Adult Nursing GI, Cardio

Several days postoperatively, a client reports pain, tenderness, and redness of the right calf. Which signs and symptoms are critical for the nurse to access for next? Nausea and abdominal distention Back pain and hematuria Chest pain and SOB Similar findings in the right arm

-Chest pain and SOB Calf pain suggests that the client may have a venous thromboembolism (VTE); Place on bedrest with leg elevated until anticoagulant therapy is started; To prevent VTE, keep the knee gatch flat; Do not place pillows behind the knees, perform leg exercises; apply antiembolism hose

Which pulse site is located below the inguinal ligament and is frequently used to assess the client's pulse during cardiac arrest? Posterior tibial pulse Femoral pulse Dorsal pedis pulse Popliteal pulse

-Femoral pulse Femoral pulse site is frequently used when a client is experiencing shock or cardiac arrest; It is located below the inguinal ligament and midway between the pubic symphysis and anterior iliac spine

Which is the correct way to accurately asses the client's radial pulse? Locate pulse on inner wrist, count for 30 seconds X 2 Locate pulse on inner wrist, count for 60 seconds divided by 2 Locate pulse on inner elbow, count for 30 seconds X 2 Locate pulse on inner elbow, count for 60 seconds divided by 2

-Locate pulse on inner wrist, count for 30 seconds X 2 This is the correct technique for measuring the radial pulse; When assessing radial pulse, use the pads of the first two or three fingers on the radial side of the wrist, have client relax the arm with the palm down, lightly press until pulse can be palpated, and count for 30 seconds if regular or for one minute (60 seconds) if irregular

The nurse identifies the correct area to assess the apical pulse is which location? Second intercostal space to right of the sternum Third intercostal space to left of sternum Fifth intercostal space at the left midclavicular line Fifth intercostal space to the left of the sternum

-Fifth intercostal space at the left midclavicular line

The nurse cares for the client with hypertension. The client tells the nurse "I no longer take my medication" Which is the most appropriate nursing action? Call the HCP Tell the client there is no choice but to take the medication Inform the client to check BP daily, and with increase should start taking meds again Explore reasons for stopping the medication

-Explore reasons for stopping the medication The client may have stopped taking the medication due to adverse effects such as orthostatic hypotension or sexual dysfunction; both are very common adverse effects; Perhaps the cost of the medication is prohibitive; By discerning the reason for the discontinuation of the medication, the nurse can plan and implement care for the client

A nurse is giving a client barium swallow test. What is the most important assessment a nurse would make to ensure that a client does not retain any barium after a barium swallow? Placing any stool passed in a specific preservative. Monitoring the stool passage and its color. Observing the color of urine. Monitoring the volume of urine.

Monitoring the stool passage and its color. Explanation: Monitoring stool passage and its color will ensure that the client remains barium free following a barium swallow test. The white or clay color of the stool would indicate barium retention. The stool should be placed in a special preservative if the client undergoes a stool analysis. Observing the color and volume of urine will not ensure that the client is barium free because barium is not eliminated through urine but through stool.

What part of the GI tract begins the digestion of food? Mouth Duodenum Esophagus Stomach

Mouth Explanation: Food that contains starch undergoes partial digestion in the mouth when it mixes with the enzyme salivary amylase, which the salivary glands secrete. Food that contains starch undergoes partial digestion in the mouth.

The client describes a test previously completed to detect a small bowel obstruction prior to admission to the hospital. The client states that the test involved insertion of a tube through the nose and lasted over 6 hours. The nurse determines which test name should be documented? upper GI enteroclysis abdominal ultrasound magnetic resonance imaging positron emission tomography

upper GI enteroclysis Explanation: Enteroclysis is a double contrast study where a duodenal tube is inserted and 500 to 1000 mL of thin barium sulfate suspension and then methylcellulose is infused. Fluoroscopy is used to visualize the filling of the intestinal loops over a period of up to 6 hours. The test is used for detection of small bowel obstruction and diverticuli. Abdominal ultrasound, magnetic resonance imaging, and positron emission tomography do not involve insertion of a duodenal tube.

The nurse teaches the client with angina prior to discharge. It is most important for the client to report which behavior? Pain following sexual activity A headache after taking nitroglycerin A change in the character of the pain Pain after eating a large meal

-A change in the character of the pain Change in the character of pain in which the pain would radiate or be accompanied by diaphoresis would be an important sign for a client and family to recognize; Client can resume sexual activity when they can tolerate the physical activity of climbing two flights of stairs ot walking one city block without SOB or chest pain; should maintain a supine position and not have intercourse after a heavy meal; A headache is a side effect of nitroglycerin; Contact health provider if client experiences dizziness, faintness, or SOB with activity

The nurse reviews the care of a postoperative client with a nursing student. The nursing student identifies which intervention to prevent thromboembolism? Maintain bed rest for the first 24 hours postoperatively Administer oxygen therapy via nasal cannula Apply an intermittent compression device to the legs Administer beta blocking agents

-Apply intermittent compression device to the legs This fosters effective circulation; Thrombus formation in the deep veins in the legs may be a source of a pulmonary embolus

The nurse identifies that which risk factor is most likely to contribute to an elevation of the client's BP? High pressure job Daily vitamins One glass of wine per day Daily exercise

-High pressure job Stress is an important factor in the development of hypertension; other risk factors include family history of hypertension, high sodium intake, and excessive calorie consumption

Which is the correct action for the nurse to take when monitoring an adult client's BP? Position the cuff loosely 2-3" above the site of brachial pulsation Position the client's arm below heart level Rapidly inflate the cuff to 200 mm Hg Record the first and fifth Kortokoff sounds as the BP reading

-Record the first and fifth Korotkoff sound as the BP reading

The nurse is caring for a man who has experienced a spinal cord injury. Throughout his recovery, the client expects to gain control of his bowels. The nurse's best response to this client would be which of the following? "It is not going to happen. Your nerve cells are too damaged." "Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact." "Over time, the nerve fibers will regrow new tracts, and you can have bowel movements again." "Wearing an undergarment will become more comfortable over time."

"Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact." Explanation: The act of defecation is a spinal reflex involving the parasympathetic nerve fibers. Normally, the external anal sphincter is maintained in a state of tonic contraction. With a spinal cord injury, the client no longer has this nervous system control and is often incontinent.

The cardiac nurse instructs a client scheduled to receive a pacemaker how the usual cardiac conduction cycle flows. Which structure does the nurse identify as the natural pacemaker of the heart? AV node Purkinje fibers Bundle of His Sinoatrial node

-Sinoatrial (SA) node Located in the junciton of the superior vena cava and the right atrium; regulates heart rate, rhythm, and regularity

The nurse instructs the client about hypertension. Which client statement indicates teaching is successful? "I will be able to tell when my BP is elevated" "Hypertension is caused by eating too much salt" "I can discontinue the medication when my BP goes down" "I know I must see my health care provider on a regular basis"

- "I know I must see my health care provider on a regular basis" Hypertension is a serious medical condition that must be constantly monitored

The nurse is monitoring a client receiving treatment for hypertension. Which blood pressure reading indicates to the nurse that the treatment is successful? 120/78 180/90 190/100 170/110

- 120/78 One of the goals of hypertensive therapy is to maintain a systolic BP of 120 or below and a diastolic pressure below 80

The nurse teaches a class about hypertension at a health fair. Which statement best describes why a person diagnosed with hypertension should not smoke? Smoking causes the arteries to constrict The tars in smoke cause changes in lung tissue The lungs are damaged by smoking Smoking residues build up in the bladder

-Smoking causes the arteries to constrict Hypertension is an arterial disease and smoking vasoconstricts which further elevates BP

When completing a nutritional assessment of a patient who is admitted for a GI disorder, the nurse notes a recent history of dietary intake. This is based on the knowledge that a portion of digested waste products can remain in the rectum for how many days after a meal is digested? 1 day 2 days 3 days 4 days

3 days Explanation: As much as 25% of the waste products from a meal may still be in the rectum 3 days after a meal is ingested.

When assisting with preparing a client scheduled for a barium swallow, which of the following would be appropriate to include? Avoid smoking for at least 12 to 24 hours before the procedure. Take vitamin K before the procedure. Take three cleansing enemas before the procedure. Avoid the intake of red meat before the procedure.

Avoid smoking for at least 12 to 24 hours before the procedure. Explanation: The nurse should instruct the client to avoid smoking for at least a day before the procedure of barium swallow because smoking stimulates gastric motility. The client is advised to take vitamin K before a liver biopsy and instructed to take three cleansing enemas before a barium enema. Instruction to avoid red meat would be appropriate for a client who is having a Hemoccult test.

The nurse assesses the apical heart rate in an infant. Where does the nurse locate the point of maximum intensity (PMI)? Between the 3rd and 4th left intercostal space At the 5th intercostal space to the right of the midclavicular line In the aortic area Between the 4th and 5th intercostal space, medial to the left midclavicular line

Between the 4th and 5th intercostal space, medial to the left midclavicular line Heartbeat is most easily heard at the point of maximum intensity; apical pulse is where the impulse of the left ventricle is felt most strongly; this is the point of maximal impulse (PMI); location: between the fourth and fifth intercostal space to the left of the midclavicular line in the infant

Which of the following is considered the gold standard for the diagnosis of liver disease? Biopsy Paracentesis Cholecystography Ultrasonography

Biopsy Explanation: Liver biopsy is considered the gold standard for the diagnosis of liver disease. Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions. Cholecystography and ultrasonography may be used to detect gallstones.

The nurse is to obtain a stool specimen from a client who reported that he is taking iron supplements. The nurse would expect the stool to be which color? Dark brown Green Red Black

Black Explanation: Ingestion of iron can cause the stool to turn black. Meat protein causes stool to appear dark brown. Ingestion of large amounts of spinach may turn stool green while ingestion of carrots and beets may cause stool to turn red.

When examining the skin of a client who is dehydrated due to fluid losses from the gastrointestinal tract, which of the following would be most important? Checking if the skin is discolored Checking if the mucous membranes are dry Examining the sclera if it is yellow Observing for distended abdominal veins

Checking if the mucous membranes are dry Explanation: Mucous membranes may be dry, and skin turgor may be poor in clients suffering from dehydration as a result of fluid losses from the GI tract. Checking the skin for discoloration and inspecting the sclera if it is yellow is taken into consideration when the client could have symptoms of jaundice, not fluid losses. Distended abdominal veins are not associated with dehydration.

A client is scheduled for several diagnostic tests to evaluate gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when the client identifies which test as not requiring the use of a contrast medium? Small bowel series Computer tomography Colonoscopy Upper GI series

Colonoscopy Explanation: A colonoscopy is a direct visual examination of the entire large intestine. It does not involve the use of a contrast agent. Contrast medium may be used with a small bowel series, computed tomography, and upper GI series.

The nurse assess the cardiac status of the client and identifies an increased pulse pressure. Pulse pressure can best be described by which definition? Difference between systolic and diastolic BP The intensity of peripheral pulses Difference between the apical pulse and radial pulse Volume of stroke and heart rate

Difference between systolic and diastolic BP Pulse pressure is the difference between systolic and diastolic BP readings; It serves as an indirect measurement of cardiac output; A difference of 30 - 40 mm Hg is considered normal; A narrowed or lowered pulse pressure can indicate hypovolemia, heart failure, shock, mitral stenosis; A widened or increased pulse pressure can indicate slow heart rate, atherosclerosis, hypertension

A few hours after eating hot and spicy chicken wings, a client presents with lower chest pain. He wonders if he is having a heart attack. How should the nurse proceed first? Further investigate the initial complaint. Explain that fatty foods can mimic chest pain. Call for an immediate electrocardiogram. Administer an over-the-counter antacid tablet.

Further investigate the initial complaint. Explanation: While fatty foods can cause discomfort similar to chest pain, the nurse must fully assess all the client's symptoms. Investigation of chief complaint begins with a complete history. The underlying cause of pain influences the characteristics, duration, pattern, location, and distribution of pain.

The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? Use all options. 1Inspection 2Auscultation 3Percussion 4Palpation

Inspection, Auscultation, Percussion, Palpation Explanation: The nurse is correct to assess the abdomen in a specific order to be able to judge the undisturbed status of the abdominal region. Begin with inspection of the abdomen using the nurse's assessment skills. Next, auscultate the abdomen before percussing and finally palpating.

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The health care provider begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption? Intrinsic factor Hydrochloric acid Histamine Liver enzyme

Intrinsic factor Explanation: Vitamin B12 absorption depends on intrinsic factor, which is secreted by parietal cells in the stomach. The vitamin binds with intrinsic factor and is absorbed in the ileum. Hydrochloric acid, histamine, and liver enzymes don't influence vitamin B12 absorption.

Swallowing is regulated by which area of the central nervous system (CNS)? Medulla oblongata Pons Cerebellum Hypothalamus

Medulla oblongata Explanation: Swallowing begins as a voluntary act that is regulated by the swallowing center in the medulla oblongata of the CNS. The act of swallowing requires the innervations of five cranial nerves (CNs), especially CN V, VII, IX, X, and XII. Swallowing is not regulated by the pons, cerebellum, or hypothalamus.

The nurse is assisting the health care provider with a gastric acid stimulation test for a client. What medication should the nurse prepare to administer subcutaneously to stimulate gastric secretions? Pentagastrin Atropine Glycopyrronium bromide Acetylcysteine

Pentagastrin Explanation: The gastric acid stimulation test usually is performed in conjunction with gastric analysis. Histamine or pentagastrin is administered subcutaneously to stimulate gastric secretions.

Which of the following is an enzyme secreted by the gastric mucosa? Pepsin Trypsin Ptyalin Bile

Pepsin Explanation: Pepsin is secreted by the gastric mucosa. Trypsin is secreted by the pancreas. The salivary glands secrete ptyalin. The liver and gallbladder secrete bile.

A group of students are studying for an examination on the gastrointestinal (GI) system and are reviewing the structures of the esophagus and stomach. The students demonstrate understanding of the material when they identify which of the following as the opening between the stomach and duodenum? Cardiac sphincter Hypopharyngeal sphincter Ileocecal valve Pyloric sphincter

Pyloric sphincter Explanation: The pyloric sphincter is the opening between the stomach and duodenum. The cardiac sphincter is the opening between the esophagus and the stomach. The hypopharyngeal sphincter or upper esophageal sphincter prevents food or fluids from re-entering the pharynx. The ileocecal valve is located at the distal end of the small intestine and regulates flow of intestinal contents into the large intestine.

Following ingestion of carrots or beets, the nurse would expect which alteration in stool color? Red Black Yellow Milky white

Red Explanation: Carrots or beets will tend to change the stool color to red. Black stools are associated with iron, licorice, and charcoal. Senna is associated with yellow stools. A milky white stool is associated with administration of barium.

The nurse is preparing to examine the abdomen of a client who reports a change in bowel pattern. The nurse would place the client in which position? Supine with knees flexed Knee-chest Lithotomy Left Sim's lateral

Supine with knees flexed Explanation: When examining the abdomen, the client lies supine with knees flexed. This position assists in relaxing the abdominal muscles. The lithotomy position commonly is used for a female pelvic examination and to examine the rectum. The knee-chest position can be used for a variety of examinations, most commonly the anus and rectum. The left Sim's lateral position may be used to assess the rectum or vagina and to administer an enema.

The nurse prepares a client for a barium enema. The nurse should place the client on which diet prior to the procedure? high-fiber diet 1 to 2 days prior soft diet 1 day prior nothing by mouth (NPO) 2 days prior clear liquids day before

clear liquids day before Explanation: The nurse should place the client on clear liquids the evening before the procedure, a low-residue diet 1 to 2 days before the test, and NPO at midnight in preparation for the barium enema.

Cystic fibrosis, a genetic disorder characterized by pulmonary and pancreatic dysfunction, usually appears in young children but can also affect adults. If the pancreas was functioning correctly, where would the bile and pancreatic enzymes enter the GI system? duodenum jejunum ileum cecum

duodenum Explanation: The duodenum, which is approximately 10 inches long, is the first region of the small intestine and the site where bile and pancreatic enzymes enter.

The major carbohydrate that tissue cells use as fuel is: chyme. proteins. glucose. fats.

glucose. Explanation: Glucose is the major carbohydrate that tissue cells use as fuel. Proteins are a source of energy after they are broken down into amino acids and peptides. Chyme stays in the small intestine for 3 to 6 hours, allowing for continued breakdown and absorption of nutrients. Ingested fats become monoglycerides and fatty acids by the process of emulsification.

The nurse recognizes which change of the gastrointestinal system is an age-related change? increased motility hypertrophy of the small intestine weakened gag reflex increased mucus secretion

weakened gag reflex Explanation: A weakened gag reflex is an age-related change of the GI system. There is decreased motility, atrophy of the small intestine, and decreased mucus secretion.

A home care nurse is caring for a client with reports of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test? "I'll avoid eating or drinking anything 6 to 8 hours before the test." "I'll drink full liquids the day before the test." "There is no need for special preparation before the test." "I'll take a laxative to clear my bowels before the test."

"I'll avoid eating or drinking anything 6 to 8 hours before the test." Explanation: The client demonstrates understanding of a barium swallow when stating he or she must refrain from eating or drinking for 6 to 8 hours before the test. No other preparation is needed. Before a lower GI series, the client should eat a low-residue or clear liquid diet for 2 days and take a potent laxative and an oral liquid preparation.

The nurse cares for the client diagnosed with a left hip fracture that has been repaired. The nurse understands which signs indicate a complication of long term immobility? Unilateral edema +2 posterior tibialis Dorsiflexion 1 second capillary refill

-Unilateral edema Indicates swelling form impaired venous return from a venous thrombosis

The nurse cares for clients on prolonged bed rest. Which commonly ordered intervention should the nurse include when caring for the clients? Use of sequential compression devices (SCD) Client education about antibiotic therapy A reduced calorie diet Isometric and isotonic exercises

-Use of sequential compression devices (SCD) Venous thromboembolism (VTE) is a serious complication of prolonged bed rest and immobility; SCDs are commonly ordered to prevent clot formation and promote tissue integrity by interrupting the venous stasis associated with prolonged bed rest and immobility; VTE is an aggregate of platelets attached to a vein wall; Risk factors include pregnancy, immediate postpartum period, prolonged immobility, use of oral contraceptives, sepsis, smoking, dehydration, HF, and trauma

Specific disease processes and ingestion of certain foods and medications may change the appearance of the stool. If blood is shed in sufficient quantities into the upper gastrointestinal (GI) tract, it produces which change in the stool appearance? Tarry-black Bright red Blood-streaked Dark brown

Tarry-black Explanation: If the blood is shed in sufficient quantities into the upper GI tract, it produces a tarry-black color, whereas blood entering the lower portion of the GI tract or passing rapidly though will cause the stool to appear bright or dark red. Lower rectal or anal bleeding is suspected if there is streaking of the blood on the surface of the stool or if blood is noted on toilet tissue. Stool is normally light or dark brown.

When preparing a client for magnetic resonance imaging (MRI) of the abdomen, which statement would indicate the need to notify the health care provider? "I haven't had anything to eat or drink since midnight last night." "I really don't like to be in small, enclosed spaces." "I left all my jewelry and my watch at home." "I brought earphones to shut out the loud noise."

"I really don't like to be in small, enclosed spaces." Explanation: An MRI scanner is a narrow, tunnel-like machine that will enclose the client during the test. Clients who are claustrophobic (fear enclosed spaces) may need sedation because it is imperative that they lie still and not panic during the test. Therefore, the nurse should notify the health care provider about the client's statement. Typically, the client is NPO for 6 to 8 hours before the test, and he or she must remove any metal objects, credit cards, jewelry, and watch before the test. The machine makes loud repetitive noises while the test is in progress, so earphones may be helpful.

The client experiences anginal chest pain on and off for 3 days before admission. The nurse completes discharge medication, activity, and follow up teaching. Which client statement indicates the client requires further teaching about angina related activity instruction? "I should not engage in sexual activity for 6 weeks" "I can return to usual activities but rest if pain comes back" "I should not use nitroglycerin as a substitute for rest if I have chest pain" "I should take a nitroglycerin tablet before activities that usually give me chest pain"

-"I should not engage in sexual activity for 6 weeks" Client may resume sexual activity in 1 week or less as ling as the client is feeling well; Continued anginal pain after the hospitalization should be reported to the HCP, but being hospitalized for angina without myocardial infarction is not an indication to abstain from sexual activity for 6 weeks

The nurse understands which factor is most important to maintain adequate circulation? Blood volume White blood cell count Aerobic exercise Effective respiration

-Blood volume In order to maintain adequate circulation, an adequate transport medium to carry nutrients and gases through the body is needed

The nurse cares for the client diagnosed with heart failure and valvular disease following rheumatic fever. When auscultating heart sounds in the aortic area, where does the nurse place the stethoscope? To the right of the sternum near the manubrium To the left of the sternum at the angle of Louis Directly over Erb's point Slightly below the point of maximal impulse

-To the right of the sternum near the manubrium Aortic area is to the right of the sternum near the manubrium; Left of the sternum at the angle of Louis is the second intercostal space and is known as the pulmonic area; Area slightly below the point of maximal impulse is known as the mitral area

The nurse understands which reason if the cause of essential hypertension? High salt diet Kidney disease Obesity Unknown

-Unknown Essential (primary) hypertension accounts of 90-95% of all cases; Hypertension may have no symptoms of headache, dizziness, anginal pain; Treatment includes medication and lifestyle changes; Kidney disease is a cause of secondary hypertension; Obesity and a high salt diet are associated risk factors for developing essential hypertension

The nurse provides care for a client diagnosed with coronary artery disease. Which client statement indicates to the nurse an understanding of the disease process? "I will notify my health care provider if I have to take any sublingual nitroglycerin." "I will massage the area around my nitroglycerin patch." "I will go to the hospital if pain persists after I have taken my medication and rested." "I will work out for 2 hours every day."

-"I will go to the hospital if pain persists after I have taken my medication and rested." If chest pain persists despite rest and administration of nitroglycerin, the client should go to the emergency room for further evaluation; The area around a nitroglycerin patch should not be massaged, this will increase the absorption rate of the medication

The nurse instructs the client to take their own pulse. Which client action indicates to the nurse that further instruction is needed? The client places a thumb over the pulse point The client uses the radial pulse point The client uses a digital watch to monitor passage of time The client counts the rate for one full minute

-The client places a thumb over the pulse point Thumb has its own pulse, which can be confused with the pulse being palpated; pulse is the measurement of the number of times the heart beats per frame of time (usually one minute)

The nurse cares for the client diagnosed with hypertension. The client states "I no longer have headaches, so my BP must be normal now." Which is the best response for the nurse to give? "If you no longer have headaches, your BP is probably normal" "High BP is usually asymptomatic and symptoms do not reliably indicate BP levels" "Since you have lost weight, your BP is probably lower" "It is good to avoid strenuous exercise to keep your BP lower"

-"High BP is usually asymptomatic and symptoms do not reliably indicate BP levels" Client not having headaches does not mean the BP is normal

The nurse cares for the client in Buck's traction awaiting repair of a fractured left femoral neck. The client reports pain in the left calf. The nurse notes the calf area is warm and red. The nurse identifies these symptoms as being caused by which pathology? The fractured bone A possible circulatory complication Skin irritation from skin traction Infection from skeletal pin insertion site

-A possible circulatory complication The extremity's immobility may cause a potential thrombus in the area

The nursing instructor teaches nursing students about the relationship of psychological risk factors in persons with coronary artery disease. Which risk factor does the instructor identify? Schizophrenia Depression Sleep disturbance Phobias

-Depression Current studies are linking depression with an increased risk of coronary artery disease due to an increase in circulating catecholamines

Which statement most accurately describes BP assessment in an adult client's lower extremities? The BP reading will be the same as in the arm The cuff is placed around thigh and stethoscope at dorsalis pedis The client will be positioned on the abdomen The systolic reading may be the same as the BP obtained at the brachial artery, but the diastolic will be 10 to 40 mm Hg higher.

-The client will be positioned on the abdomen This is the best position to obtain an accurate BP reading in the adult client's lower extremity. The nurse places the BP cuff around the thigh and the stethoscope at the popliteal artery; The BP taken in the lower extremity will usually be 10 - 40 mm Hg higher systolic, but the diastolic usually remains the same

The nurse cares for the client diagnosed with peripheral arterial disease. The client reports being awakened with severe pain in the legs. Which pathological condition does the nurse explain to the client? Arteriosclerosis Lymphedema Edema of the lower extremities Inadequate tissue oxygenation

-Inadequate tissue oxygenation Intermittent claudication results from inadequate oxygen to the tissues as a result of atherosclerosis; Client experiences cramping pain or aching in the lower extremities with exercise

The nurse teaches a client receiving an antihypertensive medication before discharge. The nurse determines that further teaching is necessary when the client makes which statement? "I should take the medication at the same time daily" "I can stop taking the medication when my BP goes down" "The HCP will check my BP and may need to change the medication" " When I first start taking the medication, I may feel some drowsiness"

-"I can stop taking the medication when my BP goes down" Usually required to take medication for the rest of their lives; Reinforce that clients are not to stop medication even though they have no symptoms and to report any side effects to the HCP

The nurse understands that the pain of angina is caused by which mechanism? Insufficient oxygen in the heart muscles Inflammation of the pericardium Ineffective contractions of the heart muscles Severe dysrhythmias

-Insufficient oxygen in the heart muscles Angina pectoris is caused by ischemia of the myocardium; inflammation of the pericardium is pericarditis; ineffective contractions of the heart muscles describes heart failure; severe dysrhythmias are the disturbance of electrical impulse formation and/or conduction

The nurse prepares to check the blood pressure of the client who weighs 250 pounds. Which is the most likely outcome if the nurse uses a regular adult sized BP cuff? The BP reading will be accurate The BP reading will be accurate if an ultrasound stethoscope is used The BP reading will be lower than the actual reading The BP will higher than the actual reading

-The BP will be higher than the actual reading BP reading will be erroneously elevated if the cuff is too narrow. The primary cause of a falsely elevated BP reading is a BP cuff that is too narrow. The cuff should be approximately 40% of the client's arm circumference midway between the olecranon and the acromion

The 350 pound client is admitted to the medical floor. Which information must the nurse obtain to ensure an accurate BP reading form the client's right arm? Circumference of the client's arm Previous BP readings Client's exact weight in kilograms Presence of pulses in the extremities

-The circumference of the client's arm The BP cuff must be correct width and length for the client's arm; The presence of pulses may influence the nurse's decision regarding the site to take the BP, but it has no bearing on choosing the appropriate cuff size

When preparing a client for magnetic resonance imaging (MRI) of the abdomen, which statement would indicate the need to notify the physician? "I haven't had anything to eat or drink since midnight last night." "I really don't like to be in small, enclosed spaces." "I left all my jewelry and my watch at home." "I will practice visualization to remain relaxed during the procedure."

"I really don't like to be in small, enclosed spaces." Explanation: An MRI scanner is a narrow, tunnel-like machine that will enclose the client during the test. Clients who are claustrophobic (fear enclosed spaces) may need sedation because it is imperative that they lie still and not panic during the test. Therefore, the nurse should notify the physician about the client's statement. Typically, the client is NPO for 6 to 8 hours before the test, and he or she must remove any metal objects, credit cards, jewelry, and watch before the test. Visualization will assist the client in relaxing during the procedure.

A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers: "It tells the physician what type of cancer is present." "It indicates if a cancer is present." "It determines functionality of the liver." "It detects a protein normally found in the blood."

"It indicates if a cancer is present." Explanation: The carcinoembryonic antigen (CEA) blood test detects the presence of cancer by identifying the presence of a protein not normally detected in the blood of a healthy person. However, it does not indicate what type of cancer is present nor does it detect the functionality of the liver.

The nurse performs BP screenings at a community center. The nurse knows which BP reading indicates Stage 1 hypertension? 160/110 mm Hg 138/88 mm Hg 128/78 mm Hg 126/72 mm Hg

- 138/88 mm Hg HTN Stage 1 is present if the systolic is within 130-139 mm Hg or the diastolic is within 80-89 mm Hg. Stage 2 hypertension is a systolic reading over 140 mm Hg and diastolic over 90 mm Hg Elevated BP is systolic within 120-129 mm Hg and diastolic less than 80 mm Hg Normal is systolic less than 120 mm Hg and diastolic under 80 mm Hg

Which is the average pulse range a nurse anticipates when conducting a physical examination for an adult client? 40-60 bpm 60-80 bpm 60-100 bpm 70-110 bpm

- 60-100 bpm

The nurse monitors the client with hypertension. The client tells the nurse "I have hypertension, but have not gone back to my health care provider since my prescription ran out." Based on this information, how does the nurse intervene? Assess client's knowledge of importance of follow up care and adhering to medication regimen Instructs the client to go to the health care provider immediately Instructs the client about a low sodium diet since they are not taking medication Insists the client go to the ER for a full evaluation

- Assess client's knowledge of the importance of follow up care and adhering to medication regimen Before performing any intervention, the nurse should assess the client for knowledge and severity of the disease process, as well as assessing how long the client has not taken the medication; Client education is an ongoing process

The nurse provides discharge instructions to the client diagnosed with a large venous stasis ulcer. Which client statement indicates to the nurse that the client understands discharge instructions? "Keeping a compression bandage on is the most important thing to do to help the ulcer heal." "I need to keep my leg lower than the level of my heart to promote blood flow for healing." "I must remember to put on my antibiotic ointment two times a day or the ulcer won't heal." "Keeping my legs propped up isn't healthy because the infection will drain into my circulation."

-"Keeping a compression bandage on is the most important thing to do to help the ulcer heal." Compression bandages provide extrinsic force to the muscles, stimulating contraction and therefore exerting pressure on the veins and promoting venous flow; Leg should be kept above level of the heart to increase venous return and minimize the amount of venous blood that pools in the leg so that healing can occur

The nurse cares for the client diagnosed with impaired arterial circulation in the lower extremities. Which short term goal is most appropriate for the nurse to add to the client's care plan? Client will control pain by elevating legs when sitting Client will use cold packs intermittently every 2 hours Client will report freedom from muscle pain while walking Client's ankle edema will decrease with leg elevation

-Client will report freedom from muscle pain while walking Arterial insufficiency is characterized by intermittent claudication caused by the inability of occluded arteries to provide adequate nutrients and oxygen to the tissues during exercise; Postural exercise and moderate walking are nursing interventions that improve circulation and decrease the cramp-like pain of claudication

The client arrives in the ER reporting severe pain in the left leg that is not relieved by rest or medication. On physical examination, the nurse is most likely to assess which symptom? Cold, mottled leg Strong popliteal pulse Edematous leg Hot, reddened leg

-Cold, mottled leg Pain in the lower extremities not relieved by rest indicated peripheral arterial disease; Pain may be described as numbness or burning; Pain sometimes relieved by placing leg in dependent position; Skin is dry, scaly, dusky, pale, mottled, and cold

The nurse plans care for the client with ulcerations and infections of the feet related to peripheral vascular disease. Which intervention does the nurse include? Use a heating pad for foot discomfort Soak the client's feet daily Elevate the feet if swollen Use lotion between the client's toes

-Elevate the feet if swollen Feet should be elevated to minimize swelling and edema; soaking the feet causes loss of moisture from the client's skin which can lead to maceration and breakdown; heating pads should not be used due to lack of sensation in the feet; lotion can cause maceration and the area between the toes can encourage the development of infection

The nurse cares for the client with hypertension and notes the client's serum renin levels are increased. Which finding best describes the effect of increased renin levels on blood pressure? Decreases serum angiotensin II levels Increases reabsorption of sodium in kidneys Increases myocardial contractility Activates the sympathetic nervous system

-Increase reabsorption of sodium in kidneys High renin levels will increase BP; Renin activates renin-angiotensin-aldosterone system; Angiotensin I converted to angiotensin II which has a potent vasoconstrictive effect; renin increases serum aldosterone levels; increased kidney reabsorption of sodium and water increase blood volume and blood pressure

The nurse cares for the client diagnosed with arterial insufficiency of the lower legs. Which intervention would the nurse include in the plan of care? Enroll the client in a heavy exercise program Instruct the client to avoid crossing the legs Apply hot compresses to the lower extremities Apply cold compresses to the lower extremities

-Instruct the client to avoid crossing the legs Client should avoid crossing legs as this practice decreases blood flow to the legs; Another activity to avoid is remaining in one position too long; Indications of peripheral arterial disease include rubor, cool and shiny skin, cyanosis, ulcers, gangrene, impaired sensation, intermittent claudication, and decreased peripheral pulses; predisposing factors include smoking, exposure to cold, emotional stress, diabetes mellitus, high fat diet, hypertension, and obesity; treatments include sympathectomy, grafting, vasodilators, anticoagulants, and endarterectomy; nursing considerations include monitoring peripheral pulses, proving good foot care, and instructing client to not cross legs, exercise regularly, and stop smoking

The nurse cares for the client diagnosed with chronic venous insufficiency. Which priority intervention dose the nurse include when planning the client's care? Administer heparin IV at 1,200 units/hour Keep legs elevated Administer oxygen at 2L/min Elevate the head of the bed 30 degrees

-Keep legs elevated This client should keep the legs elevated; Chronic venous insufficiency allows retrograde blood flow; Client may have persistent edema as well as cyanosis that worsens with dependent positioning

The nurse cares for the client diagnosed with coronary artery disease. Which symptom does the nurse expect the client to describe? Difficulty breathing when walking upstairs Severe nausea and vomiting associated with chest pain Diaphoresis associated with increased body temperature Mild chest discomfort relieved by rest and nitrates

-Mild chest discomfort relieved by rest and nitrates Anginal pain is usually relieved by rest or vasodilator medications such as nitroglycerin; Angina pectoris is quick or slow onset of chest pain caused by myocardial ischemia

Over which anatomical area on the chest wall does the nurse place the stethoscope to most clearly auscultate the apical pulse? Aortic area Erb's point Tricupsid area Mitral area

-Mitral area This is the fifth intercostal space to the left of the sternum, the apex of the heart; Apical pulse is most clearly heard here; This is also known as the point of maximal impulse (PMI); This area should be auscultated during a cardiac assessment to identify normal and abnormal heart sounds associated with the mitral valve

The nurse assesses the post-operative client for orthostatic hypotension before ambulating the client for the first time. Which action is most important for the nurse to take? Measure client's BP in at least three different positions Allow two minutes between client's changes in position Observe the client for a drop in BP and/or increase in pulse Determine if the client is taking an oral beta blocker

-Observe the client for a drop in BP and/or increase in pulse Orthostatic hypotension is defined by a drop in BP of 20 mm Hg systolic or 5 mm Hg diastolic and/or an increase in heart rate of 20 beats per minute associated with position change; at least three minutes should be allowed between position changes

The nurse understands that intermittent claudication is which description? Found in venous insufficiency Pain caused by cold Pain caused by walking Found only in the elderly

-Pain caused by walking Intermittent claudication is pain felt in the calves when the patient walks and is seen in arterial insufficiency; Venous insufficiency caused by hypertension, which stretches the veins, and when valves not functioning properly; symptoms include edema, discoloration of ankles, stasis ulcers; Vasospasms seen in Raynaud's are exacerbated by cold and stress

The nurse cares for the client diagnosed with arterial insufficiency. Which sign or symptom should the nurse expect when obtaining the client's history or performing a physical assessment? Bounding peripheral pulses Relief of pain when walking Pain in the hip, buttocks, thighs or calf Excessive growth of hair on the lower extremities

-Pain in the hip, buttocks, thighs or calf Decreased arterial blood flow leads to pain in the hip, buttocks, thigh and calf; classic symptom of arterial disease is intermittent claudication, ischemic muscle disease; indications of peripheral arterial disease include rubor, cool and shiny skin, cyanosis, ulcers, gangrene, impaired sensation, intermittent claudication, and decreased peripheral pulses

The nurse is planning discharge teaching for a client diagnosed with peripheral vascular disease. It is most important for the nurse to address which issue? The client drinks socially The client walks two miles a day The client takes vitamins daily The client smokes heavily

-The client smokes heavily Smoking is a predisposing factor for arterial peripheral vascular disease

To assess the pedal pulse, the nurse palpates in which location? The region in the back of the knee The top of the foot The groin area The inner side of the ankle below the medial malleolus

-The top of the foot Passes laterally over the foot

Which of the following is the primary function of the small intestine? Absorption Digestion Peristalsis Secretion

Absorption Explanation: Absorption is the primary function of the small intestine. Digestion occurs in the stomach. Peristalsis occurs in the colon. The duodenum secretes enzymes.

Which of the following digestive enzymes aids in the digesting of starch? Amylase Lipase Trypsin Bile

Amylase Explanation: Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein; amylase, which aids in digesting starch; and lipase, which aids in digesting fats. Bile is secreted by the liver and is not considered a digestive enzyme.

The nurse is preparing the client for an assessment of the abdomen. What should the nurse complete prior to this assessment? Prepare for a prostate examination. Ask the client to empty the bladder. Assist the client to a Fowler's position. Dim the lights for privacy.

Ask the client to empty the bladder. Explanation: The physical examination of the gastrointestinal system includes assessment of the mouth, abdomen, and rectum. It requires good light, full exposure of the abdomen, warm hands with short nails, and a relaxed client with an empty bladder. A full bladder will interfere with inspection and may elicit discomfort with palpation and percussion, thereby altering results.

A nurse is assessing a client for GI dysfunction. What is the most common symptom in a client with GI dysfunction? Diffuse pain Dyspepsia Constipation Abdominal bleeding

Dyspepsia Explanation: Dyspepsia is a condition that usually involves a combination of symptoms: abdominal pain, bloating, distention, nausea, and belching. Dyspepsia refers to altered digestion that is not associated with a pathologic condition.

Gastrin has which of the following effects on gastrointestinal (GI) motility? Increased motility of the stomach Relaxation of the colon Contraction of the ileocecal sphincter Relaxation of gastroesophageal sphincter

Increased motility of the stomach Explanation: Gastrin has the following effects on GI motility: increased motility of the stomach, excitation of the colon, relaxation of ileocecal sphincter, and contraction of the gastroesophageal sphincter.

While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure? Sigmoid colon Appendix Spleen Liver

Liver Explanation: The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of the colon, portions of the ascending and transverse colon, and a portion of the right kidney. The sigmoid colon is located in the left lower quadrant; the appendix, in the right lower quadrant; and the spleen, in the left upper quadrant.

A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered? Instruct the client to have low-residue meals. Allow the client to ingest fat-free meal. Permit the client to drink only clear liquids. Provide saline gargles to the client.

Permit the client to drink only clear liquids. Explanation: After polyethylene glycol/electrolyte solution is administered, the client should have clear liquids because this ensures watery stools, which are necessary for procedures like a barium enema. Allowing the client to ingest a fat-free meal is used in preparation for oral cholecystography. Instructing the client to have low-residue meals is a pretest procedure for barium enema. A client is offered saline gargles after esophagogastroduodenoscopy.

The nurse conducts education related to test preparation for a client scheduled to undergo an abdominal ultrasonography. The nurse should give the client which instruction? Don't undertake any strenuous exercise for 24 hours before the test. Do not consume anything sweet for 24 hours before the test. Avoid exposure to sunlight for at least 6 to 8 hours before the test. Restrict eating of solid food for 8 to 12 hours before the test.

Restrict eating of solid food for 8 to 12 hours before the test. Explanation: For a client who is scheduled to undergo an abdominal ultrasonography, the client should restrict solid food for 6 to 8 hours to avoid having images of the test obscured with gas and intestinal contents. Ultrasonography records the reflection of sound waves. Strenuous exercises, the consumption of sweets, and exposure to sunlight do not affect the results of the test in any way.

A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor? Both tests need to be done before breakfast. The ultrasonography should be scheduled before the GI procedure. The upper GI should be scheduled before the ultrasonography. The client may eat a light meal before either test.

The ultrasonography should be scheduled before the GI procedure. Explanation: Both an upper GI procedure with barium ingestion and an ultrasonography may be completed on the same day. The ultrasonography test should be completed first, because the barium solution could interfere with the transmission of the sound waves. The ultrasonography test uses sound waves that are passed into internal body structures, and the echoes are recorded as they strike tissues. Fluid in the abdomen prevents transmission of ultrasound.

The nurse performs an abdominal assessment. The nurse should perform the assessment in which order? inspection, palpation, percussion, auscultation inspection, auscultation, percussion, palpation auscultation, percussion, inspection, palpation auscultation, inspection, percussion, palpitation

inspection, auscultation, percussion, palpation Explanation: The correct order for the abdominal assessment is inspection, auscultation, percussion, and palpation.