Test #4

Which is the priority nursing diagnosis when providing care for a patient with oral trauma? a. Risk for imbalanced nutrition, less than body requirements b. Risk for infection c. Risk for ineffective airway clearance d. Risk for bleeding

C

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best? a. Assess the client's gag reflex. b. Tell the client to wait 4 hours. c. Remind the client to remain NPO. d. Allow the client cool liquids only.

A

The nurse is providing care to a patient who reports diffuse abdominal pain. Upon assessment, the nurse notes absent bowel sounds and abdominal distension. Based on this data, which medical diagnosis does the nurse suspect? a. Cirrhosis b. Bowel obstruction c. Appendicitis d. Cholelithiasis

B

Which assessment data indicates to the nurse that the patient may be experiencing hepatic encepalopathy due to increased ammonia level, a complication of cirrhosis? a. Yellow skin b. Personality changes c. Epistaxis d. Clay-colored stool

B

Which diagnostic test should the nurse anticipate to rule out peritonitis when providing care to a patient diagnosed with peptic ulcer disease? Select one: a. Hematocrit b. White blood cell c. Stool antigen d. Fecal occult blood

B

Which food should the nurse encourage for a patient, diagnosed with gastritis, when a clear liquid diet is prescribed? a. Pudding b. Broth c. Milk d. Cream soup

B

Which is the correct sequence for the abdominal exam? a. Inspection, auscultation, percussion, and palpation b. Inspection, auscultation, palpation, and percussion c. Inspection, percussion, palpation, and auscultation d. Inspection, palpation, percussion, and auscultation

B

Which organ functions as a main site for metabolizing drugs and may become impaired with the aging process? a. Spleen b. Liver c. Large intestine d. Stomach

B

Which patient activity should the nurse discourage for a patient who is diagnosed with stomatitis? a. Regular dental checkups b. Alcohol-based mouth rinses c. Mouth care after each meal d. Soft-bristle toothbrush

B

A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best? a. Ask the client to call back if this happens again today. b. Tell the client to come in to the clinic this afternoon. c. Remind the client that a small amount of bleeding is possible. d. Instruct the client to go to the emergency department.

C

A client is 1 day postoperative after having Zenker's diverticula removed. The client has a nasogastric (NG) tube to suction, and for the last 4 hours there has been no drainage. There are no specific care orders for the NG tube in place. What action by the nurse is most appropriate? a. Remove and reinsert the NG tube. b. Document the findings as normal. c. Notify the surgeon about this finding. d. Irrigate the NG tube with sterile saline.

C

A client is in the emergency department with an esophageal trauma. The nurse palpates subcutaneous emphysema in the mediastinal area and up into the lower part of the client's neck. What action by the nurse takes priority? a. Start two large-bore IVs. b. Prepare for immediate surgery. c. Assess the client's oxygenation. d. Facilitate a STAT chest x-ray.

C

Which are risk factors for the development of hiatal hernia? a. Alcohol abuse b. Oral sex c. Tobacco use d. Pregnancy e. Obesity

C,D,E

The nurse is performing an abdominal assessment of a patient who is exhibiting pain in the area of McBurney's point. Based on this data, which diagnosis does the nurse suspect? a. Cholelithiasis b. Pneumonia c. Cholecystitis d. Appendicitis

D

The nurse is providing care to a patient who is diagnosed with esophageal cancer. Which assessment finding indicates metastasis to the liver? a. Dysphagia b. Rhonchi c. Emesis d. Jaundice

D

The nurse is providing care to a patient who is hospitalized for complications associated with peptic ulcer disease. Which data supports the patient is experiencing a gastrointestinal bleed? Select one: a. Absent bowel sounds b. Emesis of undigested food c. Pain in the right arm d. Tarry stools

D

The nurse is providing care to a patient who scores a 4 with the Ranson's score. Which conclusion by the nurse is most appropriate? a. This patient has a 40% chance of mortality. b. This patient has a 100% chance of mortality. c. This patient has a 2% chance of mortality. d. This patient has a 15% chance of mortality.

D

Which bowel sound noted by the nurse during the gastrointestinal assessment indicates an early bowel obstruction? a. Epigastric b. Hyperperistaltic c. Hypoperistaltic d. Absent

D

The nurse is providing care to a patient who is hospitalized for complications associated with peptic ulcer disease. Which data supports the patient is experiencing a perforation? a. Tarry stools b. Pain in the right arm c. Emesis of undigested food d. Absent bowel sounds

B

The nurse is providing care to a patient who is status post partial gastrectomy for the treatment of gastric carcinoma. Which should the nurse include in the plan of care to decrease the risk of dumping syndrome? a. Providing larger meals at less frequent intervals b. Providing smaller meals at more frequent intervals c. Providing liquids and solids together d. Providing liquids only

B

The nurse is providing care to a patient who is suspected of having esophageal cancer. Which diagnostic test should the nurse anticipate for this patient first? a. Computed tomography b. Upper GI/ Barium Swallow c. Endoscopic ultrasonography d. Positron emission tomography

B

A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, "I need to have a bowel movement." The nurse notes that this is the first bowel movement after the procedure. Which action should the nurse take that is a priority? a. Gather supplies to collect a stool sample for the laboratory. b. Make sure the call light is in reach to signal completion. c. Stay with the client while providing privacy. d. Obtain a bedside commode for the client to use.

C

The nurse is providing care to a patient who is being admitted to rule out acute pancreatitis. Which item found in the patient's history increases the patient's risk for this disease process? a. Cystic fibrosis b. Systemic lupus c. Alcoholism d. Hypertriglyceridemia

C

Which assessment data would indicate active bleeding for a patient who is diagnosed with peptic ulcer disease? a. Coffee-ground emesis b. Absent bowel sounds c. Bright red blood in emesis d. Black tarry stools with a foul odor

C

The nurse is providing care to several patients in an outpatient clinic. Which patient is at high risk of developing gastroesophageal reflux disorder (GERD)? a. A patient who follows a strict vegetarian diet b. A patient who is six weeks pregnant c. A patient who drinks one glass of wine monthly d. A patient who is morbidly obese

D

The nurse is teaching a patient about the approved therapeutic agents for acute pancreatitis. Which patient statement indicates the need for further education? a. "Opioids are used to treat pain." b. "Spasmolytics are used to relax the sphincter of Oddi." c. "Anticholinergics are used to decrease the release of pancreatic enzymes." d. "Proton pump inhibitors are used to increase gastric acid secretions."

D

Which patient data supports Ranson's criteria for acute pancreatitis at admission? a. WBC less than 16,000/mL b. Patient age is 43 years c. Glucose greater than 200 mg/dL or >10 mmol/L d. BUN greater than 5 mg/dL

D

Which physical assessment data collected by the nurse supports the patient's diagnosis of early gastric cancer? a. Anorexia b. Nausea and vomiting c. Iron-deficiency anemia d. Palpable epigastric mass

D

A nurse works on the surgical unit. After receiving the hand-off report, which client should the nurse see first? a. Client who had an esophagectomy with a respiratory rate of 32/min b. Client who underwent diverticula removal with a pulse of 100/min c. Client who underwent hernia repair, reporting incisional pain of 7/10 d. Client who had esophageal dilation and is attempting first postprocedure oral intake

A

A patient is admitted to the emergency department reporting a burning pain in the chest of a 7 on a 0 to 10 pain scale. Gastroesophageal reflux disorder (GERD) secondary to hiatal hernia is diagnosed. Based on this data, which is the priority nursing diagnosis? a. Acute Pain b. Ineffective Health Maintenance c. Dysfunctional Gastrointestinal Motility d. Anxiety

A

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which menu selection indicates that the client correctly understands the dietary teaching? Select one: a. Broiled chicken with brown rice, steamed broccoli, glass of apple juice b. Baked tilapia, fresh green beans, cup of coffee with low-fat milk c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Ham sandwich on white bread, cup of applesauce, glass of diet cola

A

The nurse has implemented a care plan for an adult patient with gastroesophageal reflux disorder (GERD). On the next clinic visit, which statement by the patient indicates adherence to the plan of care? a. "I've lost six pounds because I eat every three hours and never before bed." b. "I have switched from margaritas to wine." c. "Spandex camisoles are worth heartburn." d. "I take a TUMS with the ranitidine to make it work better."

A

The nurse is providing care to a patient who is diagnosed with acute gastritis. Which assessment data supports this diagnosis? a. Epigastric pain b. Weight gain c. Increased appetite d. Increased blood pressure

A

The nurse is reviewing the health history for a patient who is diagnosed with chronic pancreatitis. Which data supports the patient's current diagnosis? a. Cystic fibrosis b. Hypotriglyceridemia c. Trauma d. Gallstones

A

Which diagnostic test should the nurse anticipate when providing care to a patient who is suspected of having a hiatal hernia? a. Magnetic resonance imaging (MRI) b. Complete blood count c. Esophagogastroduodenoscopy (EGD) d. Lower abdominal x-ray

C

The nurse is providing patient education for a patient who is diagnosed with gastritis. Which statement indicates the need for further education? a. "I will take an antacid if my symptoms continue." b. "I will take aspirin for headaches from now on." c. "I will eat smaller, more frequent meals." d. "I will eat bland, nonspicy foods."

C

Which principal risk factor should the nurse assess for during the health history in a patient who is suspected of having peptic ulcer disease? a. Anxiety b. Use of acetaminophen c. Stress d. H. pylori infection

D

A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find? a. Severe, steady right lower quadrant pain b. Abdominal pain that increases with knee flexion c. Abdominal pain associated with nausea and vomiting d. Marked peristalsis and hyperactive bowel sounds

A

A nurse cares for a client who has chronic cirrhosis from substance abuse. The client states, "All of my family hates me." How should the nurse respond? a. "I will help you identify a support system." b. "You must attend Alcoholics Anonymous." c. "You should make peace with your family." d. "This is not unusual. My family hates me too."

A

Which drug prescription should the nurse anticipate for a patient, diagnosed with hemorrhoids, to decrease pain? a. Benzocaine b. Hydrocortisone c. Witch hazel d. Zinc oxide

A