Exam 3- Med Surg
The nurse is performing a rectal assessment and notices a longitudinal tear or ulceration in the lining of the anal canal. The nurse documents the finding as which condition?
Anal fissure p. 1351
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?
Exhibiting hemoglobin A1C 8.2 p. 1265
The nurse is performing a community screening for colorectal cancer. Which characteristic should the nurse include in the screening?
Familial polyposis p. 1343
Which characteristic is a risk factor for colorectal cancer?
Familial polyposis p. 1343
Which medication is classified as a histamine-2 receptor antagonist?
Famotidine p. 1295
A client is prescribed a histamine (H2)-receptor antagonist. The nurse understands that this might include which medication(s)? Select all that apply.
Famotidine Nizatidine Cimetidine p. 1295
A client has been taking famotidine at home. What teaching should the nurse include with the client?
Famotidine will inhibit gastric acid secretions. p. 1295
Peptic ulcer disease occurs more frequently in people with which blood type?
O p. 1297
The nurse advises the patient who has just been diagnosed with acute gastritis to:
Refrain from food until the GI symptoms subside. p. 1294
A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:
alcohol abuse and smoking. p. 1299
The primary source of microorganisms for catheter-related infections are the skin and the
catheter hub. p. 1259
A client has been prescribed a protein intake of 0.6 g/kg of body weight. The client weighs 154 pounds. The nurse calculates the daily protein intake to be how many grams? Enter the correct number ONLY.
42 p. 1248
The nurse inserts a nasogastric tube into the right nares of a patient. When testing the tube aspirate for pH to confirm placement, what does the nurse anticipate the pH will be if placement is in the lungs?
6 p. 1250
A patient is receiving a continuous tube feeding. The nurse notes that the feeding tube was last irrigated at 2 p.m. The nurse would plan to irrigate the tube again at which time?
6 p.m. to 8 p.m. p. 1246
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?
A canker sore of the oral soft tissues p. 1266
The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance?
260 p. 1246
A patient has a gastric sump tube attached to low intermittent suction. The nurse empties the suction collection chamber and records an output of 320 mL for this 8-hour shift. The record shows that the tube had been irrigated with 20 mL of normal saline twice this shift. What would be the actual output of the gastric sump tube?
280 p. 1246
A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use?
30ml p. 1250
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?
"Avoid coffee and alcoholic beverages." p. 1283
A client reports having red stools lately. What will the nurse ask during assessment questioning?
"Have you been eating beets?" p. 1230
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?
"Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact." p. 1228
A nurse is teaching an older adult client about good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?
"I need to use laxatives regularly to prevent constipation." p. 1313
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 really don't like to be in small, enclosed spaces." p. 1236
After teaching a client about the procedure for inserting a nontunneled central catheter, the nurse determines that the client has understood the instructions based on which statement?
"I will be lying on my back but my legs will be higher than my head." p. 1258
A nurse is performing discharge teaching with a client who had a total gastrectomy. Which statement indicates the need for further teaching?
"I will have to take vitamin B12 shots up to 1 year after surgery." p. 1296
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." p. 1235
A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.)
"Is it possible that you are overusing aspirin." "It can be caused by ingestion of strong acids." "You may have ingested some irritating foods." p. 1292-1293
A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers:
"It indicates if a cancer is present." p. 1233
A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate?
"It is a vent that prevents backflow of the secretions." p. 1244
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?
"Often the area of pain is referred from another area." p. 1229
A client with a peptic ulcer is diagnosed with Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including metronidazole, omeprazole, and clarithromycin. Which statement by the client indicates the best understanding of the medication regimen?
"The medications will kill the bacteria and stop the acid production." p. 1298
The nurse is reviewing the results of a hemoccult test with the client. Which question asked by the nurse is important in screening for the potential of a false-positive result. Select all that apply.
"When was the last time that you included red meat in your diet?" "Can you tell me the amount of alcohol that you drink on an average week?" "Are you prescribed regular strength aspirin daily?" p. 1233
A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The health care provider has ordered a visualization of the small intestine via a capsule endoscopy. What will the nurse include in the client education about this procedure?
"You will need to swallow a capsule." p. 1237
Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding?
1 hour p. 1246
A client with peptic ulcer disease must begin triple medication therapy. For how long will the client follow this regimen?
10 to 14 days p. 1298
A nurse is preparing to administer a 500 mL bolus tube feeding to a patient. The nurse anticipates administering this feeding over which time frame?
10 to 15 minutes p. 1249
A nurse is caring for a client who has had extensive abdominal surgery and is in critical condition. The nurse notes that the complete blood count shows an 8 G/dL hemoglobin and a 30% hematocrit. Dextrose 5% in half-normal saline solution is infusing through a triple lumen central catheter at 125 mL/hr. The physician orders include the following:Gentamicin 80 mg IV piggyback in 50 mL D5W over 30 minutesZantac 50 mg IV piggyback in 50 mL D5W over 30 minutesOne unit of 250 mL of PRBCs (packed red blood cells) over 3 hoursFlush the nasogastric tube with 30 mL normal saline every 2 hours.
1470
A nursing student is preparing a teaching plan about peptic ulcer disease. The student knows to include teaching about the percentage of clients with peptic ulcers who experience bleeding. The percentage is
15% p. 1298
The nurse prepares a client for a barium enema. The nurse should place the client on which diet prior to the procedure?
clear liquids day before p. 1235
A nurse is preparing a presentation for a local community group of older adults about colon cancer. What would the nurse include as the primary characteristic associated with this disorder?
A change in bowel habits p. 1344
A patient is scheduled for a Billroth I procedure for ulcer management. What does the nurse understand will occur when this procedure is performed?
A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum. p. 1300
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
After assessing a client with peritonitis, how would the nurse most likely document the client's bowel sounds?
Absent p. 1323
Which of the following is the primary function of the small intestine?
Absorption p. 1225
A client comes to the clinic after developing a headache, abdominal pain, nausea, hiccupping, and fatigue about 2 hours ago. The client tells the nurse that the last food was buffalo chicken wings and beer. Which medical condition does the nurse find to be most consistent with the client's presenting problems?
Acute gastritis p. 1293
In addition to teaching a client with constipation to increase dietary fiber intake to 25 g/day, which of the following would the nurse include as important?
Adding fiber-rich foods to the diet gradually p. 1313
The nurse is caring for a patient who has dumping syndrome from high-carbohydrate foods being administered over a period of fewer than 20 minutes. What is a nursing measure to prevent or minimize the dumping syndrome?
Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time. p. 1251
A client is recovering from percutaneous endoscopic gastrostomy (PEG) tube placement. The nurse
Administers an initial bolus of 50 mL water p. 1254
A client has a family history of stomach cancer. Which factor would further increase the client's risk for developing gastric cancer? Select all that apply.
Age 55 years Previous infection with H. pylor p. 1304
The nurse is assessing an 80-year-old client for signs and symptoms of gastric cancer. The nurse differentiates which as a sign/symptom of gastric cancer in the geriatric client, but not in a client under the age of 75?
Agitation p. 1306
The nurse practitioner suspects that a patient may have a gastric ulcer after completing a history and physical exam. Select an indicator that can be used to help establish the distinction between gastric and duodenal ulcers.
Amount of hydrochloric acid (HCL) secretion in the stomach p. 1298
Which of the following digestive enzymes aids in the digesting of starch?
Amylase p. 1227
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?
Apply pressure to the bleeding site p. 1275
While caring for a patient who has had radical neck surgery, the nurse notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What does the nurse know is an expected amount of drainage in the wound unit?
Approximately 80 to 120 mL p. 1275
The nurse is preparing the client for an assessment of the abdomen. What should the nurse complete prior to this assessment?
Ask the client to empty the bladder. p. 1231
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?
Assess lung sounds bilaterally. p. 1282
When caring for a client with an acute exacerbation of a peptic ulcer, the nurse finds the client doubled up in bed with severe pain in the right shoulder. What is the initial appropriate action by the nurse?
Assess the client's abdomen and vital signs. p. 1298
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?
Assess the graft for color and temperature. p. 1272
A client with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by
Assessing lung sounds p. 1279
A client reports constipation. Which nursing measure would be most effective in helping the client reduce constipation?
Assist client to increase dietary fiber. p. 1315
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?
Atrophy of the gastric mucosa p. 1228
A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to
Auscultate lung sounds every 4 hours. p. 1259
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. p. 1235
The nurse is evaluating a client's ulcer symptoms to differentiate ulcer as duodenal or gastric. Which symptom should the nurse at attribute to a duodenal ulcer?
Awakening in pain p. 1298
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?
Baking soda and water p. 1272
Which of the following is the most definitive means of assessing for liver disease?
Biopsy p. 1241
A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects the client's stools to have which description?
Black and tarry p. 1302
The nurse is assessing a client with advanced gastric cancer. The nurse anticipates that the assessment will reveal which finding?
Bloating after meals p. 1304
The nurse is caring for a client with a history of bulimia. The client complains of retrosternal pain and dysphagia after forcibly causing herself to vomit after a large meal. The nurse suspects which condition?
Boerhaave syndrome p. 1282
The nurse is performing an abdominal assessment for a patient with diarrhea and auscultates a loud rumbling sound in the left lower quadrant. What will the nurse document this sound as on the nurse's notes?
Borborygmus p. 1315
The nurse is performing and documenting the findings of an abdominal assessment. When the nurse hears intestinal rumbling and the client then experiences diarrhea, the nurse documents the presence of which condition?
Borborygmus p. 1315
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?
Bowel perforation p. 1239
A patient is admitted to the hospital after not having had a bowel movement in several days. The nurse observes the patient is having small liquid stools, a grossly distended abdomen, and abdominal cramping. What complication can this patient develop related to this problem?
Bowel perforation p. 1313
Which clinical manifestation is not associated with hemorrhage?
Bradycardia p. 1277
In women, which of the following types of cancer exceeds colorectal cancer?
Breast p. 1344
A patient with IBD would be encouraged to increase fluids, use vitamins and iron supplements, and follow a diet designed to reduce inflammation. Select the meal choice that would be recommended for a low-residue diet.
Broiled chicken with low-fiber pasta p. 1332
A client sustained second- and third-degree burns over 30% of the body surface area approximately 72 hours ago. What type of ulcer should the nurse be alert for while caring for this client?
Curling's ulcer p. 1297
The primary source of microorganisms for catheter-related infections are the skin and which of the following?
Catheter hub p. 1259
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 mucous membranes are dry p 1800
A client informs the nurse that he has been having abdominal pain that is relieved when having a bowel movement. The client states that the physician told him he has irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder?
Chronic constipation with sporadic bouts of diarrhea p. 1318
If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?
Clamp the catheter. p. 1257-1258
The nurse is irrigating a client's colostomy when the client begins to report cramping. What is the appropriate action by the nurse?
Clamp the tubing and allow client to rest. p. 1341
The nurse is irrigating a colostomy when the patient says, "You will have to stop, I am cramping so badly." What is the priority action by the nurse?
Clamp the tubing and give the patient a rest period. p. 1341
A nurse is caring for a client with a long-term central venous catheter. Which care principle is correct?
Clean the port with an alcohol pad before administering I.V. fluid through the catheter. p. 1259
Which of the following clients is at highest risk for peptic ulcer disease?
Client with blood type O p. 1297
The nurse is providing preoperative care for a client with gastric cancer who is having a resection. What is the nursing management priority for this client?
Correcting nutritional deficits p. 1306
A nurse providing care to a patient who is receiving nasogastric tube feedings finds that the tube is clogged. Which of the following is no longer considered appropriate to use to unclog the tube?
Cranberry juice p. 1246
A client tells the nurse that the stool was colored yellow. The nurse assesses the client for
recent foods ingested p. 1230
A nurse is caring for a client receiving parenteral nutrition at home. The client was discharged from the acute care facility 4 days ago. What would the nurse include in the client's plan of care? Select all that apply.
Daily weights Intake and output monitoring Calorie counts for oral nutrients p. 1256
An older adult client seeks help for chronic constipation. What factor related to aging can cause constipation in elderly clients?
Decreased abdominal strength p. 1313
A nurse is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply.
Diarrhea Diaphoresis Tachycardia p. 1248
Which of the following appears to be a significant factor in the development of gastric cancer?
Diet p. 1306
Which is the primary symptom of achalasia?
Difficulty swallowing p. 1279
What would the nurse identify as a characteristic finding when assessing a client for pilonidal sinus?
Dilated pits of hair follicles in the cleft p. 1352
What information should the nurse include in the teaching plan for a client being treated for diverticulosis?
Drink at least 8 to 10 large glasses of fluid every day p. 1327
A client who had a Roux-en-Y bypass procedure for morbid obesity ate a chocolate chip cookie after a meal. After ingestion of the cookie, the client reported cramping pains, dizziness, and palpitation. After having a bowel movement, the symptoms resolved. What should the nurse educate the client about regarding this event?
Dumping syndrome p. 1305
Clients with Type O blood are at higher risk for which of the following GI disorders?
Duodenal ulcers p. 1297
The nursing student approaches his instructor to discuss the plan of care for his client diagnosed with peptic ulcer disease. The student asks what is the most common site for peptic ulcer formation? The instructor would state which one of the following?
Duodenum p. 1296
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?
Dysphagia p. 1279
When caring for a client with the impaired swallowing related to neuromuscular impairment, what is the nurse's priority intervention?
Elevate the head of the bed 90 degrees during meals. p. 1276
A client has been recently diagnosed with an anorectal condition. The nurse is reviewing interventions that will assist the client with managing the therapeutic regimen. What would not be included?
Encourage the client to avoid exercise. p. 1312
A health care provider suspects that a client has peptic ulcer disease. With which diagnostic procedure would the nurse most likely prepare to assist?
Endoscopy p. 1297
An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom?
Esophageal tumor p. 1287
The nurse is providing community education at the mall. The nurse is instructing on the muscular tube that connects the mouth to the stomach. The nurse outlines this structure on a drawing and labels it with which of the following?
Esophagus p. 1226
A client underwent a continent ileostomy. Within which time frame should the client expect to empty the reservoir?
Every 4 to 6 hours p. 1341
A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely?
Excess fluid volume p. 1260
A client has been receiving intermittent tube feedings for several days at home. The nurse notes the findings as shown in the accompanying documentation. The nurse reports the following as an adverse reaction to the tube feeding:
Fasting blood glucose level p. 1250
The nurse in an extended-care facility reports that a resident has clinical manifestations of fecal incontinence. The health care provider orders a diagnostic study to rule out inflammation. Which study will the nurse prepare the client for?
Flexible sigmoidoscopy p. 1316
The nurse assesses a patient who recently had a nasoenteric intubation. Symptoms of oliguria, lethargy, and tachycardia in the patient would indicate to the nurse what common complication?
Fluid volume deficit p. 1246
The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take?
Flush with 10 mL of water. p. 1250
Postoperatively, a client with a radical neck dissection should be placed in which position?
Fowler p. 1275
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. p. 1229
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 p. 1283
A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition?
Gastroesophageal reflux disease p. 1284
Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the:
Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. p. 1252
The nurse is caring for a comatose patient and administering gastrostomy feedings. What does the nurse understand is the reason that gastrostomy feedings are preferred to nasogastric (NG) feedings in the comatose patient?
Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. p. 1252
The following appears on the medical record of a male patient receiving parenteral nutrition: WBC: 6500/cu mm Potassium 4.3 mEq/L Magnesium 2.0 mg/dL Calcium 8.8 mg/dL Glucose 190 mg/dL Which finding would alert the nurse to a problem?
Glucose level p. 1250
Residual content is checked before each intermittent tube feeding. The patient would be reassessed if the residual, on two occasions, was:
Greater than 200 mL. p. 1250
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?
Hairy leukoplakia p. 1266
The nurse is assessing a client who is stating gastrointestinal upset and a feeling of bloating. Which type of meal would the nurse anticipate causing these types of symptoms?
Hamburger and French fries p. 1230
The nurse is assessing a client with an ulcer for signs and symptoms of hemorrhage. The nurse interprets which condition as a sign/symptom of possible hemorrhage?
Hematemesis p. 1296
The nurse is cautiously assessing a client admitted with peptic ulcer disease because the most common complication that occurs in 10% to 20% of clients is:
Hemorrhage p. 1302
A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, labored breathing, and appears to be confused. Which complication has the client most likely developed?
Hemorrhage p. 1305
A patient diagnosed with IBS is advised to eat a diet that is:
High in fiber. p. 1318
The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds?
Hyperactive p. 1232
An elderly client diagnosed with diarrhea is taking digoxin. Which electrolyte imbalance should the nurse be alert to?
Hypokalemia p. 1315
Review the following four examples of ideal body weight (IBW), actual weight, and body mass index (BMI). Using three criteria for each example, select the body weight that indicates morbid obesity.
IBW = 145 lbs; weight = 290 lbs; BMI = 31 kg/m2
Gastrin has which of the following effects on gastrointestinal (GI) motility?
Increased motility of the stomach p. 1227
A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, what would the nurse stress the importance of?
Increasing fluid intake to prevent dehydration p. 1334
The client is receiving a 25% dextrose solution of parenteral nutrition. The infusion machine is beeping, and the nurse determines the intravenous (IV) bag is empty. The nurse finds there is no available bag to administer. What is the priority action by the nurse?
Infuse a solution containing 10% dextrose and water. p. 1260
A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is
Inserted into the lungs p. 1246
When examining the abdomen of a client with reports of nausea and vomiting, what would the nurse do first?
Inspection p. 1231
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.
Inspection Auscultation Percussion Palpation p. 1231
A patient visited a nurse practitioner because he had diarrhea for 2 weeks. He described his stool as large and greasy. The nurse knows that this description is consistent with a diagnosis of:
Intestinal malabsorption. p. 1315
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 p. 1226
The nurse is conducting a community education program on colorectal cancer. Which statement should the nurse include in the program?
It is the third most common cancer in the United States. p. 1343
A patient with irritable bowel syndrome has been having more frequent symptoms lately and is not sure what lifestyle changes may have occurred. What suggestion can the nurse provide to identify a trigger for the symptoms?
Keep a 1- to 2-week symptom and food diary to identify food triggers. p. 1318
The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly?
Keep the vent lumen above the patient's waist to prevent gastric content reflux. p. 1244
The nurse is assessing a patient with appendicitis. The nurse is attempting to elicit a Rovsing's sign. Where should the nurse palpate for this indicator of acute appendicitis?
Left lower quadrant p. 1324
A focused GI assessment begins with a complete history and physical examination. Identify the quadrant of the abdomen to be palpated or percussed for a patient with pancreatitis.
Left upper p. 1231
The health care provider orders the insertion of a single lumen nasogastric tube. When gathering the equipment for the insertion, what will the nurse select?
Levin tube p. 1244
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. p. 1232
While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure?
Liver Page 1225
Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following?
Low residue p. 1332
A client with a recent history of rectal bleeding is being prepared for a colonoscopy. Initially, how should the nurse position the client for this test?
Lying on the left side with knees bent p. 1238
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?
Maintaining a patent airway p. 1287
A client with cancer has a neck dissection and laryngectomy. An intervention that the nurse will do is:
Make a notation on the call light system that the client cannot speak. p. 1276
Swallowing is regulated by which area of the central nervous system (CNS)?
Medulla oblongata p. 1226
Rebleeding may occur from a peptic ulcer and often warrants surgical interventions. Signs of bleeding include which of the following?
Mental confusion p. 1303
Vomiting results in which of the following acid-base imbalances?
Metabolic alkalosis p. 1328
Which of the following is considered a bulk-forming laxative?
Metamucil p. 1314
The nurse cares for a client who receives continuous enteral tube feedings and who is at low risk for aspiration. The nurse assesses the gastric residual volume to be 350 mL. The nurse determines which action is correct?
Monitoring the feeding closely. p. 1250
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?
Monitoring the stool passage and its color. p. 1235
Which is a true statement regarding gastric cancer?
Most clients are asymptomatic during the early stage of the disease. p. 1304
What part of the GI tract begins the digestion of food?
Mouth
The nurse in the ED admits a client with suspected gastric outlet obstruction. The client's symptoms include nausea and vomiting. The nurse anticipates that the physician will issue which order?
Nasogastric tube insertion p. 1303
A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and would make a recommendation when noticing which circumstance?
No land line; cell phone available and taken by family member during working hours p. 1261
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?
Notify the physician p. 1275
A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse?
Notify the surgeon about the tube's removal. p. 1245
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?
Nystatin p. 1266
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?
Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. p. 1322
Which medication classification represents a proton (gastric acid) pump inhibitor?
Omeprazole p. 1295
A nurse practitioner prescribes drug therapy for a patient with peptic ulcer disease. Choose the drug that can be used for 4 weeks and has a 90% chance of healing the ulcer.
Omeprazole p. 1298
A nursing student is caring for a client with gastritis. Which of the following would the student recognize as a common cause of gastritis? Choose all that apply.
Overuse of aspirin Irritating foods Ingestion of strong acids p. 1292-1293
Which of the following is considered an early symptom of gastric cancer?
Pain relieved by antacids p. 1304
A 66-year-old African-American client has recently visited a physician to confirm a diagnosis of gastric cancer. The client has a history of tobacco use and was diagnosed 10 years ago with pernicious anemia. He and his family are shocked about the possibility of cancer because he was asymptomatic prior to recent complaints of pain and multiple gastrointestinal symptoms. On the basis of knowledge of disease progression, the nurse assumes that organs adjacent to the stomach are also affected. Which of the following organs may be affected? Choose all that apply.
Pancreas Liver Duodenum p. 1304
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 p. 1241
Which of the following is an enzyme secreted by the gastric mucosa?
Pepsin p. 1226
The nurse is conducting a community education class on gastritis. The nurse includes that chronic gastritis caused by Helicobacter pylori is implicated in which disease/condition?
Peptic ulcers
A client is in the hospital for the treatment of peptic ulcer disease. The client reports vomiting and a sudden severe pain in the abdomen. The nurse then assesses a board-like abdomen. What does the nurse suspect these symptoms indicate?
Perforation of the peptic ulcer p. 1302
The nurse is monitoring a client's postoperative course after an appendectomy. The nurse's assessment reveals that the client has vomited, has abdominal tenderness and rigidity, and has tachycardia. The nurse reports to the physician that the client has signs/symptoms of which complication?
Peritonitis
A client with a diagnosis of acute appendicitis is awaiting surgical intervention. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and board-like. What complication does the nurse determine may be occurring at this time?
Peritonitis p. 1324
Post appendectomy, a nurse should assess the patient for abdominal rigidity and tenderness, fever, loss of bowel sounds, and tachycardia, all clinical signs of:
Peritonitis p. 1324
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?
Permit the client to drink only clear liquids. p. 1235
Tube feedings are advised for a client who is recovering from oral surgery. The nurse manages the tube feedings to minimize the risk of aspiration. Which measures should the nurse include in the care plan to reduce the risk of aspiration? Select all that apply.
Place client in semi-Fowler's position during and 30 to 60 minutes after an intermittent feeding. Check tube placement and gastric residual prior to feedings.
The nurse is caring for a client who has a gastrostomy tube feeding. Upon initiating care, the nurse aspirates the gastrotomy tube for gastric residual volume (GRV) and obtains 200 mL of gastric contents. What is the priority action by the nurse?
Place the client in a semi-Fowler's position with the head of the bed at 45 degrees. p. 1248
The nurse is teaching a client with peptic ulcer disease who has been prescribed misoprostol. What information from the nurse would be most accurate about misoprostol?
Prevents ulceration in clients taking nonsteroidal anti-inflammatory drugs (NSAIDs) p. 1295
A client with oral cancer reports dryness of the mouth. What is the nurse's best response?
Provide a humidifier for the client to use while sleeping. p. 1272
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?
Pyloric sphincter p. 1225
Which of the following is the most successful treatment for gastric cancer?
Removal of the tumor p. 1304
When a central venous catheter dressing becomes moist or loose, what should a nurse do first?
Remove the dressing, clean the site, and apply a new dressing. p. 1259
A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location?
Right lower quadrant p. 1323
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?
Serum antibodies for H. pylori p. 1233
Which of the following are characteristics associated with the Zollinger-Ellison syndrome (ZES)? Select all that apply.
Severe peptic ulcers Extreme gastric hyperacidity Gastrin-secreting tumors of the pancreas p. 1297
Which term describes an inflammation of the salivary glands?
Sialadenitis p. 1270
A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube.
Sit the client in an upright position Apply gloves to the nurse's hands Measure the length of the tube that will be inserted Apply water-soluble lubricant to the tip of the tube Tilt the client's nose upward Instruct the client to lower the head and swallow p. 1258
A client is preparing for discharge to home following a partial gastrectomy and vagotomy. Which is the best rationale for the client being taught to lie down for 30 minutes after each meal?
Slows gastric emptying p. 1300
After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected?
Stomach p. 1225
A client who has undergone colostomy surgery is experiencing constipation. Which intervention should a nurse consider for such a client?
Suggest fluid intake of at least 2 L/day p. 1349
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 p. 1231
A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?
Take long, slow breaths p. 1283
A client taking metronidazole for the treatment of H. pylori states that the medication is causing nausea. What teaching should the nurse provide to the client to alleviate the nausea?
Take the medication with meals to decrease the nausea. p. 1295
What would the nurse recognize as preventing a client from being able to take a fecal occult blood test (FOBT)?
The client has hemorrhoidal bleeding p. 1233
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?
The client lying in a lateral position, with the head of bed flat p. 1275
A client realizes that regular use of laxatives has greatly improved bowel patterns. However, the nurse cautions this client against the prolonged use of laxatives for which reason?
The client's natural bowel function may become sluggish. p. 1314
Which is a true statement regarding regional enteritis (Crohn's disease)?
The clusters of ulcers take on a cobblestone appearance. p. 1330
A client tells the nurse, "I am not having normal bowel movements." When differentiating between what are normal and abnormal bowel habits, what indicators are the most important?
The consistency of stool and comfort when passing stool p. 1312
The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length?
The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process p. 1244
Which nursing instruction is correct to provide the client following a barium enema?
The stools may be a white or clay colored. p. 1230
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?
The ultrasonography should be scheduled before the GI procedure. p. 1233
A client informs the nurse that he is taking a stimulant laxative in order to be able to have a bowel movement daily. What should the nurse inform the client about taking a stimulant laxative?
They can be habit forming and will require increasing doses to be effective. p. 1314
The nurse determines which is a true statement regarding older clients, considering the age-related effects on the gastrointestinal (GI) system?
They usually have less control of the rectal sphincter. p. 1228
A positive nitrogen balance indicates which condition?
Tissue growth p. 1256
The nurse is assisting the health care provider with a colonoscopy for a client with rectal bleeding. The health care provider requests the nurse to administer glucagon during the procedure. Why is the nurse administering this medication during the procedure?
To relax colonic musculature and reduce spasm. p. 1237
The nurse is conducting a gastrointestinal assessment. When the client reports the presence of mucus and pus in the stool, the nurse assesses for additional signs/symptoms of which disease/condition?
Ulcerative colitis p. 1315
The presence of mucus and pus in the stools suggests which condition?
Ulcerative colitis p. 1315
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 p. 1284
The nurse is assessing a client for constipation. Which review should the nurse conduct first to identify the cause of constipation?
Usual pattern of elimination p. 1313
A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. What will the nurse suspect?
Vasomotor symptoms associated with dumping syndrome p. 1305
Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?
Weakness, diaphoresis, diarrhea 90 minutes after eating p. 1373
The nurse checks residual content before each intermittent tube feeding. When should the patient be reassessed?
When the residual is greater than 200 mL p. 1251
Which of the following is the most common type of diverticulum?
Zenker's diverticulum p. 1281
The nurse collaborates with the physician and dietician to determine the best type of tube feeding for a client at risk for diarrhea due to hypertonic feeding solutions. Which type of feedings should the nurse suggest?
continuous feedings p. 1249
To ensure patency of central venous line ports, diluted heparin flushes are used
daily when not in use. p. 1258
A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for?
diaphoresis, vomiting, and diarrhea. p. 1251
A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
drink liquids only between meals. p. 1306
When gastric analysis testing reveals excess secretion of gastric acid, the nurse recognizes which medical diagnoses is supported?
duodenal ulcer p. 1241
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 p. 1225
The client is experiencing swallowing difficulties and is now scheduled to receive a gastric feeding. The client has the following oral medications prescribed: furosemide, digoxin, enteric coated aspirin, and vitamin E. The nurse would withhold which medication?
enteric coated aspirin p. 1250
Rebound hypoglycemia is a complication of parenteral nutrition caused by
feedings stopped too abruptly. p. 1259
The major carbohydrate that tissue cells use as fuel is
glucose p. 1227
The nurse cares for a client who receives continuous parenteral nutrition (PN) through a Hickman catheter and notices that the client's solution has run out. No PN solution is currently available from the pharmacy. What should the nurse do?
hang 10% dextrose and water p. 1260
Diet therapy for clients diagnosed with irritable bowel syndrome (IBS) includes:
high-fiber diet. p. 1318
The nurse caring for an older adult client diagnosed with diarrhea is administering and monitoring the client's medications. Because one of the client's medications is digitalis (digoxin), the nurse monitors the client closely for:
hypokalemia p. 1315
Which response is a parasympathetic response in the GI tract?
increased peristalsis p. 1226
The nurse prepares to administer the lavage solution to a client having a colonoscopy completed. The nurse stops and notifies the physician when noting that the client has which condition?
inflammatory bowel disease p. 1239
Which term describes a gastric secretion that combines with vitamin B12 so that it can be absorbed?
intrinsic factor p. 1226
A resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. The client receives nutrition via a PEG tube, has adapted well to the tube feedings, and remains physically and socially active. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. What is the most likely cause of this client's constipation?
lack of free water intake p. 1312
A client has symptoms suggestive of peritonitis. Nursing management would not include:
limiting analgesics to avoid the formation of paralytic ileus. p. 1323
The healthcare provider of a client with oral cancer has ordered the placement of a GI tube to provide nutrition and to deliver medications. What would be the preferred route?
nasogastric intubation p. 1244
The nurse cares for a client who receives parenteral nutrition (PN). The nurse notes on the care plan that the catheter will need to be removed 6 weeks after insertion and that the client's venous access device is a
nontunneled central catheter p. 1257
The nurse recognizes that the client diagnosed with a duodenal ulcer will likely experience
pain 2 to 3 hours after a meal. p. 1298
The nurse teaches an unlicensed caregiver about bathing clients who are receiving tube feedings. The most significant complication related to continuous tube feedings is the
potential risk for aspiration. p. 1249
The nurse cares for a client who receives feedings through a nasogastric (NG) tube and assesses the client for signs and symptoms of pulmonary complications. The nurse determines the client may be experiencing pulmonary complications when which sign is noted?
respiratory rate of 30 p. 1247
A nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. What else would the nurse expect to find?
severe abdominal pain with direct palpation or rebound tenderness p. 1323
The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every
shift p. 1250
Which procedure is performed to examine and visualize the lumen of the small bowel?
small bowel enteroscopy p. 1240
A nurse is teaching a client with malabsorption syndrome about the disorder and its treatment. The client asks which part of the GI tract absorbs food. What is the nurse's best response?
small intestine p. 1225
An older adult client in a long-term care facility is concerned about bowel regularity. During a client education session, the nurse reinforces the medically acceptable definition of "regularity." What is the actual measurement of "regular"?
stool consistency and client comfort p. 1312
The most significant complication related to continuous tube feedings is
the increased potential for aspiration. p. 1249
Which enzyme aids in the digestion of protein?
trypsin p. 1226
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 p. 1235
The nurse monitors a client with nasoenteric intubation. When should the nurse contact the physician?
urinary output 20 mL/hr p. 1245
The nurse recognizes which change of the GI system is an age-related change?
weakened gag reflex p. 1228
The nurse recognizes which change of the gastrointestinal system is an age-related change?
weakened gag reflex p. 1228
