Kaplan Focused Review GI - All

The nurse obtains a history from a client suspected of having a duodenal ulcer. The nurse expects the client to make which statement? - i have been vomiting bright red blood - i have abdominal pain and tenderness - i have frequent loose stools every day - i have increased pain immediately after eating

- i have abdominal pain and tenderness Rationale: a duodenal ulcer is the erosion of the mucosal wall of the duodenum. Epigastric pain which occurs 2-3 hours after eating is the most common symptom, and food intake relieves the pain.

The nurse obtains a history from a client with a diagnosis of cirrhosis. Which client statement does the nurse recognize as MOST directly related to the client's development of cirrhosis? - for the past several weeks i have not slept for more than five hours straight - since my spouse left me five years ago, i have been eating terribly - i have been drinking about a fifth of vodka a day for the last few months - my spouse was a heavy smoker, and i am concerned about second-hand smoke

- i have been drinking about a fifth of vodka a day for the last few months Rationale: the most common causes of cirrhosis are chronic hepatitis C infections and alcohol-induced liver disease. Alcohol has a toxic effect of the liver, which causes liver inflammation, degredation, and scarring. S/S of cirrhosis include nausea, vomiting, anorexia, weight loss, fatigue, headache, ascites, jaundice, and spider angiomas

The nurse prepares a client for a sigmoidoscopy. The nurse recognizes a need to intervene if the client makes which statement? - i took my blood pressure medication with a sip of water this morning - i havent eaten any fruits or vegetables since the day before yesterday - i had good results from the tap water enema this morning - i hope this is easier than the barium enema i had two days ago

- i hope this is easier than the barium enema i had two days ago Rationale: Barium makes it difficult to visualize the colon. No barium studies should occue three days before a sigmoidoscopy. The health care provider must be notified and the procedure will need to be postponed or rescheduled

The nurse in the same day surgery repares a client for discharge after conventional herniorrhaphy. the nurse intervenes if the client makes which statement? - i should not strain when having a bowel movement - i should cough and deep breathe every two hours - i can walk around as soon as i get home - i should notify the health care provider if i have an elevated temperature

- i should cough and deep breathe every two hours Rationale: due to hernia repair, the client should avoid coughing. Deep breathing does not present a problem. if coughing or sneezing is unavoidable the client should be taught to splint the incision.

The nurse provides care for a client receiving enteral feeding through a nasogastric tube. The client is prescribed isosorbide dinitrate 2.5mg sublingual as needed for chest pain. The nurse instructs the client's spouse about the correct administration of the medication. The nurse determines the teaching is effective if the client's spouse makes which statement? - i should irrigate the tube with 50mL of water before giving this medication - i should not give this medication in the tube. I should place the tablet under the client's tongue - i should dissolve this medication in warm water prior to instilling it - i should ask the health care provider to change the medication to liquid form

- i should not give this medication in the tube. I should place the tablet under the client's tongue Rationale: isosorbide dinitrate sublingual preparation is an antianginal medication given for treatment of angina pectoris. Only the sublingual form can be given for immediate treatment of angina. Other formulation of the medication are given orally and should not be crushed. Buccal or sublingual medication should be given as ordered to clients with a NG tube.

the nurse in the outpatient clinic instructs a client taking lansoprazole for the first time. The nurse determines further teaching is required if the client makes which statement? - i should take the medication on a full stomach - the capsules are not to be crushed or chewed - i can take this medication with antacids - i can open the capsule and sprinkle the contents on soft food, such as applesauce, and swallow immediately

- i should take the medication on a full stomach Rationale: lansoprazole is a proton-pump inhibitor and is used for the treatment of gastroesophageal reflux disease (GERD) and ulcers; take before meals

The home health nurse visits a client diagnosed with hepatitis. It is MOST important for the nurse to intervene if the client makes which statement? - i take acetaminophen when i get a head ache - i have stopped having wine with dinner - i keep my fingernails short - i wash my hands before i eat

- i take acetaminophen when i get a headache Rationale: acetaminophen is contraindicated because it is hepatotoxic. The nurse should instruct the client to avoid all medications unless prescribed by the health care provider, including over the counter medications

The nurse provides care for a client with a sigmoid colostomy. The nurse instructs the client about how to care for the stoma. The nurse knows that teaching is successful if the client makes which statement? - i will drape the area and wash the stoma with hexachlorophene soap - i will clean the stoma vigorously with alcohol wipes and pat dry - i will clean around the stoma with soap and water and pat dry - i will drapw the area and cleanse the stoma with povidone iodine

- i will clean around the stoma with soap and water and pat dry Rationale: the client will use mild soap and water. Instruct the client to not use soaps that have oil or perfumes. Mild soap and water will provide adequate cleansing with limited irritation. The nurse will teach the client to observe for skin breakdown.

The nurse instructs a client about the bowel preparation required prior to a sigmoidoscopy. The nurse identifies teaching is successful if the client makes which statement? - i can eat a regular diet prior to the test - i will be asleep when this test is performed - i will have an enema the morning of the test - i will have nasogastric suction decompression

- i will have an enema the morning of the test Rationale: this procedure is a direct visualization of the sigmoid colon, rectum, and anal canal. A tap water enema or Fleet's is given until returns are clear the morning of the procedure. The procedure is done to screen for colon cancer or explore possible causes of abdominal pain, rectal bleeding, changes in bowel habits, chronic diarrhea, and other intestinal problems.

the nurse instructs the client how to increase calories in the diet. The nurse determines teaching is effective if the client makes which statement? - i will broil all my meats - i will eat bread at all my meals - i will snack frequently on nuts and dried fruits - i only use low-fat salad dressings

- i will snack frequently on nuts and dried fruits Rationale: these foods add calories; also spread butter and or cream cheese on rolls and add butter to foods

The nurse provides care for clients in the outpatient clinic. The nurse obtains a history on a client reporting diarrhea. It is MOST important for the nurse to follow up on which client statement? - i eat a lot of processed foods - ive been taking cephalexin for the last week - i eat small meals four to six times per day - i prefer to eat my food cold

- i've been taking cephalexin for the last week Rationale: oral antibiotics given for infections may alter the natural flora of the GI tract. This change in normal flora, especially the last of lactobacillus, often causes diarrhea

The nurse provides care for a client diagnosed with a peptic ulcer. Which nursing action is MOST appropriate? - identify stress factors in the client's environment - avoid giving the client choices to make - encourage the client to become angry - avoid discussing the client's symptoms

- identify stress factors in the client's environment Rationale: It is important to identify elements in the client's environment that are contributing to stress when caring for a client with a psychophysiological disorder. Work habits and personal habits, such as smoking and drinking, must be evaluated to encourage the client to adopt a less stressful lifestyle.

The nurse provides education to an adult client to facilitate bowel elimination. Which action should the nurse encourage? - engaging in sedentary activity - increasing dietary bulk - decreasing fluid intake - using oral laxatives

- increasing dietary bulk Rationale: the foods that contain cellulose, such as whole wheat bread, fruits, and other grains, will increase the bulk in the stool which facilitates bowel elimination

The nurse provides care for a client after an appendectomy. The day after surgery, the client has severe abdominal pain, a temperature of 101F, and a rigid abdomen. The nurse suspects the client is experiencing which complication? - anesthesia intolerance - abnormal pain intolerance - infection of the peritoneal sac - bladder distention

- infection of the peritoneal sac Rationale: peritonitis can be caused by a ruptured appendix or gross contamination of the peritoneum. Signs and symptoms of peritonitis include severe abdominal pain, abdominal rigidity, decreased bowel sounds, nausea and vomiting, increased temperature, shock, and paralytic ileus. The nurse should monitor V/S, administer antibiotics and IV fluids, maintain a nasogastric tube to suction, and administer medication for pain and fever. The client may need to return to surgery to correct the cause.

To prepare a client for a paracentesis, it is ESSENTIAL for the nurse to take which action? - administer a cleansing enema - premedicate the client with a narcotic agent - restrict the client's intake of fluids - instruct the client to empty the bladder

- instruct the client to empty the bladder Rationale: a paracentesis procedure in which a needle or catheter is inserted into the peritoneal cavity to obtain ascitic fluid for diagnostic or therapeutic purposes. The client is at risk for bladder injury by the procedure if it is not empty and small

A toddler client accidentally drinks some drain cleaner and is brought to the emergency department. Which piece of equipment is most essential for the nurse when caring for this client? - intubation tray - EKG machine - Dialysis machine - gastric lavage tube

- intubation tray Rationale: an intubation tray is the most essential piece of equipment for the nurse to have on hand. Because drain cleaner is a caustic substance, there is potential for massive swelling, which would compromise respirations. An intubation tray should be immediately available so that the toddler's airway is protected.

a client reports nausea, vomiting, and abdominal pain that becomes more intense approximately one to two hours after eating. Which action does the nurse take to correctly assess for the presence and character of bowel sounds? - palpate the abdomen for tenderness before auscultating for bowel sounds - use the bell of the stethoscope to auscultate for the presence of bowel sounds - listen for bowel sounds for three to five minutes before documenting "absent bowel sounds" - assess for a positive fluid wave before listening for bowel sounds

- listen for bowel sounds for three to five minutes before documenting "absent bowel sounds" Rationale: the client is reporting nausea, vomiting and abdominal pain, listening for the absence of bowel sounds will help eliminate and determine a possible cause for these symptoms.

The nurse monitors a preschool-age client diagnosed with acetaminophen overdose. Which laboratory test result is MOST important for the nurse to evaluate? - liver function test - chest x-ray - bleeding time - white blood cell count

- liver function test Rationale: acetaminophen is metabolized by the liver so monitoring liver enzymes, specifically AST and ALT is most important. Liver damage is a potential problem after acetaminophen overdose.

The nurse on the surgical unit cares for the client after an ileostomy procedure. Which action does the nurse take FIRST? - empty the collection bag every hour - apply lotion to the peristomal skin - cover the stoma with three layers of gauze - measure the output and document it in the medical record

- measure the output and document it in the medical record Rationale: output from the ileostomy is liquid and may be copious. It is important for the nurse to assess the client's intake and output

The nurse instructs a client how to take psyllium. Which instruction is MOST important for the nurse to include? - take psyllium immediately after you have a loose bowel movement - mix psyllium with water, milk, or fruit juice, and take at about the same time each day - stir the psyllium in a fluid and let stand for two minutes to form a thicker solution - allow the psyllium to dissolve under your tongue for the best absorption

- mix psyllium with water, milk, or fruit juice, and take at about the same time each day Rationale: powder is mixed with liquid and taken immediately without letting it stand; taking it at the same time each day encourages compliance

The nurse provides care for a client diagnosed with acute cholecystitis. The client states "my stomach hurts all the way up to my right shoulder. I am experiencing some nausea and have vomited twice." Which prescription does the nurse carry out FIRST? - insert NG tube and attach to intermittent low suction - trimethobenzamide 200mg rectally three times daily - morphine 15mg IM q4h prn - NPO

- morphine 15mg IM q4h prn Rationale: Acute cholecystitis is inflammation of the gallbladder that develops over hours, usually because a gallstone obstructs the cystic duct and causes acute pain. The nurse's first action is to make the client more comfortable before performing other prescriptions

The nurse instructs a client how to increase folic acid in the diet. The nurse determines teaching is effective if the client makes which statement? - i like oatmeal for breakfast - my favorite lunch is spinach salad - i will eat more grapes, apples, and bananas each day - i will eat more chicken

- my favorite lunch is a spinach salad Rationale: spinach contains 108mg per half-cup serving; other folate-rich sources include organ meats, broccoli, asparagus, milk, orange juice

the home health nurse visits a client diagnosed with diverticulitis. The client is prescribed a clear liquid diet, and the nurse instructs the family about the appropriate foods. The nurse intervenes if the client's family makes which statement? - my grandparent can have a daily glass of prune juice - my spouse really likes apple juice - my parent drinks cranberry juice in the evening - my grandparent can eat cherry ice pop with me

- my grandparent can have a daily glass of prune juice Rationale: a clear liquid diet allows clear liquids. Prune juice is allowed on a full liquid diet. Diverticulitis is an infection of the diverticulum. Symptoms include irregular bowl function with episodes of diarrhea, crampy pain the left lower quadrant, and low grade fever.

The client comes back from an overseas trip reporting multiple, watery, bowel movements. The healthcare provider prescribes loperamide. It is MOST important for the nurse to follow up on which client statement? - i feel dizzy and my mouth feels like cotton - i should change my diet as well as take medication - my temperature is 101.2 F - i find it hard to keep my eyes open

- my temperature is 101.2 F Rationale: two signs that should prompt the client to contact the health care provider are a fever over 101.0 or if there is blood noted in stools; may need to rule out bacterial or parasitic cause of diarrhea

The nurse monitors a client recovering from hepatitis B. The nurse understands this client has developed which type of immunity to hepatitis B? - artificial active acquired immunity - natural active acquired immunity - innate immunity - artificial passive acquired immunity

- natural active acquired immunity Rationale: This client has natural active acquired immunity, which means since the client had the disease, the client has produced antibodies to fight the disease. No artificial substance was introduced into the body to trigger the immune response.

A client is returned to the unit following a total gastrectomy for stomach cancer. The client pulls the nasogastric tube out. Which action should the nurse perform immediately? - reinstate the nasogastric tube - notify the health care provider - assess the client's bowel sounds - medicate the client for pain

- notify the healthcare provider Rationale: if the NG tube must be replaced or repositioned, the hc provider should perform this task. Accumulation of secretions may occur following the removal of the tube, which can also result in rupture of the suture line and severe complications

Immediately following a liver biopsy, the nurse places a client in which position? - on the right side - on the left side - prone - supine

- on the right side Rationale: it is important to prevent fluid leakage or hemorrhage from the biopsy site. The idea position is to lie directly on the liver with the ribs pushing on the liver. The nurse will place a pillow under the costal margin to hold pressure on the insertion site. The nurse will determine prothrombin time, aPTT, and platelet count PRIOR to the procedure and report abnormal findings to the health care provider

The nurse gives discharge instructions to a family of a client diagnosed with hepatic encephalopathy. The nurse determines further teaching is necessary if the family makes which statement? - we should contact the health care provider if our parent is restless at night - our parent may have some tremors in their hands - our parent should eat meat at every meal - lactulose may cause bloating and cramps

- our parent should eat meat at every meal Rationale: the client will be placed on a low animal protein and high plant protein diet. The purpose of the low animal protein diet for a client with hepatic encephalopathy is to reduce intestinal ammonia production

The nurse provides care for a client with a nasogastric tube. Which assessment by the nurse is the MOST reliable indication the nasogastric tube is correctly positioned? - listen for active bowel sounds - pH of aspirate is 3 - marking on the rube designating the correct length remains visible just outside the nares - the tube is secured with a tube fixation device

- pH of aspirate is 3 Rationale: aspirate for gastric contents and check pH; pH of gastric aspirate is 4 or less

The nurse understands which is the principle reason for the use of enzyme inhibitors (acetacolamide) in a client with pancreatitis? - pancreatic enzymes are irritating to the liver - pancreatic enzymes escape into interstitial tissue - pancreatic enzymes are missing and must be replaced - pancreatic enzymes are inactivated and must be enhanced

- pancreatic enzymes escape into interstitial tissue Rationale: interstitial pancreatitis is characterized by a swelling of the pancreas and the escape of its digestive enzymes, lipase and amylase, into the surrounding pancreatic tissues into the peritoneal cavity, causing necrosis. Acetazolamide is a carbonic anhydrase inhibitor. It helps inactivate the enzymes to help minimize the damage they cause to normal tissue. It can also decrease the overall production of the enzymes to decrease the volume of pancreatic secretion.

The spouse of a client with a hepatitis B is given hepatitis B immune globulin (HBIg). The nurse understands this offers which type of protection? - complete - active acquired - antigen - passive acquired

- passive acquired Rationale: immune serums such as HBIg contain gamma globulins in a concentration of about 16% and are obtained from hep-B immune persons from the general population; provides rapid but short lived protection against hep-B; close contacts of a client with hep-B receive this immunization by intramuscular injection; treatment is usually repeated after 28-30 days

The nurse identifies folic acid is prescribed for which conditions? Select all that apply: - pregnancy - alcoholism - parkinson's disease - liver disease - type 1 DM - pernicious anemia

- pregnancy, alcoholism, liver disease Rationale: folic acid is used to treat anemia, liver disease, alcoholism, intestinal obstructions, and pregnancy; it has a low incidence of adverse effect; found naturally in many foods including bran, yeast, dried beans, nuts, fruits, and fresh vegetables

A parent brings a newborn client to the health care provider's office. The newborn is vomiting, had abdominal distention, and is diagnosed with pyloric stenosis. Which characteristic of the newborn's emesis does the nurse expect? - black in appearance - diminished after feedings - projectile and forceful - thick and full of mucus

- projectile and forceful Rationale: an infant with pyloric stenosis will present with projectile vomiting and abdominal distention. Other symptoms include weight loss, constipation, dehydration, and visible peristatic waves.

The nurse provides care for a client with a large abdominal wound. The nurse prepares to irrigate the wound. For protection from blood and/or other fluids, which personal protective equipment does the nurse wear along with a mask, gloves, and water resistant gown? - an N-95 respirator - a surgical cap - shoe covers - protective eyewear

- protective eyewear Rationale: protective eyewear should always be worn whenever there is a chance of blood or body fluid splashing into the nurse's face or eyes. During the irrigation of a large abdominal wound, the nurse could possibly get splashed in the eyes. Goggles, face shields, or protective glasses should be worn for eye splash protection.

The nurse records the vital signs and checks the IV and operative sites for a client who has just returned to the med-surg unit following abdominal surgery. Which additional action is ESSENTIAL before the nurse leaves the client's room? - update the client's partner on the client's condition - dim the room lights so the client can rest - administer mouth care - raise the side rails on the bed

- raise the side rails on the bed Rationale: raising the side rails helps to ensure safety for the client. in the immediate post-op period, the client is likely to be sedated and at high risk for falling. The nurse should ensure the bed is in the lowest position and locked, and the rise rails raised, and nurse call button within reach before leaving the client

The nurse understands which factor is the MOST likely source of hepatitis D? - eating infected shellfish - overly exerting oneself - practicing poor hygiene - receiving a blood transfusion

- receiving a blood transfusion Rationale: Hep D co-infects with Hep B. It is spread by contact with infected blood and/or body fluids.

The health care provider orders a clear liquid diet for the client after an appendectomy. the nurse explains to the client a clear liquid diet was ordered for which reason? - provide adequate calories - relieve thirst and maintain fluid balance - stimulate the GI tract so the client will have bowel movements - provide complete nutrition

- relieve thirst and maintain fluid balance Rationale: offer clear fluids or foods that are fluid at body temperature; requires minimal digestion and leave minimal residue; clear liquids are the initial feeding after surgery or parenteral nutrition

After an open cholecystectomy, a client is returned to the unit with a nasogastric tube connected to low intermittent suction, a T-tube in place, and a penrose drain. What is the purpose of the Penrose drain? - removes accumulated bile and blood from the surgical site - permits irrigation of the peritonuem - provides access for antibiotic infusion - creates a route for alimentation

- removes accumulated bile and blood from the surgical site Rationale: following a chole - bile and blood can collect in the gallbladder bed and cause increased pain and wound complications. A penrose drain is a flat tube that allows fluids to flow out of the wound bed by gravity

A client is schedules for bowel surgery, and a health care provider orders a low-residue diet as part of the bowel preparation. The nurse instructs the client about foods allowed on a low-residue diet. The nurse determines the teaching is effective if the client chooses which menu? - bouillon soup, grilled cheese sandwich, and grapes - corned beef, buttered peas, and custard - roast lamb, buttered rice, and sponge cake - strained cream of asparagus soup, bacon and tomato sandwich, and sugar cookie

- roast lamb, buttered rice, and sponge cake Rationale: foods allowed for a low residue diet include well-cooked tender meats, fish, and poultry; milk and cheeses, juices without pulp (no prune juice), canned fruit and ripe bananas; white bread or refined bread

The nurse provides care for a client after a traditional cholecystectomy. It is MOST important for the nurse to position the client in which position? - side lying with bed flat - supine with bed flat - semi fowler's position - lying flat with knees elevated

- semi-fowler's position Rationale: this position allows the client head and trunk to be raised 15-45 degrees. This is optimal because it will allow the client to take the necessary deep breaths to prevent pneumonia after surgery and it will place less stress on the suture line

The nurse reviews the records of a client diagnosed with Launnec cirrhosis. The nurse expects to find which lab value? - serum albumin 4.0 g/dL (40 g/L) - serum aspartate aminotranferase (AST, SGOT) 38 U/L (0.63 ukat/L) - serum alanine aminotansaminase (ALT, SGPT) 600 U/L (10.02 ukat/L) - serum lactate dehydrogenase (LDH) 150 U/L (2.5 ikat/L)

- serum alanine aminotansaminase (ALT, SGPT) 600 U/L (10.02 ukat/L) Rationale: laennec cirrhosis is a hepatic cirrhosis in which increased connective tissue spreads out from the portal spaces compressing and distorting the lobules, causing impairment of liver function, and ultimately producing the typical hobnail liver. The elevation indicates liver damage. Normal levels are between 5-35 U/L.

The nurse cares for a client receiving famotidine. The client reports resuming smoking and experiencing gastric pain about one hour after meals. Which response is BEST? - smoking decreases stomach acid production, so you will not digest foods as easily - smoking interferes with the medications effectiveness, and you are no longer receiving the full anti-ulcer effect - nicotine can increase feelings of anxiety and restlessness, which the medication lowers - if you smoke too much, you will become dizzy

- smoking interferes with the medication's effectiveness, and you are no longer receiving the full anti-ulcer effect Rationale: smoking interferes with histamine antagonists, such as famotidine. Because smoking diminishes the effectiveness of the drug, the client should be instructed to avoid smoking. Indications of gastric ulcer include pain that occurs about one hour after meals or when fasting. Pain in relieved by vomiting, but the ingestion of food does not decrease the pain

The nurse provides care for a client with a nasogastric tube in place. The client reports discomfort in the back of the throat. Which action by the nurse is BEST? - move the tube out 2 inches - change the diet to full liquids - reinstert tube into other nostril - spray with viscous lidocane solution

- spray with viscous lidocane solution Rationale: viscous lidocane is a local anesthetic. Spraying it on the irritated surface may relieve the discomfort in the back of the client's throat

When assessing the abdomen, the nurse places a client in which position? - sitting with a pillow at the back - supine or knees flexed - side lateral - sims

- supine with knees flexed Rationale: supine position relaxes the muscles and provides comfort. A small pillow may be placed under the knees for comfort

A client is given hepatitis B immune globulin (HBIg) after having unprotected sexual contact with a person diagnosed with hepatitis B. The nurse explains to the client that the medication is given for which purpose? - prevent other sexually transmitted infections - stimulate the immune system to develop antibodies to hepatitis - prevent the client from contracting hepatitis - temporarily increase the client's resistance to hepatitis

- temporarily increase the client's resistance to hepatitis Rationale: Hep B immune globulin (HBIg) contains antibodies to hep B virus (HBV). HBIg offers prompt but short-lived protection against infection with HBV. HBIg is an example of passive immunity (the short-term immunity which results from the introduction of antibodies)

The nurse provides care for a client after a total gastrectomy. The nurse is most concerned if which observation is made? - the nasogastric tube is attached to low continuous suctioning - the client's urine output during the previous 8 hours was 500mL - the client asks for oral pain medication - the client performs coughing and deep breathing every two hours and is appropriately using the incentive spirometer

- the NG tube is attached to low continuous suctioning Rationale: The suction setting should be set on low intermittent suction (LIS). LIS is preferred to prevent the NG tube from adhering to the wall of the newly formed pouch or cause trauma to the anastamosis

The nurse provides care for a client admitted with diagnosis of acute pancreatitis. The nurse administers morphine sulfate intravenously for reports of pain. Which client behavior indicates to the nurse the medication is effective? - the client sleeps for one hour - the client frequently changes position - the client states there is less nausea - the client does not report thirst

- the client sleeps for one hour Rationale: acute pancreatitis causes severe abdominal pain. Pain increases body metabolism, which increases secretion of pancreatic and gastric enzymes. The client sleeping and relaxed indicates the morphine is effective. The nurse will evaluate the client's pain on a scale before and after administering pain medication

The home health care nurse evaluates a client's ability to use aseptic technique when changing the dressing on an abdominal wound. Which client action demonstrates the BEST understanding of correct technique? - the client uses bare hands to remove the old dressing - the client utilizes warm tap water to cleanse the wound - the client applies antibiotic ointment with an ungloved finger - the client uses hand sanitizer before putting on gloves

- the client uses hand sanitizer before putting on gloves Rationale: hands are a major source of infection. Appropriate hand hygiene is essential for any aseptic technique. To change a dressing, it is important to determine the type of dressing, presence of drains, frequency of dressing change, and solutions or ointments used.

A liver scan is prescribed for a client prior to surgery. Which description BEST describes the procedure? - the client will ingest a small amount of radioactive material and venipuncture will be performed to monitor blood levels. - the client will stand in front of a large machine that takes x-ray pictures of the liver - the client will be asked to lie still which a scanning probe is passed back and forth over the body - the client's skin will be lubricated with oil and ultrasound pictures will be taken

- the client will be asked to lie still while a scanning probe is passed back and forth over the body Rationale: the client will receive trace amounts of radioactive colloid by IV infusion and then will be placed in many different positions on a table. The client must lie very still during the scan. No Follow-up care is necessary.

The nurse cares for an elderly client admitted with a diagnosis of hepatitis A. The client is anorexic, reports weakness, is incontinent of urine, and involuntary of stool. The nurse determines that care is appropriate if which observation is made? - the staff caring for the client follows standard precautions - the client is offered more frequent feeding during the afternoon and evening hours - the nurse maintains the client on strict bed rest - the nurse places the client on contact precautions

- the nurse places the client on contact precautions Rationale: hepatitis A is spread by fecal-oral routes; contact precautions are required due to fecal incontinence; instruct the client of the importance of good handwashing

The nurse makes a home care visit to a client with a diagnosis of right-sided stroke. The client's spouse reports being recently diagnosed with viral gastroenteritis and having frequent loose stools. The nurse is MOST concerned if which observation is made? - the spouse washes the hands frequently with soap and water - the spouse drinks electrolyte solution - the spouse uses a separate tube of toothpaste - the spouse prepares lunch for the client

- the spouse prepares lunch for the client Rationale: due to diarrhea, and high risk of hand contamination, the spouse should not prepare foods that will be eaten by others. If there is no other option, the spouse must be taught to thoroughly clean the hands with soap and water and use gloves when preparing food.

The nurse on the surgical unit provides care for a client with a new colostomy. How should the nurse expect the stoma to appear immediately after surgery? - the stoma should be bluish and dry - the stoma should appear beefy red and moist - the stoma should appear gray and small - the stoma should be dark red

- the stoma should be beefy red and moist Rationale: immediately following surgery, the stoma, which is formed from a loop of the intestine, is brought out to the abdominal wall and appears beefy red and moist

A client is being taught how to care for an ileostomy appliance. Which information does the nurse emphasize as most important when applying a new bag? - the wafer should be cut or molded to fit snugly around the stoma - the client should use a large collection bag to avoid having to empty or change it often - drying powder should be used in the collection bag - the collection bag should have an air vent

- the wafer should be cut or molded to fit snugly around the stoma Rationale: stool from an ileostomy can be thin or thick liquid, and contains gastric enzymes. The wafer must be formed or cut to fit snugly around the stoma to prevent leakage of the stool onto the abdomen which will excoriate the skin.

The nurse cares for the client immediately after removal of a cataract in the left eye. The health care provider orders prochlorperazine to the administered after the surgery. The nurse understands it is important to administer the medication for which reason? - to decrease the pain felt because of the sutures - to help the like sleep better - to prevent pressure on the suture line - to help dissolve the sutures

- to prevent pressure on the suture line Rationale: nausea and vomiting can put pressure on the delicate suture lines; preventing nausea and vomiting allows surgical areas to heal undisturbed; adverse effects include drowsiness, orthostatis HTN, diplopia, and photosensitivity

The nurse provides care for a client reporting nausea, vomiting, and fever. Salmonellosis is suspected. To prevent salmonellosis from spreading to other people, which intervention does the nurse include in the care plan? - complete isolation procedures including gown, gloves, and mask - restrict all visitors - instruct all family members and people who have had close contact with the client to be tested - wash hands with soap and warm water

- wash hands with soap and warm water Rationale: Salmonellosis is food poisoning caused by salmonella bacteria; organisms are found in raw meats, eggs, and dairy products, and are spread through intestinal secretions. Standard precautions are indicated with hand washing with soap and warm water.

The nurse teaches a client how to perform a routine dressing for a surgical incision using clean technique. The client performs a return demonstration. Which action by the client shows and understanding of the procedure? - washes hands before changing the dressing - the client utilizes a splash guard and mask - dons sterile gloves before each dressing change - keeps the dressing moist so it will not adhere to the wound

- washes hands before changing the dressing Rationale: washing hands is one of the best ways to decrease the risk of infection. A clean technique involves reducing the numbers of microorganisms to minimize the risk of transmission from the environment, health care personnel, or the client by performing appropriate hand hygiene and using clean gloves

The nurse in the outpatient clinic counsels a client with a diagnosis of cholecystitis. The nurse determines teaching is successful if the client makes which statement? - i really like a lot of cream on my oatmeal - we eat a lot of broiled fish and chicken - i cant wait to eat the chocolates my children gave - my favorite dish is broccoli with cheese sauce

- we eat a lot of broiled fish and chicken Rationale: broiled meats are high in protein and low in fat. The client should avoid meats that are fried or have high fat content. Cooked fruits, non-gas forming vegetables, bread, and cereals are also allowed

The nurse provides care for a client who is 5'7" tall, weighs 300lbs, and is recuperating from an exploratory laprotomy. The client cooperates with coughing and deep breathing exercises and ambulates a distance of 25 feet in the hallway. For which postoperative complication should the nurse MOST viligantly assess the client? - pneumonia - fat emboli - pulmonary emboli - wound dehiscence

- wound dehiscence Rationale: wound dehiscence is related to stress on the surgical site. The client's weight has the potential to place great stress on the incision, putting the client at high risk for the complication of wound dehiscence. Dehiscence is a separation of wound edges and typically experienced 5-6 days postoperatively. Nursing care includes placing the client in low fowler's position, no coughing, NPO, and notifying health care providers if dehiscence occurs.

The nurse teaches a client who has undergone a laproscopic cholecystectomy prior to discharge. The nurse should include which instruction? - begin light exercise immediately - limit diet to liquid and soft foods for three days - contact the healthcare provider if there is pain in the right shoulder - remove adhesive strips over puncture wounds in five days

-begin light exercise immediately Rationale: the client may begin walking immediately; avoid lifting heavy objects (more than 5lbs) for 1 week

The nurse knows that which type of feeding is MOST commonly used with infants who are intolerant of cow's milk? - evaporated milk-based formula - medium-chain-triglyceride-based formula - predigested-protein-based formula - soy-based formula

-soy-based formula Rationale: soybeans are used as the protein source in formulas for children with allergies to cow's milk; this protein is less likely to induce allergies in infants

The nurse recognizes which child client is at GREATEST risk for poisoning? - 5 month old - 2 year old - 5 year old - 7 year old

- 2 year old Rationale: a two year old is very curious and likes to explore and does not have the judgement necessary to avoid dangerous substances, so they would be at the highest risk for poisoning

The nurse cares for a client after a traditional cholecystectomy. The nurse contacts the health care provider if which observation is made? - 800mL of bloody drainage the first day postop - the client frequently reports abdominal pain during the first 24 hours - nasogastric tube connected to intermittent suction the first day postop - temperature elevation to 100F the evening of surgery

- 800mL of bloody drainage the first day postop Rationale: this amount of drainage after a chole- would indicate hemorrhage; 50mL is an appropriate amount of drainage

The nurse provides care for a client that has taken aspirin in high, prolonged dosages. Which physiological change should the nurse anticipate? - urinary frequency - hypoventilation - GI bleeding - hemoconcentration

- GI bleeding Rationale: salicylism results in GO bleeding, blood dyscrasia, and acid-base disturbances, with fluid and electrolyte imbalances. These symptoms are directly associated with prolonged high doses of aspirin.

The nurse provides care for a client who has been exposed to hepatitis B. Which vaccination does the nurse prepare to administer to the client first? - HBIg - Hep A vaccine - Hep B vaccine - Hib

- HBIg Rationale: hepatitis B immune globulin (HBIg) provides immediate, short-term protection against hepatitis B infection. HBIg has large amounts of hepatitis B antibodies taken from donated human blood and provides passive immunity

The nurse cares for a client with a diagnosis of ulcerative colitis. When reviewing the client's record, the nurse expects to find which lab value? - RBC's 4 million/mm3 - Platelet count 75,000/mm3 - Hgb 18.2 - WBC's 15,000/mm3

- WBC's 15,000/mm3 Rationale: Due to inflammation, WBC's and erythrocyte sedimentation rate will be evaluated. Normal WBC count for adults is 4500-11000. Sodium and potassium and chloride levels may be decreased due to frequent diarrhea

The nurse understands that phentermine (Adipex-P) is most prescribed for which of the following clients? - a client who is obese - a client who is dying - a client experiencing anorexia - a client who is abusing alcohol

- a client who is obese Rationale: phentermine (Apidex-P) is a short term treatment for obesity; side effects include CNS stimulation, HTN, and palpitation

The nurse evaluates client in the gastrointestinal clinic. Which client does the nurse see FIRST? - a middle-age client diagnosed with irritable bowel syndrome reports cramping and loose stools - a young adult client reports not having a bowel movement in 2 days - a school-age client diagnosed with gastroenteritis who had five diarrheal stools in the last 3 days - a newborn client experiencing projectile vomiting and irritability

- a newborn client experiencing projectile vomiting and irritability Rationale: the client's symptoms indicates pyloric stenosis. the infant is are risk for fluid and electrolyte imbalance and requires immediate intervention

The nurse provides preoperative teaching to a client scheduled for a colostomy. The nurse explains to the client that 24 hours after the surgery the colostomy drainage will be which description? - a large amount of dark bloody output - a large amount of liquid stool - formed stool with watery drainage - a scant amount of bright bloody drainage

- a scant amount of bright bloody drainage Rationale: a small amount of bleeding at the stoma is expected. The nurse will remind the client to report excessive amounts of bleeding

The nurse performs discharge teaching for a client with a diagnosis of Hepatitis B. Which precaution is included in the teaching? - burn used paper tissues - abstain from unprotected sexual intercourse - use special disinfectant in toilet - avoid touching family members

- abstain from unprotected sexual intercourse Rationale: Hep B is transmitted through blood, saliva, semen, and vaginal secretions. The client should avoid unprotected sexual intercourse

The nurse provides care for a client admitted with the diagnosis of small bowel obstruction, and has severe abdominal distension. Which finding BEST describes the reason for the distention? - Increased gastric acid pH levels - vagal nerve stimulation - accumulation of fluid in intestine - decreased perfusion of intestine

- accumulation of fluid in intestine Rationale: intestinal obstruction prevents flow of contents through the intestinal lumen. Fluid moves from interstitial and vascular spaces into intestinal lumen causing fluid accumulation and severe abdominal distention. Pain and distension from a bowel obstruction may be severe.

Which medication does the nurse have available for the treatment of acetaminophen overdose? - Vitamin K - acetylcysteine - aspirin - naloxone

- acetylcysteine Rationale: this medication is given as an antidote following an acetaminophen overdose

After inserting a needle into the ventrogluteal muscle to inject vitamin K, which action does the nurse take NEXT? - instructs the client to contract the muscle - administers the vitamin K slowly - spreads the skin with the thumb and index finger - pulls back the needle while injecting slowly

- administers the vitamin K slowly Rationale: medications should be given slowly for better absorption; all of these answers are implementations, determine which action is the safest for the question

The nurse understands which principle serves as the basis for managing childhood weight problems? - allow for slower weight gain compared to linear growth - allow for slow weight loss, approximately 1 pound per week - allow for weight loss only by exercise - allow for weight loss only under health care provider supervision

- allow for slower weight gain compared to linear growth Rationale: the nurse encourages a diet high in complex carbohydrates and fresh fruits and vegetables in addition to physical activity

The nurse understands the primary reason for maintaining a constant rate of infusion with parenteral nutrition (PN) is to prevent which complication? - the risk of fluid overload - an unstable blood glucose level - potential clotting of the catheter - electrolyte imbalance

- an unstable blood glucose level Rationale: the potential problem of administering PN is the high glucose concentration; the body must produce insulin to respond to the glucose level; rate should therefore be kept constant using an infusion pump

A client has a gastroscopy performed and a a gastric aspirate taken for analysis. The nurse understands the purpose of a gastric aspirate includes which reason? - assess acid secretion and bacterial activity in the stomach - inhibit acid secretion in the stomach - assess the mucus-producing capacity of the stomach - introduce gastric-irritating substances

- assess acid secretion and bacterial activity in the stomach Rationale: take a gastric aspirate and analyzing its pH and microbial content will show if there is an infection, or if there is excess acid in the stomach

The LPN/LVN reports to the nurse that a client's surgical wound has burst and abdominal contents are protruding. Which action does the nurse take FIRST? - assess the client's wound - call the health care provider - cover the wound with sterile saline soaked gauze - place the client on NPO status

- assess the client's wound Rationale: The LPN has described wound evisceration. The nurse, who is ultimately responsible for the client, must complete an assessment of the client's wound to verify that an evisceration has occurred and assesses the status of the client. Once assessment is complete, the nurse should establish priorities for the client's care using Maslow's hierarchy of needs.

The nurse provides care for a client diagnosed with cholelithiasis. It is MOST important for the nurse to instruct the client to avoid which foods? - apples - broccoli - lettuce - cheese - bacon - carrots

- broccoli, cheese, and bacon Rationale: avoid vegetables which can cause gas formation and lead to painful flair up of symptoms; cheese is high in cholesterol and fat. Cream, butter, whole milk, and ice cream should be avoided. the client should avoid fried foods and foods with high amounts of fat or calories; bacon and other meats high in fat and cholesterol should be avoided. Amounts of fish and meat containing high amounts of oil and fat should be reduced. Egg yolks and avocado should also be avoided.

The nurse instructs the client about appropriate foods for a high-protein diet. The nurse determines teaching is effective if the client chooses which menu? - chef salad, crackers, and iced tea - broiled fish, cream of tomato soup topped with grated cheese, and custard - peanutbutter and jelly sandwich, chips, and fruit drink - turkey sandwich with lettuce and tomato, potato salad, and milk

- broiled fish, cream of tomato soup topped with grated cheese, and custard Rationale: all of these foods contain protein by adding skim milk to the soup, grated cheese to foods, peanut butter spreads on fruits and vegetables, and using yogurt as topping for fruit or cake

The neighbor of the nurse comes running to the nurse's house saying, "I just found my 2 year old in the kitchen surrounded by several bottles of cleaning solutions and the bottles are all open!" Which action by the nurse is best? - call the poison control center - ask if the child drank anything - give the child ipecac syrup with two glasses of water - give the child a mixture of milk and burned toast

- call the poison control center Rationale: assess the child; initiate steps to stop the exposure, and call the poison control center for instruction

The woman tells the nurse that she has always had a heavy menstrual flow and needs extra iron. The nurse should recommend the client eat which food? - chicken livers - pork - hamburger - tofu

- chicken livers Rationale: liver is an excellent concentrated source of iron (7.2mg per serving); recommended daily intake for women ages 19-50 is 18mg/day, men 19 and up and post menopausal women is 8mg/day; other concentrated souces include cooked artichoke and some cereals

The home health care nurse visits a client with a diagnosis of ulcerative colitis. The client reports perineal irritation due to frequent stools. Which suggestion by the nurse is BEST? - apply a heat lamp to the perineal area three times per day - use protective plastic bed pads - clean the perineal area with soap and water after each bowel movement - increase roughage in the diet to prevent frequent stools

- clean the perineal area with soap and water after each bowel movement Rationale: cleaning the area keeps the skin free of stool and decreases irritations. The nurse can suggest the use of sitz baths. The client may apply petroleum jelly to the area to soothe irritated skin.

The nurse cares for a client post-appendectomy, and a full liquid diet is ordered. The nurse determines the client's breakfast is appropriate if it includes which foods? - only strained clear liquids - as much fruit as desired - cooked cereal - yogurt and bananas

- cooked cereal Rationale: full liquid diet includes milk and milk products (pudding and custard), all vegetable juices, all fruit juices, refined or strained cereals, eggs in custard, butter, margarine, and cream

The nurse provides care for a client with a Sengstaken-Blakemore tube to treat bleeding esophageal varices. The client suddenly develops respiratory distress. Which action does the nurse take FIRST? - auscultate breath sounds - cut the balloon port on the Sangstaken-Blakemore tube - obtain and record BP and pulse - contact the health care provider

- cut the balloon on the tube Rationale: scissors and an extra tube must be kept at the patient's bedside at all times. Accidental deflation or rupture of the gastric balloon may lead to acute respiratory distress/airway obstruction

which symptom of liver disease does the nurse expect to see in a client with Laennec cirrhosis? - cloudy urine - dark urine - orange-colored stool - tarry stool

- dark urine Rationale: the healthy liver removes and processes bilirubin from the blood and excretes bile into the intestine. when excessive bilirubin is produced, or when the liver cannot break down bilirubin into bile, the excess is excreted into the urine. Urine with abnormal bilirubin is mahogany-colored and has yellow foam when shaken

A client is diagnosed with a duodenal ulcer. The nurse understands the MOST common reason for insertion of a NG tube postoperative includes which reason? - take samples of gastric acid - assess the stomach for bleeding - decompress the stomach - permit saline irrigations

- decompress the stomach Rationale: the stomach is decompressed postoperatively to prevent distension and pressure on the suture lines

The nurse instructs a client with a sigmoid colostomy how to irrigate the colostomy. Which action does the nurse include in the teaching? - dilate the stoma gently with gloved finger - irrigate the colostomy using 30 mL of normal saline - continue irrigations until no stool is returned - returns should occur 5-10 minutes after instilling water

- dilate the stoma gently with gloved finger Rationale: The aim of the irrigation is for the bowel to be stimulated to contract and then to expel the contents of the last part of the colon. The desired result is that feces are passed only at the time of irrigation, therefore, giving the person control over when the stoma works. Dilating the stoma gently with a gloved finger is part of routine colostomy irrigation procedure.

The nurse provides care for a client diagnosed with alcoholic cirrhosis. The client is at high risk to develop which complication? - Hepatitis B - Pancreatic cancer - weight gain - Epitaxis

- epitaxis Rationale: epitaxis is an acute hemorrhage from the nostril, nasal cavity, or nasopharynx. Bleeding is a common risk factor of cirrhosis due to decreased formation of coagulation factors. Additionally, gastrointestinal bleeding is also a high risk factor for clients with cirrhosis.

The nurse instructs the family of a client diagnosed with hepatitis A how to prevent the spread of the disease. It is MOST important for the nurse to include which instruction? - family members should use separate eating utensils and drinking glasses - family members must avoid contact with the client's blood - family members can not donate blood during the next year - family members with no signs or symptoms are not infected

- family member should use separate eating utensils and drinking glasses Rationale: Hep A (HAV) is spread by fecal-oral route. The client should wash hands before eating and after using the toilet and all eating utensils and drinking glasses used by the client should be kept separate from those used by family members

The school nurse is informed that a sixth grade student in the school has been diagnosed with hepatitis A. It is MOST important for the nurse to teach the parents of the classmates to observe their children for which symptom? - fatigue - increased appetite - tarry stool - pallor

- fatigue Rationale: symptoms of hepatitis include fatigue, anorexia, RUQ pain, pruitus, and jaundice. It is important to note that most children younger than age 6 do not have symptoms when they have hep A. When symptoms are present, young children typically do not have jaundice but most older children and adults do.

The clinic nurse monitors a client recovering from hepatitis A. The nurse understands that hepatitis A is transmitted through which route? - fecal-oral - droplet - airborne - contact

- fecal-oral Rationale: Hep A is a vaccine-preventable, communicable disease of the liver caused by the hep A virus (HAV). it is usually transmitted person-to-person through fecal-oral route or consumption of contaminated food or water. Symptoms includes fatgue, low appetite, stomach, nausea, and jaundice; these symptoms usually resolve within 2 months of infection.

The nurse cares for the client with Crohn's disease. Which finding describes a common complication of Crohn's disease? - reflux esophagus - chronic constipation - fistulas - hypothermia

- fistulas Rationale: fistulas, abnormal tracts between two or more body areas, may involve the gastrointestinal tract and the skin, bladder, or vagina; they are a hallmark identification of Crohn's disease

The nurse assesses a client for return of bowel sounds after bowel resection surgery. For how many minutes does the nurse listen before bowel sounds are determined to be absent? - one minute - five minutes - ten minutes - twelve minutes

- five minutes Rationale: bowel sounds are evaluated for intensity, pitch, and frequency. Five to thirty-five clicks or gurgles every minute is the normal rate for bowel sounds. To determine an absence of bowel sounds, a nurse must listen for a total of 5 minutes in each quadrant.

The healthcare provider prescribes promethazine for the client. The nurse knows that promethazine is prescribed for which situations? Select all that apply - going on a cross-ocean cruise - having an elective operation - preventing leg cramps - enhancing pain medication after surgery - managing HTN - Treating ventricular tachycardia

- going on a cross-ocean cruise, having an elective operation, enhancing pain medication after surgery Rationale: promethazine is an anti-emetic used in a wide variety of situations; used to manage motion sickness and decrease nausea after invasive procedures; used for preoperative sedation, either alone or with other medications; and caused sedation, and when given with pain medication, it lessens the perception of discomfort; adverse effects include confusion, disorientation, and sedation

The nurse examines the abdomen of an adult client who reports being in good health on the intake questionnaire. Which assessment does the nurse ANTICIPATE? - high-pitched sounds in the upper right quadrant - no bowel sounds during five minutes of auscultation - gurgles in all quadrants during a minute of auscultation - hypoactive bowel sounds in the lower quadrants

- gurgles in all quadrants during a minute of auscultation Rationale: five to thirty-five clicks or gurgles every minute are normal bowel sounds auscultated upon abdominal assessment. The abdomen is assessed for: symmetry, contour, umbilicus, bowel sounds, arteries, peritoneal friction rub, liver size, spleen size, inguinal lymph nodes, rebound tenderness, kidneys, and abdominal reflexes

The nurse identifies which diet BEST meets the nutritional needs of the client newly diagnosed with cirrhosis? - high in fat and low in fiber - high in protein and low in sodium - high in calcium and low in fat - high in iron and low in sodium

- high in protein and low in sodium Rationale: the client will eat a balanced diet, selecting foods from all food groups; grains, fruits, vegetables, meat and beans, milk and fats. Clients with cirrhosis can often be malnourished, which makes protein an important part of the diet. Additionally, the client should limit the salt intake. Salt can lead to complications such as fluid build up in the abdomen (ascities)

The nurse instructs a client receiving lovastatin (Mevacor) for treatment of hypercholesterolemia. The nurse determines further teaching is necessary if the client states which of the following? - i dont expect to see the full effect from taking it for another two to four weeks - i always take it on an empty stomach, so it can get right to work - i will have to have my blood drawn for testing to see if my liver is doing okay - i will contact my physician if i have any unexplained muscle pain

- i always take it on an empty stomach, so it can get right to work Rationale: administer with food, because the drug absorption is reduced by 30% on an empty stomach; instruct the client about a cholesterol reduced diet

The home care nurse makes a visit to a client receiving enteral feeding through a gastrostomy tube. The client's adult caregiver reports the client has frequent loose stools. Which statement made by the adult caregiver needs further investigation by the nurse? - i give 240mL of formula over one hour - i refrigerate unused formula - i hang a new bag and tubing every 24 hours - i am able to give liquid medicines through the tube

- i am able to give liquid medicines through the tube Rationale: many liquid medications contain sorbitol which can cause osmotic diarrhea for some clients. the nurse needs to determine what medications the client is receiving and if the medications contain sorbitol.

The nurse assesses a client in the outpatient clinic with a diagnosis of ulcerative colitis. While obtaining the client's history, the nurse expects the client to make which statement? - i feel a constant sharp pan in my lower abdomen - i feel an intermittent gnawing pain in my middle abdomen - i feel an intermittent cramping pain in my lower abdomen - i feel burning pain in my upper esophagus after i eat

- i feel an intermittent cramping pain in my lower abdomen Rationale: the pain associated with UC is usually described as cramping and intermittent and is located in the lower abdomen. it occurs prior to defecation. It is important that the nurse assesses location, character, and intensity of the pain. The nurse should obtain a diet history and assess for bowel sounds and for areas of tenderness