Med-Surg Exam I and GI ATI
A nurse is preparing a community education program about hepatitis B. Which of the following statements should be included in the nurse's discussion? A hepatitis B vaccination is recommended for those traveling, especially military personnel. A hepatitis B immunization is given to infants and children. Hepatitis B is acquired by eating fruits, vegetables, shellfish, or other foods that are contaminated during handling. Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation.
A hepatitis B immunization is given to infants and children. Rationale :Hepatitis B immune globulin is given as part of the standard childhood immunizations. It may be administered as early as birth, especially in infants born to hepatitis B surface antigen (HBsAg)-negative mothers. The infants should then receive the second dose between 1 and 4 months of age.
A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority? Select one: a. Check the surgical incision. b. Ensure an adequate airway Correct c. Program the morphine pump. d. Assess the client's pain.
The correct answer is: Ensure an adequate airway
Which statement by the client indicates that the nurse's teaching about an abdominal ultrasound was effective. Select one: a. I will empty my bladder completely before the test. b. I may have to take a laxative to pass the barium afterward. c. The IV contrast may burn when it is injected. d. I will drive myself home after the test is completed. Correct
The correct answer is: I will drive myself home after the test is completed.
A community health nurse is planning an educational program to prevent the transmission of hepatitis A in a community where the virus is becoming endemic. When preparing the materials, the nurse realizes the population group likely to become infected with the hepatitis A virus is which of the following? Children and young adults Older adults Infants and pregnant women Middle-aged men
Children and Young Adults Rationale: The hepatitis A virus can be recovered from the feces, bile, and blood of infected clients. The usual mode of transmission is the fecal-oral route. Children and young adults are the two groups most frequently affected by the hepatitis A virus.
A nurse is caring for a client who is placed on a low-bacteria diet in combination with an oral selective bowel decontamination solution prior to a liver transplant. The nurse understands that the client should avoid consuming which of the following? fresh grapes mashed potatoes carbonated cola hard boiled egg
Fresh Grapes Rationale: Consuming fresh fruits with peels, such as grapes, cherries, and berries, are contraindicated. Even with proper rinsing, there is risk of contamination as organisms can easily penetrate the skin. Fresh fruits that can be rinsed and peeled are usually allowed.
For the client diagnosed with hepatitis A asking how the infection may have been contracted, which response by the nurse is correct? Select one: a. You have had Epstein-Barr virus before, and hepatitis A can co-infect you. b. You may have been infected through a recent blood transfusion. c. Some medications have been known to induce hepatitis A. d. You may have been exposed through contaminated shellfish. Correct
The correct answer is: You may have been exposed through contaminated shellfish.
A client is receiving a tube feeding via a continuous enteral pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following nursing observations requires intervention? A pitcher of water and plastic cup are sitting on the client's over-bed table within reach. The disposable feeding bag is from the previous day at 1000 and contains 200 mL of feeding. The client is lying on the right side with a visible dependent loop in the feeding tube. The head of the bed is elevated 20º.
The head of the bed is elevated 20º. Rationale:The head of the bed should be elevated at least 30º (semi-Fowler's position) while the tube feeding is administered. This position uses gravity to help the feeding go down and lessens the possibility of regurgitation.
A nurse is caring for a client with bleeding esophageal varices who was treated with a double balloon tamponade (Sengstaken Blakemore tube). Several hours after the gastric and esophageal balloons were inflated, the nurse notes that the client has become increasingly agitated, and respirations are 36/min and shallow. Which of the following is an appropriate nursing action? Advance the tube further into the client's nose. Decrease the pressure in the esophageal balloon. Raise the head of the bed to a high-Fowler's position. Use scissors to cut the tubing in front of the nose guard or sponge.
Use scissors to cut the tubing in front of the nose guard or sponge Rationale: The client's breathing problems are likely caused by an obstruction due to a displaced esophageal balloon. Using scissors to cut the tubing in front of the nose guard or sponge relieves the obstruction.
A nurse is caring for a client with severe gastroesophageal reflux disease (GERD) who is to undergo a esophagoscopy. While teaching the client about the procedure, the nurse should state, "The procedure is needed to measure the presence of acid in the esophagus." "Esophagoscopy is useful in determining how well the lower part of your esophagus works." "You should discuss this procedure with your provider." "An esophagoscopy procedure helps to determine if you have cancer."
"Esophagoscopy is useful in determining how well the lower part of your esophagus works." Rationale: Esophagoscopy is useful in determining the incompetence of the lower esophageal sphincter and the extent of inflammation, potential scarring, and strictures.
What interventions should the nurse implement for the care of a patient with a NG tube receiving tube feedings? (Select all that apply) Select one or more: a. Maintain HOB >30 degrees. Correct b. Assess for residual every 4 hours. c. Flush with sterile water before and after medications. Correct d. Check initial placement by pushing 20-30ml of air. Feedback
The correct answer is: Maintain HOB >30 degrees., Flush with sterile water before and after medications., Assess for residual every 4 hours.
A nurse assesses a client's bowel sounds 3 days following a gastroplasty for obesity and notes that they have returned. A 1 oz serving of which of the following is appropriate as an initial feeding? Vanilla pudding Apple juice Diet ginger ale Water
Water Rationale: Clear liquids, such as water, should be given for the first oral feedings, but should be limited to only 1 oz per feeding. Water does not contain sugar, which can cause diarrhea due to a hyperosmolar bolus.
A nurse is caring for a client who has returned to the unit following a laparoscopic cholecystectomy and reports severe pain in the left shoulder. The nurse should recognize that the client's pain -is due to carbon dioxide instilled into the abdomen during surgery. -is not related to the surgery and should be investigated further. -may be indicative of a peritoneal tear and requires further investigation. -has resulted from lying in one position too long on the operating room table.
-is due to carbon dioxide instilled into the abdomen during surgery. rationale: Gas (carbon dioxide) injected into the abdominal cavity during laparoscopic procedures can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1 to 2 days. Mild analgesics and a recumbent position may be helpful.
A client scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best? Select one: a. Ask the client about shellfish allergies. Correct b. Instruct the client on bowel prepartion. c. Ensure that the client has a ride home. d. Document this information on the chart.
A) Ask the client about shellfish allergies. Correct
A nurse is caring for a hospitalized client with acute pancreatitis. After treatment begins, the nurse anticipates that which serum laboratory value will return to normal within 72 hr? aldolase amylase lipase lactose dehydrogenase
Amylase Rationale: Pancreatitis is the most common reason for marked elevations in serum amylase. Serum amylase begins to increase about 3 to 6 hr following onset of acute pancreatitis. The amylase level peaks in 20 to 30 hr and returns to normal in 2 to 3 days.
A nurse is completing an admission history and assessment on a client admitted with an exacerbation of chronic pancreatitis. The nurse recognizes that which of the following findings is likely to be the cause of chronic pancreatitis? High-calorie diet Prior gastrointestinal illnesses Tobacco use Alcohol usage
Alcohol usage Rationale: Alcohol consumption is the major cause of chronic pancreatitis in the United States. Long-term alcohol consumption produces hypersecretion of protein in pancreatic secretions. The result is protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage to these cells is more likely to occur and to be more severe in clients whose diets are poor in protein content and either very high or very low in fat.
A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the client report? jaundice anorexia dark urine pale feces
Anorexia Rationale: Anorexia is an early symptom of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by failure of the damaged liver cells to detoxify an abnormal product.
The nurse is preparing the client for a CT scan of the abdomen with IV contrast. Which question will the nurse ask the client prior to the examination? Select one: a. Did you finish taking all the prescribed laxatives? b. Can you tolerate being tilted from side to side? c. Are you allergic to shrimp, scallops, or shellfish? Correct d. Have you taken any blood thinners in the past 3 days
Are you allergic to shrimp, scallops, or shellfish?
A nurse is caring for a client with a history of Laënnec's cirrhosis who is admitted to the hospital with manifestations of hepatic encephalopathy. The client denies consuming alcohol. The nurse anticipates that which of the following diagnostic enzyme tests will be ordered to investigate the possibility of alcohol abuse? Gamma-glutamyl transferase (GGT) Alkaline phosphatase (ALP) 5' Nucleotidase (5'N) Alanine aminotransferase (ALT)
Gamma-glutamyl transferase (GGT) Rationale: The GGT is more specific for the hepatobiliary system than ALP, which can be elevated in bone or liver disease. The GGT is also raised by alcohol and hepatotoxic drugs and thus is useful to monitor drug toxicity and alcohol abuse.
A nurse is teaching a client with diverticulitis about preventing acute attacks. The nurse should advise the client to consume foods that are high in vitamin C. low in fat. high in fiber. low in calories.
High in fiber Rationale: Diverticula are thought to develop as the result of long-term, low-fiber eating habits and increased intracolonic pressure that can be caused by straining at bowel movements. High-fiber foods help to strengthen and maintain active motility of the gastrointestinal tract.
Which of the following client is most at risk for gastroesophageal reflux? Select one: a. A patient taking oral hypoglycemic agents b. A patient who is underweight. c. A patient who has a nasogastric tube Correct d. A patient who drinks decaffeinated beverages
The correct answer is: A patient who has a nasogastric tube
A nurse is caring for a client who is diagnosed with fulminant hepatic failure. Which of the following procedures should the nurse expect the client to be prepared for? Portacaval anastomosis Right liver lobectomy Liver transplant Transjugular intrahepatic portosystemic shunt
Liver Transplant Rationale: Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients.
A nurse is caring for an unconscious client recovering from a closed-head injury following placement of a percutaneous endoscopic gastrostomy (PEG) tube. Which of the following actions has the highest priority? Flush the PEG tube with water before and after each feeding. Place the client in high-Fowler's position during PEG tube feedings. Cleanse the skin around the PEG tube site each shift. Aspirate the PEG tube prior to each feeding.
Place the client in high-Fowler's position during PEG tube feedings. Rationale: An unconscious client who is receiving PEG tube feedings should be positioned with the head of the bed elevated both during and after feedings to decrease the risk of aspiration.
A nurse is caring for a client after having a splenectomy following a motor vehicle crash. Which of the following client care measures has the highest priority? Monitoring for fever Encouraging early ambulation Promoting lung aeration Observing for hemorrhage
Promoting lung aeration Rationale: Postoperative pain causes splinting, shallow breathing, and under-aeration of the lung's left lower lobe because of close proximity of the spleen to the diaphragm. Slow, deep, and relaxed breaths will facilitate greater lung expansion and oxygen use; therefore, preventing atelectasis from developing.
A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following should the nurse monitor prior to the procedure? Prothrombin time (PT) Serum albumin Aspartate aminotransferase (AST) Hemoglobin and hematocrit
Prothrombin time (PT) Rationale: The major complication following a liver biopsy is hemorrhage. Many clients with liver disease have clotting defects and are at risk for bleeding. Along with the PT, the activated partial thromboplastin time (aPTT) and the platelet count should be monitored. Liver dysfunction causes the production of blood clotting factors to be reduced, which leads to an increased incidence of bruising, nosebleeds, bleeding from wounds, and gastrointestinal bleeding. This is due to a deficient absorption of vitamin K from the gastrointestinal tract caused by the inability of liver cells to use vitamin K to make prothrombin.
A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The client's respiratory rate is 8 breaths/min. What action by the nurse is best? Select one: a. Provide physical stimulation Correct b. Administer naloxone (Narcan). c. Ventilate with a bag-valve-mask d. Call the Rapid Response Team
Provide physical stimulation
The nurse is screening clients at a community health fair. Which client is at the highest risk for the development of colorectal cancer? Select one: a. An older woman with a BMI of 19.2 who works 65 hours/week b. A middle-aged woman with a history of irritable bowel syndrome c. An older man who travels extensively and eats fast food frequently Correct d. A young adult who drinks eight cups of coffee every day
The correct answer is: An older man who travels extensively and eats fast food frequently
The nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD) completed. The client tells the nurse that her mouth is very dry after the procedure. Which is the nurse's best action? Select one: a. Provide the client with a few ice chips. b. Keep the client NPO. c. Check the client's gag reflex Correct d. Offer the client sips of clear liquids. Feedback
The correct answer is: Check the client's gag reflex
A nurse is caring for a client admitted with a bowel obstruction who develops severe abdominal pain. Which of the following assessment findings should indicate to the nurse that a possible bowel perforation has occurred? Elevated blood pressure Bowel sounds increased in frequency and pitch Rigid abdomen Emesis of undigested food
Rigid abdomen Rationale: Abdominal tenderness and rigidity occur with a perforated bowel. As fluid escapes into the peritoneal cavity, there is a reduction in circulating blood volume and a blood pressure lower than normal, or hypotension, results.
A nurse is caring for a client who is scheduled to have an esophagogastroduodenoscopy (EGD). The nurse should recognize that this procedure is used to do which of the following? Visualize colon polyps. Sclérose esophageal varices. Evaluate the ileum. Determine the presence of free air in the abdomen.
Sclérose esophageal varices. Rationale: EGD is the direct visualization of mucus in the upper gastrointestinal tract using a flexible fiberoptic endoscope. The endoscope used for EGD can be positioned to cauterize the bleeding varices to prevent extensive blood loss.
A client returns to the nursing unit 1 hr following physical therapy. The nurse notes that the infusion pump for the client's total parenteral nutrition (TPN) is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following? Hypertension and crackles Excessive thirst and urination Fever and chills Shakiness and diaphoresis
Shakiness and diaphoresis Rationale: The nurse should be aware that the client has the potential for the development of hypoglycemia due to the sudden withdrawal of the TPN solution. Other potential signs of hypoglycemia may include weakness, anxiety, confusion, and hunger.
The nurse recognizes which client as being at greatest risk of developing hepatitis B? Select one: a. A college student who has had several sexual partners Correct b. An older woman who has eaten raw shellfish c. A businessman who travels frequently d. A woman who takes acetaminophen daily for headaches
The correct answer is: A college student who has had several sexual partners
The nurse is caring for a client who has acute viral gastroenteritis. Which dietary instruction will the nurse provide to the client? Select one: a. Drink plenty of water to prevent dehydration. b. You can have any kind of clear liquids to drink. c. Drink Gatorade if you do not like the taste of Pedialyte. Correct d. You can have sips of cola or ginger ale to help relieve the nausea.
The correct answer is: Drink Gatorade if you do not like the taste of Pedialyte.
The nurse is caring for a client who just completed a computed tomography (CT) scan with oral barium contrast. Which instructions will the nurse provide to the client? Select one: a. You may not drive or operate heavy machinery today. b. Do not eat or drink anything for 6 hours after the test. c. Do not take any blood thinners for 24 hours after the test. d. Drink plenty of fluids over the next few days. Correct
The correct answer is: Drink plenty of fluids over the next few days.
The nurse implements which best action for the client admitted to the hospital who is jaundiced and suspected of having contracted hepatitis B? Select one: a. Medicating the client with PRN prochlorperazine maleate (Compazine) to relieve nausea b. Placing the client on a clear liquid diet to reduce the workload of the liver c. Encouraging rest during this period Correct d. Assisting the client with ambulation to prevent thrombus formation
The correct answer is: Encouraging rest during this period
Which of the following statements made by the client indicates an understanding of the management of hiatal hernia? Select one: a. I will remain upright for several hours after each meal. Correct b. I will sleep at night lying on my left side to prevent nighttime reflux. c. I will lay down for 30 minutes after each meal d. I will have my blood count done in 2 weeks to check for anemia.
The correct answer is: I will remain upright for several hours after each meal.
Which statement indicates that the client needs additional teaching about her or his colonoscopy? Select one: a. I will take my Coumadin with a sip of water tomorrow morning. Correct b. I may have gas and abdominal cramps after the test. c. I will take nothing by mouth after midnight on the day of the test. d. I will take strong laxatives the afternoon before the test.
The correct answer is: I will take my Coumadin with a sip of water tomorrow morning.
he nurse is providing discharge teaching for a client who has peptic ulcer disease caused by Helicobacter pylori infection. Which statement by the client indicates that additional teaching is needed? Select one: a. I will take a multivitamin every morning with breakfast. b. I will avoid drinking coffee, even if it is decaffeinated. c. I will go to my tai chi class to wind down after a busy day. d. I will take my medication every day until my heartburn is gone. Correct
The correct answer is: I will take my medication every day until my heartburn is gone.
The client tells the nurse that her husband is repulsed by her colostomy and refuses to be intimate with her after surgery. How should the nurse respond? Select one: a. You could try to wear longer, fuller lingerie that will better hide the ostomy appliance. b. If you are not careful, you can hurt the stoma if you get intimate with your husband. c. Let us talk to the ostomy nurse to help you and your husband work through this. Correct d. You should empty the pouch first so that it will be less noticeable for your husband.
The correct answer is: Let us talk to the ostomy nurse to help you and your husband work through this.
During an initial assessment, a client with gastrointestinal problems reports the use of non-steroidal anti-inflammatory drugs (NSAIDs) three times a day for arthritis pain. What would be the nurse's best response? Select one: a. NSAIDs can result in ulcers or bleeding. Correct b. NSAIDs can interfere with the absorption of nutrients. c. NSAIDs are not helpful for arthritis pain. d. NSAIDs should be taken only twice daily.
The correct answer is: NSAIDs can result in ulcers or bleeding.
The nurse conducts a physical assessment for a client with anorexia and severe abdominal pain. The nurse notes that the abdomen is rigid and the client's temperature is 101.1° F (38.4° C). Which condition does the nurse suspect based on this information? Select one: a. Perforated gastric ulcer with peritonitis Correct b. Exacerbation of ulcerative colitis c. Ruptured aortic aneurysm d. Acute cholecystitis
The correct answer is: Perforated gastric ulcer with peritonitis
The nurse is caring for a client with a gastric ulcer who suddenly develops sharp mid-epigastric pain. The nurse notes that the client's abdomen is hard and very tender to light palpation. Which is the priority action of the nurse? Select one: a. Insert a nasogastric (NG) tube to low intermittent suction. b. Assess the client's pain and administer analgesics. c. Prepare the client for emergency surgery. Correct d. Place the client in a knee-chest position.
The correct answer is: Prepare the client for emergency surgery.
The nurse is caring for a client with a gastric ulcer who suddenly develops sharp mid-epigastric pain. The nurse notes that the client's abdomen is hard and very tender to light palpation. Which is the priority action of the nurse? Select one: a. Placing the client in a knee-chest position b. Preparing the client for emergency surgery Correct c. Administering morphine 2 mg IV as ordered by the physician d. Inserting a nasogastric tube to low intermittent suction
The correct answer is: Preparing the client for emergency surgery
A nursing student is studying nutritional problems and learns that kwashiorkor is distinguished from marasmus with which finding? Select one: a. Deficit of calories b. Lack of all nutrients c. Unknown cause of malnutrition d. Specific lack of protein Correct
The correct answer is: Specific lack of protein
A client is receiving total parenteral nutrition (TPN) and it has ran out. There isn't another bag of TPN to hang. What is the best action from the nurse? Select one: a. Start Dextrose 10% IV Correct b. Administer insulin SQ c. Start Normal Saline with Dextrose 5% d. Start Dextrose 5% IV
The correct answer is: Start Dextrose 10% IV
Which assessment finding leads the nurse to check the clients abdomen for an acquired umbilical hernia? Select one: a. The client states that he has a lump near his navel after moving a piano. Correct b. The client is taking lansoprazole (Prevacid), 30 mg PO daily. c. The client had a cholecystectomy last year. d. The client has a history of irritable bowel syndrome.
The correct answer is: The client states that he has a lump near his navel after moving a piano.
The nurse is caring for a client who is at risk for developing gastritis. Which finding from the client's history leads the nurse to this conclusion most? Select one: a. The client recently traveled to Mexico and South America. b. The client takes naproxen sodium (Naprosyn) 500 mg daily for arthritis pain. Correct c. The client is lactose-intolerant and cannot drink milk. d. The client works at least 60 hours per week in a stressful job.
The correct answer is: The client takes naproxen sodium (Naprosyn) 500 mg daily for arthritis pain.
The nurse is caring for a client who is hospitalized with an exacerbation of Crohns disease. What does the nurse expect to find during the physical assessment? Select one: a. Dullness is noted in the lower abdominal quadrants. b. A positive Murphy sign with rebound tenderness is present. c. The client reports that abdominal cramping is worse at night. d. The clients bowel sounds are hyperactive in all quadrants. Correct
The correct answer is: The clients bowel sounds are hyperactive in all quadrants.
What laboratory test provides a more sensitive indicator of nutrition deficiency? Select one: a. Cholesterol b. Transferrin c. Thyroxine-binding prealbumin Correct d. Hemoglobin
The correct answer is: Thyroxine-binding prealbumin
Which of the following complications would the nurse expect to observe in the client with progressive dysphagia and a history of achalasia? Select one: a. Pneumothorax b. Aneurysm c. Esophageal varices Incorrect d. Weight loss
The correct answer is: Weight loss
A client just experienced an episode of reflux with regurgitation. What assessment by the nurse is the priority? Select one: a. Teach the client to sit up when sleeping b. Auscultate the lungs for crackles Correct c. Inspect the oral cavity d. Call the physician
he correct answer is: Auscultate the lungs for crackles