomy is from the small intestine." The name of the ostomy reflects the region the surgeon brings to the surface of the abdominal wall. Therefore, when the colon is the site of surgical intervention, the site is a colostomy (colon + ostomy). When the ileum is the site of surgical intervention, the abdominal stoma is an ileostomy (ileum + ostomy).
A nurse is providing teaching about nutrients to a client. Which of the following statements should the nurse include? •A. "Carbohydrates transport nutrients throughout the body." • B. "Fats prevent ketosis." • c. "Protein builds and repairs body tissue." • D. "Carbohydrates help regulate body temperature."
Correct Answer: C. "Protein builds and repairs body tissue." The primary function of protein involves building and repairing body tissues (e.g. muscles, tendons, and collagen). The skin, hair, and nails are also made of protein structures. A diet that is low in protein can impair wound healing.
A nurse is caring for a client who is 2 days postoperative following gastric surgery and has an NG tube inserted. Which of the following findings should the nurse report to the provider? • A. Dryness of the mucous membranes • B. Hypoactive bowel sounds in all quadrants • c. 200 mL of bright red drainage from the NG tube • D. Suction set at continuous low suction
Correct Answer: C. 200 mL of bright red drainage from the NG tube The nurse should notify the provider immediately if 200 mL of bright red drainage comes from the NG tube 2 days following gastric surgery. Drainage should be either a yellow-green color or clear. Bright red drainage indicates blood loss and can be the result of a disrupted suture line or other internal bleeding. Volume loss from blood is a medical emergency, and the provider should be immediately notified.
A nurse is planning discharge teaching for a client who is postoperative following a traditional open cholecystectomy. Which of the following learning needs of the client is the nurse's priority? • A. Dietary recommendations • B. Incision care • c. Coughing and deep-breathing exercises D. Pain management
Correct Answer: C. Coughing and deep-breathing exercises The greatest risk to the client is respiratory compromise. Therefore, learning how to perform coughing and deep-breathing exercises to promote lung expansion and secretion removal is the priority.
A nurse is planning care for a client who has cholelithiasis. Which of the following interventions should the nurse include in the plan? • A. Restrict the client's fluid intake • B. Restrict the client's calcium intake •C. Decrease the client's fat intake • D. Decrease the client's potassium intake
Correct Answer: C. Decrease the client's fat intake The nurse should decrease the client's fat intake to reduce the occurrence of biliary colic.
A nurse is caring for a child who had her spleen removed following a bicycle accident. The child's parent asks the nurse about the role of the spleen in the body. The nurse should explain that the spleen performs which of the following functions? • A. Maintains fluid balance • B. Regulates calcium in the blood • C. Destroys old blood cells • D. Produces prothrombin
Correct Answer: C. Destroys old blood cells The nurse should tell the parent that the spleen destroys old blood cells, filters antigens, and stores platelets. A client without a spleen has an increased risk of infection and sepsis due to a reduced immune function.
A nurse is caring for a client from the Middle East who has celiac disease. Which of the following actions should the nurse perform regarding the client's diet? • A. Provide foods prepared according to kosher dietary law • B. Ask the kitchen to prepare grits to meet the client's dietary need for grains • C. Determine the client's dietary preferences • D. Prepare a diet tray that includes vegetable and barley soup
Correct Answer: C. Determine the client's dietary preferences While generalizations are often made regarding the traditional eating practices of clients based on their cultural backgrounds, individual food choices can deviate from these generalizations. The nurse should assess the client's dietary habits before planning to meet dietary needs.
A nurse is providing teaching to a client who has constipation. Which of the following instructions should the nurse include? • A. Use bismuth subsalicylate regularly • B. Consume a low-fiber diet • C. Eat yogurt with live cultures • D. Use bisacodyl suppositories regularly
Correct Answer: C. Eat yogurt with live cultures Yogurt with live bacterial cultures provides dietary probiotics that help maintain and promote bowel function..
A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend? • A. Foods high in vitamin C • B. Foods low in fat • C. Foods high in fiber • D. Foods low in calories
Correct Answer: C. Foods high in fiber Long-term low-fiber eating habits and increased intracolonic pressure lead to straining during bowel movements, causing the development of diverticula. High-fiber foods help strengthen and maintain the active motility of the gastrointestinal tract.
A nurse is caring for a client who has abdominal pain and possible pancreatitis. Which of the following laboratory results should the nurse identify as an indication of pancreatitis? • A. Decreased white blood cell (WBC) count • B. Increased albumin level • C. Increased serum lipase level • D. Decreased blood glucose level
Correct Answer: C. Increased serum lipase level Due to the release of lipase into the pancreas and autodigestion, pancreatitis causes an increased serum lipase level.
A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings indicates that a possible bowel perforation has occurred? • A. Elevated blood pressure • B. Bowel sounds increased in frequency and pitch • C. Rigid abdomen • D. Emesis of undigested food
Correct Answer: C. Rigid abdomen Abdominal tenderness and rigidity indicate a bowel perforation. As fluid escapes into the peritoneal cavity, a reduction in circulating blood volume occurs, lowering blood pressure.
A nurse is caring for a client who has cholelithiasis and will undergo a cholecystectomy. The client states she does not understand how she will be alright without her gallbladder. The nurse should explain to the client that which of the following is the main function of the gallbladder? A. Producing bile • B. Adding digestive enzymes to bile • C. Storing bile • D. Eliminating bile
Correct Answer: C. Storing bile The primary function of the gallbladder is to store bile. Because this organ is only for storage, the client's liver will still produce the bile needed for digestion. Small amounts of bile will continuously enter the duodenum, where it will perform various functions.
A nurse in the emergency department is caring for a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? • A. Famotidine • B. Esomeprazole • c. vasopressin • D. Omeprazole
Correct Answer: C. Vasopressin Vasopressin constricts the splanchnic bed and decreases portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varices.
A nurse is providing postoperative teaching about the management of dumping syndrome to a client who had a partial gastrectomy. Which of the following instructions should the nurse include in the teaching? • A. "Consume at least 4 oz of fluid with meals." • B. "Take a short walk after each meal." • c. "Use honey to flavor foods such as cereal" • D. "Eat protein with each meal."
Correct Answer: D. "Eat protein with each meal." The nurse should instruct the client to eat meals that are high in protein and fat with low to moderate carbohydrate content. Protein should be included in every meal because it delays digestion, which helps reduce the manifestations of dumping syndrome.
A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching? • A. "Because most of my colon is still intact and functioning, my stool will be formed." • B. "My stoma will appear large at first, but it will shrink over the next several weeks." • c. "My colostomy will begin to function in 2 to 6 days after surgery." D. "I'll have to consume a soft diet after surgery."
Correct Answer: D. "I'll have to consume a soft diet after surgery." The nurse should identify that this statement requires further teaching. After surgery, the client quickly returns to a regular diet, and there are no food restrictions unless the client chooses to decrease the intake of foods that increase gas or odor.
A nurse is caring for a client who has colitis and reported increased exacerbations due to stress at work. Which of the following responses should the nurse make? •A. "I will contact the social worker so you can discuss career alternatives." •B. "Have you thought about discussing the possibility of a part-time assignment with your employer?" •c. "Why don't you ask your employer to relieve you of some work until you are stronger?" D. "Perhaps we should review your coping mechanisms and talk about other alternatives."
Correct Answer: D. "Perhaps we should review your coping mechanisms and talk about other alternatives." Reviewing coping mechanisms and alternative coping patterns will promote coping skills that can assist the client in reducing stress.
A nurse is completing a history and physical assessment for a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? • A. High-calorie diet • B. Prior gastrointestinal illnesses C. Tobacco use D. Alcohol use
Correct Answer: D. Alcohol use Alcohol consumption is a major cause of chronic pancreatitis in the US. Long-term alcohol use disorder produces hypersecretion of protein in pancreatic secretions, which results in protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage to these cells is more likely to occur and to be more severe in clients whose diets are poor in protein content and either very high or very low in fat.
A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect? • A. Increased blood pressure •B. Decreased heart rate • c. Yellowing of the skin • D. Boardlike abdomen
Correct Answer: D. Boardlike abdomen The nurse should expect this client who is experiencing perforation of a peptic ulcer to exhibit manifestations of a board-like abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation causes hemorrhaging.
A nurse is caring for a client who has diverticulitis and a new prescription for a low-fiber diet. Which of the following food items should the nurse remove from the client's meal tray? A. Canned fruit B. White bread C. Broiled hamburger D. Coleslaw
Correct Answer: D. Coleslaw Coleslaw contains raw cabbage, which is high in fiber. Clients who are following a low-fiber diet should avoid most raw vegetables.
A nurse is caring for a client who has gastrointestinal bleeding. The provider suspects a bleeding lesion in the colon. The initial approach to treatment likely will involve which of the following procedures? • A. Exploratory laparotomy •B. Double-contrast barium enema • C. Magnetic resonance imaging • D. Colonoscopy
Correct Answer: D. Colonoscopy A colonoscopy requires the insertion of a flexible scope into the rectum. The provider advances the scope carefully until it enters the colon. It can provide direct visualization of the inside of the colon and helps the provider identify the exact cause and location of bleeding.
A nurse is teaching a client who has cirrhosis of the liver and a history of alcohol consumption. The nurse should explain that alcohol can cause liver cirrhosis through which of the following actions? •A. Increasing the workload of the liver by releasing stored glycogen •B. Causing ulceration of liver tissue that can lead to bleeding •C. Dilating veins in the portal circulation • D. Destroying liver cells that are later replaced with scar tissue
Correct Answer: D. Destroying liver cells that are later replaced with scar tissue The development of cirrhosis in a client who consumes alcohol is related to liver inflammation and cell destruction. Over time, nonfunctional scar tissue and fibrosis replace the necrotic liver cells.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? • A. Hypertension •B. Excessive thirst C. Fever • D. Diaphoresis
Correct Answer: D. Diaphoresis The nurse should recognize that this client has the potential to develop hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger.
A nurse is updating the plan of care for a client who has dumping syndrome. Which of the following instructions should the nurse include? •A. Consume beverages with meals •B. Eat 3 large meals per day • C. Include high-fiber foods in the diet • D. Eat a source of protein with each meal
Correct Answer: D. Eat a source of protein with each meal The nurse should include in the client's plan of care the instruction to eat a source of protein with each meal because protein delays gastric emptying.
A nurse is assessing a client who has a complete intestinal obstruction. Which of the following findings should the nurse expect? • A. Absence of bowel sounds in all 4 abdominal quadrants • B. Passage of blood-tinged liquid stool •C. Presence of flatus • D. Hyperactive bowel sounds above the obstruction
Correct Answer: D. Hyperactive bowel sounds above the obstruction The nurse should expect the client to have hyperactive bowel sounds above the obstruction because the intestinal peristalsis above the obstruction attempts to push the obstruction through the intestines. With a complete intestinal obstruction, there are no bowel sounds below the obstruction.
A nurse is teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse include? • A. Smoking cessation •B. Benefits of a diet high in cruciferous vegetables • c. New types of ostomy appliances • D. Importance of colonoscopy screening starting at age 50 years old
Correct Answer: D. Importance of colonoscopy screening starting at age 50 years old Screening examinations for colorectal cancer are secondary prevention (an action that promotes early detection of disease).
A nurse is monitoring the laboratory results of a client who has end-stage liver failure. Which of the following results should the nurse expect? • A. Decreased lactate dehydrogenase • B. Increased serum albumin • c. Decreased serum ammonia • D. Increased prothrombin time
Correct Answer: D. Increased prothrombin time Clients who have end-stage liver failure have an inadequate supply of clotting factors and an increased (i.e. prolonged) prothrombin time.
A nurse is providing dietary teaching to a client who has dumping syndrome following gastric bypass surgery 4 days ago. Which of the following recommendations should the nurse include in the teaching? A. Avoid foods containing protein • B. Drink liquids during each meal C. Eat foods that contain simple sugars D. Maintain a supine position after meals
Correct Answer: D. Maintain a supine position after meals The nurse should instruct the client to lie supine after eating to help slow the rapid emptying of food into the small intestine. A client who has dumping syndrome should decrease the amount of food eaten at once, eat small meals more frequently, and eliminate fluids at mealtime. Fluid shifts occur in the upper gastrointestinal tract when food contents and simple sugars exit the stomach too rapidly, attracting fluid into the upper intestine and decreasing blood volume, which causes the client to experience nausea and vomiting, sweating, syncope, palpitations, increased heart rate, and hypotension.
A nurse is planning an in-service training session for a group of nurses regarding the role of enzymes in digestion. Which of the following enzymes plays a role in the digestion of protein? A. Amylase • B. Lipase • C. Steapsin • D. Pepsin
Correct Answer: D. Pepsin Pepsin is an enzyme secreted by the gastric mucosa that breaks down protein into polypeptides. Other enzymes such as trypsin and aminopeptidase further break down the polypeptides into amino acids, which can be used by the body.
A nurse is caring for a client who is postoperative following a laparotomy. The client has an indwelling urinary catheter and a Jackson-Pratt drain in place. Which of the following findings indicates that the client is developing a postoperative complication? • A. Pain scale score of 5 out of 10 • B. Urine output of 65 mL/hr • c. 20 mL of bright red drainage from the drain D. Pulse oximetry of 85%
Correct Answer: D. Pulse oximetry of 85% After abdominal surgery, clients should have an oxygen saturation above 93%. A client whose oxygen saturation is 85% has hypoxemia and requires immediate intervention.
A nurse is performing a gastrointestinal assessment of a client who has liver cirrhosis with abdominal distention. Which of the following actions should the nurse take to assess for changes in the client's abdominal distention? •A. Percuss the abdomen for tympanic sounds •B. Inspect the contour of the abdominal wall • C. Instruct the client to report increased abdominal discomfort • D. Take serial measurements of the abdomen with a tape measure
Correct Answer: D. Take serial measurements of the abdomen with a tape measure Measuring the abdomen is the most effective way to assess for a change in abdominal distention because it provides concrete, objective data that can be compared at various points in time to monitor changes.
A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings requires intervention? • A. A full pitcher of water is sitting on the client's bedside table within the client's reach. •B. The disposable feeding bag is from the previous day at 1000 and contains 200 mL of feeding. • C. The client is lying on the right side with a visible dependent loop in the feeding tube. • D. The head of the bed is elevated to 20°.
Correct Answer: D. The head of the bed is elevated to 20°. The head of the bed should be elevated to at least 30° (semi-Fowler's position) while the tube feeding is administered. This position uses gravity to help the feeding move through the digestive system and lessens the possibility of regurgitation.
A nurse enters a client's room and notes smoke coming from a wastebasket in the adjacent bathroom. Which of the following actions should the nurse take first? •A. Close the door to the client's room • B. Attempt to extinguish the fire •C. Activate the facility's fire alarm system • D. Transport the client to an area away from the smoke
D. Transport the client to an area away from the smoke
A nurse is providing teaching to the guardian of a child who has celiac disease. Which of the following foods should the nurse instruct the guardian to omit from the child's diet? • A. Corn tortillas • B. Reduced-fat milk • c. Canned fruits • D. Wheat bread
D. Wheat Bread
