EXAM 2 N403 PREPU
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? "Take antacids with meals." "Limit fluid intake with meals." "Lie down after meals to promote digestion." "Avoid coffee and alcoholic beverages."
"Avoid coffee and alcoholic beverages." Explanation: To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren't gastric irritants.
A client is scheduled for magnetic resonance imaging (MRI). During the client teaching, what will the nurse discuss? "The examination will take only 15 minutes." "You must be NPO for the day before the examination." "Do you experience any claustrophobia?" "You must remove all jewelry but can wear your wedding ring."
"Do you experience any claustrophobia?" Explanation: MRI is a noninvasive technique that uses magnetic fields and radio waves to produce images of the area being studied. Clients must be NPO for 6 to 8 hours before the study and remove all jewelry and other metals. The examination takes 60 to 90 minutes and can induce feelings of claustrophobia, because the scanner is close fitting.
An adolescent client with multiple dental caries is discussing diet with the nurse. What client statement identifies a risk factor for dental caries? "I visit my dentist every year." "I floss before I go to bed each night." "I brush my teeth in the morning and evening." "I drink a can of carbonated soda at lunch every day."
"I drink a can of carbonated soda at lunch every day." Explanation: The client's statement of drinking a carbonated soda with refined sugar at lunch every day puts the client at risk for dental caries. The other statements are measures to prevent dental caries, including brushing teeth after meals, flossing daily, and having regular dental visits.
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 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."
"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.
A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment? "I'll eat frequent, small, bland meals that are high in fiber." "I'll lie down immediately after a meal." "I'll eat three large meals every day without any food restrictions." "I'll gradually increase the amount of heavy lifting I do."
"I'll eat frequent, small, bland meals that are high in fiber." Explanation: In hiatal hernia, the upper portion of the stomach protrudes into the chest when intra-abdominal pressure increases. To minimize intra-abdominal pressure and decrease gastric reflux, the client should eat frequent, small, bland meals that can pass easily through the esophagus. Meals should be high in fiber to prevent constipation and minimize straining on defecation (which may increase intra-abdominal pressure from the Valsalva maneuver). Eating three large meals daily would increase intra-abdominal pressure, possibly worsening the hiatal hernia. The client should avoid spicy foods, alcohol, and tobacco because they increase gastric acidity and promote gastric reflux. To minimize intra-abdominal pressure, the client shouldn't recline after meals, lift heavy objects, or bend.
A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers: "It detects a protein normally found in the blood." "It indicates if a cancer is present." "It tells the physician what type of cancer is present." "It determines functionality of the liver."
"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 asks a client to point to where pain is felt. The client asks why this is important. What is the nurse's best response? "If the health care provider massages over the exact painful area, the pain will disappear." "The area may determine the severity of the pain." "This determines the pain medication to be ordered." "Often the area of pain is referred from another area."
"Often the area of pain is referred from another area." Explanation: Pain can be a major symptom of disease. The location and distribution of pain can be referred from a different area. If a client points to an area of pain and has other symptoms associated with a certain disease, this is valuable information for treatment.
When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. How is aphthous stomatitis best described by the nurse? Acid indigestion An acute stomach infection A canker sore of the oral soft tissues An early sign of peptic ulcer disease
A canker sore of the oral soft tissues Explanation: Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks. Aphthous stomatitis isn't an acute stomach infection, acid indigestion, or early sign of peptic ulcer disease.
The nurse is instructing the client on sensations commonly experienced when a contrast agent is injected into the body during diagnostic studies. Which sensation is most common? A warm sensation Heart palpitations Chills Light-headedness
A warm sensation Explanation: The nurse informs the client that he or she may experience a warm sensation and nausea when the contrast agent is instilled. The client is instructed to take a couple of deep breaths, and, many times, the sensation will go away. The other options are not frequently encountered.
The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment? Abdominal distention Sore throat Thirst Drowsiness
Abdominal distention Explanation: The nurse is correct to fully assess the client experiencing abdominal distention following an esophagogastroduodenoscopy (EGD). Abdominal distention could indicate complications such as perforation and bleeding. The client experiences drowsiness from the sedative during the early recovery process and a sore throat from passage of the scope. The client may also experience thirst because the client has not had liquids for a period of time.
Which of the following digestive enzymes aids in the digesting of starch? Lipase Trypsin Amylase 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.
A nurse is completing an assessment on a client with a postoperative neck dissection. The nurse notices excessive bleeding from the dressing site and suspects possible carotid artery rupture. What action should the nurse take first? Summon assistance Elevate the head of the patient's bed Apply pressure to the bleeding site Notify the surgeon to repair the vessel
Apply pressure to the bleeding site Explanation: The first action for the nurse is to apply pressure to the bleeding site. The nurse will need to obtain assistance, elevate the head of the bed, and notify the surgeon, but client care is most important initially.
A nurse caring for a client who has had radical neck surgery notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What is an expected, normal amount of drainage? Approximately 80 to 120 mL Between 120 and 160 mL Greater than 160 mL Between 40 and 80 mL
Approximately 80 to 120 mL Explanation: Between 80 to 120 mL may drain over the first 24 hours. Drainage of greater than 120 mL may be indicative of a chyle fistula or hemorrhage.
The nurse is preparing the client for an assessment of the abdomen. What should the nurse complete prior to this assessment? Dim the lights for privacy. Ask the client to empty the bladder. Prepare for a prostate examination. Assist the client to a Fowler's position.
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 client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse? Suction the oral cavity of the client. Assess lung sounds bilaterally. Obtain consent for the esophagogastroscopy. Administer prescribed morphine intravenously.
Assess lung sounds bilaterally. Explanation: All these activities are things the nurse may do for a client with a foreign body in the esophagus. This client is at risk for esophageal perforation, and thus pneumothorax. By auscultating lung sounds the nurse will be able to assess if a pneumothorax is present. The client has little saliva in the oral cavity and does not need to be suctioned. A client may also report pain with a foreign body. However, ABCs (airway, breathing, circulation) take priority. The consent for the esophagogastroscopy may be obtained after the nurse has completed the client assessment.
A client is postoperative following a graft reconstruction of the neck. What intervention is the most important for the nurse to complete with the client? Reinforce the neck dressing when blood is present on the dressing. Cleanse around the drain using aseptic technique. Administer prescribed intravenous vancomycin at the correct time. Assess the graft for color and temperature.
Assess the graft for color and temperature. Explanation: Assessing the graft for color and temperature addresses circulation and is most important for the nurse to complete. Reinforcing the neck dressing is important, but not the priority. Administering medication and cleansing the drain site are not most important interventions with the client after graft reconstruction of the neck.
An older adult client is admitted to an acute care facility for treatment of an acute flare-up of a chronic gastrointestinal condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the gastrointestinal tract. Which age-related change increases the risk of anemia? Decrease in intestinal flora Dulling of nerve impulses Increase in bile secretion Atrophy of the gastric mucosa
Atrophy of the gastric mucosa Explanation: Atrophy of the gastric mucosa reduces hydrochloric acid secretion; this, in turn, impairs absorption of iron and vitamin B12, increasing the risk of anemia as a person ages. A decrease in hydrochloric acid increases, not decreases, intestinal flora; as a result, the client is at increased risk for infection, not anemia. A reduction, not increase, in bile secretion may lead to malabsorption of fats and fat-soluble vitamins. Dulling of nerve impulses associated with aging increases the risk of constipation, not anemia.
The nurse is performing a focused abdominal assessment of a client with a history of bowel obstruction. The nurse has positioned the client appropriately and inspected the client's abdomen carefully. What action should the nurse perform next? Palpate the lower two quadrants Auscultate the client's abdomen Perform percussion, if tolerated Palpate the upper two quadrants
Auscultate the client's abdomen Explanation: Abdominal auscultation is done before palpation because palpation disrupts normal bowel sounds. Percussion would have a similar disruptive effect.
When assisting with preparing a client scheduled for a barium swallow, which of the following would be appropriate to include? Avoid the intake of red meat before the procedure. 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 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 is creating a plan of care for a client who is not able to tolerate brushing his teeth. The nurse includes which mouth irrigation in the plan of care? Full-strength peroxide Mouthwash and water Baking soda and water Dextrose and water
Baking soda and water Explanation: When a client is unable to tolerate teeth brushing, the following irrigating solutions are recommended: 1 tsp baking soda in 8 oz warm water, half-strength hydrogen peroxide, or normal saline solution.
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? Black Green Red Dark brown
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.
During a colonoscopy with moderate sedation, the patient groans with obvious discomfort and begins bleeding from the rectum. The patient is diaphoretic and has an increase in abdominal girth from distention. What complication of this procedure is the nurse aware may be occurring? Infection Colonic polyp Rectal fissure Bowel perforation
Bowel perforation Explanation: Immediately after the test, the patient is monitored for signs and symptoms of bowel perforation (e.g., rectal bleeding, abdominal pain or distention, fever, focal peritoneal signs).
A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. What instruction will the nurse give to the client? Brush and floss daily. Use a hard-bristled toothbrush. Rinse with an alcohol-based solution. Continue with the usual diet.
Brush and floss daily. Explanation: The description of erythema, edema, and pain of the mouth following radiation treatment describes stomatitis. Nursing considerations include prophylactic mouth care such as brushing and flossing daily. A soft-bristled toothbrush is recommended. The client is to avoid alcohol-based mouth rinses and hot or spicy foods that may be part of the client's usual diet.
A patient is scheduled for a fiberoptic colonoscopy. What does the nurse know that fiberoptic colonoscopy is most frequently used to diagnose? Cancer Inflammatory bowel disease Bowel disease of unknown origin Occult bleeding
Cancer Explanation: This procedure is used commonly as a diagnostic aid and screening device. It is most frequently used for cancer screening and for surveillance in patients with previous colon cancer or polyps. In addition, tissue biopsies can be obtained as needed, and polyps can be removed and evaluated. Other uses of colonoscopy include the evaluation of patients with diarrhea of unknown cause, occult bleeding, or anemia; further study of abnormalities detected on barium enema; and diagnosis, clarification, and determination of the extent of inflammatory or other bowel disease.
Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis? Chancre Lichen planus Leukoplakia Actinic cheilitis
Chancre Explanation: A chancre is a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis. Lichen planus is a white papule at the intersection of a network of interlacing lesions. Actinic cheilitis is an irritation of the lips associated with a scaling, crusting fissure. Leukoplakias are white patches usually found in the buccal mucosa.
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? Examining the sclera if it is yellow Checking if the skin is discolored Observing for distended abdominal veins Checking if the mucous membranes are dry
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.
Which is an accurate statement regarding cancer of the esophagus? It is seen more frequently in European Americans than in African Americans. Chronic irritation of the esophagus is a known risk factor. It is three times more common in women than men in the United States . It usually occurs in the fourth decade of life.
Chronic irritation of the esophagus is a known risk factor. Explanation: In the United States, cancer of the esophagus has been associated with the ingestion of alcohol and the use of tobacco. In the United States, carcinoma of the esophagus occurs more than three times more often in men than in women. It is seen more frequently in African Americans than in European Americans. It usually occurs in the fifth decade of life.
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? Colonoscopy Small bowel series Computer tomography 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.
Which is the primary symptom of achalasia? Difficulty swallowing Pulmonary symptoms Heartburn Chest pain
Difficulty swallowing Explanation: The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The client may also report chest pain and heartburn that may or may not be associated with eating. Secondary pulmonary complications may result from aspiration of gastric contents.
The nurse is obtaining a history on a patient who comes to the clinic. What symptom described by the patient is one of the first symptoms associated with esophageal disease? Pain Dysphagia Regurgitation of food Malnutrition
Dysphagia Explanation: Dysphagia (difficulty swallowing), the most common symptom of esophageal disease, may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute odynophagia (pain on swallowing).
A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test? Serve dairy products. Serve the client his usual diet. Order a high-fiber diet. Encourage plenty of fluids.
Encourage plenty of fluids. Explanation: The nurse should encourage plenty of fluids because adequate fluid intake is necessary to avoid dehydration that may be caused by the bowel preparation and to prevent fecal impaction after the procedure. The client may be placed on a low-residue diet 1 to 2 days before the procedure to reduce the contents in the GI tract. Fiber intake is limited in a low-residue diet. Because dairy products leave a residue, they aren't allowed the evening before the test. Clear liquids only are allowed the evening before the test.
Which of the following is a proton pump inhibitor used in the treatment of gastroesophageal reflux disease (GERD)? Select all that apply. Esomeprazole (Nexium) Lansoprazole (Prevacid) Famotidine (Pepcid) Rabeprazole (AcipHex) Nizatidine (Axid)
Esomeprazole (Nexium), Lansoprazole (Prevacid), Rabeprazole (AcipHex)
An older adult client seeks medical attention for a report of general difficulty swallowing. Which assessment finding is most significant as related to this symptom? Esophageal tumor Gastritis Gastroesophageal reflux disease Hiatal hernia
Esophageal tumor Explanation: Esophageal tumor is most significant and can result in advancing cancer. Esophageal cancer is a serious condition that presents with a symptom of difficulty swallowing as the tumor grows. Hiatal hernia, gastritis, and GERD can lead to serious associated complications but less likely to be as significant as esophageal tumor/cancer.
An elderly client states, "I don't understand why I have so many caries in my teeth." What assessment made by the nurse places the client at risk for dental caries? Using a soft-bristled toothbrush Exhibiting hemoglobin A1C 8.2 Eating fruits and cheese in diet Drinking fluoridated water
Exhibiting hemoglobin A1C 8.2 Explanation: Measures used to prevent and control dental caries include controlling diabetes. A hemoglobin A1C of 8.2 is not controlled. It is recommended for hemoglobin A1C to be less than 7 for people with diabetes. Other measures to prevent and control dental caries include drinking fluoridated water; eating foods that are less cariogenic, which include fruits, vegetables, nuts, cheese, or plain yogurt; and brushing teeth evenly with a soft-bristled toothbrush.
An adult patient is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the patient has completed the test? This series includes analysis of gastric secretions. Fluids must be increased to facilitate the evacuation of the stool. Stool will be yellow for the first 24 hours postprocedure. The barium may cause diarrhea.
Fluids must be increased to facilitate the evacuation of the stool. Explanation: Postprocedural patient education includes information about increasing fluid intake, evaluating bowel movements for evacuation of barium, and noting increased number of bowel movements. This is done because barium, due to its high osmolarity, may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output. The barium series does not analyze gastric secretions.
Postoperatively, a client with a radical neck dissection should be placed in which position? Prone Supine Fowler Side-lying
Fowler Explanation: The client should be placed in the Fowler position to facilitate breathing and promote comfort. This position also promotes expansion of the lungs because the diaphragm is pulled downward and the abdominal viscera are pulled away from the lungs. The other positions are not the position of choice postoperatively.
A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate? Gastroesophageal reflux disease Diverticulitis Peptic ulcer disease Esophageal cancer
Gastroesophageal reflux disease Explanation: Symptoms may include pyrosis (burning sensation in the esophagus), dyspepsia (indigestion), regurgitation, dysphagia or odynophagia (pain on swallowing), hypersalivation, and esophagitis.
A client with human immunodeficiency virus (HIV) comes to the clinic and is experiencing white patches on the lateral border of the tongue. What type of lesions does the nurse document? Aphthous stomatitis Nicotine stomatitis Hairy leukoplakia Erythroplakia
Hairy leukoplakia Explanation: Hairy leukoplakia is a condition often seen in people who are HIV positive in which white patches with rough, hairlike projections form, typically on lateral border of the tongue. Aphthous stomatitis is typically a recurrent round or oval sore or ulcer on the inside of the lips and cheeks or underneath the tongue and is not associated with HIV. Erythroplakia describes a red area or red spots on the lining of the mouth and is not associated with HIV. Nicotine stomatitis is a white patch in the mouth caused by extreme heat from smoking.
A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett's esophagus and has been admitted to a medical unit. The nurse is writing a care plan for this patient. What information is essential to include? He will need to undergo an upper endoscopy every 6 months to detect malignant changes. Antacids may be discontinued when symptoms of heartburn subside Liver enzymes must be checked regularly as H2 receptor antagonists may cause hepatic damage. Small amounts of blood are likely to be present in his stools and should not cause concern.
He will need to undergo an upper endoscopy every 6 months to detect malignant changes. Explanation: In the patient with Barrett's esophagus, the cells lining the lower esophagus have undergone change and are no longer squamous cells. The altered cells are considered precancerous and are a precursor to esophageal cancer. To facilitate early detection of malignant cells, upper endoscopies may be performed every 6 to 12 months. H2 receptor antagonists are commonly prescribed for patients with GERD; however, monitoring of liver enzymes is not routine. Stools that contain evidence of frank bleeding or which are tarry are not expected and should be reported immediately. When antacids are prescribed for patients with GERD, they should be taken as ordered whether or not the patient is symptomatic.
The nurse is caring for a client during the postoperative period following radical neck dissection. Which finding should be reported to the physician? Crackles that clear after coughing Temperature of 99.0°F (37.2°C) Serous drainage on the dressing High epigastric pain and/or discomfort
High epigastric pain and/or discomfort Explanation: The nurse should report high epigastric pain and/or discomfort because this can be a sign of impending rupture. Crackles that clear after coughing, serous drainage on the dressing, and a temperature of 99.0°F are normal findings in the immediate postoperative period and do not need to be reported to the physician.
The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon return to the nursing unit, what does the nurse identify as the client goal? Decrease nausea and vomiting Recover from the general anesthesia Increase the amount of fluids Ambulate independently
Increase the amount of fluids Explanation: The client, returning from an upper gastrointestinal series, needs to increase fluids in an effort to eliminate the barium from the body through a bowel movement. General anesthesia is not used. The client typically does not have nausea and vomiting following the procedure. If the client is able to ambulate independently prior to the procedure, the client will be able to ambulate independently following.
Gastrin has which of the following effects on gastrointestinal (GI) motility? Increased motility of the stomach Contraction of the ileocecal sphincter Relaxation of gastroesophageal sphincter Relaxation of the colon
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.
A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess? Foul breath Increasing difficulty in swallowing Sensation of a mass in throat Hiccups
Increasing difficulty in swallowing Explanation: The client first becomes aware of intermittent and increasing difficulty in swallowing with esophageal cancer. As the tumor grows and the obstruction becomes nearly complete, even liquids cannot pass into the stomach. Other clinical manifestations may include the sensation of a mass in the throat, foul breath, and hiccups, but these are not the most common initial clinical manifestation with clients with esophageal cancer.
A client has a radical neck dissection to treat cancer of the neck. The nurse develops the care plan and includes all the following diagnoses. The nurse identifies the highest priority diagnosis as Impaired tissue integrity related to surgical intervention Ineffective airway clearance related to obstruction by mucus Imbalanced nutrition: less than body requirements, related to treatment Risk for infection related to surgical intervention
Ineffective airway clearance related to obstruction by mucus Explanation: All the nursing diagnoses are appropriate for a client who has a radical neck dissection. According to Maslow's hierarchy of needs, physiological needs take priority. Under physiological needs, airway, breathing, circulation (ABCs) take highest priority. Thus, ineffective airway clearance is the highest priority nursing diagnosis.
A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. What is the nurse's best intervention? Instruct the client to swish prescribed nystatin solution for 1 minute. Remove the plaque from the mouth by rubbing with gauze. Provide saline rinses prior to meals. Encourage the client to ingest a soft or bland diet.
Instruct the client to swish prescribed nystatin solution for 1 minute. Explanation: A cheesy white plaque in the mouth that looks like milk curds and can be rubbed off is candidiasis. The most effective treatment is antifungal medication such as nystatin (Mycostatin). When used as a suspension, the client is to swish vigorously for at least 1 minute and then swallow. Other measures such as providing saline rinses or ingesting a soft or bland diet are comfort measures. The nurse does not remove the plaques; doing so will cause erythema and potential bleeding.
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? Histamine Liver enzyme Intrinsic factor Hydrochloric acid
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.
After 20 seconds of auscultating for bowel sounds on a client recovering from abdominal surgery, the nurse hears nothing. What should the nurse do based on the assessment findings? Listen longer for the sounds. Call the health care provider to report absent bowel sounds. Return in 1 hour and listen again to confirm findings. Document that the client is constipated.
Listen longer for the sounds. Explanation: Auscultation is used to determine the character, location, and frequency of bowel sounds. The frequency and character of sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minutes. Normal sounds are heard about every 5 to 20 seconds, whereas hypoactive sounds can be one or two sounds in 2 minutes. Postoperatively, it is common for sounds to be reduced; therefore, the nurse needs to listen at least 3 to 5 minutes to verify absent or no bowel sounds.
For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone? Radiation Lithotripsy Chemotherapy Biopsy
Lithotripsy Explanation: Lithotripsy uses shock waves to disintegrate stones. It may be used instead of surgical extraction for parotid stones and smaller submandibular stones. Radiation, chemotherapy, and biopsy do not use shock waves to disintegrate a stone.
The nurse is caring for a geriatric client and notices polypharmacy. Which diagnostic studies are anticipated? Complete blood count Blood chemistry Liver function studies Urinalysis
Liver function studies Explanation: The liver metabolizes and biotransforms the medications ingested. Geriatric clients who experience polypharmacy or multiple medications have an elevated risk of liver impairment. Routine liver function studies monitor the status of the liver and its ability to metabolize.
Which of the following are functions of saliva? Select all that apply. Metabolism Elimination Lubrication Digestion Protection against harmful bacteria
Lubrication, Protection against harmful bacteria, digestion, and metabolism Explanation: The three main functions of saliva are lubrication, protection against harmful bacteria, and digestion. Elimination and metabolism are not functions of saliva.
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, what should the nurse assign highest priority to? Ensuring adequate nutrition Maintaining a patent airway Preventing injury Helping the client cope with body image changes
Maintaining a patent airway Explanation: Rapid growth of cancer cells in the esophagus may put pressure on the adjacent trachea, jeopardizing the airway. Therefore, maintaining a patent airway is the highest care priority for a client with esophageal cancer. Helping the client cope with body image changes, ensuring adequate nutrition, and preventing injury are appropriate for a client with this disease, but are less crucial than maintaining airway patency.
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? Observing the color of urine. Placing any stool passed in a specific preservative. Monitoring the volume of urine. Monitoring the stool passage and its color.
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.
The nurse working in the recovery room is caring for a client who had a radical neck dissection. The nurse notices that the client makes a coarse, high-pitched sound upon inspiration. Which intervention by the nurse is appropriate? Document the presence of stridor Lower the head of the bed Administer a breathing treatment Notify the physician
Notify the physician Explanation: The presence of stridor, a coarse, high-pitched sound upon inspiration, in the immediate postoperative period following radical neck dissection, indicates obstruction of the airway, and the nurse must report it immediately to the physician.
A client has been taking a 10-day course of antibiotics for pneumonia. The client has been having white patches that look like milk curds in the mouth. What treatment will the nurse educate the client about? Acyclovir Fluocinolone acetonide oral base gel Nystatin Cephalexin
Nystatin Explanation: Candidiasis is a fungal infection that results in a cheesy white plaque in the mouth that looks like milk curds. It commonly occurs in antibiotic therapy. Antifungal medications such as nystatin (Mycostatin), amphotericin B, clotrimazole, or ketoconazole may be prescribed.
The nurse is working with clients with digestive tract disorders. Which of the following organs does the nurse realize has effects as an exocrine gland and an endocrine gland? Liver Pancreas Gallbladder Stomach
Pancreas Explanation: The pancreas is both an exocrine gland, one that releases secretions into a duct or channel, and an endocrine gland, one that releases substances directly into the bloodstream. The other organs have a variety of functions but do not have a combination function such as the pancreas.
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 Acetylcysteine Atropine Glycopyrronium bromide
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? Ptyalin Trypsin Pepsin 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 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? Allow the client to ingest fat-free meal. Instruct the client to have low-residue meals. 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 as 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 client has returned to the floor following a radical neck dissection. Anesthesia has worn off. What is the nurse's priority action? Empty the Jackson-Pratt device (portable drainage device). Administer morphine for report of pain. Provide feeding through the gastrostomy tube. Place the client in the Fowler's position.
Place the client in the Fowler's position. Explanation: All the options are activities the nurse may do; however, the nurse has to prioritize according to Maslow's hierarchy of needs. Physiological needs are addressed first. Under physiological needs, ABCs (airway, breathing, circulation) take priority. Placing the client in the Fowler's position facilitates breathing and promotes comfort.
A nurse practitioner, who is treating a patient with GERD, knows that this type of drug helps treat the symptoms of the disease. The drug classification is: H2-receptor antagonists. Proton pump inhibitors. Antacids Antispasmodics
Proton pump inhibitors. Explanation: Proton pump inhibitors are the strongest inhibitors of acid secretions. The H2-receptor antagonists are the next most powerful.
A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an): Extension of the esophagus through an opening in the diaphragm. Protrusion of the upper stomach into the lower portion of the thorax. Twisting of the duodenum through an opening in the diaphragm. Involution of the esophagus, which causes a severe stricture.
Protrusion of the upper stomach into the lower portion of the thorax. Explanation: It is important for the patient and his family to understand the altered association between the esophagus and the stomach. The diaphragm opening, through which the esophagus passes, becomes enlarged and part of the upper stomach moves up into the lower portion of the thorax. The abnormality is not an involuntary, protruding, or twisted segment.
A 59-year-old woman with a recent history of heartburn, regurgitation, and occasional dysphagia has been diagnosed with a sliding hiatal hernia following an upper GI series. The nurse is providing patient education about the management of this health problem. What should the nurse suggest as a management strategy to this patient? Remaining upright for at least 1 hour following each meal Drinking one to two glasses of water before and after each meal Minimizing her intake of highly spiced foods and dairy products Abstaining from alcohol
Remaining upright for at least 1 hour following each meal Explanation: Management for a sliding hernia includes frequent, small feedings that can pass easily through the esophagus. The patient is advised not to recline for 1 hour after eating, to prevent reflux or movement of the hernia, and to elevate the head of the bed on 4- to 8-inch (10- to 20-cm) blocks to prevent the hernia from sliding upward. Fluid intake is encouraged, but this should be ingested throughout a meal, not just before and after the meal. It is not necessary to refrain from drinking alcohol, spicy foods, or dairy products.
The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client? A complete blood count including differential Gastric analysis A sigmoidoscopy Serum antibodies for H. pylori
Serum antibodies for H. pylori Explanation: Helicobacter pylori, a bacterium, is believed to be responsible for the majority of peptic ulcers. Blood tests are used to determine whether there are antibodies to H. pylori in the blood. A complete blood count with differential can indicate bleeding and infection associated with a bleeding ulcer. A sigmoidoscopy assesses the lower gastrointestinal tract. Gastric analysis is more common in analyzing gastric fluid in determining problems with the secretory activity of the gastric mucosa.
Which term is used to describe stone formation in a salivary gland, usually the submandibular gland? Sialolithiasis Stomatitis Parotitis Sialadenitis
Sialolithiasis Explanation: Salivary stones are formed mainly from calcium phosphate. Parotitis refers to inflammation of the parotid gland. Sialadenitis refers to inflammation of the salivary glands. Stomatitis refers to inflammation of the oral mucosa.
The nurse is answering questions regarding fecal matter for a client who is scheduled for a colon resection. The client is asking questions regarding the composition of the fecal matter and when it becomes a formed mass. The nurse is most correct to state at which location? Cecum Ileum Sigmoid colon Duodenum
Sigmoid colon Explanation: Water is reabsorbed by means of diffusion across the intestinal membrane as the contents move through the colon. By the time the mixture reaches the descending and sigmoid colon, the portion of the bowel adjacent to the rectum, it is a formed mass. The ileum and duodenum are located in the small intestine. The cecum is located at the beginning of the large intestine.
The nurse is providing care to a client who has had a percutaneous liver biopsy. The nurse would monitor the client for which of the following? Passage of stool Signs and symptoms of bleeding Intake and output Return of the gag reflex
Signs and symptoms of bleeding Explanation: A major complication after a liver biopsy is bleeding, so it would be important for the nurse to monitor the client for signs and symptoms of bleeding. Return of the gag reflex would be important for the client who had an esophagogastroduodenoscopy to prevent aspiration. Monitoring the passage of stool would be important for a client who had a barium enema or colonoscopy. Monitoring intake and output is a general measure indicated for any client. It is not specific to a liver biopsy.
It is important for a nurse to have an understanding of the major digestive enzymes and their actions. Choose the gastric mucosa secretion that plays an important role in the digestion of triglycerides. Ptyalin Steapsin Trypsin Amylase
Steapsin Explanation: Ptyalin and amylase work to digest starch; trypsin works on proteins and polypeptides. Triglycerides are digested by steapsin, and pharyngeal and pancreatic lipase.
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? Lithotomy Supine with knees flexed Knee-chest 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.
While preparing a client for an upper GI endoscopy (esophagogastroduodenoscopy), the nurse should implement which interventions? Choose all that apply. Tell the client he must be on a clear liquid diet for 24 hours before the procedure. Inform the client that he will receive a sedative before the procedure. Tell the client that he may eat and drink immediately after the procedure. Tell the client he shouldn't eat or drink for 6 to 12 hours before the procedure. Administer a preparation to cleanse the GI tract, such as Golytely or Fleets Phospha-Soda.
Tell the client he shouldn't eat or drink for 6 to 12 hours before the procedure. Inform the client that he will receive a sedative before the procedure. Explanation: The client should be NPO for 8 hours prior to the examination. Before the introduction of the endoscope, the client is given a local anesthetic gargle or spray. Midazolam (Versed), a sedative that provides moderate sedation and relieves anxiety during the procedure, may be administered. Atropine may be administered to reduce secretions, and glucagon may be administered to relax smooth muscle.
A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge? The client doesn't exhibit rectal tenesmus. The client reports diminished duodenal inflammation. The client has normal gastric structures. The client is free from esophagitis and achalasia.
The client is free from esophagitis and achalasia. Explanation: Dysphagia may be the reason why a client with esophagitis or achalasia seeks treatment. Therefore, when the client is free of esophagitis or achalasia, he is ready for discharge. Dysphagia isn't associated with rectal tenesmus, duodenal inflammation, or abnormal gastric structures.
A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention? Foley catheter bag containing 500 ml of amber urine A piggyback infusion of levofloxacin The client lying in a lateral position, with the head of bed flat Serosanguineous drainage on the dressing
The client lying in a lateral position, with the head of bed flat Explanation: A client who has had neck surgery is at risk for neck swelling. To prevent respiratory complications, the head of the bed should be at least at a 30-degree angle. This position gives the lungs room to expand and decreases swelling by promoting venous and lymphatic drainage. This position also minimizes the risk of aspiration. Serosanguineous drainage on the dressing, a Foley bag containing amber urine, and levofloxacin infusing aren't causes for concern.
A client receives a local anesthetic to suppress the gag reflex for a diagnostic procedure of the upper GI tract. Which nursing intervention is advised for this patient? The client should be monitored for cramping or abdominal distention. The client should be monitored for any breathing-related disorder or discomforts. The client should not be given any food and fluids until the gag reflex returns. The client's fluid output should be measured for at least 24 hours after the procedure.
The client should not be given any food and fluids until the gag reflex returns. Explanation: For a client receiving a local anesthetic that suppresses the gag reflex, the nurse is advised to withhold food and fluids until the reflex returns.
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 client may eat a light meal before either test. The upper GI should be scheduled before the ultrasonography.
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.
A nurse is caring for a newly admitted patient with a suspected gastrointestinal (GI) bleed. The nurse assesses the patient's stool after a bowel movement and notes it to be a tarry-black color. The nurse recognizes that the bleeding is likely occurring where? The lower GI tract The upper GI tract The esophagus The anal area
The upper GI tract Explanation: Blood shed in sufficient quantities in the upper GI tract will produce a tarry-black color (melena). Blood entering the lower portion of the GI tract or passing rapidly through it will appear bright or dark red. Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool or if blood is noted on toilet tissue.
A client has a new order for metoclopramide. What extrapyramidal side effect should the nurse assess for in the client? Uncontrolled rhythmic movements of the face or limbs Dry mouth not relieved by sugar-free hard candy Hyperactivity Anxiety or irritability
Uncontrolled rhythmic movements of the face or limbs Explanation: Metoclopramide is a prokinetic agent that accelerates gastric emptying. Because metoclopramide can have extrapyramidal side effects that are increased in certain neuromuscular disorders, such as Parkinson's disease, it should be used only if no other option exists, and the client should be monitored closely for uncontrolled rhythmic movements of the face or limbs. Metoclopramide side effects are headache, confusion, and drowsiness. Anxiety, hyperactivity, and a dry mouth are not common side effects.
A client was diagnosed with pernicious anemia. Which vitamin cannot be absorbed without an intrinsic factor? Vitamin C Vitamin B12 Vitamin A Vitamin D
Vitamin B12 Explanation: Vitamin B12 needs to be absorbed in the ileum, where the pH is higher than in the stomach. This vitamin is transported by a glycoprotein known as intrinsic factor.
A nurse is providing discharge instructions for a client who fell from a bicycle, resulting in a fractured jaw. The client underwent surgical intervention with rigid fixation. What teaching should the nurse include with client education? Solid foods that the client can ingest Foods that are low in calories Reminders to rinse the mouth with an alcohol-based solution Ways to obtain nutritional supplementation
Ways to obtain nutritional supplementation Explanation: The client who had rigid fixation of the jaw should be instructed not to chew food for the first 1 to 4 weeks. The client needs to obtain optimal caloric and protein intake, so the nurse should include ways to obtain supplemental nutrition. Solid foods require chewing, so a liquid diet is recommended. Rinsing with an alcohol-based solution is drying to the mucous membranes. Foods need to be high in calories to support adequate nutrition.
Which of the following assessment findings would be most important for indicating dumping syndrome in a post gastrectomy client? Persistent loose stools, chills, hiccups after eating Weakness, diaphoresis, diarrhea 90 minutes after eating Abdominal distention, elevated temperature, weakness before eating Constipation, rectal bleeding following bowel movements
Weakness, diaphoresis, diarrhea 90 minutes after eating Explanation: Dumping syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramping, and diarrhea from the rapid emptying of the chyme after eating. Elevated temperature and chills can be a significant finding for infection and should be reported. Constipation with rectal bleeding is not indicative of dumping syndrome.
The nurse prepares a client for a barium enema. The nurse should place the client on which diet prior to the procedure? nothing by mouth (NPO) 2 days prior clear liquids day before soft diet 1 day prior high-fiber diet 1 to 2 days prior
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 cecum jejunum ileum
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 nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question? a low-fat diet pantoprazole elevation of upper body on pillows metoclopramide
metoclopramide Explanation: The instructions are appropriate for the client experiencing gastroesophageal reflux disease. The client is prescribed carbidopa/levodopa (Sinemet), which is used for Parkinson's disease. Metoclopramide can have extrapyramidal effects, and these effects can be increased in clients with Parkinson's disease.
A client with gastroesophageal reflux disease (GERD) comes to the physician's office reporting a burning sensation in the esophagus. The nurse documents that the client is experiencing dysphagia. dyspepsia. pyrosis. odynophagia.
pyrosis. Explanation: Pyrosis refers to a burning sensation in the esophagus and indicates GERD. Indigestion is termed dyspepsia. Difficulty swallowing is termed dysphagia. Pain upon swallowing is termed odynophagia.
A client tells the nurse that the stool was colored yellow. The nurse assesses the client for pilonidal cyst. ingestion of bismuth. occult blood. recent foods ingested.
recent foods ingested. Explanation: The nurse should assess for recent foods that the client ingested, as ingestion of senna can cause the stool to turn yellow. Ingestion of bismuth can turn the stool black and, when occult blood is present, the stool can appear to be tarry black.
The nurse is caring for client scheduled to undergo radical neck dissection. During preoperative teaching, the nurse states that an associated complication is clavicle fracture. venous engorgement. shoulder drop. neck distension.
shoulder drop. Explanation: The nurse should include shoulder drop as an associated complication of radical neck dissection. Another associated complication is poor cosmesis, which is a visible depression in the neck. Clavicle fracture, venous engorgement, and neck distension are not complications associated with radical neck dissection.
Which procedure is performed to examine and visualize the lumen of the small bowel? peritoneoscopy colonoscopy panendoscopy small bowel enteroscopy
small bowel enteroscopy Explanation: Small bowel enteroscopy is the endoscopic examination and visualization of the lumen of the small bowel. Colonoscopy is the examination of the entire large intestine with a flexible fiberoptic colonoscope. Panendoscopy is the examination of both the upper and lower GI tracts. Peritoneoscopy is the examination of GI structures through an endoscope inserted percutaneously through a small incision in the abdominal wall.
The nurse is assisting the physician in a percutaneous liver biopsy. In assisting with positioning, the nurse should assist the client into a: dorsal recumbent position. high Fowler's position. lithotomy position. supine position.
supine position. Explanation: The nurse is correct to instruct the client to assume the supine position. Also, the nurse places a rolled towel beneath the right lower ribs.
The nurses assesses the client for blood in the stool due to an upper GI condition. The nurse understands that if there is blood in the stool, the stool will be which color? bright red tarry black green milky white
tarry black Explanation: Blood that is shed in sufficient quantities from the upper GI tract produces a tarry-black stool. Blood from the lower portion of the GI tract will appear bright or dark red. A milky white stool is indicative of a client who received barium. A green stool is indicative of a client who has eaten spinach.
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? positron emission tomography abdominal ultrasound upper GI enteroclysis magnetic resonance imaging
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 recognizes which change of the gastrointestinal system is an age-related change? weakened gag reflex hypertrophy of the small intestine increased motility 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.
