Med surg test 4

A nurse is assessing a client's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding? A. Irrigate the ostomy to clear a possible obstruction. B. Contact the primary care provider to report this finding. C. Document that the stoma appears healthy and well perfused. D. Document a nursing diagnosis of Impaired Skin Integrity

C Rationale: A healthy, viable stoma should be shiny and pink to bright red. This finding does not indicate that the stoma is blocked or that skin integrity is compromised

. A client is scheduled for the creation of a continent ileostomy. What dietary guidelines should the nurse encourage during the weeks following surgery? A. A minimum of 30 g of soluble fiber daily B. Increased intake of free water and clear juices C. High intake of strained fruits and vegetables D. A high-calorie, high-residue diet

C Rationale: A low-residue diet is followed for the first 6 to 8 weeks. Strained fruits and vegetables are given. These foods are important sources of vitamins A and C. Adequate fluid intake is important, but it does not need to be particularly high. High fiber intake would lead to complications.

A client who has been experiencing changes in his bowel function is scheduled for a barium enema. What instruction should the nurse provide for post procedure recovery? A. Remain NPO for 6 hours post procedure. B. Administer a Fleet enema to cleanse the bowel of the barium. C. Increase fluid intake to evacuate the barium. D. Avoid dairy products for 24 hours' post procedure.

C Rationale: Adequate fluid intake is necessary to rid the GI tract of barium. The client must not remain NPO after the test and enemas are not used to cleanse the bowel of barium. There is no need to avoid dairy products.

. A client's screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this client's health problem? A. Adherence to a high-fiber diet will help the polyps resolve. B. The client should be assured that this is a normal, age-related physiologic change. C. The client's polyps constitute a risk factor for cancer. D. The presence of polyps is associated with an increased risk of bowel obstruction.

C Rationale: Although most polyps do not develop into invasive neoplasms, they must be identified and followed closely. They are very common, but are not classified as a normal, age-related physiologic change. Diet will not help them resolve and they do not typically lead to obstructions.

An older adult has a diagnosis of Alzheimer disease and has recently been experiencing fecal incontinence. However, the nurse has observed no recent change in the character of the client's stools. What is the nurse's most appropriate intervention? A. Keep a food diary to determine the foods that exacerbate the client's symptoms. B. Provide the client with a bland, low-residue diet. C. Toilet the client on a frequent, scheduled basis. D. Liaise with the primary provider to obtain an order for loperamide.

C Rationale: Because the client's fecal incontinence is most likely attributable to cognitive decline, frequent toileting is an appropriate intervention. Loperamide is unnecessary in the absence of diarrhea. Specific foods are not likely to be a cause of, or solution to, this client's health problem.

A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms? A. A pattern of distinct exacerbations and remissions B. Severe diarrhea C. An absence of blood in stool D. Involvement of the rectal mucosa

C Rationale: Bloody stool is far more common in cases of UC than in Crohn disease. Rectal involvement is nearly 100% in cases of UC (versus 20% in Crohn) and clients with UC typically experience severe diarrhea. UC is also characterized by a pattern of remissions and exacerbations, while Crohn disease often has a more prolonged and variable course.

A nurse is planning discharge teaching for a 21-year-old client with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the client's coping after discharge? A. The family's ability to take care of the client's special diet needs B. The family's ability to monitor the client's changing health status C. The family's ability to provide emotional support D. The family's ability to manage the client's medication regimen

C Rationale: Emotional support from the family is key to the client's coping after discharge. A 21-year-old would be expected to self-manage the prescribed medication regimen and the family would not be primarily responsible for monitoring the client's health status. It is highly beneficial if the family is willing and able to accommodate the client's dietary needs, but emotional support is paramount and cannot be solely provided by the client alone.

A nurse is providing health education to a teenage client newly diagnosed with type 1 diabetes mellitus, as well as the client's family. The nurse teaches the client and family nonpharmacologic measures that will decrease the body's need for insulin. What measure provides the greatest impact on glucose reduction? A. Adequate sleep B. Low stimulation C. Exercise D. Low-fat diet

C Rationale: Exercise lowers blood glucose, increases levels of HDLs, and decreases total cholesterol and triglyceride levels. Low-fat intake and low levels of stimulation do not reduce a client's need for insulin. Adequate sleep is beneficial in reducing stress, but does not have an effect that is as pronounced as that of exercise.

A clinic client has described recent dark-colored stools, and the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the client's current health status would contraindicate FOBT? A. Gastroesophageal reflux disease (GERD) B. Peptic ulcers C. Hemorrhoids D. Recurrent nausea and vomiting

C Rationale: FOBT should not be performed when there is hemorrhoidal bleeding. GERD, peptic ulcers, and nausea and vomiting do not contraindicate the use of FOBT as a diagnostic tool.

A client newly diagnosed with type 2 diabetes is attending a nutrition class. What general guideline should the nurse teach the clients at this class? A. Low fat generally indicates low sugar. B. Protein should constitute 30% to 40% of caloric intake. C. Most calories should be derived from carbohydrates. D. Animal fats should be eliminated from the diet.

C Rationale: For all levels of caloric intake, 50% to 60% of calories should be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein. Low fat does not automatically mean low sugar. Dietary animal fat does not need to be eliminated from the diet.

The nurse is caring for a client scheduled for a colonoscopy. The nurse should assist the client into what position during this diagnostic test? A) in a knee-chest position (lithotomy position) B) lying prone with legs drawn toward the chest C) Lying on the left side with legs drawn toward the chest D) in a prone position with two pillows elevating the buttocks

C Rationale: For the best visualization, colonoscopy is performed while the client is lying on the left side with the legs drawn up towards chest. A knee-chest position, lying on the stomach with legs drawn to the chest, and a prone position with two pillows elevating the legs do not allow for the best visualization

The management of the client's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the client is managing the tube correctly? A. "I clean my stoma twice a day with alcohol." B. "The only time I flush my tube is when I'm putting in medications." C. "I flush my tube with water before and after each of my medications." D. "I try to stay still most of the time to avoid dislodging my tube."

C Rationale: Frequent flushing is needed to prevent occlusion, and should not just be limited to times of medication administration. Alcohol will irritate skin surrounding the insertion site and activity should be maintained as much as possible.

A client who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The client has since become comatose and the client's family asks the nurse why the health care provider is recommending the removal of the client's NG tube and the insertion of a gastrostomy tube. What is the nurse's best response? A. "It eliminates the risk for infection." B. "Feeds can be infused at a faster rate." C. "Regurgitation and aspiration are less likely." D. "It allows caregivers to provide personal hygiene more easily."

C Rationale: Gastrostomy is preferred over NG feedings in the client who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG feedings. Both tubes carry a risk for infection; this change in care is not motivated by the possibility of faster infusion or easier personal care

A nurse is working with a client who has chronic constipation. What should be included in client teaching to promote normal bowel function? A. Use glycerin suppositories on a regular basis. B. Limit physical activity in order to promote bowel peristalsis. C. Consume high-residue, high-fiber foods. D. Resist the urge to defecate until the urge becomes intense.

C Rationale: Goals for the client include restoring or maintaining a regular pattern of elimination by responding to the urge to defecate, ensuring adequate intake of fluids and high-fiber foods, learning about methods to avoid constipation, relieving anxiety about bowel elimination patterns, and avoiding complications. Ongoing use of pharmacologic aids should not be promoted, due to the risk of dependence. Increased mobility helps to maintain a regular pattern of elimination. The urge to defecate should be heeded.

A client with type 1 diabetes has told the nurse that the client's most recent urine test for ketones was positive. What is the nurse's most plausible conclusion based on this assessment finding? A. The client should withhold the next scheduled dose of insulin. B. The client should promptly eat some protein and carbohydrates. C. The client's insulin levels are inadequate. D. The client would benefit from a dose of metformin.

C Rationale: Ketones in the urine signal that there is a deficiency of insulin and that control of type 1 diabetes is deteriorating. Withholding insulin or eating food would exacerbate the client's ketonuria. Metformin will not cause short-term resolution of hyperglycemia.

A client asks the nursing assistant for a bedpan. When the client is finished, the nursing assistant notifies the nurse that the client has bright red streaking of blood in the stool. The nurse's assessment should focus on what potential cause? A. Diet high in red meat B. Upper GI bleed C. Hemorrhoids D. Use of iron supplements

C Rationale: Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool. Hemorrhoids are often a cause of anal bleeding since they occur in the rectum. Blood from an upper GI bleed would be dark rather than frank. Iron supplements make the stool dark, but not bloody and red meat consumption would not cause frank blood.

A nurse is providing client education for a client with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The client has recently been prescribed misoprostol. What would the nurse be most accurate in informing the client about the drug? A. It reduces the stomach's volume of hydrochloric acid B. It increases the speed of gastric emptying C. It protects the stomach's lining D. It increases lower esophageal sphincter pressure

C Rationale: Misoprostol is a synthetic prostaglandin that, like prostaglandin, protects the gastric mucosa. NSAIDs decrease prostaglandin production and predispose the client to peptic ulceration. Misoprostol does not reduce gastric acidity, improve emptying of the stomach, or increase lower esophageal sphincter pressure

A nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem? A. Consumes one or more protein drinks daily. B. Takes over-the-counter antacids frequently throughout the day. C. Smokes one pack of cigarettes daily. D. Reports a history of social drinking on a weekly basis

C Rationale: Nicotine reduces secretion of pancreatic bicarbonate, which inhibits neutralization of gastric acid and can underlie gastritis. Protein drinks do not result in gastric inflammation. Antacid use is a response to experiencing symptoms of gastritis, not the etiology of gastritis. Alcohol ingestion can lead to gastritis; however, this generally occurs in clients with a history of consumption of alcohol on a daily basis.

A nurse is providing preprocedure education for a client who will undergo a lower GI tract study the following week. What should the nurse teach the client about bowel preparation? A. "You'll need to fast for at least 18 hours prior to your test." B. "Starting today, take over-the-counter (OTC) stool softeners twice daily." C. "You'll need to have enemas the day before the test." D. "For 24 hours before the test, insert a glycerin suppository every 4 hours."

C Rationale: Preparation of the client includes emptying and cleansing the lower bowel. This often necessitates a low-residue diet 1 to 2 days before the test; a clear liquid diet and a laxative the evening before; NPO after midnight; and cleansing enemas until returns are clear the following morning.

The nurse is providing health education to a client with a gastrointestinal disorder. What should the nurse describe as a major function of the GI tract? A. The breakdown of food particles into cell form for digestion B. The maintenance of fluid and acid-base balance C. The absorption into the bloodstream of nutrient molecules produced by digestion D. The control of absorption and elimination of electrolytes

C Rationale: Primary functions of the GI tract include the breakdown of food particles into molecular form for digestion; the absorption into the bloodstream of small nutrient molecules produced by digestion; and the elimination of undigested unabsorbed food stuffs and other waste products. Nutrients must be broken down into molecular form, not cell form. Fluid, electrolyte, and acid-base balance are primarily under the control of the kidneys

A client who underwent a gastric resection 3 weeks ago is having their diet progressed on a daily basis. Following the latest meal, the client reports dizziness and palpitations. Inspection reveals that the client is diaphoretic. What is the nurse's best action? A. Insert a nasogastric tube promptly. B. Reposition the client supine. C. Monitor the client closely for further signs of dumping syndrome. D. Assess the client for signs and symptoms of aspiration.

C Rationale: The client's symptoms are characteristic of dumping syndrome, which results in a sensation of fullness, weakness, faintness, dizziness, palpitations, diaphoresis, cramping pains, and diarrhea. Aspiration is a less likely cause for the client's symptoms. Supine positioning will likely exacerbate the symptoms and insertion of an NG tube is contraindicated due to the nature of the client's surgery.

A critical care nurse is caring for a client diagnosed with acute pancreatitis. The nurse knows this client should be started on parenteral nutrition (PN) after what indications? A. 5% deficit in body weight compared to pre-illness weight and increased caloric need B. Calorie deficit and muscle wasting combined with low electrolyte levels C. Inability to take in adequate oral food or fluids within 7 days D. Significant risk of aspiration coupled with decreased level of consciousness

C Rationale: The indications for PN include an inability to ingest adequate oral food or fluids within 7 days. Weight loss, and muscle wasting combined with electrolyte imbalances, and aspiration indicate a need for nutritional support, but this does not necessarily have to be parenteral.

A nurse is providing anticipatory guidance to a client who is preparing for a total gastrectomy. The nurse learns that the client is anxious about numerous aspects of the surgery. What intervention is most appropriate to alleviate the client's anxiety? A. Emphasize the fact that gastric surgery has a low risk of complications. B. Encourage the client to focus on the benefits of the surgery. C. Facilitate the client's contact with support services. D. Obtain an order for a PRN benzodiazepine.

C Rationale: The services of clergy, psychiatric clinical nurse specialists, psychologists, social workers, and psychiatrists are made available, and can reduce the client's anxiety. This is preferable to antianxiety medications. Downplaying the risks of surgery or focusing solely on the benefits is a simplistic and patronizing approach.

A nurse is preparing to discharge a client after recovery from gastric surgery. What is an appropriate discharge outcome for this client? A. Bowel movements maintain a loose consistency. B. Three large meals per day are tolerated. C. Weight is maintained or gained. D. High calcium diet is consumed.

C Rationale: Weight loss is common in the postoperative period, with early satiety, dysphagia, reflux and regurgitation, and elimination issues contributing to this problem. The client should weigh oneself daily, with a goal of maintaining or gaining weight. The client should not have bowel movements that maintain a loose consistency, because this would indicate diarrhea and would warrant intervention as it is a symptom of dumping syndrome. The client should be able to tolerate six small meals per day, rather than three large meals. The client does not require a diet excessively rich in calcium but should consume a diet high in calories, iron, vitamin A and vitamin C

The nurse is administering medications to a client through a feeding tube. Which action should the nurse take? A. Flush the tube with 5 mL of water before administering medication. B. Turn the tube feeding off for 1 hour before administering the medication. C. Administer each medication separately. D. Flush with 50 mL of water between each medication.

C Rationale: When administering several medications through a feeding tube, each medication should be administered separately with 15 mL of water administered between each medication. Prior to administering medication, the tube feed should be paused (there is no need to wait one hour) and flushed with 15 mL of water

A client is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the client to first seek care? A. Hematemesis and persistent sensation of fullness B. Abdominal bloating and recurrent constipation C. Intermittent pain and bloody stool D. Unexplained bowel incontinence and fatty stools

C Rationale: When the client is symptomatic from a tumor of the small intestine, benign tumors often present with intermittent pain. The next most common presentation is occult bleeding. The other listed signs and symptoms are not normally associated with the presentation of small intestinal tumors.

The nurse is caring for a client with a duodenal ulcer and is relating the client's symptoms to the physiologic functions of the small intestine. What do these functions include? Select all that apply. A. Secretion of hydrochloric acid (HCl) B. Reabsorption of water C. Secretion of mucus D. Absorption of nutrients E. Movement of nutrients into the bloodstream

C, D, E Rationale: The small intestine folds back and forth on itself, providing a very large surface area for secretion and absorption, the process by which nutrients enter the bloodstream through the intestinal walls. Water reabsorption primarily takes place in the large bowel. HCl is secreted by the stomach

A client with a peptic ulcer disease has had metronidazole added to their current medication regimen. What health education related to this medication should the nurse provide? A. Take the medication on an empty stomach. B. Take up to one extra dose per day if stomach pain persists. C. Take at bedtime to mitigate the effects of drowsiness. D. Avoid drinking alcohol while taking the drug.

D Rationale: Alcohol must be avoided when taking metronidazole and the medication should be taken with food. This drug does not cause drowsiness and the dose should not be adjusted by the client.

A client has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes? A. Preventing infection B. Maintaining skin and tissue integrity C. Preventing nausea and vomiting D. Maintaining fluid and electrolyte balance

D Rationale: All of the listed focuses of care are important for the client with a small bowel obstruction. However, the client's risk of fluid and electrolyte imbalances is an immediate threat to safety, and is a priority in nursing assessment and interventions.

A client with a recent history of intermittent bleeding is undergoing capsule endoscopy to determine the source of the bleeding. When explaining this diagnostic test to the client, what advantage should the nurse describe? A. The entire peritoneal cavity can be visualized. B. The test allows for painless biopsy collection. C. The capsule is endoscopically placed in the intestine. D. The test is noninvasive.

D Rationale: Capsule endoscopy allows for the noninvasive visualization of the mucosa of the small intestine. This procedure allows visualization of the GI tract, but not the peritoneal cavity. The capsule consists of a chip video camera without a mechanism to obtain a biopsy. The capsule is swallowed and is not endoscopically placed in the small intestine.

A nurse is creating a care plan for a client receiving nasogastric tube feedings. Which intervention should the nurse include? A. Check the gastric residual volume every 4 hours. B. Hold the tube feeding if the gastric residual volume is greater than 200 mL. C. Position client flat in bed during feedings. D. Use client assessment findings to determine tolerance of feedings.

D Rationale: Client indicators of tolerance to tube feedings include abdominal distention, client report of discomfort, vomiting, hypoactive bowel sounds, and diarrhea. Previously, gastric residual volume (GRV) was checked as an indicator of tube feeding tolerance. Professional organizations such as the Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (ASPEN) no longer advocate using GRVs to monitor tolerance of enteral feedings. Therefore, unless policy states otherwise, GRV should not be checked every 4 hours and the feeding should not be held for a GRV greater than 250 mL. The head of the bed should be elevated 30 degrees while a tube feeding is being administered to reduce the risk for aspiration.

A client has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. Which of the following actions should the nurse prioritize? A. Teaching the client about necessary nutritional modification B. Helping the client weigh treatment options C. Teaching the client about the etiology of gastritis D. Providing the client with physical and emotional support

D Rationale: For acute gastritis, the nurse provides physical and emotional support and helps the client manage the symptoms, which may include nausea, vomiting, heartburn, and fatigue. The scenario describes a newly diagnosed client; teaching about the etiology of the disease, lifestyle modifications, or various treatment options would be best provided at a later time

. A client has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. What would be the nursing care most needed by the client at this time? A. Teaching the client about necessary nutritional modification B. Helping the client weigh treatment options C. Teaching the client about the etiology of gastritis D. Providing the client with physical and emotional support

D Rationale: For acute gastritis, the nurse provides physical and emotional support and helps the client manage the symptoms, which may include nausea, vomiting, heartburn, and fatigue. The scenario describes a newly diagnosed client; teaching about the etiology of the disease, lifestyle modifications, or various treatment options would be best provided at a later time.

A nurse is caring for an older adult who has been experiencing severe Clostridium difficile-related diarrhea. When reviewing the client's most recent laboratory tests, the nurse should prioritize what finding? A. White blood cell level B. Creatinine level C. Hemoglobin level D. Potassium level

D Rationale: In elderly clients, it is important to monitor the client's serum electrolyte levels closely. Diarrhea is less likely to cause an alteration in white blood cell, creatinine, and hemoglobin levels.

A client has been experiencing occasional episodes of constipation and has been unable to achieve consistent relief by increasing physical activity and improving the client's diet. When introducing the client to the use of laxatives, what teaching should the nurse emphasize? A. The effect of laxatives on electrolyte levels B. The underlying causes of constipation C. The risk of fecal incontinence D. The risk of becoming laxative-dependent

D Rationale: Laxatives should not normally be used on an ongoing basis because of the risk of dependence. In most cases they have a minimal effect on electrolyte levels. A client who has increased activity and improved diet likely has an understanding of the usual causes of constipation. Excessive laxative use could lead to diarrhea or fecal incontinence, but for most clients the risk of dependence is more significant.

A client seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education? A. "Drinking beverages after your meal, rather than with your meal, may bring some relief." B. "It's best to avoid dry foods, such as rice and chicken, because they're harder to swallow." C. "Many clients obtain relief by taking over-the-counter antacids 30 minutes before eating." D. "Instead of eating three meals a day, try eating smaller amounts more often."

D Rationale: Management for a hiatal hernia includes frequent, small feedings that can pass easily through the esophagus. Avoiding beverages and particular foods or taking OTC antacids are not noted to be beneficial.

A nurse is caring for a client hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize? A. Strategies for maintaining an alkaline gastric environment B. Safe technique for self-suctioning C. Techniques for positioning correctly to promote gastric healing D. Strategies for avoiding irritating foods and beverages

D Rationale: Measures to help relieve pain include instructing the client to avoid foods and beverages that may be irritating to the gastric mucosa and instructing the client about the correct use of medications to relieve chronic gastritis. An alkaline gastric environment is neither possible nor desirable. There is no plausible need for self-suctioning. Positioning does not have a significant effect on the presence or absence of gastric healing.

A school nurse is teaching a group of high school students about risk factors for diabetes. What action has the greatest potential to reduce an individual's risk for developing diabetes? A. Have blood glucose levels checked annually. B. Stop using tobacco in any form. C. Undergo eye examinations regularly. D. Lose weight, if obese

D Rationale: Obesity is a major modifiable risk factor for diabetes. Smoking is not a direct risk factor for the disease. Eye examinations are necessary for persons who have been diagnosed with diabetes, but they do not screen for the disease or prevent it. Similarly, blood glucose checks do not prevent diabetes

A nasogastric tube is being inserted in a client with the COVID virus. Which action should the nurse take? A. Place the client in a prone position. B. Administer bolus feedings. C. Place a mask over the client's nose. D. Wear personal protective equipment

D Rationale: Personal protective equipment must be worn when placing a nasogastric tube in a client with COVID since it is considered an aerosol-generating procedure as tube placement often generates a cough. The client should be placed in a supine position for the placement of the nasogastric tube to assure proper visualization, assessment, and advancement of the tube. If possible, a mask should be placed over the client's mouth to avoid transmission of the virus if the client coughs. The mask cannot be placed over the client's nose since the tube will be placed through the nares. The feedings should be administered as a continuous feeding, rather than a bolus, to reduce the risk of contact with bodily fluids and aerosolized droplets.

A client will be undergoing a urea breath test for the detection of Helicobacter pylori. Which instruction should the nurse give to the client to prepare for this test? A. Ingest a capsule of carbon-labeled urea ingested three days before the test. B. Take prescribed antibiotics one month before the test. C. Fast for 12 hours before the test. D. Avoid taking cimetidine 24 hours before the test.

D Rationale: The client undergoing a urea breath test should avoid taking cimetidine for 24 hours before the test. The capsule with the carbon-labeled urea is ingested at the time of the test and a breath sample is obtained 10 to 20 minutes later. Antibiotics should be avoided for one month before the test. There is no need to fast for this test.

A nurse is caring for a client who has a diagnosis of GI bleed. During shift assessment, the nurse finds the client to be tachycardic and hypotensive, and the client has an episode of hematemesis while the nurse is in the room. In addition to monitoring the client's vital signs and level of conscious, what would be a priority nursing action for this client? A. Place the client in a prone position. B. Provide the client with ice water to slow any GI bleeding. C. Prepare for the insertion of an NG tube. D. Notify the health care provider.

D Rationale: The nurse must always be alert for any indicators of hemorrhagic gastritis, which include hematemesis (vomiting of blood), tachycardia, and hypotension. If these occur, the health care provider is notified and the client's vital signs are monitored as the client's condition warrants. Putting the client in a prone position could lead to aspiration. Giving ice water is contraindicated as it would stimulate more vomiting.

A client has experienced symptoms of dumping syndrome following gastric surgery. To what physiologic phenomenon does the nurse attribute this syndrome? A. Irritation of the phrenic nerve due to diaphragmatic pressure B. Chronic malabsorption of iron and vitamins A and C C. Reflux of bile into the distal esophagus D. Influx of extracellular fluid into the small intestine

D Rationale: The rapid bolus of hypertonic food from the stomach to the small intestines draws extracellular fluid into the lumen of the intestines to dilute the high concentrations of electrolytes and sugars, which results in intestinal dilation, increased intestinal transit, hyperglycemia, and the rapid onset of GI and vasomotor symptoms, which characterizes dumping syndrome. It is not a result of phrenic nerve irritation, malabsorption, or bile reflux.

A nurse is providing care for a client who has a diagnosis of irritable bowel syndrome (IBS). When planning this client's care, the nurse should collaborate with the client and prioritize what goal? A. Client will accurately identify foods that trigger symptoms. B. Client will demonstrate appropriate care of his ileostomy. C. Client will demonstrate appropriate use of standard infection control precautions. D. Client will adhere to recommended guidelines for mobility and activity.

A Rationale: A major focus of nursing care for the client with IBS is to identify factors that exacerbate symptoms. Surgery is not used to treat this health problem and infection control is not a concern that is specific to this diagnosis. Establishing causation likely is more important to the client than managing physical activity.

A client was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize? A. Esophageal or pyloric obstruction related to scarring B. Uncontrolled proliferation of H. pylori C. Gastric hyperacidity related to excessive gastrin secretion D. Chronic referred pain in the lower abdomen

A Rationale: A severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. Scarring can occur, resulting in pyloric stenosis (narrowing or tightening) or obstruction. Chronic referred pain to the lower abdomen is a symptom of peptic ulcer disease, but would not be an expected finding for a client who has ingested a corrosive substance. Bacterial proliferation and hyperacidity would not occur.

A nurse is caring for a client who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the client? A. Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN. B. Administer a hypertonic dextrose solution for 1 to 2 hours after discontinuing the PN. C. Administer 3 ampules of dextrose 50% immediately prior to discontinuing the PN. D. Administer 3 ampules of dextrose 50% 1 hour after discontinuing the PN.

A Rationale: After administration of the PN solution is gradually discontinued, an isotonic dextrose solution is given for 1 to 2 hours to protect against rebound hypoglycemia. The other listed actions would likely cause hyperglycemia

A teenage client is brought to the emergency department with symptoms of hyperglycemia. Based on the fact that the pancreatic beta cells are being destroyed, the client would be diagnosed with what type of diabetes? A. Type 1 diabetes B. Type 2 diabetes C. Non-insulin-dependent diabetes D. Prediabetes

A Rationale: Beta cell destruction is the hallmark of type 1 diabetes. Non- insulin-dependent diabetes is synonymous with type 2 diabetes, which involves insulin resistance and impaired insulin secretion, but not beta cell destruction. Prediabetes is characterized by normal glucose metabolism, but previous history of hyperglycemia, often during illness or pregnancy.

A medical client's CA 19-9 levels have become available and they are significantly elevated. How should the nurse best interpret this diagnostic finding? A. The client may have cancer, but other GI disease must be ruled out. B. The client most likely has early-stage colorectal cancer. C. The client has a genetic predisposition to gastric cancer. D. The client has cancer, but the site is unknown.

A Rationale: CA 19-9 levels are elevated in most clients with advanced pancreatic cancer, but they may also be elevated in other conditions such as colorectal, lung, and gallbladder cancers; gallstones; pancreatitis; cystic fibrosis; and liver disease. A cancer diagnosis cannot be made solely on CA 19-9 results

A client with gastritis required hospital treatment for an exacerbation of symptoms and receives a subsequent diagnosis of pernicious anemia due to malabsorption. When planning the client's continuing care in the home setting, what assessment question is most relevant? A. "Does anyone in your family have experience at giving injections?" B. "Are you going to be anywhere with strong sunlight in the next few months?" C. "Are you aware of your blood type?" D. "Do any of your family members have training in first aid?"

A Rationale: Clients with malabsorption of vitamin B12 need information about lifelong vitamin B12 injections; the nurse may instruct a family member or caregiver how to administer the injections or make arrangements for the client to receive the injections from a health care provider. Questions addressing sun exposure, blood type and first aid are not directly relevant.

A client presents to the clinic reporting symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes? A. Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L) B. Random plasma glucose greater than 150 mg/dL (8.3 mmol/L) C. Fasting plasma glucose greater than 116 mg/dL (6.4 mmol/L) on two separate occasions D. Random plasma glucose greater than 126 mg/dL (7.0 mmol/L)

A Rationale: Criteria for the diagnosis of diabetes include symptoms of diabetes plus random plasma glucose greater than or equal to 200 mg/dL (11.1 mmol/L), or a fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L).

A 35-year-old client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize? A. Insertion of a nasogastric tube B. Insertion of a central venous catheter C. Administration of a mineral oil enema D. Administration of a glycerin suppository and an oral laxative

A Rationale: Decompression of the bowel through a nasogastric tube is necessary for all clients with small bowel obstruction. Peripheral IV access is normally sufficient. Enemas, suppositories, and laxatives are not indicated if an obstruction is present

A client has come to the outpatient radiology department for diagnostic testing that will allow the care team to evaluate and remove polyps. The nurse should prepare the client for what procedure? A. Colonoscopy B. Barium enema C. ERCP D. Upper gastrointestinal fibroscopy

A Rationale: During a colonoscopy, tissue biopsies can be obtained, as needed, and polyps can be removed and evaluated. This is not possible during a barium enema, ERCP, or gastroscopy.

A client has come to the clinic reporting blood in the stool. A fecal occult blood test is performed but is negative. Based on the client's history, the health care provider suggests a colonoscopy, but the client refuses, citing a strong aversion to the invasive nature of the test. What other test might the provider order to check for blood in the stool? A. A laparoscopic intestinal mucosa biopsy B. A fecal immunochemical test (FIT) C. Computed tomography (CT) D. Magnetic resonance imagery (MRI)

A Rationale: Fecal immunochemical tests (FIT) may be more accurate than guaiac testing and useful for clients who refuse invasive testing. CT or MRI cannot detect blood in stool. Laparoscopic intestinal mucosa biopsy is not performed.

A client presents to the clinic reporting vomiting and burning in the mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what? A. Infection with Helicobacter pylori B. Excessive stomach acid secretion C. An incompetent pyloric sphincter D. A metabolic acid-base imbalance

A Rationale: H. pylori infection may be determined by endoscopy and histologic examination of a tissue specimen obtained by biopsy, or a rapid urease test of the biopsy specimen. Excessive stomach acid secretion leads to gastritis; however, peptic ulcers are caused by colonization of the stomach by H. pylori. Sphincter dysfunction and acid-base imbalances do not cause peptic ulcer disease

. A client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with minor cell changes. What principle should be integrated into the client's subsequent care? A. The client will be monitored closely to detect malignant changes. B. Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage. C. Small amounts of blood are likely to be present in the stools and are not cause for concern. D. Antacids may be discontinued when symptoms of heartburn subside.

A Rationale: In the client with Barrett esophagus, the cells lining the lower esophagus have undergone change and are no longer squamous cells. The altered cells are considered precancerous and are a precursor to esophageal cancer, necessitating close monitoring. H2 receptor antagonists are commonly prescribed for clients with GERD; however, monitoring of liver enzymes is not routine. Stools that contain evidence of frank bleeding or that are tarry are not expected and should be reported immediately. When antacids are prescribed for clients with GERD, they should be taken as prescribed whether or not the client is symptomatic

A nurse is preparing to place a client's prescribed nasogastric tube. What anticipatory guidance should the nurse provide to the client? A. Insertion is likely to cause some gagging. B. Insertion will cause some short-term pain. C. A narrow-gauge tube will be inserted before being replaced with a larger-gauge tube. D. Topical anesthetics will be used to reduce discomfort during insertion.

A Rationale: Insertion may cause gagging until the tube has passed beyond the throat. Insertion is often unpleasant, but not normally painful. Anesthetic is not usually applied and there is no initial need for a small-gauge tube.

A client with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the client may be prescribed what drug? A. Metoclopramide B. Omeprazole C. Lansoprazole D. Calcium carbonate

A Rationale: Metoclopramide (Reglan) is useful in promoting gastric motility. Omeprazole and lansoprazole are proton pump inhibitors that reduce gastric acid secretion. Calcium carbonate does not affect gastric emptying

A client comes to the clinic reporting pain in the epigastric region. What statement by the client is specific to the presence of a duodenal ulcer? A. "My pain resolves when I have something to eat." B. "The pain begins right after I eat." C. "I know that my father and my grandfather both had ulcers." D. "I seem to have bowel movements more often than I usually do."

A Rationale: Pain relief after eating is associated with duodenal ulcers. This type of ulcer is not associated with family history or increased frequency of bowel movements. Pain immediately after eating is typical of gastric ulcers, not duodenal.

Diagnostic imaging and physical assessment have revealed that a client with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? A. Peritonitis B. Gastritis C. Gastroesophageal reflux D. Acute pancreatitis

A Rationale: Perforation is the erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. Chemical peritonitis develops within a few hours of perforation and is followed by bacterial peritonitis. Gastritis, reflux, and pancreatitis are not acute complications of a perforated ulcer.

A client who experienced a large upper gastrointestinal (GI) bleed due to gastritis has had the bleeding controlled and is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence? A. Tachycardia, hypotension, and tachypnea B. Tarry, foul-smelling stools C. Diaphoresis and sudden onset of abdominal pain D. Sudden thirst, unrelieved by oral fluid administration

A Rationale: Tachycardia, hypotension, and tachypnea are signs of recurrent bleeding. Clients who have had one GI bleed are at risk for recurrence. Tarry stools are expected short-term findings after a hemorrhage. Hemorrhage is not normally associated with sudden thirst or diaphoresis

A diabetes nurse educator is teaching a group of clients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic client? A. Do not eliminate insulin when nauseated and vomiting. B. Report elevated glucose levels greater than 150 mg/dL (8.3 mmol/L). C. Eat three substantial meals a day, if possible. D. Reduce food intake and insulin doses in times of illness.

A Rationale: The most important issue to teach clients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take their usual insulin or oral hypoglycemic agent dose, and then attempt to consume frequent, small portions of carbohydrates. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL (16.6 mmol/L).

The nurse is providing care for a client whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the client's medication regimen? A. Antidiarrheal medications 30 minutes before a meal B. Antiemetics on a PRN basis C. Vitamin B12 injections to prevent pernicious anemia D. Beta adrenergic blockers to reduce bowel motility

A Rationale: The nurse administers antidiarrheal medications 30 minutes before a meal as prescribed to decrease intestinal motility and administers analgesics as prescribed for pain. Antiemetics, vitamin B12 injections and beta blockers do not address the signs, symptoms, or etiology of inflammatory bowel disease.

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN? A. Checking the client's capillary blood glucose levels regularly B. Having the client frequently rate his or her hunger on a 10-point scale C. Measuring the client's heart rhythm at least every 6 hours D. Monitoring the client's level of consciousness each shift

A Rationale: The solution, used as a base for most TPN, consists of a high dextrose concentration and may raise blood glucose levels significantly, resulting in hyperglycemia. This is a more salient threat than hunger, though this should be addressed. Dysrhythmias and decreased LOC are not among the most common complications

A client has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurse's priority during this aspect of the client's care? A. Measure and record drainage. B. Monitor drainage for change in color. C. Titrate the suction every hour. D. Feed the client via the G tube as prescribed.

A Rationale: This drainage should be measured and recorded because it is a significant indicator of GI function. The nurse should indeed monitor the color of the output, but fluid balance is normally the priority. Frequent titration of the suction should not be necessary and feeding is contraindicated if the G tube is in place for drainage.

A client is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this client's care, which of the following nursing diagnoses should the nurse prioritize? A. Ineffective tissue perfusion related to bowel ischemia B. Imbalanced nutrition: Less than body requirements related to impaired absorption C. Anxiety related to bowel obstruction and subsequent hospitalization D. Impaired skin integrity related to bowel obstruction

A Rationale: When the bowel is completely obstructed, the possibility of strangulation and tissue necrosis (i.e., tissue death) warrants surgical intervention. As such, this immediate physiologic need is a nursing priority. Nutritional support and management of anxiety are necessary, but bowel ischemia is a more immediate threat. Skin integrity is not threatened

A client has sought care because of recent dark-colored stools. As a result, a fecal occult blood test has been ordered. The nurse should give what instructions to the client? A) "Take no NSAIDs within 72 hours of the rest" B) "Take prescribed medications as usual" C) "Avoid over-the-counter (OTC) vitamin C supplements" D) "Do not use fiber supplements before the test"

A Rationale: in the past, clients were advised to avoid ingesting red meats, aspirin, non-steroidal anti-inflammatory drugs, turnips, and horseradish for 72 hours prior to he study because it was thought that these were associated with false-positive results; likewise, clients were advised ingesting vitamin C from supplements or foods as it was believed that this was associated with false-negative results. However, these restrictions are no longer advised as their effects on test results have not been established; plus, they unnecessarily restricted client participation in screening

The nurse is preparing to perform a client's abdominal assessment. What examination sequence should the nurse follow? A) inspection, auscultation, percussion, and palpation B) Inspection, palpation, auscultation, and percussion C) inspection, percussion, palpation, and auscultation D) inspection, palpation, percussion, and auscultation

A Rationale: when performing a focused assessment of the client's abdomen, auscultation should always precede percussion and palpation because they may alter bowel sounds. The traditional sequence for all other focused assessments is inspection, palpation, percussion, and auscultation

A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how a person's health is affected by the absence of the appendix. How should the nurse best respond? A) "Your appendix doesn't play a major role in health, so you won't notice any difference after your recovery from surgery" B) "The surgeon will encourage you to limit your fat intake for a few weeks after the surgery, but your body will then begin to compensate" C) "Your body will absorb slightly fewer nutrients form the food you eat but you won't be aware of this" D) "Your small intestine will adapt over time to the absence of your appendix"

A rationale: The appendix is an appendage of the cecum (not the small intestine) that has little or no physiologic function. Its absence does not affect digestion or absorption

A nurse is preparing to discharge a client home on parenteral nutrition. What should an effective home care teaching program address? Select all that apply. A. Preparing the client to troubleshoot for problems B. Teaching the client and family strict aseptic technique C. Teaching the client and family how to set up the infusion D. Teaching the client to flush the line with sterile water E. Teaching the client when it is safe to leave the access site open to air

A,B,C Rationale: An effective home care teaching program prepares the client to store solutions, set up the infusion, change the dressings, and troubleshoot for problems. The most common complication is sepsis. Strict aseptic technique is taught for hand hygiene, handling equipment, changing the dressing, and preparing the solution. Tap water is never used for flushes and the access site must never be left open to air.

A client has been experiencing significant psychosocial stress in recent weeks. The nurse is aware of the hormonal effects of stress, including norepinephrine release. Release of this substance would have what effect on the client's gastrointestinal function? Select all that apply. A. Decreased motility B. Increased sphincter tone C. Increased enzyme release D. Inhibition of secretions E. Increased peristalsis

A,B,D Rationale: Norepinephrine generally decreases GI motility and secretions, but increases muscle tone of sphincters. Norepinephrine does not increase the release of enzymes.

An adult client with a history of dyspepsia has been diagnosed with chronic gastritis. The nurse's health education should include what guidelines? Select all that apply. A. Avoid drinking alcohol B. Adopt a low-residue diet C. Avoid nonsteroidal anti-inflammatories D. Take calcium gluconate as prescribed E. Prepare for the possibility of surgery

A,E Rationale: Clients with chronic gastritis are encouraged to avoid alcohol and NSAIDs. Calcium gluconate is not a common treatment and the condition is not normally treated with surgery. Dietary modifications are usually recommended, but this does not necessitate a low-residue diet.

A nurse is caring for a client who just has been diagnosed with a peptic ulcer. When teaching the client about his new diagnosis, how should the nurse best describe it? A. Inflammation of the lining of the stomach B. Erosion of the lining of the stomach or intestine C. Bleeding from the mucosa in the stomach D. Viral invasion of the stomach wall

B Rationale: A peptic ulcer is erosion of the lining of the stomach or intestine. Peptic ulcers are often accompanied by bleeding and inflammation, but these are not the definitive characteristics.

A client with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the client has a perforated ulcer? A. The client has abdominal bloating that developed rapidly. B. The client has a rigid, "board-like" abdomen that is tender. C. The client is experiencing intense lower right quadrant pain. D. The client is experiencing dizziness and confusion with no apparent hemodynamic changes.

B Rationale: An extremely tender and rigid (board-like) abdomen is suggestive of a perforated ulcer. None of the other listed signs and symptoms is suggestive of a perforated ulcer.

A female client has presented to the emergency department with right upper quadrant pain; the health care provider has ordered abdominal ultrasound to rule out cholecystitis. The client expresses concern to the nurse about the safety of this diagnostic procedure. How should the nurse best respond? A. "Abdominal ultrasound is very safe, but it can't be performed if you're pregnant." B. "Abdominal ultrasound poses no known safety risks of any kind." C. "Current guidelines state that a person can have up to 3 ultrasounds per year." D. "Current guidelines state that a person can have up to 6 ultrasounds per year."

B Rationale: An ultrasound produces no ill effects and there are not specific limits on its use, even during pregnancy.

The nurse is providing care for a client who has recently been diagnosed with chronic gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease? A. Performing 15 minutes of physical activity at least three times per week B. Avoiding taking aspirin to treat pain or fever C. Taking multivitamins as prescribed and eating organic foods whenever possible D. Maintaining a healthy body weight

B Rationale: Aspirin and other NSAIDs are implicated in chronic gastritis because of their irritating effect on the gastric mucosa. Organic foods and vitamins confer no protection. Exercise and a healthy body weight are beneficial to overall health but do not prevent gastritis.

A nurse is caring for a newly admitted client with a suspected GI bleed. The nurse assesses the client's stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location? A. Sigmoid colon B. Upper GI tract C. Large intestine D. Anus or rectum

B Rationale: Blood shed in sufficient quantities in the upper GI tract will produce a tarry-black color (melena). Blood entering the lower portion of the GI tract or passing rapidly through it will appear bright or dark red. Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool or if blood is noted on toilet tissue.

A client has been prescribed cimetidine for the treatment of peptic ulcer disease. When providing relevant health education for this client, the nurse should ensure the client is aware of what potential outcome? A. Bowel incontinence B. Drug-drug interactions C. Abdominal pain D. Heat intolerance

B Rationale: Cimetidine is associated with several drug-drug interactions. This drug does not cause bowel incontinence, abdominal pain, or heat intolerance.

A nurse has auscultated a client's abdomen and noted one or two bowel sounds in a 2-minute period of time. How should the nurse document the client's bowel sounds? A. Normal B. Hypoactive C. Hyperactive D. Paralytic ileus

B Rationale: Documenting bowel sounds is based on assessment findings. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation. Paralytic ileus is a medical diagnosis that may cause absent or hypoactive bowel sounds, but the nurse would not independently document this diagnosis.

A nurse is providing care for a client whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis? A. Encourage the client to conduct online research into colostomies. B. Engage the client in dialogue about the implications of having the colostomy. C. Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem. D. Emphasize the fact that the colostomy is temporary measure and is not permanent.

B Rationale: For many clients, being able to dialogue frankly about the effect of the ostomy with a nonjudgmental nurse is helpful. Emphasizing the benefits of the intervention is unlikely to improve the client's body image, since the benefits are likely already known. Online research is not likely to enhance the client's body image and some ostomies are permanent.

During a client's scheduled home visit, an older adult client has stated to the community health nurse that the client has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following? A. Regular application of an OTC antibiotic ointment B. Increased fluid and fiber intake C. Daily use of OTC glycerin suppositories D. Use of an NSAID to reduce inflammation

B Rationale: Hemorrhoid symptoms and discomfort can be relieved by good personal hygiene and by avoiding excessive straining during defecation. A high-residue diet that contains fruit and bran along with an increased fluid intake may be all the treatment that is necessary to promote the passage of soft, bulky stools to prevent straining. Antibiotics, regular use of suppositories, and NSAIDs are not recommended, as they do not address the etiology of the health problem.

A nurse is conducting health screening with a diverse group of clients. Which client likely has the most risk factors for developing hemorrhoids? A. A 45-year-old teacher who stands for 6 hours per day B. A pregnant woman at 28 weeks' gestation C. A 37-year-old construction worker who does heavy lifting D. A 60-year-old professional who is under stress

B Rationale: Hemorrhoids commonly affect 50% of clients after the age of 50. Pregnancy may initiate hemorrhoids or aggravate existing ones. This is due to increased constipation during pregnancy. The significance of pregnancy is greater than that of standing, lifting, or stress in the development of hemorrhoids.

A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has not had ostomy output for the past 12 hours. The client also reports worsening nausea. What is the nurse's priority action? A. Facilitate a referral to the wound-ostomy-continence (WOC) nurse. B. Report signs and symptoms of obstruction to the health care provider. C. Encourage the client to mobilize in order to enhance motility. D. Contact the health care provider and obtain a swab of the stoma for culture

B Rationale: It is important to report nausea and abdominal distention, which may indicate intestinal obstruction. This requires prompt medical intervention. Referral to the WOC nurse is not an appropriate short-term response, since medical treatment is necessary. Physical mobility will not normally resolve an obstruction. There is no need to collect a culture from the stoma because infection is unrelated to this problem.

A nurse is assessing a client who has peptic ulcer disease. The client requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the client? A. Most affected clients acquired the infection during international travel. B. Infection typically occurs due to ingestion of contaminated food and water. C. Many people possess genetic factors causing a predisposition to H. pylori infection. D. The H. pylori microorganism is endemic in warm, moist climates.

B Rationale: Most peptic ulcers result from infection with the gram-negative bacteria H. pylori, which may be acquired through ingestion of food and water. The organism is endemic to many areas, not only warm, moist climates. Genetic factors have not been identified.

The nurse is discussing macrovascular complications of diabetes with a client. The nurse would address what topic during this dialogue? A. The need for frequent eye examinations for clients with diabetes B. The fact that clients with diabetes have an elevated risk of myocardial infarction C. The relationship between kidney function and blood glucose levels D. The need to monitor urine for the presence of albumin

B Rationale: Myocardial infarction and stroke are considered macrovascular complications of diabetes, while the effects on vision and kidney function are considered to be microvascular.

A nurse is initiating parenteral nutrition (PN) to a postoperative client who has developed complications. The nurse should initiate therapy by performing which of the following actions? A. Starting with a rapid infusion rate to meet the client's nutritional needs as quickly as possible B. Initiating the infusion slowly and monitoring the client's fluid and glucose tolerance C. Changing the rate of administration every 2 hours based on serum electrolyte values D. Increasing the rate of infusion at mealtimes to mimic the circadian rhythm of the body

B Rationale: PN solutions are initiated slowly and advanced gradually each day to the desired rate as the client's fluid and glucose tolerance permits. The formulation of the PN solutions is calculated carefully each day to meet the complete nutritional needs of the individual client based on clinical findings and laboratory data. It is not infused more quickly at mealtimes.

The nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. What are these nursing actions attempting to prevent? A. Gastric ulcers B. Aspiration C. Abdominal distention D. Diarrhea

B Rationale: Protecting the client from aspirating is essential because aspiration can cause pneumonia, a potentially life-threatening disorder. Gastric ulcers are not a common complication of tube feeding in clients with ET tubes. Abdominal distention and diarrhea can both be associated with tube feeding, but prevention of these problems is not the primary rationale for confirming placement.

The nurse is assessing a client who had an ileostomy created three days ago for the treatment of irritable bowel disease. The nurse observes that the client's stoma is bright red and there are scant amounts of blood on the stoma. What is the nurse's best action? A. Contact the care provider to have the client's hemoglobin and hematocrit measured. B. Document these expected assessment findings. C. Apply barrier ointment to the stoma as prescribed. D. Cleanse the stoma with alcohol or chlorhexidine.

B Rationale: Redness and slight bleeding are expected, so no further intervention or assessment is likely necessary

. A nurse is caring for a client with type 1 diabetes. The client's medication administration record includes the administration of regular insulin three times daily. Knowing that the client's lunch tray will arrive at 11:45 AM, when should the nurse administer the client's insulin? A. 10:45 AM B. 11:30 AM C. 11:45 AM D. 11:50 AM

B Rationale: Short-acting insulin is called regular insulin. It is in a clear solution and is usually given 15 minutes before a meal or in combination with a longer-acting insulin. Earlier administration creates a risk for hypoglycemia; later administration creates a risk for hyperglycemia.

A nurse at an outpatient surgery center is caring for a client who had a hemorrhoidectomy. What discharge education topics should the nurse address with this client? A. The appropriate use of antibiotics to prevent postoperative infection B. The correct procedure for taking a sitz bath C. The need to eat a low-residue, low-fat diet for the next 2 weeks D. The correct technique for keeping the perianal region clean without the use of water

B Rationale: Sitz baths are usually indicated after perianal surgery. A low-residue, low-fat diet is not necessary and water is used to keep the region clean. Postoperative antibiotics are not routinely prescribed.

The nurse is caring for a client with gastrointestinal symptoms who reports being under a significant amount of stress at home and at work. Which gastrointestinal effect of stress should the nurse anticipate is affecting this client? A. Increased gastric acid secretion B. Slowed peristalsis C. Increased enteric blood flow D. Relaxed sphincter muscles

B Rationale: Stress stimulates the sympathetic nervous system which slows motility in the gastrointestinal tract, reduces gastric secretions, and causes vasoconstriction. Stimulation of the parasympathetic nervous system causes the non-voluntary sphincters to relax.

A client has just been diagnosed with type 2 diabetes. The health care provider has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did the health care provider prescribe for this client? A. A sulfonylurea B. A biguanide C. A thiazolidinedione D. An alpha-glucosidase inhibitor

B Rationale: Sulfonylureas exert their primary action by directly stimulating the pancreas to secrete insulin, and therefore require a functioning pancreas to be effective. Biguanides inhibit the production of glucose by the liver and are in used in type 2 diabetes to control blood glucose levels. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Alpha-glucosidase inhibitors work by delaying the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.

. A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis? A. Imbalanced nutrition: Less than body requirements related to decreased oral intake B. Risk for infection related to possible rupture of appendix C. Constipation related to decreased bowel motility and decreased fluid intake D. Chronic pain related to appendicitis

B Rationale: The client with a diagnosis of appendicitis has an acute risk of infection related to the possibility of rupture. This immediate physiologic risk is a priority over nutrition and constipation, though each of these concerns should be addressed by the nurse. The pain associated with appendicitis is acute, not chronic

A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response? A. Administer a Fleet enema as prescribed and remain with the client. B. Contact the primary care provider promptly and report these signs of perforation. C. Position the client supine and insert an NG tube. D. Page the primary provider and report that the client may be obstructed.

B Rationale: The client's change in status is suggestive of perforation, which is a surgical emergency. Obstruction does not have this presentation involving fever and abdominal rigidity. An enema would be strongly contraindicated. An order is needed for NG insertion and repositioning is not a priority

The nurse is caring for a client who is undergoing diagnostic testing for suspected malabsorption. When taking this client's health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis? A. Recurrent constipation coupled with weight loss B. Foul-smelling diarrhea that contains fat C. Fever accompanied by a rigid, tender abdomen D. Bloody bowel movements accompanied by fecal incontinence

B Rationale: The hallmarks of malabsorption syndrome from any cause are diarrhea or frequent, loose, bulky, foul-smelling stools that have increased fat content and are often grayish (steatorrhea). Constipation and bloody bowel movements are not suggestive of malabsorption syndromes. Fever and a tender, rigid abdomen are associated with peritonitis.

A nurse is caring for a client who is receiving parenteral nutrition. When writing this client's plan of care, which of the following nursing diagnoses should be included? A. Risk for peripheral neurovascular dysfunction related to catheter placement B. Ineffective role performance related to parenteral nutrition C. Bowel incontinence related to parenteral nutrition D. Chronic pain related to catheter placement

B Rationale: The limitations associated with PN can make it difficult for clients to maintain their usual roles. PN does not normally cause bowel incontinence and catheters are not associated with chronic pain or neurovascular dysfunction.

. An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform? A. Encourage the client to take stool softener daily. B. Assess the client's food and fluid intake. C. Assess the client's surgical history. D. Encourage the client to take fiber supplements.

B Rationale: The nurse should follow the nursing process and perform an assessment prior to interventions. The client's food and fluid intake is more likely to affect bowel function than surgery

A client has been scheduled for a urea breath test in one month's time. What nursing diagnosis most likely prompted this diagnostic test? A. Impaired dentition related to gingivitis B. Risk for impaired skin integrity related to peptic ulcers C. Imbalanced nutrition: Less than body requirements related to enzyme deficiency D. Diarrhea related to Clostridium difficile infection

B Rationale: Urea breath tests detect the presence of Helicobacter pylori, the bacteria that can live in the mucosal lining of the stomach and cause peptic ulcer disease. This test does not address fluid volume, nutritional status, or dentition

A client's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next? A. Withdraw the NG tube 2 inches (5 cm) and reattempt aspiration. B. Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating. C. Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers. D. Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider.

B Rationale: Warm water irrigation is one of the methods that can be used to unclog a feeding tube. Removal is not warranted at this early stage and a flicking motion is unlikely to have an effect. The tube should not be withdrawn, even a few centimeters.

A client has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the client to describe what sign or symptom? A. Burning pain on swallowing B. Regurgitation of undigested food C. Symptoms mimicking a myocardial infarction D. Chronic parotid abscesses

B Rationale: An esophageal diverticulum is an outpouching of mucosa and submucosa that protrudes through the esophageal musculature. Food becomes trapped in the pouch and is frequently regurgitated when the client assumes a recumbent position. The client may experience difficulty swallowing; however, burning pain is not a typical finding. Symptoms mimicking a heart attack are characteristic of GERD. Chronic parotid abscesses are not associated with a diagnosis of esophageal diverticulum.

A nurse is creating a care plan for a client who is receiving parenteral nutrition. The client's care plan should include nursing action(s) relevant to what potential complications? Select all that apply. A. Dumping syndrome B. Clotted or displaced catheter C. Pneumothorax D. Hyperglycemia E. Line sepsis

B,C,D,E Rationale: Common complications of PN include a clotted or displaced catheter, pneumothorax, hyperglycemia, and infection from the venous access device (line sepsis). Dumping syndrome applies to enteral nutrition, not PN.

An adult client has been diagnosed with diverticular disease after ongoing challenges with constipation. The client will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply. A. Anticholinergic medications B. Increased fiber intake C. Enemas on alternating days D. Reduced fat intake E. Fluid reduction

B,D Rationale: Clients whose diverticular disease does not warrant hospital treatment often benefit from a high-fiber, low-fat diet. Neither enemas nor anticholinergics are indicated, and fluid intake is encouraged.