Med Surg; GI quizzes:
Melena:
Black, tarry stools.
Esophagogastro-duodenoscopy:
Examination of the esophagus, stomach, and duodenum through an endoscope to inspect, treat, or obtain specimens from any of the upper GI structures.
A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is used to do which of the following? A. To visualize polyps in the colon B. To detect an ulceration in the stomach C. To identify an obstruction in the biliary tract D. To determine the presence of free air in the abdomen
A. A sigmoidoscopy or barium enema is used to visualize the lower gastrointestinal tract, where polyps are found. B. CORRECT: An EGD is used to visualize the esophagus, stomach, and duodenum with a lighted tube to detect a tumor, ulceration, or obstruction. C. Identifying an obstruction in the biliary tract is performed during endoscopic retrograde cholangiopancreatography (ERCP). D. The measurement of free air, which is a gas, is obtained using fluoroscopy or an x-ray, not an EGD.
A nurse is assessing a client who is in the early stages of hepatitis A. which of the following manifestations should the nurse expect? A. Jaundice B. Anorexia C. Dark urine D. Pale feces
A. Jaundice is a late manifestation of hepatitis A. B. CORRECT: Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product. C. Dark urine is a late manifestation of hepatitis A. D. Pale feces is a late manifestation of hepatitis A.
A physician has ordered a liver biopsy for a client with cirrhosis whose condition has recently deteriorated. The nurse reviews the clients recent laboratory findings and recognizes that which of the following findings will place the client at risk for complications? A. Low platelet count B. Low sodium level C. Decreased prothrombin time D. Low hemoglobin
A. Low platelet count ?
Which of the following symptoms will a nurse observe most commonly in clients with pancreatitis? A. Severe, radiating abdominal pain B. Black, tarry stools and dark urine C. Increased and painful urination D. Increased appetite and weight gain
A. Severe, radiating abdominal pain
A nurse is providing care to a client who is 1 day post paracentesis. The nurse observes clear, pale-yellow fluid leaking from the puncture site. Which of the following is an appropriate nursing intervention? A. Place a clean towel near the drainage site B. Apply a dry, sterile dressing C. Attach an ostomy back D. Place the client in a supine position
B. Apply a dry, sterile dressing
Which of the following is an appropriate nursing intervention for a pt. who has an inguinal hernia? A. Turn, cough, & deep breath every hour while awake to prevent pneumonia. B. Avoid prolonged standing. C. Decrease fiber intake to control diarrhea. D. Monitor your stools for occult blood.
B. Avoid prolonged standing.
Which dietary modification is utilized for a patient diagnosed with acute pancreatitis? A. High-protein diet B. Elimination of Coffee C. Low carbohydrate diet D. High-fat diet
B. Elimination of Coffee
What should the nurse advise a pt. who has diverticulitis to eat? A. High fiber foods. B. Low fiber foods. C. Low carb foods. D. High carb foods
B. Low fiber foods.
The nurse is providing care for a patient who just had a paracentesis to treat ascites. Which of the following findings indicate that the procedure was effective? A. Increased heart rate B. Presence of a fluid wave C. Decreased shortness of breath D. Post procedure weight unchanged from pre procedure weight
C. Decreased shortness of breath
Which of the following nursing diagnosis might be appropriate for a pt with ulcerative colitis? A. Pain R/T the passage of stones. B. Risk for injury from falling R/T dizziness and low BP immediately after meals. C. Fatigue R/T blood loss caused by frequent bloody stools. D. Risk of injury R/T auto digestion of the pancreas.
C. Fatigue R/T blood loss caused by frequent bloody stools.
Which of the following is an appropriate nursing intervention for a patient who has had an EGD? A. Give food and water as soon as the test is completed. B. Enemas until clear. C. Monitor for hemorrhage r/t organ perforation. D. Administer a sedative.
C. Monitor for hemorrhage r/t organ perforation.
A nurse is completing an admission assessment of a client who has pancreatitis. which of the following is an expected finding? A. Pain in right upper quadrant radiating to right shoulder B. Report of pain being worse when sitting upright C. Pain relieved with defecation D. Epigastric pain radiating to left shoulder
D. Epigastric pain radiating to left shoulder
A nurse is completing the admission assessment of a client who has acute pancreatitis. Which of the following findings is the priority to be reported to the provider? A. A history of cholelithiasis B. Serum amylase levels three times greater than the expected value C. Client report of severe pain radiating to the back that is rated at an "8" D. Hand spasms present when blood pressure is checked
D. Hand spasms present when blood pressure is checked "trouso's sign"
The nurse is providing care for a patient who has acute Hepatitis B. Which of the following findings should the nurse expect? A. Joint pain B. Obstipation C. Periumbilical discoloration D. Right upper quadrant tenderness
D. Right upper quadrant tenderness
A nurse is caring for a client who had a Paracentesis. Which of the following findings indicate the bowel was perforated during the procedure? A. Client report of upper chest pain B. Decreased urine output C. Pallor D. Temperature elevation
D. Temperature elevation
You are working in the paracentesis clinic. Which of the following clients is most likely to have an adverse reaction to the lidocaine local anesthetic? A. Asian (Chinese) B. African american C. Caucasian D. Hispanic (Puerto rican) E. Native american (Navajo)
E. Native american (Navajo)
Barium swallow:
Fluoroscopic observation of a client swallowing a flavored barium solution and its progress down the esophagus to detect structural abnormalities of the esophagus as well as swallowing discoordination and oral aspiration.
The prototype drug for proton pump inhibitors:
Omeprazole (prilosec)
Percutaneous liver biopsy:
Procedure in which a small core of liver tissue is obtained by placing a needle directly into the liver through the lateral abdominal wall.
Endoscopic retrograde cholangio-pancreatography:
Procedure in which an endoscope is used to visualize the common bile duct and the pancreatic and hepatic ducts through the ampulla of Vater in the duodenum.
Barium enema:
Radiographic study used to identify polyps, tumors, inflammation, strictures, and other abnormalities of the colon after instilling barium solution rectally.
The action of H2 Receptor Antagonists :
They block histamine and reduce gastric acid production
The serious side effects associated with ondansetron (Zofran):
arrhythmias, hypotension, & extrapyramidal effects
The diet restrictions that should be taught for treatment of peptic ulcers:
avoiding Highly acidic, Spicey foods, alcohol, & caffeine
Method ondansetron (Zofran) prevents nausea & Vomiting:
blocks 5-HT3 Serotonin receptors
The drug that used to be the prototype for H2 receptor Antagonists:
cimetidine (Tagamet)
The common adverse effects of magnesium hydroxide:
cramps, Diarrhea, and nausea Caused by overactive GI activity
Reason omeprazole should not be crushed or chewed:
enteric Coated granules & Acid labile
Serious Side effects of ranitidine (Zantac):
neutropenia, Agranulocytosis, Thrombocytopenia Aplastic anemia
The prototype drug for H2 Receptor antagonists:
ranitidine (Zantac)
The reason omeprazole dose may need to be adjusted in Asians:
the duration Of action is lengthened
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? A. Hypertension B. Excessive thirst C. Fever D. Diaphoresis
A. A client experiencing fluid volume overload will exhibit hypertension. B. A client experiencing hyperglycemia will exhibit excessive thirst. C. A client who has an infection will have an increased temperature. D. CORRECT: The nurse should recognize that the client has the potential for the development of hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis. other potential manifestations of hypoglycemia can include weakness, anxiety, confusion. and hunger.
A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occurred? A. Elevated blood pressure B. Bowel sounds increased in frequency and pitch C. Rigid abdomen D. Emesis of undigested food
A. A client who has experienced a bowel perforation will not display an elevated blood pressure. However, hypotension or shock can be present. B. Intestinal peristalsis increases in frequency and intensity as the bowel attempts to move intestinal contents past the obstructed area. Bowel sounds are silent with a bowel perforation C. CORRECT: Abdominal tenderness and rigidity occur with a bowel perforation. As fluid escapes into the peritoneal cavity, there is a reduction in circulating blood volume and a lowered blood pressure. or hypotension, results. D. Vomiting is frequent and copious with a small bowel obstruction. This does not indicate a bowel perforation.
A nurse is completing a history and physical assessment for a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? A. High-calorie diet B. Prior gastrointestinal illnesses C. Tobacco use D. Alcohol use
A. A high-calorie diet can contribute to heart disease and obesity but it does not cause chronic pancreatitis. B. A prior gastrointestinal illness does not cause or contribute to chronic pancreatitis. C. tobacco use can contribute to heart disease and increases the risk of cancer development. but it does not cause chronic pancreatitis. D. CORRECT: Alcohol consumption is one of the major causes of chronic pancreatitis in the U.S. Long-term alcohol use disorder produces hyper secretion 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 teaching a client who has Barrett's esophagus and is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? A. "This procedure is performed to measure the presence of acid in your esophagus." B. "This procedure can determine how well the lower part of your esophagus works." C. "This procedure is performed while you are under general anesthesia." D. "This procedure can determine if you have colon cancer."
A. A pH probe study, which involves the insertion of a specially designed probe into the distal esophagus. is performed to monitor for the presence of acid in the normally alkaline esophagus. B. CORRECT: An EGD is useful in determining the function of the esophageal lining and the extent of inflammation, potential scarring, and strictures. C. An EGD is performed while the client receives moderate sedation. D. A colonoscopy is performed to detect colon cancer.
Which of the following is an appropriate nursing intervention for a pt. who has GERD? A. Advise pt. to remain upright after meals. B. Withhold fluids during meal time. C. Administer the appropriate immunoglobulin. D. Give the prescribed steroids with half a glass of milk.
A. Advise pt. to remain upright after meals.
A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. which of the following laboratory findings should the nurse monitor prior to the procedure? A. Prothrombin time B. Serum lipase C. Bilirubin D. Calcium
A. CORRECT: A major complication following a liver biopsy is hemorrhage. Many clients who have liver disease have clotting defects and are at risk for bleeding. Along with the prothrombin time (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. B. Serum lipase is monitored to detect pancreatic disease and does not need to be monitored prior to this procedure. C. Bilirubin is monitored to detect biliary obstruction and does not need to be monitored prior to this procedure. D. Calcium is monitored to detect kidney failure or pancreatitis and does not need to be monitored prior to this procedure.
A nurse is caring for a client who has celiac disease. which of the following foods should the nurse remove from the client's meal tray? A. Wheat toast B. Tapioca pudding C. Hard-boiled egg D. Mashed potatoes
A. CORRECT: Celiac disease is an autoimmune disorder characterized by a permanent intolerance to wheat, barley, and rye. Wheat toast contains gluten and should be removed from the clients tray. B. Tapioca pudding is rich in dairy and does not contain gluten. Therefore, it is an acceptable food to include in the clients diet. C. A hard-boiled egg does not contain gluten and is a good source of protein. Therefore, it is an acceptable food to include in the client's diet. D. Mashed potatoes do not contain gluten and are a good source of protein and potassium. Therefore mashed potatoes are an acceptable food to include in the clients diet.
A nurse is caring for a client who has a history of cirrhosis and is admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? A. Gamma-gluramyl transferase (GGT) B. Alkaline phosphatase (ALP) C. Serum bilirubin D. Alanine aminotransferase (ALT]
A. CORRECT: The GGT laboratory test is specific to the hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. Therefore, it is useful for monitoring drug toxicity and excessive alcohol use. B. ALP is elevated in biliary obstruction and most forms of liver dysfunction. It does not differentiate between alcohol and other causative factors for liver disease. C. The serum bilirubin test is used to detect the function of the liver and its ability to excrete bilirubin. Elevated levels can determine liver disease or biliary tract disease. D. The largest concentration of the enzyme ALT is found in liver tissue. However. it is also present in kidney, heart. and skeletal muscle tissues. Because it is elevated in various toes of tissue damage. it is not helpful in identifying excessive alcohol use.
A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? A. Right shoulder pain B. Urine output 20 mL/hr C. Temperature 38.4 degrees C (101.1 degrees F) D. Oxygen saturation 92%
A. CORRECT: The client can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1-2 days. Mild analgesics and a recumbent position can help with client comfort. B. Urine output following surgery should be at least 30 mL/hr. Less than this amount can indicate hypovolemia or renal complications and should be reported to the provider immediately. C. A temperature greater than 38.4. C (101.1 F) can indicate infection and should be reported to the provider immediately. D. An oxygen saturation of less than 95% can indicate an impaired gas exchange following surgery and should be reported to the provider immediately.
A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? A. Children B. Older adults C. Women who are pregnant D. Middle-aged men
A. CORRECT: The hepatitis A virus can be contracted 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 often affected by the hepatitis A virus. Typically, a child or young adult acquires the infection at school, through poor hygiene, hand-to-mouth contact, or another form of close contact. B. Older adults are not often affected by or at risk for developing hepatitis A. C. Women who are pregnant are not often affected by or at risk for developing hepatitis A. D. Middle-aged men are not often affected by or at risk for developing hepatitis A.
A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should the nurse anticipate returning to the expected reference range within 72 hr after treatment begins? A. Aldolase B. Lipase C. Amylase D. Lactic dehydrogenase
A. Elevated aldolase levels are caused by inflammation of the muscles, also known as myositis. The levels of aldolase are not affected by pancreatic disorders. B. Lipase levels in clients who have pancreatitis increase after a rise in serum amylase and stay elevated for up to 14 days longer than amylase. C. CORRECT: Pancreatitis is the most common diagnosis for marked elevations in serum amylase. Serum amylase begins to increase about 3 to 6 hr following the onset of acute pancreatitis. The amylase level peaks in 20 to 30 hr and returns to the expected reference range within 2 to 3 days. D. Lactic dehydrogenase (LDH) increases are typically seen in clients who have anemia, leukemia, or liver damage.
A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? A. Endoscopic sclerotherapy B. Liver lobectomy C. Liver transplant D. Transjugular intrahepatic portal-systemic shunt placement
A. Endoscopic sclerotherapy is the injection of a sclerotherapy agent during endoscopy to target esophageal varies that are actively bleeding. This promotes thrombosis, which eventually leads to sclerosis. B. A liver lobectomy is used for a client who has localized cancer of a lobe of the liver. This is not appropriate for a client experiencing rapidly progressive liver failure. C. CORRECT: 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. D. A transjugular intrahepatic portal-systemic shunt is placed to treat esophageal varies through placement of a stent into the portal vein. The stent serves as a shunt between the portal circulation and the hepatic vein, thereby reducing portal hypertension. It is not used for fulminant hepatic failure.
A nurse in the emergency dependent is caring for a client who has bleeding esophageal varies. The nurse should anticipate a prescription for which of the following medications? A. Famotidine B. Esomeprazole C. Vasopressin D. Omeprazole
A. Famotidine is an H2 receptor antagonist used to treat stress ulcers. B. Esomeprazole is a proton pump inhibitor used to treat gastrointestinal reflux disease. C. CORRECT: Vasopressin constricts the splanchnic bed and decreases portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varies. D. Omeprazole is a proton pump inhibitor used to treat duodenal and gastric ulcers.
A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A. Fried chicken B. Mashed potatoes C. Dinner roll D. Tapioca pudding
A. Fried chicken
What should the nurse advise a pt. who has diverticulosis to eat? A. High fiber foods. B. Low fiber foods. C. Low carb foods. D. High carb foods
A. High fiber foods.
A nurse is preparing a community education program about hepatitis B. Which of the following statements should the nurse include in the teaching? A. "A hepatitis B immunization is recommended for those who travel, especially military personnel." B. "A hepatitis B immunization is given to infants and children." C. "Hepatitis B is acquired by earring foods that are contaminated during handling." D. "Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation."
A. The hepatitis A vaccine is recommended for those who travel, especially military personnel It is also recommended for other at-risk groups. B. CORRECT: Hepatitis B immune globulin is given as part of the standard childhood immunizations. It can be administered as early as birth. especially in infants born to hepatitis B Surface antigen (HBSAg) negative mothers. These infants should receive the second dose between 1 and 4 months of age. C. Hepatitis A is acquired by eating fruits. vegetables, shellfish. or other foods that are contaminated during handling. Hepatitis B is acquired by exposure to blood or body fluids from an infected person. D. Good personal hygiene habits and proper sanitation can help prevent the spread of hepatitis A.
A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect? A. Increased blood pressure B. Decreased heart rate C. Yellowing of the skin D. Boardlike abdomen
A. The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of shock, including hypotension. B. The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of shock, including tachycardia. C. The nurse should expect a client who has liver disease to exhibit jaundice, or yellowing of the skin. D. CORRECT: The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of a boardlike abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation causes hemorrhaging.
A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? A. Vanilla pudding B. Apple juice C. Diet ginger ale D. Clear liquids
A. Vanilla pudding contains sugar, which can cause diarrhea due to hyperosmolarity. Clear liquids should be given as the first oral feeding. B. The sugar content of apple juice can cause diarrhea due to hyperosmolarity. Clear liquids should be given as the first oral feeding. C. The client should avoid carbonated beverages because they can distend the stomach. causing pressure on the internal sutures or staples. Pressure can cause leaking into the peritoneum resulting in peritonitis. D. CORRECT: Clear liquids. such as water or broth. can be given for the first oral feedings. but should be limited to only 30 mL (1 oz) per feeding. Water does not contain sugar. which could cause diarrhea due to hyperosmolarity.
A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks. which of the following foods should the nurse recommend? A. Foods high in vitamin C B. Foods low in fat C. Foods high in fiber D. Foods low in calories
A. Vitamin C functions as an antioxidant as well as a coenzyme. It can be associated with prevention of cancer of the stomach. esophagus and colon. However, it does not improve or prevent acute diverticulitis attacks. B. Low-fat foods do not improve or prevent acute diverticulitis attacks. C. CORRECT: The result of long-term, low-fiber eating habits along with increased intracolonic pressure lead to straining during bowel movements, causing the development of diverticula. High-fiber foods help strengthen and maintain active motility of the gastrointestinal tract. D. Low-calorie foods do not improve or prevent acute diverticulitis attacks.
A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patients stools will have what characteristics? A. Watery with blood and mucus B. Hard and black or tarry C. Dry and streaked with blood D. Loose with visible fatty streaks
A. Watery with blood and mucus
A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings requires intervention by the nurse? A. A full pitcher of water is sitting on the clients bedside table within the clients reach. B. The disposable feeding bag from the previous day at 1000, and contains 200 mL of feeding. C. The client is lying on the right side with a visible dependent loop in the feeding tube. D. The head of the bed is elevated 20 degrees.
A. the nurse should monitor the clients intake and output and should observe the client for manifestations of dehydration, such as dry mucous membranes, thirst, and decreased urinary output. A pitcher of water at the clients bedside does not require intervention by the nurse. B. The clients feeding bag should be changed every 24 hrs. The 200 mL remaining in the bag is sufficient to last until the bag needs to be changed. Because the rate is 75 mL/hr, the nurse will need 150 mL to cover the 2 hr until the bag needs to be changed. The 50 mL left in the bag will ensure that the bag does not run dry, causing air to enter the clients stomach. C. This observation does not require intervention because the feeding is not by gravity, but by a pump. and is set at a constant rate. The clients side-lying position will not affect the pump's rate of flow unless the client is lying on the tubing. D. CORRECT: The head of the bed should be elevated at least 30. (Semi-Fowler's position) while the tube feeding is administered. This position uses gravity to help the feeding move down through the digestive system and lessens the possibility of regurgitation.
The nurse is providing care for a patient who has peritonitis. The patient expresses anxiety about the impending surgery. Which of the following actions should the nurse take? A. "Why are you feeling so anxious?" B. "Tell me more about your concerns." C. "You should distract yourself by reading a magazine" D. "You have nothing to worry about. Your surgeon is excellent." E. "Others who have had this procedure have had great results."
B. "Tell me more about your concerns."
Which of the following promotes rest and healing of the bowel in a pt. who has ulcerative colitis? A. High fiber diet B. Maintaining NPO status as ordered C. Low carb diet D. Avoiding licorice and caffeine
B. Maintaining NPO status as ordered
Which of the following is a priority for a pt. who is hemorrhaging from a perforated duodenal ulcer? A. Administer the sedative prior to the PY test. B. Monitor for shock. C. Position the pt. on his back with a pillow under his right ribs and his right hand under his head. D. Guiac his stool
B. Monitor for shock.
A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? A. Flush the tube with water. B. Place the client in semi-Fowler's position. C. Cleanse the skin around the tube site. D. Aspirate the tube for residual contents.
B. Place the client in semi-Fowler's position. The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second priority in the ABC priority-setting framework because adequate ventilatory effort is essential for oxygen exchange to occur. Circulation is the third priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. A client who is receiving PEG tube feedings should be positioned with the head of the bed elevated at least 30° during and after feedings to decrease the risk of aspiration. Therefore, this is the priority action by the nurse.
You are assigned to a client who is recovering from abdominal surgery. She tells you that the client in the next room has chronic hepatitis and she is afraid she will catch it. Which answer would best help this client? A. "Don't worry. That kind of hepatitis can only be transmitted sexually" B. "There are many kinds of hepatitis. Do you know which one she has?" C. "Hospital staff always use precautions to prevent any possibility of transmission of infectious diseases to other clients" D. "There is no problem, that client is not a carrier of the disease"
C. "Hospital staff always use precautions to prevent any possibility of transmission of infectious diseases to other clients" ??
Which of the following is an appropriate nursing intervention for a pt. who has gastritis? A. Lavage the NG tube with iced saline. B. Give sucralfate with meals and follow it with antacids. C. Advise the pt. to avoid irritating foods such as spicy foods. D. Advise the pt. to drink milk every two hours.
C. Advise the pt. to avoid irritating foods such as spicy foods.
The physician orders cholestyramine (questran) for the client with cirrhosis. The nurse determines that the drug is effective when the client exhibits which of the following? A. Reduced serum ammonia levels B. Improved clotting ability C. Decreased complaints of pruritus D. Improved serum protein levels
C. Decreased complaints of pruritus
What is the cause of a 'non-mechanical' bowel obstruction? A. A tumor or twisting of the bowel B. Constipation. C. General anesthesia, narcotics, and handling of the bowel during surgery. D. Adhesions
C. General anesthesia, narcotics, and handling of the bowel during surgery.
A nurse is reviewing the health record of a client who has pancreatitis. The physical exam report by the provider indicates the presence of cullens sign. Which of the following is an appropriate action by the nurse to identify this finding? A. Tap lightly at the costovertebral margin on the clients back. B. Palpate the clients Right lower quadrant C. Inspect the skin around the umbilicus D. Auscultate the area below the clients scapula
C. Inspect the skin around the umbilicus
A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct? A. Maintain a high-fat diet and drink at least 3 L of fluid a day. B. Maintain a high sodium, high-calorie diet C. Maintain a high carbohydrate, low-fat diet D. Maintain a high-fat, high-carbohydrate diet
C. Maintain a high carbohydrate, low-fat diet
The nurse notes that the clients total bilirubin is 1.0 mg/dl. Which action by the nurse is correct? A. Access the clients sclerae for evidence of jaundice B. Check the clients stool for presence of occult blood C. Record the results as normal D. Test the clients urine for blood.
C. Record the results as normal
Which of the following should the nurse advise a pt who has ulcerative colitis to call the doctor for? A. Occasional abdominal cramping B. Nine mucous bloody stools per day. C. Signs of colon perforation and peritonitis. D. Diarrhea.
C. Signs of colon perforation and peritonitis.
Which of the following is a true statement regarding regional enteritis (Crohn's disease)? A. It has a progressive disease pattern B. It is characterized by lower left quadrant abdominal pain. C. The clusters of ulcers take on a cobble stone appearance. D. The lesions are in continuous contact with one another.
C. The clusters of ulcers take on a cobble stone appearance.
A college student is diagnosed with Hepatitis A (HAV). Which of the following actions by the nurse best accomplishes the goal of reducing potential transmission of HAV? A. The nurse dons a mask and gown when providing direct care B. The nurse maintains the client in private room at all times C. The nurse preforms vigorous handwashing after leaving the room. D. The nurse wears gloves whenever entering the clients room
C. The nurse preforms vigorous handwashing after leaving the room.
The nurse is providing discharge teaching for a patient who has chronic hepatitis C. Which of the following statements by the patient indicates an understanding of the teaching? A. "I will decrease my intake of calories." B. "I will need treatment for 3 months" C. "I will avoid alcohol until i am no longer contagious" D. "I will avoid medications that contain acetaminophen"
D. "I will avoid medications that contain acetaminophen"
A client is diagnosed with Hepatitis A (HAV). Which of the following should the nurse include in client education? A. "This type of hepatitis can now be cured by using a new medication every day for 12 weeks." B. "You cannot transmit this type of Hepatitis to others unless you have unprotected sex." C. "It's just fine to continue working as a food handler as long as you wear gloves." D. "You and everyone in your household should preform good handwashing."
D. "You and everyone in your household should preform good handwashing."
A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patients increased risk of bleeding. The nurse recognizes that this risk is related to the patients inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A. Alterations in glucose metabolism B. Retention of bile salts C. Inadequate production of albumin by hepatocytes D. Inability of the liver to use vitamin K
D. Inability of the liver to use vitamin K
The use of metroclopramide:
GI stimulant to Treat GERD and Antiemetic
The potential electrolyte imbalances w/use of aluminum hydroxide w/magnesium hydroxide:
Hypophosphatemia & hypermagnesiemia
Ultrasonography:
Technique that uses high-frequency sound waves to show the size and location of organs and to outline structures and abnormalities.
Radionuclide imaging:
Technique used to detect lesions in organs using a radioactive natural or synthetic element that is injected intravenously or ingested orally.
PY test:
Test in which a client's breath is analyzed after consuming 14 C-urea capsules to detect Helicobacter pylori, the bacteria associated with peptic ulcer disease.
