GI Disorders

22. The client is diagnosed with Crohn's disease. Which statement by the client supports this diagnosis? 1. "My pain is on the right lower side of my abdomen." 2. "I have bright red blood in my stool all the time." 3. "I have episodes of diarrhea and constipation." 4. "My abdomen is hard and rigid, and I have a fever."

1. "My pain is on the right lower side of my abdomen." 22. 1. The terminal ileum is the most common site for Crohn's disease (previously called regional enteritis), which causes right lower quadrant pain. 2. Stools are liquid or semiformed and usually do not contain blood. 3. Episodes of diarrhea and constipation may be a clinical manifestation of colon cancer, not Crohn's disease. 4. A fever and hard, rigid abdomen are clinical manifestations of peritonitis, a complication of Crohn's disease. TEST-TAKING HINT: The test taker should eliminate option "2" because of the word "all," which is an absolute. There are very few absolutes in the health-care arena.

144. The nurse is caring for clients on a medical unit. Which client information should be brought to the attention of the HCP immediately? 1. A serum sodium of 128 mEq/L in a client diagnosed with obstipation. 2. The client diagnosed with fecal impaction after two hard formed stools. 3. A serum potassium level of 3.8 mEq/L in a client diagnosed with diarrhea. 4. The client diagnosed with diarrhea after two semiliquid stools totaling 300 mL.

1. A serum sodium of 128 mEq/L in a client diagnosed with obstipation. 144. 1. Normal serum sodium levels are 135 to 145 mEq/L, so the client's 128 mEq/L value requires intervention. 2. The client diagnosed with a fecal impaction is beginning to move the stool; this indicates an improvement. 3. Normal potassium levels are 3.5 to 5.5 mEq/L. A level of 3.8 mEq/L is within normal limits and does not require intervention. 4. This client has been having diarrhea and now is having semiliquid stools, so this client is getting better. TEST-TAKING HINT: The test taker must determine if the client is experiencing a potentially life-threatening complication, such as the potential for seizures. Answer options "2," "3," and "4" are expected for the disease process and are normal or show improvement.

39. The 85-year-old male client diagnosed with cancer of the colon asks the nurse, "Why did I get this cancer?" Which statement is the nurse's best response? 1. "Research shows a lack of fiber in the diet can cause colon cancer." 2. "It is not common to get colon cancer at your age; it is usually in young people." 3. "No one knows why anyone gets cancer; it just happens to certain people." 4. "Women usually get colon cancer more often than men but not always."

1. "Research shows a lack of fiber in the diet can cause colon cancer." 39. 1. A long history of low-fiber, high-fat, and high-protein diets results in prolonged transit time. This allows the carcinogenic agents in the waste products to have greater exposure to the lumen of the colon. 2. The older the client, the greater the risk of developing cancer of the colon. 3. Risk factors for cancer of the colon include increasing age, family history of colon cancer or polyps, a history of IBD, obesity, cigarette and alcohol use, and eating a high-fat, high-protein, low-fiber diet. 4. Males have a slightly higher incidence of colon cancers than do females. TEST-TAKING HINT: The test taker should realize cancers, in general, have an increasing incidence with age. Cancer etiologies are not an exact science, but most cancers have some risk factor if only advancing age.

99. The client is diagnosed with a Salmonella infection secondary to eating some slightly cooked hamburger meat. Which clinical manifestations should the nurse expect the client to report? 1. Abdominal cramping, nausea, and vomiting. 2. Neuromuscular paralysis and dysphagia. 3. Gross amounts of explosive bloody diarrhea. 4. Frequent "rice-water stool" with no fecal odor.

1. Abdominal cramping, nausea, and vomiting. 99. 1. Symptoms develop 6 hours to 6 days after ingesting the Salmonella bacteria and include diarrhea, abdominal cramping, nausea, and vomiting, along with a low-grade fever (CDC, 2019). 2. Neuromuscular paralysis and dysphagia occur with botulism, a severe life-threatening form of food poisoning caused by C. botulinum. 3. Gross explosive bloody diarrhea is a clinical manifestation of hemorrhagic colitis caused by E. coli. 4. Gray cloudy diarrhea with no fecal odor, blood, or pus is caused by cholera, which is endemic in parts of Asia, the Middle East, and Africa. TEST-TAKING HINT: Often when two options have the same clinical manifestation, such as diarrhea and stool, this should make the test taker realize either one of these two options is correct, so the other two options can be eliminated, or both are incorrect.

6. The nurse is caring for an adult client diagnosed with GERD. Which condition is the most common comorbid disease associated with GERD? 1. Adult-onset asthma. 2. Pancreatitis. 3. Peptic ulcer disease. 4. Increased gastric emptying.

1. Adult-onset asthma. 6. 1. In adult-onset asthma, a large number of cases are caused by GERD. Additionally, GERD can make existing asthma symptoms difficult to control (Banki, 2020). 2. Pancreatitis is not related to GERD. 3. Peptic ulcer disease, gastritis, and gastric cancer are related to H. pylori bacterial infections and can lead to changes in the levels of gastric acid, but it is not related to reflux (Waldum, Kleveland, & Sordal, 2016). 4. GERD is related to gastric emptying because increased gastric emptying would be a benefit to a client diagnosed with decreased functioning of the lower esophageal sphincter. However, increased gastric emptying is not a disease. TEST-TAKING HINT: Option "4" is not a disease, only a gastrointestinal process, which should alert the test taker to eliminate this option.

24. Which problem is most appropriate for the nurse to identify for the client diagnosed with diarrhea? 1. Alteration in skin integrity. 2. Chronic pain perception. 3. Fluid volume excess. 4. Ineffective coping.

1. Alteration in skin integrity. 24. 1. When clients have multiple liquid stools, the rectal area can become irritated. The integrity of the skin can be impaired. 2. Pain experienced by this client would be acute, rather than chronic. 3. Fluid volume deficit is appropriate, rather than fluid volume excess. 4. Ineffective coping is a psychosocial problem and is not appropriate for a client diagnosed with diarrhea.

112. The client has an eviscerated abdominal wound. Which intervention should the nurse implement? 1. Apply sterile normal saline dressing. 2. Use sterile gloves to replace protruding parts. 3. Place the client in a reverse Trendelenburg position. 4. Administer intravenous antibiotics immediately (STAT).

1. Apply sterile normal saline dressing. 112. 1. Evisceration is a life-threatening condition in which the abdominal contents protrude through the ruptured incision. The nurse must protect the bowel from the environment by placing a sterile normal saline gauze on it, which prevents the intestines from drying out and necrosing. 2. The nurse should not attempt to replace the protruding bowel. 3. This position places the client with the HOB elevated, which will make the situation worse. 4. Antibiotics will not protect the protruding bowels, which must be the priority. Antibiotics will be administered at a later time to prevent infection, but this is not urgent. TEST-TAKING HINT: The test taker must understand the word "evisceration" to answer this question.

153. The parents of a female toddler bring the child to the pediatrician's office with nausea, vomiting, and diarrhea. Which intervention should the nurse implement first? 1. Ask the parent about the child's diet. 2. Assess the child's tissue turgor. 3. Give the child a sucker if she is "good." 4. Notify the HCP the child is waiting to be seen.

1. Ask the parent about the child's diet. 152. 1. This blood gas is metabolic acidosis, a potentially lethal situation. The nurse should notify the HCP immediately. 2. These results for sodium and potassium are WNL. The glucose is at the edge of the normal. 3. The results of the hemoglobin and hematocrit are not in the range to require more blood at this time. The nurse can give the results to the HCP on rounds. 4. This pulse oximetry reading is WNL. TEST-TAKING HINT: The nurse must be able to interpret common laboratory results. Part of the assessment of a symptom requires knowing the normal ranges.

45. The nurse is caring for a postoperative client with a nasogastric tube set to low intermittent suction. Which intervention should the nurse implement first based on the blood gas results? Arterial Blood GasClientNormal Values pH 7.48 7.35-7.45 Pco2 46 35-45 mmHg Hco3 20 22-26 mEq/L O2 saturation 96 95%-99% 1. Assess the output in the suction canister. 2. Apply oxygen by nasal cannula. 3. Have the client take slow, deep breaths. 4. Place the client on stool specimen collection.

1. Assess the output in the suction canister. 145. 1. This blood gas indicates metabolic alkalosis with partial compensation. The pH level is high, indicating alkalosis. The HCO3 level is low, indicating an alkalosis problem. The Paco2 is outside the normal range, indicating lungs are trying to retain acid to help correct the pH, but the pH is not in the normal range (partial compensation). The NG tube could be removing too much acid from the stomach. The nurse should assess the NGT output. 2. This is a metabolic problem, not respiratory. 3. This is a metabolic problem, not respiratory. 4. The client has an NGT removing acidic contents from the stomach; stool specimen or observation is not indicated. TEST-TAKING HINT: The nurse must be able to interpret common laboratory results. Part of the assessment of a symptom requires determining what therapies can impact the result.

28. Which physical examination should the nurse implement first when assessing the client diagnosed with peptic ulcer disease? 1. Auscultate bowel sounds in all four quadrants. 2. Palpate the abdominal area for tenderness. 3. Percuss the abdominal borders to identify organs. 4. Assess the tender area progressing to nontender.

1. Auscultate bowel sounds in all four quadrants. 28. 1. Auscultation should be used before palpation or percussion when assessing the abdomen. Manipulation of the abdomen can alter bowel sounds and give false information. 2. Palpation gives appropriate information the nurse needs to collect, but if done before auscultation, the sounds will be altered. 3. Percussion of the abdomen does not give specific information about peptic ulcer disease. 4. Tender areas should be assessed last to prevent guarding and altering the assessment. This includes palpation, which should be done after auscultation. TEST-TAKING HINT: The word "first" requires the test taker to rank in order the interventions needing to be performed. The test taker should visualize caring for the client. This will assist the test taker in making the correct choice.

33. Which oral medication should the nurse question before administering to the client diagnosed with peptic ulcer disease? 1. Celecoxib. 2. Omeprazole. 3. Metronidazole. 4. Acetaminophen.

1. Celecoxib. 33. 1. Celecoxib (Celebrex) is an NSAID used to treat arthritis. NSAIDs can cause irritation to the stomach, and the use by a client diagnosed with peptic ulcer disease should be questioned. 2. Prilosec, a proton pump inhibitor, decreases gastric acid production, and its use should not be questioned by the nurse. 3. Metronidazole (Flagyl), an antimicrobial, is administered to treat peptic ulcer disease secondary to H. pylori bacteria. 4. Acetaminophen (Tylenol), a nonnarcotic analgesic, can be safely administered to a client diagnosed with peptic ulcer disease. TEST-TAKING HINT: The test taker needs to understand how medications work, adverse effects of medications, when to question administering a specific medication, and how to administer the medication safely. By learning classifications, the test taker should be able to make a knowledgeable selection in most cases.

136. The client has dark, watery, and shiny-appearing stool. Which intervention should the nurse implement first? 1. Check for a fecal impaction. 2. Encourage the client to drink fluids. 3. Check the EHR for sodium and potassium levels. 4. Apply a protective barrier cream to the perianal area.

1. Check for a fecal impaction. 136. 1. This is a symptom of diarrhea moving around an impaction higher up in the colon. The nurse should assess for an impaction when observing this finding. 2. Encouraging the client to drink fluids should be done, but it is not the first intervention. 3. The sodium level is usually not a problem for clients experiencing diarrhea, but the potassium level may be checked. However, again, this is not the first intervention. 4. A protective cream can be applied to an excoriated perineum, but first, the nurse should assess the situation. TEST-TAKING HINT: The first step of the nursing process is assessment, after which a nursing diagnosis and interventions follow. The nurse should assess first.

31. The nurse is facilitating a support group for clients diagnosed with Crohn's disease. Which information is most important for the nurse to discuss with the clients? 1. Discuss coping skills to assist with the adaptation to lifestyle modifications. 2. Teach about drug administration, dosages, and scheduled times. 3. Teach dietary changes necessary to control symptoms. 4. Explain the care of the ileostomy and necessary equipment.

1. Discuss coping skills to assist with the adaptation to lifestyle modifications. 31. 1. The objectives for support groups are to help members cope with chronic diseases and help manage symptom control. 2. Drug administration, dosage, and scheduled times should be discussed in the hospital before discharge or in the HCP's office; therefore, this is not a priority at the support group meeting. 3. Dietary changes should be taught at the time the disease is diagnosed, but this is not a priority at the support group meeting. 4. An ileostomy may be the surgical option for clients unresponsive to medical treatment, but other nonsurgical treatments would be topics of discussions during support group meetings.

57. The client diagnosed with acute diverticulitis has a nasogastric tube draining green liquid bile. Which intervention should the nurse implement? 1. Document the findings as normal. 2. Assess the client's bowel sounds. 3. Determine the client's last bowel movement. 4. Insert the NG tube at least 2 more inches.

1. Document the findings as normal. 57. 1. Green bile contains hydrochloric acid and should be draining from the NG tube; therefore, the nurse should take no action and document the findings. 2. There is no reason for the nurse to assess the client's bowel sounds because the drainage is normal. 3. The client's last bowel movement would not affect the NG tube drainage. 4. Bile draining from the NG tube indicates the tube is in the stomach, and there is no need to advance the tube farther. TEST-TAKING HINT: The test taker must know what drainage is normal for tubes inserted into the body. Any type of blood or coffee-ground drainage would be abnormal and require intervention by the nurse.

26. The nurse is caring for a client diagnosed with rule out peptic ulcer disease. Which test confirms this diagnosis? 1. Esophagogastroduodenoscopy (EGD). 2. Magnetic resonance imaging (MRI). 3. Occult blood test. 4. Gastric acid stimulation test.

1. Esophagogastroduodenoscopy (EGD). 26. 1. The EGD, or upper GI endoscopy, is an invasive diagnostic test that visualizes the esophagus, stomach, and duodenum to diagnose an ulcer accurately and evaluate the effectiveness of the client's treatment. 2. An MRI shows cross-sectional images of tissue or blood flow. 3. An occult blood test shows the presence of blood but not the source. 4. A gastric acid stimulation test is used to understand the pathophysiology of ulcer disease and evaluate gastric fluid, but it is not a definitive diagnosis for ulcers (Van Leeuwen & Bladh, 2017). TEST-TAKING HINT: If the test taker has no idea what the correct answer is, knowledge of anatomy can help identify the answer. A peptic ulcer is an ulcer in the stomach, and in option "1" the word "esophagogastroduodenoscopy" has "gastro," which refers to the stomach. Therefore, this would be the best option to select as the correct answer.

46. The nurse is preparing the postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement? 1. Establish rapport with the client to decrease the embarrassment of assessing the site. 2. Encourage the client to lie in the lithotomy position twice a day. 3. Milk the tube inserted during surgery to allow the passage of flatus. 4. Digitally dilate the rectal sphincter to express old blood.

1. Establish rapport with the client to decrease the embarrassment of assessing the site. 46. 1. The site of the surgery can cause embarrassment when the nurse assesses the site; therefore, the nurse should establish a positive relationship. 2. The lithotomy position is with the client's legs in stirrups for procedures such as Pap smears and some surgeries such as transurethral resection of the prostate, not for the client postoperative hemorrhoidectomy. 3. A tube is not placed in the client's rectum after this surgery. 4. The rectal sphincter does not need to be digitally dilated.

103. Which nursing problem is a priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning? 1. Fluid volume deficit. 2. Nausea. 3. Acute pain. 4. Impaired urinary elimination.

1. Fluid volume deficit. 103. 1. Fluid volume deficit secondary to diarrhea is the priority because of the potential for metabolic acidosis and hypokalemia, which are both life-threatening, especially in older clients. 2. Nausea may occur, but it is not the priority. However, excessive vomiting could lead to potential complications. 3. Acute pain secondary to abdominal cramping may occur, but it is not the priority. 4. Impaired urinary elimination is not a priority. The client has diarrhea, not urine output problems. TEST-TAKING HINT: Always notice the client's age because it is usually a significant clue as to the correct answer. Prioritizing questions may have more than one potential appropriate nursing problem, but only one has priority. Remember Maslow's hierarchy of needs.

34. The nurse is caring for an older client diagnosed with acute gastritis. Which client problem is the priority for this client? 1. Fluid volume deficit. 2. Altered nutrition: less than body requirements. 3. Impaired tissue perfusion. 4. Alteration in comfort.

1. Fluid volume deficit. 34. 1. Pediatric and geriatric clients have an increased risk for fluid volume and electrolyte imbalances. The nurse should always be alert to this possible complication. 2. Altered nutrition may be appropriate, depending on how long the client has been unable to eat, but it is not a priority over fluid volume deficit. 3. Impaired tissue perfusion may be appropriate if the mucosal lining of the stomach is unable to heal, but it is not a priority over fluid volume deficit. 4. Alteration in comfort may be appropriate, but it is not a priority over fluid volume deficit.

48. The nurse at the scene after a knife fight is caring for a young man with a knife protruding from an abdominal wound. Which action should the nurse implement? 1. Stabilize the knife. 2. Remove the knife gently. 3. Turn the client on the side. 4. Apply pressure to the insertion site.

1. Stabilize the knife. 48. 1. The nurse should not remove any penetrating object in the abdomen; removal could cause further internal damage. 2. Removal of the knife could cause further internal damage. 3. The client should be kept on the back, and the knife should be stabilized. 4. The nurse should stabilize the knife and notify Emergency Medical Services as quickly as possible.

8. The nurse is administering a proton pump inhibitor to a client diagnosed with peptic ulcer disease. Which statement supports the rationale for administering this medication? 1. It prevents the final transport of hydrogen ions into the gastric lumen. 2. It blocks receptors controlling hydrochloric acid secretion by the parietal cells. 3. It protects the ulcer from the destructive action of the digestive enzyme pepsin. 4. It neutralizes the hydrochloric acid secreted by the stomach.

1. It prevents the final transport of hydrogen ions into the gastric lumen. 8. 1. This statement is the rationale for proton pump inhibitors. 2. This statement explains the rationale for histamine receptor antagonists. 3. This statement describes how mucosal protective agents work in the body. 4. This statement is the rationale for antacids.

42. The nurse caring for a client 1 day postoperative sigmoid resection notes a moderate amount of dark reddish-brown drainage on the midline abdominal incision. Which intervention should the nurse implement first? 1. Mark the drainage on the dressing with the time and date. 2. Change the dressing immediately using sterile technique. 3. Notify the health-care provider immediately. 4. Reinforce the dressing with a sterile gauze pad.

1. Mark the drainage on the dressing with the time and date. 42. 1. The nurse should mark the drainage on the dressing to determine if active bleeding is occurring because dark reddish-brown drainage indicates old blood. This allows the nurse to assess what is actually happening. 2. Surgical dressings are initially changed by the surgeon; the nurse should not remove the dressing until the surgeon orders the dressing change to be done by the nurse. 3. The nurse should assess the situation before notifying the HCP. 4. The nurse may need to reinforce the dressing if the dressing becomes saturated, but this would be after a thorough assessment is completed. TEST-TAKING HINT: The question is asking the test taker to determine which intervention must be implemented first, and assessment is the first step of the nursing process. Options "2," "3," and "4" would not be implemented before assessing. Marking the dressing allows the nurse to assess the dressing and determine if active bleeding is occurring.

39. The nurse is caring for the client 1 day post-upper gastrointestinal (UGI) series. Which assessment data warrant intervention? 1. No bowel movement. 2. Oxygen saturation 96%. 3. Vital signs within normal baseline. 4. Intact gag reflex.

1. No bowel movement. 39. 1. The nurse should monitor the client for the first bowel movement to document the elimination of barium, which should be eliminated within 2 days. If the client does not have a bowel movement, a laxative may be needed to help the client to eliminate the barium before it becomes too hard to pass. 2. An oxygen saturation of 96% is acceptable and does not require intervention. 3. Vital signs should be monitored to recognize and treat complications before the client is in danger. Baseline is a desired outcome. 4. The client's throat is not anesthetized for this procedure, so the gag reflex is not pertinent information in this procedure.

2. The client receiving antibiotic therapy reports white, cheesy plaques in the mouth. Which intervention should the nurse implement? 1. Notify the HCP to obtain an antifungal medication. 2. Explain the patches will go away naturally in about 2 weeks. 3. Instruct to rinse the mouth with diluted hydrogen peroxide and water daily. 4. Allow the client to verbalize feelings about having the plaques.

1. Notify the HCP to obtain an antifungal medication. 2. 1. Candidiasis, or thrush, presents as white, cheesy plaques, which bleed when rubbed and is a side effect of antibiotic therapy. Candidiasis is treated with antifungal solution, swished around the mouth, held for at least 1 minute, and then swallowed. Candidiasis can be prevented if Lactobacillus acidophilus is administered concurrently with antibiotic therapy. 2. White painless patches disappearing in approximately 2 weeks are leukoplakia, caused by tobacco use, which may be cancerous and should be evaluated by an HCP. 3. A solution of hydrogen peroxide is not recommended to treat candidiasis. 4. The nurse needs to treat the client's mouth, not use therapeutic communication.

55. The client diagnosed with acute diverticulitis is reporting severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and T 102°F. Which intervention should the nurse implement? 1. Notify the health-care provider. 2. Prepare to administer a sodium phosphate enema. 3. Administer an antipyretic suppository. 4. Continue to monitor the client closely.

1. Notify the health-care provider. 55. 1. These are signs of peritonitis, which is life-threatening. The HCP should be notified immediately. 2. A sodium phosphate (Fleet's) enema will not help a life-threatening complication of diverticulitis. 3. A medication administered to help decrease the client's temperature will not help a life-threatening complication. 4. These are clinical manifestations indicating a possible life-threatening situation and require immediate intervention. TEST-TAKING HINT: In most instances, the test taker should not select the option stating to notify the HCP immediately, but in some situations, it is the correct answer. The test taker should look at all the other options and determine if the option is information the HCP requires or if it is an independent intervention that will help the client.

37. The nurse working in a skilled nursing facility is collaborating with the dietitian concerning the meals of an immobile client. Which foods are most appropriate for this client? 1. Oatmeal and wheat toast. 2. Cream of wheat and biscuits. 3. Cottage cheese and canned peaches. 4. Tuna on a croissant and applesauce.

1. Oatmeal and wheat toast. 37. 1. Oatmeal and wheat toast are high-fiber foods and are recommended for immobile clients to help prevent constipation. 2. Cream of wheat and biscuits are low-fiber foods. 3. Cottage cheese and canned peaches are low-fiber foods. 4. Tuna is a good source of protein for the client, but croissants have a high fat content and are a factor in weight gain if consistently eaten. Applesauce is low in fiber.

142. The client presents to the emergency department experiencing frequent watery, bloody stools after eating some undercooked meat at a fast-food restaurant. Which intervention should be implemented first? 1. Obtain a stool sample from the client. 2. Initiate antibiotic therapy intravenously. 3. Have the laboratory draw a complete blood count. 4. Administer diphenoxylate and atropine.

1. Obtain a stool sample from the client. 142. 1. This client may have developed an infection from the undercooked meat. The nurse should obtain a stool specimen for the laboratory to analyze. 2. Antibiotic therapy is initiated in only the most serious cases of infectious diarrhea; the diarrhea must be assessed first. A specimen for culture should be obtained before beginning medication. 3. A complete blood count will provide an estimate of blood loss, but it is not the first intervention. 4. The antidiarrheal medication diphenoxylate and atropine (Lomotil) would be administered after the specimen collection. TEST-TAKING HINT: All options in a priority-setting question may be interventions the nurse could implement, but the right answer will be the one implemented first. Collecting a stool sample is assessment, which is the first step in the nursing process.

13. The clinic nurse is caring for a client 67 inches tall, weighing 100 kg. The client reports occasional pyrosis, which resolves with standing or taking antacids. Which treatment should the nurse expect the HCP to order? 1. Place the client on a weight loss program. 2. Instruct the client to eat three balanced meals. 3. Tell the client to take an antiemetic before each meal. 4. Discuss the importance of decreasing alcohol intake.

1. Place the client on a weight loss program. 13. 1. Obesity increases the risk of pyrosis (heartburn); therefore, losing weight could help decrease the incidence. 2. Eating small, frequent meals along with decreased intake of spicy foods have been linked to the prevention of heartburn (pyrosis). 3. Antiemetics decrease nausea, which does not occur with heartburn. Antacids neutralize the acid of the stomach and are used to treat heartburn. 4. Drinking alcoholic beverages increases heartburn and should be avoided, not decreased.

11. The nurse is performing an admission assessment on a client diagnosed with GERD. Which clinical manifestations would indicate GERD? 1. Pyrosis, water brash, and eructation. 2. Weight loss, dysarthria, and diarrhea. 3. Decreased abdominal fat, proteinuria, and constipation. 4. Mid-epigastric pain, positive Helicobacter pylori test, and melena.

1. Pyrosis, water brash, and eructation. 11. 1. Pyrosis is heartburn, water brash is the feeling of saliva secretion as a result of reflux, and eructation is burping or belching—all symptoms of GERD. 2. Gastroesophageal reflux disease does not cause weight loss. 3. There is no change in abdominal fat, no proteinuria (the result of a filtration problem in the kidney), and no alteration in bowel elimination for the client diagnosed with GERD. 4. Midepigastric pain, a positive H. pylori test, and melena are associated with gastric ulcer disease. TEST-TAKING HINT: Frequently, incorrect answer options will contain the symptoms of a disease of the same organ system.

2. The nurse caring for a client diagnosed with GERD writes the client problem of "behavior modification." Which intervention should be included for this problem? 1. Teach the client to sleep with a wedge pillow under the head. 2. Encourage the client to decrease the amount of smoking. 3. Instruct the client to take over-the-counter medication for relief of pain. 4. Discuss the need to attend Alcoholics Anonymous to quit drinking.

1. Teach the client to sleep with a wedge pillow under the head. 2. 1. The client should elevate the HOB on blocks or use a foam wedge to use gravity to help keep the gastric acid in the stomach and prevent reflux into the esophagus. Behavior modification is changing one's behavior. 2. The client should be encouraged to quit smoking altogether. Referral to support groups for smoking cessation should be made. 3. The nurse should be careful when recommending over-the-counter (OTC) medications. This is not the most appropriate intervention for a client diagnosed with GERD. 4. The client should be instructed to discontinue using alcohol, but the stem does not indicate the client is an alcoholic. TEST-TAKING HINT: Clients are encouraged to quit, not decrease, smoking. Current research indicates smoking is damaging to many body systems, including the gastrointestinal system. The test taker should not assume anything not in the stem of a question.

115. The client following abdominal surgery has a Jackson Pratt (JP) drainage device. Which assessment data warrant immediate intervention by the nurse? 1. The bulb is round and has 40 mL of fluid. 2. The drainage tube is taped to the dressing. 3. The JP insertion site is pink and has no drainage. 4. The JP bulb has suction and is sunken in.

1. The bulb is round and has 40 mL of fluid. 115. 1. The JP bulb should be depressed, which indicates suction is being applied. A round bulb indicates the bulb is full and needs to be emptied, and suction reapplied. 2. The tube should be taped to the dressing to prevent accidentally pulling the drain out of the insertion site. 3. The insertion site should be pink and without any clinical manifestations of infection, which include drainage, warmth, and redness. 4. The JP bulb should be sunken in or depressed, indicating suction is being applied. TEST-TAKING HINT: The stem is asking which data need intervention by the nurse. Option "2" can be ruled out because all tubes and drains should be secured. A pink insertion site with no drainage is expected, which would cause the test taker to eliminate option "3" as a possible correct answer.

7. Which outcome should the nurse identify for the client diagnosed with aphthous stomatitis? 1. The client will be able to cope with perceived stress. 2. The client will consume a balanced diet. 3. The client will deny any difficulty swallowing. 4. The client will take antacids as prescribed.

1. The client will be able to cope with perceived stress. 7. 1. The cause of canker sores (aphthous stomatitis) is unknown. The small ulcerations of soft oral tissue are linked to stress, trauma, allergies, viral infections, and metabolic disorders. Therefore, being able to cope with stress is the desired outcome. 2. The client diagnosed with recurrent erythematous macule cankers will not have malnutrition; therefore, a balanced diet is not applicable to this client. 3. The client diagnosed with cankers should not have difficulty swallowing. 4. Antacids are not a treatment for canker sores.

49. The nurse writes the problem "risk for impaired skin integrity" for a client with a sigmoid colostomy. Which expected outcome would be appropriate for this client? 1. The client will have intact skin around the stoma. 2. The client will be able to change the ostomy bag. 3. The client will express anxiety about body changes. 4. The client will maintain fluid balance.

1. The client will have intact skin around the stoma. 49. 1. Intact skin around the stoma is the most appropriate outcome for the problem of "impaired skin integrity." 2. The client's ability to change the ostomy bag is a goal for a knowledge deficit problem or self-care. 3. Expressing anxiety about body changes is a goal for an alteration in body image. 4. Maintaining a balance in fluid is a goal for a nursing diagnosis of risk for a fluid deficit.

4. Which data should the nurse report to the HCP when assessing the oral cavity of an older client? 1. The client's tongue is rough and beefy red. 2. The client's tonsils are 11 on a grading scale. 3. The client's mucosa is pink and moist. 4. The client's uvula rises with the mouth open.

1. The client's tongue is rough and beefy red. 4. 1. A rough, beefy-red tongue may indicate the client has pernicious anemia and should be evaluated by the HCP. 2. A score of +1 on the tonsil grading scale shows the tonsils are extending to the haryngopalatine arch, which is normal. 3. The mucosa should be pink and moist; therefore, the nurse would not need to notify the HCP. 4. Symmetrical movement of the uvula is normal and should not be reported to the HCP

42. The nurse is teaching the client scheduled for a colostomy and diagnosed with colon cancer. Which behavior indicates the nurse is utilizing adult learning principles? 1. The nurse repeats the information as indicated by the client's questions. 2. The nurse teaches in one session all the information the client needs. 3. The nurse uses a video so the client can hear the medical terms. 4. The nurse waits until the client asks questions about the surgery.

1. The nurse repeats the information as indicated by the client's questions. 42. 1. The nurse should realize the client is anxious about the diagnosis of cancer and the impending surgery. Therefore, the nurse should be prepared to repeat information as necessary. The learning principle the nurse needs to consider is "anxiety decreases learning." 2. Small manageable sessions increase learning, especially when the client is anxious. 3. Videos are not the best teaching tool for adults. Short videos are useful for children. 4. The nurse should assess the client's readiness and willingness to learn and not wait until the client asks questions about the surgery.

13. Which clinical manifestation should the nurse expect to find in a client diagnosed with ulcerative colitis? 1. Twenty bloody stools a day. 2. Oral temperature of 102°F. 3. Hard, rigid abdomen. 4. Urinary stress incontinence

1. Twenty bloody stools a day. 13. 1. The colon is ulcerated and unable to absorb water, resulting in bloody diarrhea. Ten to 20 bloody diarrhea stools are the most common symptom of ulcerative colitis. 2. Inflammation and dehydration can cause a low-grade temperature elevation but this is not an expected finding in the client diagnosed with ulcerative colitis. 3. A hard, rigid abdomen indicates peritonitis, which is a complication of ulcerative colitis but not an expected symptom. 4. Stress incontinence is not a symptom of colitis. TEST-TAKING HINT: If the test taker is not sure of the answer, the test taker should use knowledge of anatomy and physiology to help identify the correct answer. The colon is responsible for absorbing water, and if the colon can't do its job, then water will not be absorbed, causing diarrhea (option "1"). Colitis is inflammation of the colon; therefore, option "4" referring to the urinary system can be eliminated.

17. The client diagnosed with IBD is prescribed total parenteral nutrition (TPN). Which intervention should the nurse implement? 1. Check the client's glucose level. 2. Administer an oral hypoglycemic. 3. Assess the peripheral intravenous site. 4. Monitor the client's oral food intake.

1. check the clients glucose level17. 1. TPN is high in dextrose, which is glucose; therefore, the client's blood glucose level must be monitored closely. 2. The client may be on sliding-scale regular insulin coverage for the high glucose level. 3. The TPN must be administered via a central line in the subclavian vein because of the high glucose level. 4. The client is NPO to put the bowel at rest, which is the rationale for administering the TPN. TEST-TAKING HINT: The test taker may want to select option "3" because it has the word "assess," but the test taker should remember to note the adjective "peripheral," which makes this option incorrect. Remember, the words "check" and "monitor" are words meaning "assess."

101. The client diagnosed with gastroenteritis is being discharged from the emergency department. Which interventions should the nurse include in the discharge teaching? Select all that apply. 1. If diarrhea persists for more than 96 hours, contact the health-care provider. 2. Instruct the client to wash hands thoroughly before handling any type of food. 3. Explain the importance of decreasing steroids gradually as instructed. 4. Discuss how to collect all stool samples for the next 24 hours. 5. Tell the client to drink clear liquids or electrolyte solutions.

101. Correct answers are 2 and 5. 1. If diarrhea persists more than 48 hours, the client should notify the HCP. Diarrhea for more than 96 hours could lead to metabolic acidosis, hypokalemia, and possible death. 2. Washing hands should be done by the client at all times, but especially when the client has gastroenteritis. The bacteria in feces may be transferred to other people via food if hands are not washed properly. 3. Steroids are not used in the treatment of gastroenteritis; antidiarrheal medication is usually prescribed. 4. The client may be asked to provide a stool specimen for culture, ova, parasites, and fecal leukocytes, but the client is not asked for a 24-hour stool collection. 5. The client should be instructed to drink clear fluids or electrolyte solutions to replace lost fluids and prevent dehydration. TEST-TAKING HINT: If the test taker did not know any of the answers to this question, hand washing should be selected because it is the number-one intervention for preventing any type of contamination or nosocomial infection.

107. Which nursing interventions should be included in the care plan for the 84-year-old client diagnosed with acute gastroenteritis? Select all that apply. 1. Assess the skin turgor on the back of the client's hands. 2. Monitor the client for orthostatic hypotension. 3. Record the frequency and characteristics of sputum. 4. Use standard precautions when caring for the client. 5. Institute safety precautions when ambulating the client.

107. Correct answers are 2, 4, and 5. 1. The nurse should assess skin turgor over the sternum in the older client because the loss of subcutaneous fat associated with aging makes skin turgor assessment on the arms less reliable. 2. Orthostatic hypotension indicates fluid volume deficit, which can occur in an older client having many episodes of diarrhea. 3. The nurse should record the frequency and characteristics of stool, not sputum, in the client diagnosed with gastroenteritis. 4. Standard precautions, including wearing gloves and hand washing, help prevent the spread of the infection to others. 5. The older client is at risk for orthostatic hypotension; therefore, safety precautions should be instituted to ensure the client doesn't fall as a result of a decrease in BP. TEST-TAKING HINT: This is an alternate-type question requiring the test taker to choose all interventions that apply. The test taker should look at each option and consider if this is an intervention for an "older" client. Older people are a special population, usually requiring specific interventions addressing the aging process no matter what the disease process.

118. The client has a nasogastric tube. The HCP orders IV fluid replacement based on the previous hour's output plus the baseline IV fluid ordered of 125 mL/hr. From 0800 to 0900, the client's NG tube drained 45 mL. At 0900, what rate should the nurse set for the IV pump?

118. 170 mL/hr. The NG tube drainage of 45 mL must be added to the 125 mL/hr IV rate, which equals 170 (125 + 45 = 170). The nurse should infuse 170 mL in the next hour. TEST-TAKING HINT: The stem states the previous hour's NG tube output plus the baseline IV rate. The test taker must observe the keywords in the stem. Don't forget to use the drop-down calculator when taking the NCLEX-RN®.

12. Which interventions should the nurse discuss regarding the prevention of an acute exacerbation of diverticulosis? Select all that apply. 1. Eat a low-fiber diet. 2. Drink 2,500 mL of water daily. 3. Avoid eating foods with seeds. 4. Walk 30 minutes a day. 5. Take an antacid every 2 hours.

12. Correct answers are 2, 3, and 4. 1. A high-fiber diet will prevent constipation, the primary reason for diverticulosis and diverticulitis. A low-fiber (residue) diet is prescribed for acute diverticulitis. 2. Increased fluids help to keep the stool soft and prevent constipation. 3. It is controversial if seeds cause an exacerbation of diverticulosis, but this is an appropriate intervention to teach until proven otherwise. 4. Exercise helps to prevent constipation, which can cause an exacerbation of diverticulitis. 5. There are no medications used to help prevent an acute exacerbation of diverticulosis and diverticulitis. Antacids are used to neutralize hydrochloric acid in the stomach.

139. The client diagnosed with AIDS is experiencing voluminous diarrhea. Which interventions should the nurse implement? Select all that apply. 1. Monitor diarrhea, documenting amount, character, and consistency. 2. Assess the client's tissue turgor every day. 3. Encourage the client to drink carbonated soft drinks. 4. Weigh the client daily in the same clothes and at the same time. 5. Assist the client with a warm sitz bath prn.

139. Correct answers are 1, 4, and 5. 1. It is important to keep track of the amounts, color, and other characteristics of body fluids excreted. 2. Skin turgor should be assessed at least every 6 to 8 hours, not daily. 3. Carbonated soft drinks increase flatus in the GI tract, and the increased sugar will act as an osmotic laxative and increase diarrhea. 4. Daily weights are the best method of determining fluid loss and gain. 5. Sitz baths will assist in keeping the client's perianal area clean without having to rub. The warm water is soothing, providing comfort. TEST-TAKING HINT: The test taker should note the time frame for any answer option. "Every day" is not often enough to assess for dehydration in a client diagnosed with massive ("voluminous") fluid loss. If the test taker were not aware of the definition, then an associated word, "volume," would be a hint.

146. The 70-year-old client is admitted to the medical unit diagnosed with acute diverticulitis. Which interventions should the nurse implement? Select all that apply. 1. Tell the client not to eat or drink. 2. Start an intravenous line. 3. Assess the client for abdominal tenderness. 4. Have the dietitian consult for a low-residue diet. 5. Place the client on bedrest with bathroom privileges.

146. Correct answers are 1, 2, 3, and 5. 1. The client should remain NPO until the inflammation in the colon resolves. 2. The client should have an IV to maintain hydration while being NPO. 3. The nurse should assess the client for complications of a ruptured diverticulum. 4. The client will be NPO to rest the bowel. 5. The client is kept on bedrest with bathroom privileges to decrease colon activity. Ambulation increases peristalsis. TEST-TAKING HINT: The test taker must make decisions based on basic principles. If the client has a diagnosis of gastrointestinal disease, the treatment will depend on allowing the bowel to rest. When choosing options for a "select all that apply" question, each option is treated as a true or false question.

147. The nurse is admitting a client diagnosed with protein calorie malnutrition. Which interventions should the RN implement? Select all that apply. 1. Place the client on a 72-hour calorie count. 2. Ask the client to describe the stools. 3. Have the UAP weigh the client. 4. Obtain a list of current medications. 5. Make a referral to the dietitian.

147. Correct answers are 1, 2, 3, 4, and 5. 1. The nurse should assess the client's intake; a 72-hour calorie count will allow the nurse to do this. 2. Protein calorie malnutrition can result from several different diseases. Diarrhea can impact the ability to absorb calories and nutrition from food. 3. Daily weights will monitor the client's weight loss or gain. 4. The nurse should assess medications for drug and food interactions. 5. The dietitian can be invaluable in assisting this client to gain or at least maintain weight. TEST-TAKING HINT: To answer "select all that apply" questions, the test taker must read each option as a true or false question. One option does not rule out another one.

148. The client at the eating disorder clinic weighs 35 kg and is 5 ft 7 inches tall. What would the nurse document as the body mass index (BMI)?

148. 12.06 BMI. This client is extremely underweight. To figure the BMI, the test taker must first multiply the height in inches times the height in inches. This client is 67 inches tall. 67 × 67 = 4489 The next step is to divide the weight in pounds by the sum of the height times the height: 35 × 2.2 = 77 pounds77 ÷ 4489 = 0.01715 Then multiply this number times the conversion of 703: 0. 01715 × 703 = 12.06 TEST-TAKING HINT: The nurse must be able to work common math problems to determine the client's needs.

154. The weight loss clinic nurse identifies the concept of nutrition for a client diagnosed with obesity. Which interventions should the nurse implement? Select all that apply. 1. Ask the client about previous diet attempts. 2. Refer the client to the dietitian. 3. Discuss maintaining a sedentary lifestyle. 4. Weigh the client. 5. Assist the client to set a realistic weight loss goal.

154. Correct answers are 1, 2, 4, and 5. 1. Knowledge of previous weight loss attempts will assist in planning a weight loss program. 2. The dietitian will monitor the nutritional intake and help in planning a nutritionally balanced diet. 3. The client should be encouraged to maintain an active lifestyle. 4. The client's weight will be useful in determining the client's progress. 5. Clients desiring weight loss frequently want a quick fix. The nurse should assist the client in determining a consistent weight loss goal in order to achieve behavior modification to maintain weight loss. TEST-TAKING HINT: The test taker must read each option of a "select all that apply" question as a true or false question.

134. The nurse is caring for a client using cathartics frequently. Which statement made by the client indicates an understanding of the discharge teaching? 1. "In the future, I will eat a banana every time I take the medication." 2. "I don't have to have a bowel movement every day." 3. "I should limit the fluids I drink with my meals." 4. "If I feel sluggish, I will eat a lot of cheese and dairy products."

2. "I don't have to have a bowel movement every day." 134. 1. Bananas are encouraged for clients diagnosed with potassium loss from diuretics; a banana is not needed for harsh laxative (cathartic) use. Harsh laxatives should be discouraged because they cause laxative dependence and a narrowing of the colon with long-term use. 2. It is not necessary to have a bowel movement every day to have normal bowel functioning. 3. Limiting fluids will increase the problem; the client should be encouraged to increase the fluids in the diet. 4. If the client is feeling "sluggish" from not being able to have a bowel movement, these foods increase constipation because they are low in residue (fiber). TEST-TAKING HINT: The test taker must understand words such as "cathartic." Limiting fluids is used for clients diagnosed with renal disease or congestive heart failure, but increasing fluids is recommended for most other conditions.

44. The client with a new colostomy is being discharged. Which statement made by the client indicates the need for further teaching? 1. "If I notice any skin breakdown, I will call the HCP." 2. "I should drink only liquids until the colostomy starts to work." 3. "I should not take a tub bath until the HCP okays it." 4. "I should not drive or lift more than 5 pounds."

2. "I should drink only liquids until the colostomy starts to work." 44. 1. If the tissue around the stoma becomes excoriated, the client will be unable to pouch the stoma adequately, resulting in discomfort and leakage. The client understands the teaching. 2. The client should be on a regular diet, and the colostomy will have been working for several days before discharge. The client's statement indicates the need for further teaching. 3. Until the incision is completely healed, the client should not sit in bathwater because of the potential contamination of the wound by the bathwater. The client understands the teaching. 4. The client has had major surgery and should limit lifting to minimal weight. The client understands the teaching. TEST-TAKING HINT: This is an abdominal surgery, and all instructions for major surgery apply. This is an "except" question; therefore, three options would indicate the client understands the teaching.

10. Which statement made by the client indicates to the nurse the client may be experiencing GERD? 1. "My chest hurts when I walk up the stairs in my home." 2. "I take antacid tablets with me wherever I go." 3. "My spouse tells me I snore very loudly at night." 4. "I drink six to seven soft drinks every day."

2. "I take antacid tablets with me wherever I go." 10. 1. Pain in the chest when walking up stairs indicates angina. 2. Frequent use of antacids indicates an acid reflux problem. 3. Loud snoring could indicate sleep apnea but not GERD. 4. Carbonated beverages increase stomach pressure. Six to seven soft drinks a day would not be tolerated by a client diagnosed with GERD. TEST-TAKING HINT: The stem of the question indicates an acid problem. The drug classification of antacid, or "against acid," provides the test taker a hint as to the correct answer.

20. The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy? 1. "My stoma should be pink and moist." 2. "I will irrigate my ileostomy every morning." 3. "If I get a red, bumpy, itchy rash, I will call my HCP." 4. "I will change my pouch if it starts leaking."

2. "I will irrigate my ileostomy every morning." 20. 1. A pink and moist stoma indicates viable tissue and adequate circulation. A purple stoma indicates necrosis. 2. An ileostomy will drain liquid all the time and should not routinely be irrigated. A sigmoid colostomy may need daily irrigation to evacuate feces. 3. A red, bumpy, itchy rash indicates infection with the yeast Candida albicans, which should be treated with medication. 4. The ileostomy drainage has enzymes and bile salts, which are irritating and harsh to the skin; therefore, the pouch should be changed if any leakage occurs. TEST-TAKING HINT: This is an "except" question, and the test taker must identify which option is not a correct action for the nurse to implement. Sometimes flipping the question—"Which interventions indicate the client understands the teaching?"—can assist in identifying the correct answer.

1. The male client tells the nurse he has been experiencing "heartburn" at night that awakens him. Which assessment question should the nurse ask? 1. "How much weight have you gained recently?" 2. "What have you done to alleviate the heartburn?" 3. "Do you consume many milk and dairy products?" 4. "Have you been around anyone with a stomach virus?"

2. "What have you done to alleviate the heartburn?" 1. 1. Clients having heartburn are frequently diagnosed as having GERD. GERD can occasionally cause weight loss but not weight gain. 2. Most clients diagnosed with GERD have been self-medicating with over-the-counter medications before seeking advice from an HCP. It is important to know what the client has been using to treat the problem. 3. Milk and dairy products contain lactose, which is important if considering lactose intolerance but is not important for "heartburn." 4. Heartburn is not a symptom of a viral illness. TEST-TAKING HINT: Clients will use common terms such as "heartburn" to describe symptoms. The nurse must be able to interpret or clarify the meaning of terms used with the client. Part of the assessment of a symptom requires determining what aggravates and alleviates the symptom.

54. The nurse is preparing to administer the initial dose of an aminoglycoside antibiotic to the client diagnosed with acute diverticulitis. Which intervention should the nurse implement? 1. Obtain a serum trough level. 2. Ask about drug allergies. 3. Monitor the peak level. 4. Assess the vital signs.

2. Ask about drug allergies. 54. 1. Peak and trough levels are drawn after the client has received at least three to four doses of medication, not after the initial dose because the client has just been admitted. 2. The nurse should always ask about allergies to any medication when administering medications, but especially when administering antibiotics, which are notorious for allergic reactions. 3. The peak and trough levels are not drawn before the first dose; they are ordered after multiple doses. 4. The nurse should question when to administer the medication, but there is no vital sign preventing the nurse from administering an antibiotic. TEST-TAKING HINT: The test taker must read the stem closely to realize the client is receiving the initial dose, causing the test taker to eliminate options "1" and "3" as possible correct answers. Both options "2" and "4" are assessment data, but the test taker should ask which one will directly affect the administration of the medication.

38. Which intervention should the nurse implement when administering a potassium supplement? 1. Determine the client's allergies. 2. Ask the client about leg cramps. 3. Monitor the client's blood pressure. 4. Monitor the client's complete blood count.

2. Ask the client about leg cramps. 38. 1. The nurse should inquire about drug allergies before administering all medications, not just potassium. 2. Leg cramps occur when serum potassium levels are too low or too high. If the client has leg cramps, this could indicate an imbalance, which could lead to cardiac dysrhythmias. 3. The BP does not evaluate for dysrhythmias, a possible result of abnormal potassium levels. 4. The complete blood count does not include the potassium level; a chemistry panel is needed.

15. The client diagnosed with IBD has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first? 1. Notify the health-care provider. 2. Assess the client for muscle weakness. 3. Request telemetry for the client. 4. Prepare to administer potassium IV.

2. Assess the client for muscle weakness. 15. 1. The HCP should be notified so potassium supplements can be ordered, but this is not the first intervention. 2. Muscle weakness may be a clinical manifestation of hypokalemia; hypokalemia can lead to cardiac dysrhythmias and can be life-threatening. Assessment is a priority for a potassium level just below the normal level, which is 3.5 to 5.3 mEq/L. 3. Hypokalemia can lead to cardiac dysrhythmias; therefore, requesting telemetry is appropriate, but it is not the first intervention. 4. The client will need potassium to correct the hypokalemia, but it is not the first intervention. TEST-TAKING HINT: When the question asks which action should be implemented first, remember assessment is the first step in the nursing process. If the answer option addressing assessment is appropriate for the situation in the question, then the test taker should select it as the correct answer.

26. The nurse is caring for the client scheduled for an abdominal perineal resection for Stage IV colon cancer. Which client problem should the nurse include in the intraoperative care plan? 1. Fluid volume deficit. 2. Impaired tissue perfusion. 3. Infection of the surgical site. 4. Risk for immunosuppression.

2. Impaired tissue perfusion. 26. 1. Fluid deficit is a potential problem, not an actual problem. The client's fluid balance should be managed by intravenous fluids. 2. The perfusion of the surgical site is compromised as a result of the surgical incision, especially when a graft is used. 3. Infection is a potential problem, but not at the time of surgery. 4. After surgery, not during surgery, the client may require chemotherapy, which can cause immunosuppression.

116. The postanesthisia care nurse is caring for a client after abdominal surgery with gastric decompression in place and reporting nausea. Which intervention should the nurse implement first? 1. Medicate the client with a narcotic analgesic (IVP). 2. Assess the nasogastric tube for patency. 3. Check the temperature for elevation. 4. Hyperextend the neck to prevent stridor.

2. Assess the nasogastric tube for patency. 116. 1. Medicating the client with an analgesic could increase the client's nausea unless the nausea is caused by pain. The nurse should assess the etiology to determine the interventions. 2. The stem indicates the client has had abdominal surgery and gastric decompression is in place, which is a nasogastric (NG) tube. If the NG tube is not patent, this will cause nausea. Irrigating the NG tube may relieve nausea. 3. Checking the temperature will not treat nausea. 4. Hyperextending the neck will assist the client to breathe but will not treat nausea. TEST-TAKING HINT: Assessment is the first step in the nursing process. Checking the NG tube for patency and taking the temperature are the only assessment interventions. Temperature does not correlate with nausea. Medication may be administered, but it would be an antiemetic, not a narcotic analgesic.

138. The dietitian and the nurse in a long-term care facility are planning the menu for the day. Which foods should be recommended for the immobile clients with no swallowing issues? 1. Cheeseburger and milk shake. 2. Canned peaches and a sandwich on whole-wheat bread. 3. Mashed potatoes and mechanically ground red meat. 4. Biscuits and gravy with bacon.

2. Canned peaches and a sandwich on whole-wheat bread. 138. 1. Cheeseburgers and milkshakes are low-residue foods and can make constipation worse. 2. Canned peaches are soft and can be chewed and swallowed easily while providing some fiber; whole-wheat bread is higher in fiber than white bread. These foods will be helpful for clients diagnosed with slowed gastric motility as a result of a lack of exercise or immobility. 3. Mashed potatoes and mechanically ground meat do not provide high fiber. 4. Biscuits, gravy, and bacon are refined flour foods or processed meat (fat). These will not help clients to prevent constipation. TEST-TAKING HINT: The test taker must realize the consequences of immobility include constipation.

43. The client reports unhappiness with the HCP to the nurse. Which intervention should the nurse implement next? 1. Call the HCP and suggest a talk with the client. 2. Determine what about the HCP is bothering the client. 3. Notify the nursing supervisor to arrange a new HCP to take over. 4. Explain the client cannot request another HCP until after discharge.

2. Determine what about the HCP is bothering the client. 43. 1. The nurse should first assess the situation before informing the HCP of the client's concerns and then allow the HCP and client to discuss the situation. 2. The nurse should determine what is concerning the client. It could be a misunderstanding or a real situation where the client's care is unsafe or inadequate. 3. If a new HCP is to be arranged, it is the HCP's responsibility to arrange for another HCP to assume responsibility for the care of the client. 4. The choice of HCP is ultimately the client's. If the HCP cannot arrange for another HCP, the client may be discharged and obtain a new HCP. TEST-TAKING HINT: The nurse should assess the situation; the first step in the nursing process is assessment.

17. The client is diagnosed with esophageal diverticula. Which lifestyle modification should be taught by the nurse? 1. Raise the foot of the bed to 45 degrees to increase peristalsis. 2. Eat the evening meal at least 2 hours before bed. 3. Eat a low-fat, low-cholesterol, high-fiber diet. 4. Wear an abdominal binder to strengthen the abdominal muscles.

2. Eat the evening meal at least 2 hours before bed. 17. 1. The client should elevate the head, not the foot, of the bed to prevent the reflux of stomach contents. 2. The evening meal should be eaten at least 2 hours before going to bed. Small, frequent meals and semisoft foods ease the passage of food, which decreases clinical manifestations of the disease process. 3. This diet is recommended for a client diagnosed with coronary artery disease, not for esophageal diverticula. 4. Restrictive clothing should be avoided, and abdominal binders do not strengthen muscles and would not benefit this client.

43. The nurse is caring for the client 1 day postoperative sigmoid colostomy. Which independent nursing intervention should the nurse implement? 1. Change the infusion rate of the intravenous fluid. 2. Encourage the client to verbalize feelings about body image. 3. Administer opioid narcotic medications for pain management. 4. Assist the client out of bed to sit in the chair twice daily.

2. Encourage the client to verbalize feelings about body image. 43. 1. The rate of the intravenous fluid is a collaborative nursing intervention because it requires an order from the HCP. 2. Encouraging the client to verbalize feelings about body changes assists the client to accept these changes. This is an independent intervention not requiring an HCP's order. 3. Medication administration is a collaborative intervention because it requires an order by the HCP. 4. The activity level immediately postoperative requires an order by the HCP.

35. The nurse is assessing the client diagnosed with chronic gastritis. Which clinical manifestation(s) support this diagnosis? 1. Rapid onset of midsternal discomfort. 2. Epigastric pain relieved by eating food. 3. Dyspepsia and hematemesis. 4. Nausea and projectile vomiting.

2. Epigastric pain relieved by eating food. 35. 1. Acute gastritis is characterized by sudden epigastric pain or discomfort, not midsternal chest pain. 2. Chronic pain in the epigastric area relieved by ingesting food is a clinical manifestation of chronic gastritis. 3. Dyspepsia (heartburn) and hematemesis (vomiting blood) are frequent symptoms of acute gastritis. 4. Projectile vomiting is not a clinical manifestation of chronic gastritis.

111. The client is 1 day postoperative major abdominal surgery. Which client problem is the priority? 1. Impaired skin integrity. 2. Fluid and electrolyte imbalance. 3. Altered bowel elimination. 4. Altered body image.

2. Fluid and electrolyte imbalance. 111. 1. The client has a surgical incision, which impairs the skin integrity, but it is not the priority because it is sutured under sterile conditions. 2. After abdominal surgery, the body distributes fluids to the affected area as part of the healing process. These fluids are shifted from the intravascular compartment to the interstitial space, which causes potential fluid and electrolyte imbalance. 3. Bowel elimination is a problem, but after general anesthesia wears off, the bowel sounds will return, and this is not a life-threatening problem. 4. Psychosocial problems are not a priority over actual physiological problems. TEST-TAKING HINT: When identifying priority problems, the test taker can eliminate any psychosocial problem as a potentially correct answer if there are applicable physiological problems.

36. The client with a history of peptic ulcer disease is admitted into the intensive care department with frank gastric bleeding. Which priority intervention should the nurse implement? 1. Maintain a strict record of intake and output. 2. Insert a nasogastric (NG) tube and begin saline lavage. 3. Assist the client with keeping a detailed calorie count. 4. Provide a quiet environment to promote rest.

2. Insert a nasogastric (NG) tube and begin saline lavage. 36. 1. Maintaining a strict record of intake and output is important to evaluate the progression of the client's condition, but it is not the most important intervention. 2. Inserting a nasogastric tube and lavaging the stomach with saline is the most important intervention because this removes blood and may slow the bleeding (Hoffman & Sullivan, 2020). 3. A calorie count is important information assisting in the prevention and treatment of a nutritional deficit, but this intervention does not address the client's immediate and life-threatening problem. 4. Promoting a quiet environment aids in the reduction of stress, which can cause further bleeding, but this will not stop the bleeding. TEST-TAKING HINT: The test taker is required to rank the importance of interventions in the question. Using Maslow's hierarchy of needs to rank physiological needs first, the test taker should realize inserting a nasogastric tube and beginning lavage is solving a circulation or fluid deficit problem.

60. The client is admitted to the medical floor with acute diverticulitis. Which collaborative intervention should the nurse anticipate the HCP ordering? 1. Administer total parenteral nutrition. 2. Maintain NPO and nasogastric tube. 3. Maintain on a high-fiber diet and increase fluids. 4. Obtain consent for abdominal surgery.

2. Maintain NPO and nasogastric tube. 60. 1. Total parenteral nutrition is not an expected order for this client. 2. The bowel must be put at rest. Therefore, the nurse should anticipate orders for maintaining the client NPO and a nasogastric tube. 3. These orders would be instituted when the client is getting better, and the bowel is not inflamed. 4. Surgery is not the first consideration when the client is admitted to the hospital. TEST-TAKING HINT: "Collaborative" means the nurse must care for the client with another discipline, and the HCP would have to order all of the distracters. The test taker should remember food and fluid probably should be stopped in the client diagnosed with lower gastrointestinal problems.

16. The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement? 1. Provide a low-residue diet. 2. Rest the client's bowel. 3. Assess vital signs daily. 4. Administer antacids orally.

2. Rest the client's bowel. 16. 1. The client's bowel should be placed on rest, and no foods or fluids should be introduced into the bowel. 2. Whenever a client has an acute exacerbation of a gastrointestinal disorder, the first intervention is to place the bowel on rest. The client should be NPO with intravenous fluids to prevent dehydration. 3. The vital signs must be taken more often than daily in a client having an acute exacerbation of ulcerative colitis. 4. The client will receive anti-inflammatory and antidiarrheal medications, not antacids, which are used for gastroenteritis. TEST-TAKING HINT: "Acute exacerbation" is the key phrase in the stem of the question. The word "acute" should cause the test taker to eliminate any daily intervention.

35. Which assessment data indicate to the nurse the client's gastric ulcer has perforated? 1. Reports of sudden, sharp pain in the back. 2. Rigid, boardlike abdomen with rebound tenderness. 3. Frequent, clay-colored, liquid stool. 4. Reports of vague abdominal pain in the right upper quadrant.

2. Rigid, boardlike abdomen with rebound tenderness. 35. 1. Sudden sharp pain felt in the back, chest, and upper body indicates angina or myocardial infarction. 2. A rigid, boardlike abdomen with rebound tenderness is the classic clinical manifestation of peritonitis, which is a complication of a perforated gastric ulcer. 3. Clay-colored stools indicate liver disorders, such as hepatitis. 4. Clients diagnosed with gallbladder disease report vague to sharp abdominal pain in the right upper quadrant. TEST-TAKING HINT: The only two answer options that refer to the abdomen are options "2" and "4." Therefore, the test taker should select one of these two because a gastric ulcer involves the stomach.

105. The 79-year-old client diagnosed with acute gastroenteritis is admitted to the medical unit. Which task would be most appropriate for the RN to delegate to the UAP? 1. Evaluate the client's intake and output. 2. Take the client's vital signs. 3. Change the client's intravenous solution. 4. Assess the client's perianal area.

2. Take the client's vital signs. 105. 1. The UAP can calculate the client's intake and output, but the nurse must evaluate the data to determine if it is normal for the elderly client diagnosed with acute gastroenteritis. 2. The UAP can take the vital signs for a stable client; the nurse must interpret and evaluate the vital signs. 3. The UAP cannot administer medications, and IV solutions are considered to be medications. 4. The nurse cannot delegate assessment. The client may have an excoriated perianal area secondary to diarrhea; therefore, the nurse should assess the client. TEST-TAKING HINT: The nurse should not delegate any nursing task requiring judgment or assessment and cannot delegate the administration of medications. Words such as "evaluate" mean the same thing as "assess"; therefore, options "1," "3," and "4" can be eliminated.

119. The nurse is caring for clients in a surgical unit. Which client should the nurse assess first? 1. The client 4 hours after an inguinal hernia repair with an absence of voiding. 2. The client admitted with abdominal pain who suddenly has no pain. 3. The client 4 hours postoperative abdominal surgery with no bowel sounds. 4. The client 1 day post-appendectomy who is being discharged.

2. The client admitted with abdominal pain who suddenly has no pain. 119. 1. A client not voiding within 4 hours after any surgery is not a priority. This is an acceptable occurrence, but if the client hasn't voided for 8 hours, then the nurse should assess further. 2. A sudden cessation of pain may indicate a ruptured appendix, which could lead to peritonitis, a life-threatening complication; therefore, the nurse should assess this client first. 3. Bowel sounds should return within 24 hours after abdominal surgery. Absent bowel sounds at 4 hours postoperative are not of great concern to the nurse. 4. The client being discharged is stable and not a priority for the nurse. TEST-TAKING HINT: The stem is asking which client the nurse should see first. Therefore, the test taker should look for life-threatening or serious complications or abnormal assessment data for the disease process.

31. Which expected outcome should the nurse include for a client diagnosed with peptic ulcer disease? 1. The client's pain is controlled with the use of NSAIDs. 2. The client maintains lifestyle modifications. 3. The client has no clinical manifestations of hemoptysis. 4. The client takes antacids with each meal.

2. The client maintains lifestyle modifications. 31. 1. Use of NSAIDs increases and causes problems associated with peptic ulcer disease. 2. Maintaining lifestyle changes such as following an appropriate diet and reducing stress indicates the client is complying with the medical regimen. Compliance is the goal of treatment to prevent complications. 3. Hemoptysis is coughing up blood, which is not a clinical manifestation of peptic ulcer disease. This would not be an expected outcome. 4. Antacids should be taken 1 to 3 hours after meals, not with each meal. TEST-TAKING HINT: Expected outcomes are positive completion of goals; maintaining lifestyle modifications would be an appropriate goal for any client diagnosed with any chronic illness.

137. The charge nurse has just received the shift report. Which client should the nurse see first? 1. The client diagnosed with Crohn's disease who, on the previous shift, had two semiformed stools. 2. The elderly client admitted from another facility, reporting constipation. 3. The client diagnosed with AIDS had a 200-mL diarrhea stool and has elastic skin tissue turgor. 4. The client diagnosed with hemorrhoids having spots of bright red blood on the toilet tissue.

2. The elderly client admitted from another facility, reporting constipation. 137. 1. This client is improving; semiformed stools are better than diarrhea. 2. This client has just arrived, so the nurse does not know if the report is valid and needs intervention unless assessed. Older people have difficulty with constipation as a result of decreased gastric motility, medications, poor diet, and immobility. 3. The client has diarrhea, but only 200 mL, and has elastic tissue turgor, indicating the client is not dehydrated. 4. This is not normal, but it is expected for a client diagnosed with hemorrhoids. TEST-TAKING HINT: The test taker should notice descriptive words such as "older," which should alert the test taker to the age range having an implication in answering the question. Answer options "3" and "4" are expected for the disease processes.

27. Which specific data should the nurse obtain from the client suspected of having peptic ulcer disease? 1. History of side effects experienced from all medications. 2. Use of NSAIDs. 3. Any known allergies to drugs and environmental factors. 4. Medical histories of at least three generations.

2. Use of NSAIDs. 27. 1. A history of problems the client has experienced with medications is taken during the admission interview. This information does not specifically address peptic ulcer disease. 2. The use of NSAIDs places the client at risk for peptic ulcer disease and hemorrhage. NSAIDs suppress the production of prostaglandin in the stomach, which is a protective mechanism to prevent damage from hydrochloric acid. 3. Allergies are included for safety, but this is not specific for peptic ulcer disease. 4. Information needs to be obtained about past generations so the nurse can analyze any potential health problems, but this is not specific for peptic ulcer disease. TEST-TAKING HINT: The words "specific data" indicate there will be appropriate data in one or more of the answer options, but only one is specific to peptic ulcer disease.

1. The nurse is caring for the client diagnosed with Clostridium difficile. Which intervention should the nurse implement to prevent health-care-associated infection spread to other clients? 1. Wash hands with Betadine for 2 minutes after giving care. 2. Wear nonsterile gloves when handling GI excretions. 3. Clean the perianal area with soap and water after each stool. 4. Flush the commode twice when disposing of stool.

2. Wear nonsterile gloves when handling GI excretions. 1. 1. The nurse should use soap and water for 15 to 30 seconds before and after caring for the client. Betadine is a surgical scrub. 2. Clean gloves should be worn when providing care to prevent the transfer of the bacteria found in the stool. This will prevent the spread of bacteria to other clients in the health-care facility (nosocomial). But this is not a substitute for good hand hygiene. 3. The nurse should clean the perianal area or instruct the client to clean the area, but this will not prevent the spread of the bacteria to other clients. 4. Flushing the commode twice is not necessary when disposing of stool and will not prevent a nosocomial infection.

120. The 84-year-old client comes to the clinic reporting right lower abdominal pain. Which question is most appropriate for the nurse to ask the client? 1. "When was your last bowel movement?" 2. "Did you have a high-fat meal last night?" 3. "Can you describe the type of pain?" 4. "Have you been experiencing any gas?"

3. "Can you describe the type of pain?" 120. 1. The last bowel movement does not help identify the cause of the client's right lower abdominal pain. This might be appropriate for a client with left lower abdominal pain. 2. Information about a high-fat meal would be asked if the nurse suspected the client had a gallbladder problem. 3. An older client may experience a ruptured appendix with minimal pain; therefore, the nurse should assess the characteristics of the pain. 4. The passage of flatus (gas) does not help determine the cause of right lower abdominal pain. TEST-TAKING HINT: The test taker should go back to basics and assess the client.

19. The client diagnosed with Crohn's disease is crying and tells the nurse, "I can't take it anymore. I never know when I will get sick and end up here in the hospital." Which statement is the nurse's best response? 1. "I understand how frustrating this must be for you." 2. "You must keep thinking about the good things in your life." 3. "I can see you are very upset. I'll sit down, and we can talk." 4. "Are you contemplating committing suicide?"

3. "I can see you are very upset. I'll sit down, and we can talk." 19. 1. The nurse should never state an understanding of what the client is going through. 2. Telling the client to think about the good things is not addressing the client's feelings. 3. The client is crying and is expressing feelings of powerlessness; therefore, the nurse should allow the client to talk. 4. The client is crying and states, "I can't take it anymore," but this is not a suicidal comment or situation. TEST-TAKING HINT: There are rules applied to therapeutic responses. Do not say "understand" and do not ask "why." The test taker should select an option where some type of feeling is being reflected in the statement.

45. The nurse is caring for the client diagnosed with hemorrhoids. Which statement indicates further teaching is needed? 1. "I should increase fruits, bran, and fluids in my diet." 2. "I will use warm compresses and take sitz baths daily." 3. "I must take a laxative every night and have a stool daily." 4. "I can use an analgesic ointment or suppository for pain."

3. "I must take a laxative every night and have a stool daily." 45. 1. Clients diagnosed with hemorrhoids need to eat high-fiber diets and increase fluid intake to keep the stools soft and prevent constipation; therefore, the teaching is effective. 2. Warm compresses or sitz baths decrease pain; therefore, the teaching is effective. 3. Laxatives can be harsh to the bowel and are habit-forming; they should not be taken daily. Stool softeners soften stool and can be taken daily. 4. Analgesic ointments, suppositories, and astringents can be used to decrease pain and decrease edema; therefore, the teaching has been effective.

106. Which statement indicates to the emergency department nurse the client diagnosed with acute gastroenteritis understands the discharge teaching? 1. "I will probably have some leg cramps while I have gastroenteritis." 2. "I should decrease my fluid intake until the diarrhea subsides." 3. "I should reintroduce solid foods very slowly back into my diet." 4. "I should only drink bottled water until the abdominal cramping stops."

3. "I should reintroduce solid foods very slowly back into my diet." 106. 1. Leg cramps could indicate hypokalemia, which is a potential complication of excessive diarrhea and should be reported to the HCP. 2. The client should increase fluid intake because oral rehydration is the primary treatment for gastroenteritis to replace lost fluid as a result of diarrhea and to prevent dehydration. 3. Reintroducing solid foods slowly, in small amounts, will allow the bowel to rest and the mucosa to return to normal functioning after acute gastroenteritis. 4. Bottled water should be consumed when contaminated water is suspected, and an oral glucose electrolyte solution, such as Gatorade or Pedialyte, should be recommended. TEST-TAKING HINT: Both options "2" and "4" refer to fluids, which should make the test taker either eliminate both of these or select from one of these two as the right answer.

102. Which medication should the nurse expect the HCP to order to treat the client diagnosed with botulism secondary to eating contaminated canned goods? 1. An antidiarrheal medication. 2. An aminoglycoside antibiotic. 3. An antitoxin medication. 4. An ACE inhibitor medication.

3. An antitoxin medication. 102. 1. Antidiarrheal medications are contraindicated with botulism because the toxin needs to be expelled from the body. 2. Aminoglycoside antibiotics will not be ordered because there is no bacterium with botulism; it is caused by a neurotoxin. 3. A botulism antitoxin neutralizes the circulating toxin and is prescribed for a client diagnosed with botulism. 4. An angiotensin-converting enzyme (ACE) inhibitor is prescribed for a client diagnosed with cardiovascular disease. TEST-TAKING HINT: The keyword in this question is "treat." Because botulism does not end in -itis, and thus is not an infection, the use of an antibiotic can be eliminated.

59. The nurse is working in an outpatient clinic. Which client is most likely to have a diagnosis of diverticulosis? 1. A 60-year-old male with a sedentary lifestyle. 2. A 72-year-old female with multiple childbirths. 3. A 63-year-old female with hemorrhoids. 4. A 40-year-old male with a family history of diverticulosis.

3. A 63-year-old female with hemorrhoids. 59. 1. A sedentary lifestyle may lead to obesity and contribute to hypertension or heart disease but usually not to diverticulosis. 2. Multiple childbirths are not a risk factor for developing diverticulosis. 3. Hemorrhoids would indicate the client has chronic constipation, which is a strong risk factor for diverticulosis. Constipation increases the intraluminal pressure in the sigmoid colon, leading to weakness in the intestinal lining, which, in turn, causes outpouchings, or diverticula. 4. Family history is not a risk factor. Having daily bowel movements and preventing constipation will decrease the chance of developing diverticulosis. TEST-TAKING HINT: The test taker must know constipation is the leading risk factor for diverticulosis, and if the test taker knows hemorrhoids are caused by constipation, it would lead the test taker to select option "3" as the correct answer.

32. The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data require further intervention? 1. Bowel sounds auscultated 15 times in 1 minute. 2. Belching after eating a heavy and fatty meal late at night. 3. A decrease in systolic blood pressure (BP) of 20 mmHg from lying to sitting. 4. A decreased frequency of distress located in the epigastric region.

3. A decrease in systolic blood pressure (BP) of 20 mmHg from lying to sitting. 32. 1. The range for normoactive bowel sounds is from 5 to 35 times per minute. This would require no intervention. 2. Belching after a heavy, fatty meal is a symptom of gallbladder disease. Eating late at night may cause symptoms of esophageal disorders. 3. A decrease of 20 mmHg in BP after changing position from lying to sitting to standing is orthostatic hypotension. This could indicate the client is bleeding. 4. A decrease in the quality and quantity of discomfort shows an improvement in the client's condition. This would not require further intervention. TEST-TAKING HINT: When the question asks about further intervention, the test taker should examine the answer options for an unexpected outcome requiring further assessment.

100. The client is diagnosed with gastroenteritis. Which laboratory data warrant immediate intervention by the nurse? 1. A serum sodium level of 137 mEq/L. 2. Arterial blood gases of pH 7.37, Po2 95, Pco2 43, HCO3 24. 3. A serum potassium level of 3.3 mEq/L. 4. A stool sample positive for fecal leukocytes.

3. A serum potassium level of 3.3 mEq/L 100. 1. The normal serum sodium level is 135 to 145 mEq/L; therefore, an intervention by the nurse is not needed. 2. These are normal arterial blood gas results; therefore, the nurse would not need to intervene. 3. In gastroenteritis, diarrhea often results in metabolic acidosis and loss of potassium. The normal serum potassium level is 3.5 to 5.3 mEq/L; therefore, a level of 3.3 mEq/L would require immediate intervention. Hypokalemia can lead to life-threatening cardiac dysrhythmias. 4. A stool specimen showing fecal leukocytes supports the diagnosis of gastroenteritis and does not warrant immediate intervention by the nurse. TEST-TAKING HINT: The test taker should read the stem and be certain what the question is asking—in this case, which data require "immediate intervention"? Therefore, the test taker is identifying an answer not normal for the disease process.

48. The client presents with a complete blockage of the large intestine from a tumor. Which HCP's order would the nurse question? 1. Obtain consent for a colonoscopy and biopsy. 2. Start an IV of 0.9% saline at 125 mL/hr. 3. Administer 3 L of polyethylene glycol. 4. Give tap water enemas until it is clear.

3. Administer 3 L of polyethylene glycol. 48. 1. The client will need to have diagnostic tests, so this is an appropriate intervention. 2. The client with an intestinal blockage will need to be hydrated. 3. This client has an intestinal blockage from a solid tumor blocking the colon. Although the client needs to be cleaned out for the colonoscopy, polyethylene glycol (GoLYTELY) could cause severe cramping without a reasonable benefit to the client and could cause a medical emergency. 4. Tap water enemas until clear would be instilling water from below the tumor to try to rid the colon of any feces. The client can expel this water. TEST-TAKING HINT: The stem states a "complete blockage," which indicates the client needs surgery. Therefore, options "1" and "2" are appropriate for surgery. The stem asks the test taker which order would be questioned, so this is an "except" question.

140. The RN, a licensed practical nurse (LPN), and a UAP are caring for clients on a medical floor. Which nursing task would be most appropriate to assign to the LPN? 1. Assist the UAP to learn to perform blood glucose checks. 2. Monitor the potassium levels of a client diagnosed with diarrhea. 3. Administer a bulk laxative to a client diagnosed with constipation. 4. Assess the abdomen of a client reporting abdominal pain.

3. Administer a bulk laxative to a client diagnosed with constipation. 140. 1. The RN will be responsible for signing off on the UAP when competent to perform the blood glucose. The nurse should do this to determine the competency of the UAP. 2. The laboratory values may require the nurse to interpret and act on the results. The nurse cannot delegate tasks requiring professional judgment. 3. The LPN can administer medications such as a laxative. 4. The nurse cannot delegate assessment. TEST-TAKING HINT: Nurses cannot delegate any activity requiring professional judgment, assessment, teaching, or evaluation.

133. The client admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented? 1. Administer an antidiarrheal medication every day and prn. 2. Perform bowel training every 2 hours. 3. Administer an oil retention enema. 4. Prepare for a upper gastrointestinal (UGI) series x-ray.

3. Administer an oil retention enema. 133. 1. An antidiarrheal medication would slow down the peristalsis in the colon, worsening the problem. 2. The client has an immediate need to evacuate the bowel, not a need for bowel training. 3. Oil retention enemas will help to soften the feces and evacuate the stool. 4. A UGI series adds barium to the already hardened stool in the colon. Barium enemas x-ray the colon; a UGI series x-rays the stomach and jejunum. TEST-TAKING HINT: If the test taker understands fecal impaction is the opposite of diarrhea, then answer option "1" can be eliminated. Knowledge of anatomy and physiology eliminates option "4" because stool is formed in the colon and transported to the anus, part of the lower gastrointestinal tract.

110. The client, after abdominal surgery, tells the nurse, "I felt something give way in my stomach." Which intervention should the nurse implement first? 1. Notify the surgeon immediately. 2. Instruct the client to splint the incision. 3. Assess the abdominal wound incision. 4. Administer pain medication intravenously.

3. Assess the abdominal wound incision. 110. 1. The nurse may notify the surgeon if warranted, but it is not the first intervention. 2. The nurse should instruct the client to splint the incision when coughing, then take further action. 3. Assessing the surgical incision is the first intervention because this may indicate the client has wound dehiscence. 4. The nurse should never administer pain medication without assessing for potential complications. TEST-TAKING HINT: The stem is asking which intervention is first. This means all four answer options could be possible actions, but only one is first. The test taker should use the nursing process and select the option addressing assessment because it is the first step in the nursing process.

52. The nurse is discussing the therapeutic diet for the client diagnosed with diverticulosis. Which meal indicates the client understands the discharge teaching? 1. Fried fish, mashed potatoes, and iced tea. 2. Ham sandwich, applesauce, and whole milk. 3. Chicken salad on whole-wheat bread and water. 4. Lettuce, tomato, and cucumber salad and coffee.

3. Chicken salad on whole-wheat bread and water. 52. 1. Fried foods increase cholesterol. Mashed potatoes do not have the peel, which is needed for increased fiber. 2. Applesauce does not have the peel, which is needed for increased fiber, and the option does not identify which type of bread; whole milk is high in fat. 3. Chicken salad, which has vegetables such as celery, grapes, and apples, and whole-wheat bread are high in fiber, which is the therapeutic diet prescribed for clients diagnosed with diverticulosis. An adequate intake of water helps prevent constipation. 4. Tomatoes and cucumbers have seeds, and many HCPs recommend clients diagnosed with diverticulosis avoid seeds because of the possibility of the seeds entering the diverticulum and becoming trapped, leading to peritonitis. TEST-TAKING HINT: The test taker must know a high-fiber diet is prescribed for diverticulosis, and at least five to six foods are encouraged or discouraged for the different types of diets. High-fiber foods are foods with peels (potato, apple) and whole-wheat products.

3. Which instructions should be discussed with the client diagnosed with GERD? Select all that apply. 1. Eat a low-carbohydrate, low-sodium diet. 2. Lie down for 30 minutes after eating. 3. Do not eat spicy foods or acidic foods. 4. Drink two glasses of water before bedtime. 5. Do not wear tight-fitting clothes or belts.

3. Correct answers are 3 and 5. 1. The client should eat a low-fat, high-fiber diet. 2. The client should not lie down for at least 2 hours after each meal to prevent gastric reflux. 3. The client should avoid irritants, such as spicy foods or acidic foods, as well as alcohol, caffeine, and tobacco, because they increase gastric secretions. 4. The client should avoid food or drink 2 hours before bedtime or lying down after eating. 5. The client should avoid wearing tight-fitting clothes or belts around the abdomen to prevent squeezing of the stomach and causing reflux.

156. The nurse is teaching the American Diabetes Association diet to a client diagnosed with diabetes mellitus type 2. Which should the nurse teach the client? 1. Instruct the client to weigh all food before cooking it. 2. Teach the client to eat only carbohydrates if the blood glucose is low. 3. Demonstrate how to determine the number of carbohydrates being eaten. 4. Explain that proteins should be 75% of the recommended diet.

3. Demonstrate how to determine the number of carbohydrates being eaten. 156. 1. Weighing the food is no longer recommended, but if the client weighs the food, then it should be weighed after cooking because cooking changes the weight of the food. 2. The client should eat some carbohydrates but also protein foods to maintain blood glucose levels. 3. The client can be taught how to read food labels by looking at the serving size and total grams of carbohydrates (America Diabetes Association, 2019). 4. Seventy-five percent of the diet being protein places a great burden on the kidneys and can result in acidosis. This is unhealthy. TEST-TAKING HINT: The nurse must be able to provide basic teaching for diets.

117. The nurse is assessing the client recovering from abdominal surgery. The client is using a patient-controlled analgesia (PCA) pump, has shallow respirations, and refuses to deep breathe. Which intervention should the nurse implement? 1. Insist the client take deep breaths. 2. Notify the surgeon to request a chest x-ray. 3. Determine the last time the client used the PCA pump. 4. Administer oxygen at 2 L/min via nasal cannula.

3. Determine the last time the client used the PCA pump. 117. 1. The nurse cannot force the client to do anything; this would be considered assault. 2. There are no data to support the need for a chest x-ray. 3. Shallow respirations and refusal to deep breathe could be the result of abdominal pain. The nurse should assess the client for pain and determine the last time the PCA pump was used. 4. Based on the information given, the client does not need oxygen. TEST-TAKING HINT: If the test taker is unsure of the answer, identifying keywords in the stem—"abdominal surgery" and "PCA"—should guide the test taker to select an option related to one of these keywords. "Determine" can be substituted for the word "assess," which is the first step of the nursing process.

12. Which disease is the client diagnosed with GERD at greater risk for developing? 1. Hiatal hernia. 2. Gastroenteritis. 3. Esophageal cancer. 4. Gastric cancer.

3. Esophageal cancer. 12. 1. A hiatal hernia places the client at risk for GERD; GERD does not predispose the client for developing a hiatal hernia. 2. Gastroenteritis is an inflammation of the stomach and intestine, usually caused by a virus. 3. Barrett's esophagus results from long-term erosion of the esophagus as a result of the reflux of stomach contents secondary to GERD. This is a precursor to esophageal cancer. 4. The problems associated with GERD result from the reflux of acidic stomach contents into the esophagus, which is not a precursor to gastric cancer. TEST-TAKING HINT: The test taker may associate hiatal hernia with GERD. One can be a result of the other, and this can confuse the test taker. If the test taker did not have any idea of the correct answer, option "3" has the word "esophageal" in it, as does the stem of the question, and, therefore, the test taker should select this as the correct answer.

143. The clinic nurse is talking on the phone to a client with diarrhea. Which intervention should the nurse discuss with the client? 1. Tell the client to measure the amount of stool. 2. Recommend the client come to the clinic immediately. 3. Explain the client should follow the BRAT diet. 4. Discuss taking an over-the-counter histamine-2 blocker.

3. Explain the client should follow the BRAT diet. 143. 1. The clinic nurse should not ask the client to measure stool at home; this is done in the acute care setting. 2. Unless the client has had diarrhea for longer than 48 hours, the client does not need to be seen in the clinic. 3. The BRAT (bananas, rice, applesauce, and toast) diet is recommended for a client diagnosed with diarrhea because it is low residue and produces nutrition while not irritating the GI system. 4. Histamine-2 blockers decrease gastric acid production and would not be prescribed for a client diagnosed with diarrhea. TEST-TAKING HINT: The test taker should realize diarrhea involves the gastrointestinal system, and selecting an intervention addressing the GI system would be an appropriate choice.

46. The nurse is caring for clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society's recommendations for the early detection of colon cancer in persons of average risk? 1. A digital rectal examination should be done yearly beginning at age 60. 2. At middle age, a fecal occult blood test should be done every 3 years. 3. Have a colonoscopy at age 45 and then once every 10 years. 4. A stool-based DNA test should be done yearly after age 40.

3. Have a colonoscopy at age 45 and then once every 10 years. 46. 1. A digital rectal examination is done to detect prostate cancer and should be started at age 40 years. 2. "Middle age" is a relative term; specific ages are used for recommendations. At the age of 45 years, the American Cancer Society (2018) recommends a fecal occult blood test every year. 3. The American Cancer Society recommends a colonoscopy at age 45 and every 10 years thereafter for people at average risk of colorectal cancer. Screening can be performed with a stool-based test at more frequent intervals (American Cancer Society, 2018). 4. A stool-based test is an option for persons at low risk of colon cancer, beginning at 45 years old. A fecal immunochemical test is done yearly, and a multitargeted stool DNA test (MT-sDNA) is done every 3 years. TEST-TAKING HINT: A digital examination is an examination performed by the examiner's finger and does not examine the entire colon.

32. The nurse is caring for a client diagnosed with ulcerative colitis. Which clinical manifestation(s) support this diagnosis? 1. Increased appetite and thirst. 2. Elevated hemoglobin. 3. Multiple bloody, liquid stools. 4. Exacerbations unrelated to stress.

3. Multiple bloody, liquid stools. 32. 1. Clients suffering from ulcerative colitis experience anorexia, not an increased appetite. 2. The hemoglobin and hematocrit are decreased, not elevated, as a result of blood loss. 3. Clients report as many as 10 to 20 liquid, bloody stools in a day. 4. Stressful events have been linked to an increase in symptoms. The nurse needs to assess for perceived stress in the client's life producing symptoms.

51. The client is admitted to the medical unit with a diagnosis of acute diverticulitis. Which HCP's order should the nurse question? 1. Insert a nasogastric tube. 2. Start an IV with D5W at 125 mL/hr. 3. Put the client on a clear liquid diet. 4. Place the client on bedrest with bathroom privileges.

3. Put the client on a clear liquid diet. 51. 1. The client will have a nasogastric tube because the client will be NPO, which will decompress the bowel and remove hydrochloric acid. 2. Preventing dehydration is a priority with the NPO client. 3. The nurse should question a clear liquid diet because the bowel must be put on total rest, which means NPO. 4. The client is in severe pain and should be on bedrest, which will help rest the bowel. TEST-TAKING HINT: This is an "except" question. Therefore, the test taker must identify which answer option is incorrect for the stem. Sometimes flipping the question helps in selecting the correct answer. In this question, the test taker could ask, "Which HCP orders would be expected for a client diagnosed with diverticulitis?" The unexpected option would be the correct answer.

18. The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement? 1. Weigh the client daily and document in the client's EHR. 2. Teach coping strategies such as dietary modifications. 3. Record the frequency, amount, and color of stools. 4. Monitor the client's oral fluid intake every shift.

3. Record the frequency, amount, and color of stools. 18. 1. Weighing the client each day will help identify if the client is experiencing malnutrition, but it is not the priority intervention during an acute exacerbation. 2. Coping strategies help develop healthy ways to deal with this chronic disease, which has remissions and exacerbations, but it is not the priority intervention. 3. The severity of diarrhea helps determine the need for fluid replacement. The liquid stool should be measured as part of the total output. 4. The client will be NPO when there is an acute exacerbation of IBD to allow the bowel to rest. TEST-TAKING HINT: The test taker can apply Maslow's hierarchy of needs and select the option addressing a physiological need.

23. The client diagnosed with ulcerative colitis is prescribed a low-residue diet during exacerbations. Which meal selection indicates the client understands the diet teaching? 1. Grilled hamburger on a wheat bun and fried potatoes. 2. A chicken salad sandwich and lettuce and tomato salad. 3. Roast pork, white rice, and plain custard. 4. Fried fish, whole grain pasta, and fruit salad.

3. Roast pork, white rice, and plain custard. 23. 1. Fried potatoes, along with pastries and pies, should be avoided. 2. Raw vegetables should be avoided because they are hard to digest. 3. A low-residue diet is a low-fiber diet. Products made of refined flour or finely milled grains, along with roasted, baked, or broiled meats, are recommended. 4. Fried foods should be avoided, and whole grains are high in fiber. Nuts and fruits with peels should be avoided. TEST-TAKING HINT: The test taker must know about therapeutic diets prescribed by HCPs. Remember, a low-residue diet is the same as low fiber.

14. The client diagnosed with type 2 diabetes is prescribed prednisone for an acute exacerbation of IBD. Which intervention should the nurse discuss with the client? 1. Take this medication on an empty stomach. 2. Notify the HCP if experiencing a moon face. 3. Take the steroid medication as prescribed. 4. Notify the HCP if the blood glucose is over 160.

3. Take the steroid medication as prescribed. 14. 1. Steroids can cause erosion of the stomach and should be taken with food. 2. A moon face is an expected side effect of steroids. 3. Prednisone, a steroid, must be tapered off to prevent adrenal insufficiency; therefore, the client must take this medication as prescribed. 4. Steroids may increase the client's blood glucose, but diabetic medication regimens are usually not altered for the short period of time the client, diagnosed with an acute exacerbation, is prescribed steroids. TEST-TAKING HINT: The test taker should know few medications must be taken on an empty stomach, which would cause option "1" to be eliminated. All medications should be taken as prescribed—don't think the answer is too easy.

9. The RN charge nurse is making assignments. Staffing includes a registered nurse with 5 years of medical-surgical experience, a newly graduated registered nurse, and two unlicensed assistive personnel (UAPs). Which client should be assigned to the most experienced nurse? 1. The 39-year-old client diagnosed with lower esophageal dysfunction reporting pyrosis. 2. The 54-year-old client diagnosed with Barrett's esophagus scheduled to have an endoscopy this morning. 3. The 46-year-old client diagnosed with gastroesophageal reflux disease wheezing in all five lobes. 4. The 68-year-old client 3 days postoperative for hiatal hernia needs to be ambulated four times today.

3. The 46-year-old client diagnosed with gastroesophageal reflux disease wheezing in all five lobes. 9. 1. Pyrosis is heartburn and is expected in a client diagnosed with GERD. The new graduate can care for this client. 2. Barrett's esophagus is a complication of GERD; new graduates can prepare a client for a diagnostic procedure. 3. This client is exhibiting symptoms of asthma, a complication of GERD. This client should be assigned to the most experienced nurse. 4. This client can be cared for by the new graduate, and ambulating can be delegated to the UAP. TEST-TAKING HINT: The most experienced nurse should be assigned to the client requiring more experience and knowledge about the disease process, potential complications, and medications for assessment and care. The term "most experienced" in the stem is the key to answering this question.

150. The clinic nurse is returning client calls. Which client should the nurse call first? 1. The 39-year-old client reporting headache pain with a 3 on the pain scale. 2. The 45-year-old client needing a prescription refill for warfarin. 3. The 54-year-old client diagnosed with diabetes type 1 who is vomiting. 4. The 60-year-old client needing financial aid to buy food.

3. The 54-year-old client diagnosed with diabetes type 1 who is vomiting. 150. 1. A 3 on the pain scale indicates mild pain. This would not be the first client for the nurse to return the call. 2. A prescription refill would not be a reason for the nurse to make this client first. 3. A client diagnosed with diabetes type 1 and vomiting is at risk for diabetes ketoacidosis. The nurse should have the client come in immediately. 4. This client needs a referral to a social worker. The client is not the first one to receive a return call. TEST-TAKING HINT: The nurse must be able to interpret the implications of disease processes and comorbid conditions (vomiting). Part of the assessment of a symptom requires determining what other diseases can impact the result.

108. The nurse has received the a.m. shift report. Which client should the nurse assess first? 1. The 44-year-old client diagnosed with peptic ulcer disease reporting acute epigastric pain. 2. The 74-year-old client diagnosed with acute gastroenteritis and four diarrhea stools during the night. 3. The 65-year-old client diagnosed with IBD, tented skin turgor, and dry mucous membranes. 4. The 15-year-old client diagnosed with food poisoning, who vomited several times during the night shift.

3. The 65-year-old client diagnosed with IBD, tented skin turgor, and dry mucous membranes. 108. 1. Epigastric pain is expected in a client diagnosed with peptic ulcer disease. 2. Four diarrheal stools are not unusual in a client diagnosed with gastroenteritis. 3. Tented skin turgor and dry mucous membranes indicate dehydration, which warrants the nurse assessing this client first. 4. Vomiting is expected in a client diagnosed with food poisoning. TEST-TAKING HINT: When managing clients, the nurse must be able to prioritize care. Therefore, the test taker must be able to determine which client's reports or clinical manifestations are not expected of the disease process. The test taker should always look at the client's age because it may help determine the best answer.

155. The client diagnosed with bulimia has a BMI of 20. Which scientific rationale explains this finding? Body Mass Index CategoryBMI Lower RangeBMI Upper Range Underweight Less than 18.5 — Ideal weight 18.5 24.9 Overweight 25 29.9 Obese 30 or greater — 1. The BMI is low because the client does not eat and exercises frequently. 2. The BMI is within the normal range because the client's therapy is effective. 3. The BMI is WNL because the client vomits or uses laxatives to prevent weight gain. 4. The BMI is high, and the client needs to try new methods of weight control.

3. The BMI is WNL because the client vomits or uses laxatives to prevent weight gain. 155. 1. The BMI is not low; these symptoms are associated with anorexia. 2. The BMI is WNL but does not indicate the therapy is effective. 3. The client diagnosed with bulimia binge eats and then induces vomiting or uses laxatives to prevent weight gain. 4. The BMI is WNL. TEST-TAKING HINT: The test taker will be required to interpret graphs on the NCLEX-RN® and associate the graph information with disease processes. (BMI graph from National Heart, Lung, and Blood Institute, 2020.)

113. The client is diagnosed with peritonitis. Which assessment data indicate to the nurse the client's condition is improving? 1. The client is using more pain medication on a daily basis. 2. The client's nasogastric tube is draining coffee-ground material. 3. The client has a decrease in temperature and a soft abdomen. 4. The client has had two soft-formed bowel movements.

3. The client has a decrease in temperature and a soft abdomen. 113. 1. The client needing more pain medication indicates the client's condition is getting worse. 2. Coffee-ground material indicates old blood from the gastrointestinal system. 3. Because the clinical manifestations of peritonitis are elevated temperature and rigid abdomen, a reversal of these clinical manifestations indicates the client is getting better. 4. Two soft-formed bowel movements are normal, but this does not have anything to do with peritonitis. TEST-TAKING HINT: The -itis of peritonitis means inflammation, which is associated with an elevated temperature. A decrease in temperature would be a sign the client is improving.

38. The nurse is admitting a client to a medical floor with a diagnosis of adenocarcinoma of the rectosigmoid colon. Which assessment data support this diagnosis? 1. The client reports up to 20 bloody stools per day. 2. The client has a feeling of fullness after a heavy meal. 3. The client has diarrhea alternating with constipation. 4. The client reports right lower quadrant pain.

3. The client has diarrhea alternating with constipation. 38. 1. Frequent bloody stools are a symptom of IBD. IBD is a risk factor for cancer of the colon, but the symptoms are different when the colon becomes cancerous. 2. Most people have a feeling of fullness after a heavy meal; this does not indicate cancer. 3. The most common symptom of colon cancer is a change in bowel habits, specifically, diarrhea alternating with constipation. 4. Lower right quadrant pain with rebound tenderness would indicate appendicitis. TEST-TAKING HINT: The test taker could eliminate option "4" based on anatomical position. The rectosigmoid colon is in the left lower quadrant.

5. Which report is significant for the nurse to assess in the adolescent male client using oral tobacco? 1. The client reports clear to white sputum. 2. The client has an episodic blister on the upper lip. 3. The client reports a nonhealing sore in the mouth. 4. The client has bilateral ducts at the second molars.

3. The client reports a nonhealing sore in the mouth. 5. 1. Clear to white sputum is not significant in the client using oral tobacco. 2. Episodic blisters on the lips are herpes simplex 1 and are not specific to this client. 3. The presence of any nonhealing sore on the lips or mouth may be oral cancer. Oral cancer risk increases by using oral tobacco. 4. Bilateral Stensen's ducts visible at the site of the second molars are normal assessment data.

15. Which information should the nurse teach the client post-barium enema procedure? 1. The client should not eat or drink anything for 4 hours. 2. The client should remain on bedrest until the sedative wears off. 3. The client should take a mild laxative to help expel the barium. 4. The client will have a normal elimination color and pattern.

3. The client should take a mild laxative to help expel the barium. 15. 1. The client may resume a regular diet. 2. The client will not be sedated for this procedure; therefore, the client does not need to be on bedrest. 3. The nurse needs to teach the client to take a mild laxative to help evacuate the barium and return to the client's normal bowel routine. Failure to pass the barium could cause constipation when the barium hardens. 4. The client can expect to pass white- or light-colored stools until the barium has completely been evacuated.

8. The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the health-care provider (HCP)? 1. The client's esophageal pH test was positive. 2. The client's abdominal x-ray shows a hiatal hernia. 3. The client's WBC count is 14,000/mm3. 4. The client's hemoglobin is 13.8 g/dL.

3. The client's WBC count is 14,000/mm3. 8. 1. In esophageal pH monitoring, gastric pH is monitored for 24 hours for esophageal symptoms. A positive result would be expected for a client diagnosed with GERD. This would not warrant notifying the HCP. 2. Hiatal hernias are frequently the cause of GERD; therefore, this finding would not warrant notifying the HCP. 3. The client's WBC count is elevated, indicating a possible infection, which warrants notifying the HCP. 4. This is a normal hemoglobin result and would not warrant notifying the HCP. TEST-TAKING HINT: When the test taker is deciding when to notify a HCP, the answer should be data not normal for the disease process or signaling a potential or life-threatening complication.

6. The client is diagnosed with ulcerative colitis. Which clinical manifestation warrants immediate intervention by the nurse? 1. The client has 20 bloody stools a day. 2. The client's oral temperature is 99.8°F. 3. The client's abdomen is hard and rigid. 4. The client reports urinating when coughing.

3. The client's abdomen is hard and rigid. 6. 1. The colon is ulcerated and unable to absorb water; 10 to 20 bloody diarrhea stools are the most common symptom of ulcerative colitis and do not warrant immediate intervention. 2. This is not an elevated temperature and does not warrant immediate intervention by the nurse. 3. A hard, rigid abdomen indicates peritonitis, a complication of ulcerative colitis, and warrants immediate intervention. 4. Stress incontinence is not a symptom of colitis and does not warrant immediate intervention.

149. The client presents to the outpatient clinic reporting diarrhea for 2 days. Which laboratory data should the nurse monitor? 1. The sodium level. 2. The albumin level. 3. The potassium level. 4. The glucose level.

3. The potassium level. 149. 1. Sodium is retained by the body before potassium. The sodium level would be in the normal range after 2 days of diarrhea. 2. Albumin is the protein level synthesized by the liver; the albumin level should not be affected. 3. Potassium is excreted through diarrhea; the nurse should assess the client's potassium level. 4. Glucose should not be affected. TEST-TAKING HINT: The nurse must be able to interpret common laboratory results and how they affect the body. Part of the assessment of a symptom requires determining what therapies can impact the result.

30. The nurse is caring for a client diagnosed with hemorrhaging duodenal ulcer. Which collaborative interventions should the nurse implement? Select all that apply. 1. Perform a complete pain assessment. 2. Assess the client's vital signs frequently. 3. Administer a proton pump inhibitor intravenously. 4. Obtain permission and administer blood products. 5. Monitor the intake of a soft, bland diet.

30. Correct answers are 3 and 4. 1. A pain assessment is an independent intervention the nurse should implement frequently. 2. Evaluating vital signs is an independent intervention the nurse should implement. If the client is able, BPs should be taken lying, sitting, and standing to assess for orthostatic hypotension. 3. This is a collaborative intervention the nurse should implement. It requires an order from the HCP. 4. Administering blood products is collaborative, requiring an order from the HCP. 5. The diet requires an order by the HCP, but a diet will not be ordered because the client is NPO. TEST-TAKING HINT: Descriptive words such as "collaborative" or "independent" can be the deciding factor when determining if an answer option is correct or incorrect. These are keywords the test taker should identify.

37. The occupational health nurse is preparing a presentation to a group of factory workers about preventing colon cancer. Which information should be included in the presentation? Select all that apply. 1. Wear a high-filtration mask when around chemicals. 2. Eat several servings of cruciferous vegetables daily. 3. Take a multivitamin every day. 4. Do not engage in high-risk sexual behaviors. 5. Avoid smoking and tobacco use.

37. Correct answers are 2 and 5. 1. Some cancers have a higher risk of development when the client is occupationally exposed to chemicals, but cancer of the colon is not one of them. 2. Cruciferous vegetables, such as broccoli, cauliflower, and cabbage, are high in fiber. One of the risks for cancer of the colon is a high-fat, low-fiber, and high-protein diet. The longer the transit time (the time from ingestion of the food to the elimination of the waste products), the greater the chance of developing cancer of the colon. 3. A multivitamin may improve immune system function, but it does not prevent colon cancer. 4. High-risk sexual behavior places the client at risk for sexually transmitted diseases.A history of multiple sexual partners and initial sexual experience at an early age does increase the risk for the development of cancer of the cervix in females. 5. Smoking and tobacco use are risk factors for many disease processes, including the development of colorectal cancer. TEST-TAKING HINT: The colon processes waste products from eating foods, and option "2" is the only option to mention food. Therefore, option "2" would be an option to select. Option "5" discusses smoking and tobacco use, which is a common risk factor for many diseases.

36. The nurse identifies the problem of "fluid volume deficit" for a client diagnosed with gastritis. Which intervention should be included in the plan of care? 1. Obtain permission for a blood transfusion. 2. Prepare the client for TPN. 3. Monitor the client's lung sounds every shift. 4. Assess the client's intravenous site.

4. Assess the client's intravenous site. * 36. 1. There are no data to suggest the client needs a blood transfusion. 2. TPN is not a treatment for a client diagnosed with a fluid volume deficit. TPN provides calories for nutritional deficits, not fluid deficits. 3. If the client's problem were fluid volume excess, assessing lung sounds would be appropriate. 4. Fluid administration is the medical treatment for dehydration, so the nurse must monitor and ensure the IV site is patent.

3. The nurse is preparing a client diagnosed with GERD for discharge following an esophagogastroduodenoscopy (EGD). Which statement indicates the client understands the discharge instructions? 1. "I should not eat for at least 1 day following this procedure." 2. "I can lie down whenever I want after a meal. It won't make a difference." 3. "The stomach contents won't bother my esophagus but will make me nauseous." 4. "I should avoid orange juice and eating tomatoes after this procedure."

4. "I should avoid orange juice and eating tomatoes after this procedure." 3. 1. The client is allowed to eat as soon as the gag reflex has returned. 2. An esophagogastroduodenoscopy is a diagnostic procedure, not a cure. Therefore, the client still has GERD and should be instructed to stay in an upright position for 2 to 3 hours after eating. 3. Stomach contents are acidic and will erode the esophageal lining. 4. Orange juice and tomatoes are acidic and prone to trigger acid reflux. The client diagnosed with GERD should avoid acidic foods to allow the esophagus to heal and to reduce heartburn. TEST-TAKING HINT: This question assumes the test taker has knowledge of diagnostic procedures for specific disease processes.

40. The client is reporting painful swallowing secondary to mouth ulcers. Which statement indicates the nurse's teaching is effective? 1. "I will brush my teeth with a soft-bristle toothbrush." 2. "I will rinse my mouth with Listerine mouthwash." 3. "I will swish with antifungal solution and then swallow." 4. "I will avoid spicy foods, tobacco, and alcohol."

4. "I will avoid spicy foods, tobacco, and alcohol." 40. 1. A soft-bristle toothbrush will not affect painful swallowing. 2. An alcohol-based mouthwash (Listerine) is irritating to the oral cavity and can increase pain. 3. An antifungal medication should be used with candidiasis and is not an effective treatment for plain mouth ulcers. 4. Irritating substances should be avoided during the outbreaks of ulcers in the mouth. Spicy foods, alcohol, and tobacco are common irritants the client should avoid.

34. The nurse has administered an antibiotic, a proton pump inhibitor, and bismuth subsalicylate for peptic ulcer disease secondary to H. pylori. Which data would indicate to the nurse the medications are effective? 1. A decrease in alcohol intake. 2. Maintaining a bland diet. 3. A return to previous activities. 4. A decrease in gastric distress.

4. A decrease in gastric distress. 34. 1. Decreasing alcohol intake indicates the client is making some lifestyle changes. 2. The client diagnosed with PUD is prescribed a regular diet, but the type of diet does not determine if the medication is effective. 3. The return to previous activities indicates the client has not adapted to the lifestyle changes and has returned to the previous behaviors, which precipitated the peptic ulcer disease. 4. Antibiotics, proton pump inhibitors, and bismuth subsalicylate (Pepto-Bismol) are administered to decrease the irritation of the ulcerative area and cure the ulcer. A decrease in gastric distress indicates the medication is effective. TEST-TAKING HINT: To determine the effectiveness of a medication, the test taker must know the scientific rationale for administering the medication. Peptic ulcer disease causes gastric distress. If gastric distress is relieved, then the medication is effective.

7. The nurse is administering morning medications at 0730. Which medication should have priority? 1. A proton pump inhibitor. 2. A nonnarcotic analgesic. 3. A histamine receptor antagonist. 4. A mucosal barrier agent.

4. A mucosal barrier agent. 7. 1. Proton pump inhibitors can be administered at routine dosing times, usually 0900 or after breakfast. 2. Pain medication is important, but a nonnarcotic medication, such as Tylenol, can be administered after a medication, which must be timed. 3. A histamine receptor antagonist can be administered at routine dosing times. 4. A mucosal barrier agent must be administered on an empty stomach for the medication to coat the stomach. TEST-TAKING HINT: Basic knowledge of how medications work is required to administer medications for peak effectiveness. There are very few medications requiring a specific time. The test taker should memorize these specific medications.

49. The client diagnosed with diverticulitis is reporting severe pain in the left lower quadrant and has an oral temperature of 100.6°F. Which intervention should the nurse implement first? 1. Notify the health-care provider. 2. Document the findings in the EHR. 3. Administer an oral antipyretic. 4. Assess the client's abdomen.

4. Assess the client's abdomen. 49. 1. These are classic clinical manifestations of diverticulitis; therefore, the HCP does not need to be notified. 2. These are normal findings for a client diagnosed with diverticulitis, but on admission, the nurse should assess the client and document the findings in the client's EHR. 3. The nurse should not administer any food or medications. 4. The nurse should assess the client to determine if the abdomen is soft and nontender. A rigid tender abdomen may indicate peritonitis. TEST-TAKING HINT: The test taker must remember to apply the nursing process when answering test questions. Assessment is the first step in the nursing process. Although the clinical manifestations are normal and could be documented, the nurse should always assess.

104. Which data should the nurse expect to assess in the client diagnosed with acute gastroenteritis? 1. Decreased gurgling sounds on auscultation of the abdominal wall. 2. A hard, firm, edematous abdomen on palpation. 3. Frequent, small melena-type liquid bowel movements. 4. Bowel assessment reveals loud, rushing bowel sounds.

4. Bowel assessment reveals loud, rushing bowel sounds. 104. 1. The client would have increased gurgling sounds, revealing hyperactive bowel movements. 2. A hard, firm, edematous abdomen is not expected in a client diagnosed with gastroenteritis; this would indicate a possible complication and require further assessment. 3. The client has increased liquid bowel movements (diarrhea) but should not have blood in the stool, which is the definition of melena. 4. Borborygmi, or loud, rushing bowel sounds, indicates increased peristalsis, which occurs in clients diagnosed with diarrhea and is the primary clinical manifestation in a client diagnosed with acute gastroenteritis. TEST-TAKING HINT: The test taker should realize that, in an acute condition, the assessment data would be abnormal, which may help select the correct answer for some questions.

4. The nurse is planning the care of a client diagnosed with lower esophageal sphincter dysfunction. Which dietary modifications should be included in the plan of care? Select all that apply. 1. Allow any of the client's favorite foods as long as the amount is limited. 2. Have the client perform eructation exercises several times a day. 3. Eat four to six small meals a day and limit fluids during mealtimes. 4. Encourage the client to consume a glass of red wine with one meal a day. 5. Maintain an ideal body weight with a healthy diet and exercise.

4. Correct answers are 3 and 5. 1. The client is instructed to avoid spicy and acidic foods and any food that produces symptoms. 2. Eructation means belching, which is a symptom of GERD. 3. Clients should eat small, frequent meals and limit fluids with the meals to prevent reflux into the esophagus from a distended stomach. 4. Clients are encouraged to forgo all alcoholic beverages because alcohol relaxes the lower esophageal sphincter and increases the risk of reflux. 5. Clients should maintain an ideal body weight because obesity increases intraabdominal pressure, causing GERD. TEST-TAKING HINT: The word "any" in option "1" should give the test taker a clue that, unless there are absolutely no dietary restrictions, this is an incorrect answer. Option "2" requires knowledge of medical terminology.

98. Which intervention should the nurse include when discussing ways to help prevent potential episodes of gastroenteritis from Clostridium botulism? 1. Make sure all hamburger meat is well cooked. 2. Ensure all dairy products are refrigerated. 3. Discuss why campers should drink only bottled water. 4. Discard damaged canned goods.

4. Discard damaged canned goods. 98. 1. Well-cooked meat will help prevent gastroenteritis secondary to staphylococcal food poisoning. 2. Refrigerating dairy products will help prevent gastroenteritis secondary to eating foods kept at room temperature, causing staphylococcal food poisoning. 3. Drinking bottled water will help prevent gastroenteritis secondary to Escherichia coli found in contaminated water. 4. Any discolored food, food from a damaged can or jar, or food from a can or jar not having a tight seal should be destroyed without tasting or touching it. TEST-TAKING HINT: The test taker should be careful with words such as "all," "only," and "never"; few absolutes exist in the health-care field.

5. The nurse is caring for a client diagnosed with GERD. Which nursing interventions should be implemented? 1. Place the client prone in bed and administer nonsteroidal anti-inflammatory medications. 2. Have the client remain upright at all times and walk for 30 minutes three times a week. 3. Instruct the client to maintain a supine position and take antacids before meals. 4. Elevate the head of the bed (HOB) 30 degrees and discuss lifestyle modifications with the client.

4. Elevate the head of the bed (HOB) 30 degrees and discuss lifestyle modifications with the client. 5. 1. The client is encouraged to lie with the HOB elevated, but this is difficult to achieve when on the stomach. NSAIDs inhibit prostaglandin synthesis in the stomach, which places the client at risk for developing gastric ulcers. The client is already experiencing gastric acid difficulty. 2. The client will need to lie down at some time, and walking will not help with GERD. 3. The client should not lie supine flat on the back. The bed should be elevated. Antacids are taken 1 and 3 hours after a meal. 4. The HOB should be elevated to allow gravity to help in preventing reflux. Lifestyle modifications of losing weight, making dietary modifications, attempting smoking cessation, discontinuing the use of alcohol, and not stooping or bending at the waist all help to decrease reflux. TEST-TAKING HINT: Option "2" has an "all," which should alert the test taker to eliminate this option. If the test taker has no idea of the answer, lifestyle modifications are an educated guess for most chronic problems.

41. The client had an abdominal perineal resection and is being discharged. Which discharge information should the nurse teach? 1. The stoma should be a white, blue, or purple color. 2. Limit ambulation to prevent the pouch from coming off. 3. Take pain medication when the pain level is at an "8." 4. Empty the pouch when it is one-third to one-half full.

4. Empty the pouch when it is one-third to one-half full. 41. 1. The stoma should be light to a medium pink, the color of the intestines. A blue or purple color indicates a lack of circulation to the stoma and is a medical emergency. 2. The stoma should be pouched securely for the client to be able to participate in normal daily activities. The client should be encouraged to ambulate to aid in recovery. 3. Pain medication should be taken before the pain level reaches a "5." Delaying taking medication will delay the onset of pain relief, and the client will not receive full benefit from the medication. 4. The pouch should be emptied when it is one-third to one-half full to prevent the contents from becoming too heavy for the seal to hold and to prevent leakage from occurring. TEST-TAKING HINT: Normal mucosa is pink, not white, and clients are always encouraged to ambulate after surgery to prevent the complications related to immobility. Remember basic concepts when answering questions, especially about postoperative nursing care

50. The nurse is teaching the client diagnosed with diverticulosis. Which instruction should the nurse include in the teaching session? 1. Discuss the importance of drinking 1,000 mL of water daily. 2. Instruct the client to exercise at least three times a week. 3. Teach the client about eating a low-residue diet. 4. Explain the need to have regular bowel movements.

4. Explain the need to have regular bowel movements. 50. 1. The client should drink at least 3,000 mL of water daily to help prevent constipation. 2. The client should exercise daily to help prevent constipation. 3. The client should eat a high-fiber diet to help prevent constipation. 4. The client should have regular bowel movements. Frequency of bowel movements varies by individual, but daily or every 2 days is common. Constipation may cause diverticulitis, which is a potentially life-threatening complication of diverticulosis. TEST-TAKING HINT: The test taker must be careful to distinguish between -osis and -itis. Diverticulosis is the condition of having small pouches in the colon, and preventing constipation is the most important action the client can take to prevent diverticulitis (inflammation of the diverticulum).

109. The male client had abdominal surgery, and the nurse suspects the client has peritonitis. Which assessment data support the diagnosis of peritonitis? 1. Absent bowel sounds and potassium level of 3.9 mEq/L. 2. Abdominal cramping and hemoglobin of 14 g/dL. 3. Profuse diarrhea and stool specimens show Campylobacter. 4. Hard, rigid abdomen and WBC count 22 (103 cells/microL).

4. Hard, rigid abdomen and WBC count 22 (103 cells/microL). 109. 1. Absent bowel sounds indicate a paralytic ileus, not peritonitis, and the potassium level is within normal limits (3.5 to 5.3 mEq/L). 2. Abdominal cramping would not make the nurse suspect peritonitis, and the hemoglobin is normal (male 14 to 17 g/dL, female 11.7 to 15.5 g/dL). 3. Campylobacter is a cause of profuse diarrhea, but it does not support a diagnosis of peritonitis. 4. A hard, rigid abdomen indicates an inflamed peritoneum (abdominal wall cavity) resulting from an infection, which results in an elevated WBC level. TEST-TAKING HINT: The -itis of peritonitis means inflammation, and if the test taker has no idea what the answer is, an elevated WBC count should provide the key to selecting option "4" as the correct answer.

25. The nurse is assessing a client reporting abdominal pain. Which data support the diagnosis of a bowel obstruction? 1. Steady, aching pain in one specific area. 2. Sharp back pain radiating to the flank. 3. Sharp pain increases with deep breaths. 4. Intermittent colicky pain near the umbilicus.

4. Intermittent colicky pain near the umbilicus. 25. 1. Steady, aching pain is associated with a peritoneal inflammation, which may be secondary to a ruptured spleen or perforated ulcer or other abdominal organs. 2. Sharp pain in the back and flank indicate kidney involvement. 3. Sharp pain increasing with deep breaths indicates muscular involvement. 4. Intermittent and colicky pain located near the umbilicus is indicative of a small bowel obstruction; lumbar pain is indicative of colon involvement.

21. The client diagnosed with IBD is prescribed sulfasalazine. Which statement best describes the rationale for administering this medication? 1. It is administered rectally to help decrease colon inflammation. 2. This medication slows gastrointestinal (GI) motility and reduces diarrhea. 3. This medication kills the bacteria causing the exacerbation. 4. It acts topically on the colon mucosa to decrease inflammation.

4. It acts topically on the colon mucosa to decrease inflammation. 21. 1. Sulfasalazine (Azulfidine), a disease-modifying antirheumatic drug (DMARD), cannot be administered rectally. Mesalamine, a similar gastrointestinal anti-inflammatory, can be given by mouth, enema, or rectally. Corticosteroids may be administered by enema for the local effect of decreasing inflammation while minimizing the systemic effects. 2. Antidiarrheal agents slow the gastrointestinal motility and reduce diarrhea. 3. IBD is not caused by bacteria. 4. Sulfasalazine (Azulfidine), a DMARD, acts topically on the colonic mucosa to inhibit the inflammatory process. TEST-TAKING HINT: If the test taker doesn't know the answer, then the test taker could eliminate options "2" and "3" because they do not contain the word "inflammation"; IBD is inflammatory bowel disease.

114. The client developed a paralytic ileus after abdominal surgery. Which intervention should the nurse include in the plan of care? 1. Administer a laxative of choice. 2. Encourage the client to increase oral fluids. 3. Instruct the client to take deep breaths. 4. Maintain a patent nasogastric tube.

4. Maintain a patent nasogastric tube. 114. 1. The client is NPO; therefore, no medication would be administered. 2. The client is NPO, so no food or fluids are allowed. 3. Deep breathing will help prevent pulmonary complications but does not address the client's paralytic ileus. 4. A paralytic ileus is the absence of peristalsis; therefore, the bowel will be unable to process any oral intake. A nasogastric tube is inserted to decompress the bowel until surgical intervention or until bowel sounds return spontaneously. TEST-TAKING HINT: If the test taker realizes the stem of the question says part of the gastrointestinal system, the ileus, is paralyzed, the test taker should know allowing the client to take anything by mouth would be an inappropriate action, so options "1" and "2" could be eliminated. Deep breathing addresses the respiratory system, not the gastrointestinal system, so option "3" could also be eliminated.

11. The nurse identifies the client problem "alteration in gastrointestinal system" for the older client. Which statement reflects the most appropriate rationale for this problem? 1. Older clients have the ability to chew food more thoroughly with dentures. 2. Older clients have an increase in digestive enzymes, which helps with digestion. 3. Older clients have an increased need for laxatives because of a decrease in bile. 4. Older clients have an increase in bacteria in the GI system, resulting in diarrhea.

4. Older clients have an increase in bacteria in the GI system, resulting in diarrhea. 11. 1. Dentures are not an improvement over the client's own teeth in mastication. 2. The secretion of digestive enzymes and bile are decreased in older people, resulting in an alteration in nutrition and elimination. 3. Bile does not affect the motility of the intestines. The older client's perception of the need for laxatives is caused by the client's misunderstanding about normal bowel function. 4. When the motility of the gastrointestinal tract decreases, bacteria remain in the gut longer and multiply, which results in diarrhea.

135. The client has been experiencing difficulty and straining when expelling feces. Which intervention should the nurse discuss with the client? 1. Explain some blood in the stool will be normal for the client. 2. Instruct the client in manual removal of feces. 3. Encourage the client to use a cathartic laxative on a daily basis. 4. Place the client on a high-fiber diet.

4. Place the client on a high-fiber diet. 135. 1. Blood may indicate a hemorrhoid, but it is not normal to expel blood when having a bowel movement. 2. Nurses manually remove feces; it is not a self-care activity. 3. Cathartic use on a daily basis creates dependence and a narrowing of the lumen of the colon, creating a much more serious problem. 4. A high-fiber (residue) diet provides bulk for the colon to use in removing the waste products of metabolism. Bulk laxatives and fiber from vegetables and bran assist the colon to work more effectively. TEST-TAKING HINT: Blood is not normal in any circumstance. It may be expected but is not "normal" unless inside a vessel.

29. Which problems should the nurse include in the plan of care for the client diagnosed with peptic ulcer disease to observe for physiological complications? 1. Alteration in bowel elimination patterns. 2. Knowledge deficit in the causes of ulcers. 3. Inability to cope with changing family roles. 4. Potential for alteration in gastric emptying.

4. Potential for alteration in gastric emptying. 29. 1. There is no indication from the question there is a problem or potential problem with bowel elimination. 2. Knowledge deficit does not address physiological complications. 3. This client may have problems from changing roles within the family, but the question asks for potential physiological complications, not psychosocial problems. 4. Potential for alteration in gastric emptying is caused by edema or scarring associated with an ulcer, which may cause a feeling of "fullness," vomiting of undigested food, or abdominal distention. TEST-TAKING HINT: This question asks the test taker to identify a physiological problem identifying a complication of the disease process. Therefore, options "2" and "3" could be eliminated because they do not address physiological problems.

44. The nurse is caring for the client recovering from intestinal surgery. Which assessment finding requires immediate intervention? 1. Presence of thin, pink drainage in the Jackson Pratt. 2. Guarding when the nurse touches the abdomen. 3. Tenderness around the surgical site during palpation. 4. Reports of chills and feeling feverish.

4. Reports of chills and feeling feverish. 44. 1. Thin pink drainage is expected in the Jackson Pratt (JP) bulb. 2. Guarding is a normal occurrence when touching a tender area on the abdomen and does not require immediate intervention. 3. Tenderness around the surgical site is a normal finding and does not require intervention. 4. Reports of chills, sudden onset of fever, tachycardia, nausea, and hiccups are symptoms of peritonitis, which is a life-threatening complication.

25. Which assessment data support the client's diagnosis of gastric ulcer to the nurse? 1. Presence of blood in the client's stool for the past month. 2. Reports of a burning sensation moving like a wave. 3. Sharp pain in the upper abdomen after eating a heavy meal. 4. Reports of epigastric pain shortly after ingesting food.

4. Reports of epigastric pain shortly after ingesting food. 25. 1. The presence of blood does not specifically indicate the diagnosis of an ulcer. The client could have hemorrhoids or cancer, resulting in the presence of blood. 2. A wavelike burning sensation is a symptom of gastroesophageal reflux. 3. Sharp pain in the upper abdomen after eating a heavy meal is a symptom of gallbladder disease. 4. In a client diagnosed with a gastric ulcer, the pain usually occurs shortly after eating a meal. In contrast, a client diagnosed with a duodenal ulcer has pain beginning 2 to 3 hours after meals that is often relieved by eating. A duodenal ulcer often causes pain during the night due to nocturnal gastric acid secretion. TEST-TAKING HINT: This question asks the test taker to identify assessment data specific to the disease process. Many diseases have similar symptoms, but the timing of symptoms or their location may help rule out some diseases and provide the HCP with a key to diagnose a specific disease—in this case, peptic ulcer disease. Nurses are usually the major source of information for the health-care team.

33. The client is diagnosed with an acute exacerbation of IBD. Which food selection would be the best choice for a meal? 1. Roast beef on wheat bread and a milkshake. 2. Hamburger, french fries, and a cola. 3. Pepper steak, brown rice, and iced tea. 4. Roasted turkey, instant mashed potatoes, and water.

4. Roasted turkey, instant mashed potatoes, and water. 33. 1. Wheat bread and whole grains should be avoided, and most clients cannot tolerate milk products. 2. Fried foods such as hamburgers and french fries should be avoided. Raw fruits and vegetables such as lettuce and tomatoes are usually not tolerated. 3. Whole grains such as brown rice should be avoided. White rice can be eaten. Spicy meats and foods should be avoided. 4. Meats can be eaten if prepared by roasting, baking, or broiling. Vegetables should be cooked, not raw, and skins should be removed. Instant mashed potatoes do not have the skin. A low-residue diet should be eaten.

47. The nurse writes a psychosocial problem of "risk for altered sexual functioning related to new colostomy." Which intervention should the nurse implement? 1. Tell the client there should be no intimacy for at least 3 months. 2. Ensure the client and significant other are able to change the ostomy pouch. 3. Demonstrate with charts possible sexual positions for the client to assume. 4. Teach the client to protect the pouch from becoming dislodged during sex.

4. Teach the client to protect the pouch from becoming dislodged during sex. 47. 1. Intimacy involves more than sexual intercourse. The client can be sexually active whenever the wounds are healed sufficiently not to cause pain. 2. This is an appropriate nursing intervention for home care, but it has nothing to do with sexual activity. 3. The nurse is not a sexual counselor and would not have these types of charts. The nurse should address sexuality with the client but would not be considered an expert capable of explaining the advantages and disadvantages of sexual positioning. 4. A pouch that becomes dislodged during the sexual act would cause embarrassment for the client with body image issues already. TEST-TAKING HINT: Option "2" does not address the issue, and option "3" is outside of the nurse's professional expertise. Option "1" could be eliminated because of the word "no," which is an absolute word.

151. The occupational health nurse has had five clients come to the clinic reporting abdominal cramping, nausea, and vomiting. Which information should the nurse teach the employees to decrease the spread of this condition? 1. Teach the employees to cough into the sleeve. 2. Teach the housekeepers to use an antibacterial soap. 3. Teach the coworkers to get a hepatitis vaccine. 4. Teach the employees to wash their hands frequently.

4. Teach the employees to wash their hands frequently. 151. 1. This is a gastrointestinal issue, not a respiratory virus. 2. Antibacterial soap will not affect a virus. A virus is not a bacterium. 3. A hepatitis vaccine prevents hepatitis, but this is a gastrointestinal viral illness. 4. Hand washing will prevent the spread of the virus and decrease the risk for the employees. TEST-TAKING HINT: The test taker should remember basic infection control standards.

141. The client is placed on percutaneous endoscopic gastrostomy (PEG) tube feedings. Which occurrence warrants immediate intervention by the nurse? 1. The client tolerates the feedings being infused at 50 mL/hr. 2. The client pulls the nasogastric feeding tube out. 3. The client reports being thirsty. 4. The client is incontinent of green, watery stool.

4. The client is incontinent of green, watery stool. 141. 1. The client is tolerating the feeding change, so there is no need for immediate action. 2. The client has a PEG tube inserted into the stomach through the abdominal wall. The client does not have a nasogastric feeding tube. 3. Reports of being thirsty should be addressed; the client may require some ice chips in the mouth or oral care, but this is not a priority over assessing the client's ability to swallow. 4. This client needs to be cleaned immediately, the abdomen must be assessed, and a determination must be made regarding the type of feeding and the additives and medications being administered and skin damage occurring. This occurrence is the priority. TEST-TAKING HINT: The test taker must identify assessment data indicating a complication secondary to the disease process when the stem asks which occurrence warrants immediate intervention.

10. The client with a diagnosis of possible colon cancer is 2 hours post-sigmoidoscopy procedure. Which assessment data warrant immediate intervention by the nurse? 1. The client has hyperactive bowel sounds. 2. The client is eating a hamburger the family brought. 3. The client is sleepy and wants to sleep. 4. The client's BP is 96/60 and an apical pulse is 108.

4. The client's BP is 96/60 and an apical pulse is 108. 10. 1. The client has been NPO and had laxatives; therefore, hyperactive bowel sounds do not warrant immediate intervention. 2. The client is able to eat after the procedure, so this does not warrant immediate intervention. 3. The client received sedation during the procedure and may have been up during the night having bowel movements, resulting in the client being exhausted and sleepy. 4. These are clinical manifestations of hypovolemic shock requiring immediate intervention by the nurse.

53. The client is 2 hours postcolonoscopy. Which assessment data warrant immediate intervention by the nurse? 1. The client has a soft, nontender abdomen. 2. The client has a loose, watery stool. 3. The client has hyperactive bowel sounds. 4. The client's pulse is 104 and BP is 98/60.

4. The client's pulse is 104 and BP is 98/60. 53. 1. The client's abdomen should be soft and nontender; therefore, this finding would not require immediate intervention. 2. The client had to clean the bowel before the colonoscopy; therefore, the watery stool is expected. 3. The client was NPO and received bowel preparation before the colonoscopy; therefore, hyperactive bowel sounds might occur and do not warrant immediate intervention. 4. Bowel perforation is a potential complication of a colonoscopy. Therefore, clinical manifestations of hypotension—decreased BP and increased pulse—warrant immediate intervention from the nurse. TEST-TAKING HINT: This is an "except" question. The test taker is being asked to select which data are abnormal for a procedure. The test taker should remember any invasive procedure could possibly lead to hemorrhaging, and signs of shock should always be considered a possible correct answer.

40. The nurse is planning the care of a client with an abdominal-perineal resection for cancer of the colon. Which interventions should the nurse implement? Select all that apply. 1. Provide meticulous skincare to the stoma. 2. Assess the flank incision. 3. Maintain the indwelling catheter. 4. Irrigate the (JP) drains every shift. 5. Position the client semirecumbent.

40. Correct answers are 1, 3, and 5. 1. Colostomy stomas are openings through the abdominal wall into the colon, through which feces exit the body. Feces can be irritating to the abdominal skin, so careful and thorough skin care is needed. 2. There are midline and perineal incisions, not flank incisions. 3. The client will have an indwelling catheter to monitor the urine output after surgery, assessing renal perfusion. 4. Jackson Pratt drains are emptied every shift, but they are not irrigated. 5. The client should not sit upright because this causes pressure on the perineum. TEST-TAKING HINT: The test taker could eliminate option "2" because flank and abdominal perineal are not in the same areas. This is an alternative-type question requiring the test taker to choose more than one option.

45. The nurse is preparing to hang a new bag of total parenteral nutrition for a client with an abdominal perineal resection. The bag has 1,500 mL of 50% dextrose, 10 mL of trace elements, 20 mL of multivitamins, 20 mL of potassium chloride, and 500 mL of lipids. The bag is to infuse over the next 24 hours. At what rate should the nurse set the pump?

45. 85 mL/hr. First, determine the total amount to be infused over 24 hours: 1500 + 500 + 20 + 20 = 2,040 mL over 24 hours Then, determine the rate per hour: 2,040 ÷ 24 = 85 mL/hr TEST-TAKING HINT: Check and recheck calculations. The division should be carried out to the second or third decimal place before rounding.

47. The client is newly diagnosed with irritable bowel syndrome (IBS). Which interventions should the nurse teach the client to reduce symptoms? Select all that apply. 1. Instruct the client to avoid drinking fluids with meals. 2. Explain the need to decrease gluten and foods that contain FODMAPs. 3. Teach the client how to perform gentle perianal care. 4. Encourage the client to attend a support group meeting. 5. Reinforce the need to take a probiotic tablet daily.

47. Correct answers are 1, 2, 4, and 5. 1. Avoidance of fluids during meals will help prevent abdominal distention, which causes symptoms of IBS. Do not confuse inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). 2. Avoidance of gluten and foods that contain FODMAPs. Gluten, found in wheat, barley, and rye, can contribute to IBS symptoms. A low FODMAP diet is a special diet that reduces certain foods containing carbohydrates—apples, beans, dairy products, honey, and sweeteners ending in"-ol" that can improve symptoms (National Institute of Diabetes and Digestive and Kidney Diseases, 2017). 3. Clients diagnosed with IBS do have altered bowel habits such as diarrhea and constipation, but perianal care will not prevent IBS. 4. IBS does have a psychological component, a client newly diagnosed with IBS may find a support group meeting assists in coping with diet changes and IBS management to reduce symptoms. 5. Probiotics are encouraged by physicians and the efficacy is being researched (NIDDK, 2017).

50. The client is admitted to the emergency department reporting acute epigastric pain and vomiting a large amount of bright red blood at home. Which interventions should the nurse implement? Rank in order of priority. 1. Assess the client's vital signs. 2. Insert a nasogastric tube. 3. Begin iced saline lavage. 4. Start an IV with an 18-gauge needle. 5. Type and crossmatch for a blood transfusion.

50. Correct order is 1, 4, 5, 2, 3. 1. The nurse should assess the vital signs to determine if the client is in hypovolemic shock. The stem of the question does not provide information indicating the client is hypovolemic. The client's perception of a large amount of blood may differ from the nurse's assessment. 4. The nurse should start the IV line to replace fluid volume. 5. While the nurse is starting the IV, a blood sample for typing and cross-matching should be obtained and sent to the laboratory. 2. An NG tube should be inserted so that direct iced saline can be instilled to cause constriction, which will decrease the bleeding. 3. The iced saline lavage will help decrease bleeding.

56. The nurse is preparing to administer a 250 mL intravenous antibiotic to the client. The medication must infuse in 1 hour. An intravenous pump is not available, and the nurse must administer the medication via gravity with IV tubing at 10 gtts/min. At what rate should the nurse infuse the medication?

56. 42 gtts/min. The nurse must use the formula: or, 2,500 ÷ 60 minutes = 41.66 gtts/min, which should be rounded up to 42 gtts/min. TEST-TAKING HINT: The test taker must know how to calculate dosage and understand calculation questions. Remember to use the drop-down calculator if needed; the test taker can ask for an erase slate during state board examinations.

58. The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis? Select all that apply. 1. Eat a high-fiber diet. 2. Increase fluid intake. 3. Elevate the HOB after eating. 4. Walk 30 minutes a day. 5. Take an antacid every 2 hours.

58. Correct answers are 1, 2, and 4. 1. A high-fiber diet will help to prevent constipation, which is the primary reason for diverticulitis. 2. Increased fluids will help keep the stool soft and prevent constipation. 3. This will not do anything to help prevent diverticulitis. 4. Exercise will help prevent constipation. 5. No medications are prescribed to prevent an acute exacerbation of diverticulitis. Antacids are used to neutralize hydrochloric acid in the stomach. TEST-TAKING HINT: This is an alternate-type question where the test taker must select more than one option. To correctly identify the answers, the test taker should think about what part of the GI system is affected. Knowing diverticulosis occurs in the sigmoid colon would help eliminate options "3" and "5" because these would be secondary to stomach disorders.