NUR2011 Final Study Set 4
Which teaching is a priority for the client with gastroesophageal reflux? a. "Eat four to six small meals each day." b. "Eat a small evening snack 1 to 2 hours before bed." c. "Drink carbonated beverages between meals only." d. "You may include orange or tomato juice with your breakfast."
a. "Eat four to six small meals each day."
What will the nurse teach the client with diverticula about dietary needs? a. "Eat soft foods and smaller meals." b. "Only eat puréed foods." c. "Avoid drinking liquids with meals." d. "Avoid dairy products."
a. "Eat soft foods and smaller meals."
Which statement in the client postfundoplication indicates a need for additional dietary teaching? a. "I should eat three meals a day." b. "I will drink only decaffeinated coffee." c. "I can begin oral intake by taking only clear fluids." d. "I must eliminate carbonated beverages from my diet."
a. "I should eat three meals a day." Once the client can tolerate clear fluids, the diet may be advanced. The client should eliminate alcohol, caffeine, and carbonated beverages from the diet. The client should be instructed to eat smaller, more frequent meals because the food storage area of the stomach is reduced by the surgery, and not to eat within 3 hours of bedtime.
The nurse is to insert a nasogastric tube for a client with upper GI bleeding. Which instructions will the nurse give to the client before starting the procedure? a. "You may take some sips of water when I begin to insert the tube into your nose." b. "Please hold your breath when I insert this small tube through your nose down into your stomach." c. "Please tilt your head down toward your chest when the tube gets to the back of your throat." d. "I will measure the distance from the end of your nose to your navel to know how far to insert the tube."
a. "You may take some sips of water when I begin to insert the tube into your nose."
The nurse is caring for a client who has received multiple serious injuries in a motor vehicle accident. The client asks the nurse why ranitidine (Zantac) is prescribed because she does not have any abdominal pain. Which is the nurse's best response? a. "Zantac will help prevent the development of a stomach ulcer from the stress of your injuries." b. "Zantac will help prevent aspiration pneumonia when you are anesthetized during surgery tomorrow." c. "Zantac will help your throat heal after it was irritated from the nasogastric tube." d. "Zantac will help prevent nausea and vomiting from the narcotic pain medications that you are taking."
a. "Zantac will help prevent the development of a stomach ulcer from the stress of your injuries." Clients who have sustained traumatic injuries are at risk for development of stress ulcers during recovery. H2 antagonist medications may be prescribed to prevent stress ulcers. Zantac will not prevent aspiration pneumonia, esophageal healing after nasogastric intubation, or nausea from narcotic pain medications.
Which is the priority assessment of a client experiencing regurgitation? a. Auscultating lungs for crackles b. Inspecting the oral cavity c. Palpating the cervical lymph nodes d. Culturing the throat for bacterial infection
a. Auscultating lungs for crackles
The nurse is caring for a client who recently has undergone a Billroth II procedure. Two hours after eating lunch, the client becomes dizzy, diaphoretic, and confused. Which is the nurse's priority action? a. Checking the client's blood sugar level b. Increasing the client's IV infusion rate c. Auscultating the client's bowel sounds d. Placing the client in high Fowler's position
a. Checking the client's blood sugar level
Which is an explanation of conditions that foster esophageal reflux? a. Decreased lower esophageal sphincter (LES) tone b. Spasms of the lower esophageal sphincter c. Tensing of the upper esophageal sphincter d. Decreased intra-abdominal pressure
a. Decreased lower esophageal sphincter (LES) tone Esophageal reflux can occur when the intra-abdominal pressure is elevated or when the sphincter tone of the LES is decreased.
Which interventions can the nurse delegate to unlicensed personnel when caring for a client with esophageal cancer? (Select all that apply.) a. Maintaining intake and output b. Maintaining calorie count c. Administering tube feeding d. Assessing the vital signs e. Teaching changes in daily activities f. Changing incision dressing
a. Maintaining intake and output b. Maintaining calorie count
The nurse is caring for a client who will undergo Billroth I surgery the following day. Which interventions will be included in the postoperative plan of care for the client? (Select all that apply.) a. Monitor and record accurate intake and output (I&O). b. Reposition the client in bed at least every 2 hours. c. Remind the client to use the incentive spirometer twice daily. d. Change abdominal dressings daily using medical asepsis. e. Remind the client daily to use PCA before pain becomes severe. f. Teach the client to select high-carbohydrate, high-protein foods. g. Irrigate the nasogastric tube with normal saline every 8 hours PRN.
a. Monitor and record accurate intake and output (I&O). b. Reposition the client in bed at least every 2 hours. e. Remind the client daily to use PCA before pain becomes severe.
The nurse is caring for a client with peptic ulcer disease. Which interventions will be included in the nursing care plan to monitor for complications? (Select all that apply.) a. Monitor and record intake and output. b. Monitor hemoglobin and hematocrit laboratory values. c. Send samples of all stools to the laboratory for hemoccult testing. d. Percuss the abdomen for shifting dullness every shift and PRN. e. Perform iliopsoas muscle test and obturator test every shift and PRN. f. Check for positive scratch test and Murphy's sign every shift and PRN. g. Check vital signs and orthostatic blood pressure every 4 hours and PRN.
a. Monitor and record intake and output. b. Monitor hemoglobin and hematocrit laboratory values. c. Send samples of all stools to the laboratory for hemoccult testing. g. Check vital signs and orthostatic blood pressure every 4 hours and PRN.
Which is the primary nursing intervention for a client with early esophageal cancer? a. Nutritional support b. Pulmonary toileting c. Fluid and electrolyte balance d. Therapeutic treatments
a. Nutritional support The major concern for a client with esophageal cancer is weight loss secondary to dysphasia. Therefore, nutritional support is required, with intake monitored and weight maintained.
The nurse is caring for a client with suspected upper GI bleeding. The nurse inserts an NG tube for gastric lavage and checks placement of the tube in the stomach. When aspirating fluid from the tube, the pH is found to be 6. Which is the priority action of the nurse? a. Obtaining an order for a STAT chest x-ray b. Asking the client to speak and auscultating over the lung fields c. Checking to determine if the tube is coiled in the back of the client's throat d. Instilling an air bolus into the tube while auscultating over the epigastric area
a. Obtaining an order for a STAT chest x-ray
The nurse is caring for a client who has been brought to the emergency room with upper GI bleeding. The client is unconscious and requires lavage to stop the bleeding. Which is the nurse's priority action? a. Preparing to intubate the client with an endotracheal tube b. Inserting a 20-gauge IV and starting a normal saline IV infusion c. Obtaining a 14 French nasogastric tube and iced normal saline for the procedure d. Setting up the suction unit with collection canister and medium intermittent suction
a. Preparing to intubate the client with an endotracheal tube
The nurse is obtaining the history of a client with a sliding hernia. Which of the following symptoms would the nurse expect to see in this client? (Select all that apply.) a. Reflux b. Bleeding c. Dysphagia d. Belching e. Breathlessness f. Vomiting
a. Reflux c. Dysphagia d. Belching e. Breathlessness
The nurse is caring for a male client with peptic ulcer disease. Which assessment finding indicates to the nurse that the client most likely has an ulcer in the stomach rather than the duodenum? a. The client's body mass index (BMI) is 17.6. b. The client's stool is positive for occult blood. c. The client has had four ulcers in the last 5 years. d. The client's hemoglobin is 13 g/dL and hematocrit is 42%.
a. The client's body mass index (BMI) is 17.6. A BMI of 17.6 indicates that the client is underweight. This finding is more commonly seen with gastric ulcers than duodenal ulcers because the pain is made worse with food ingestion. Occult blood and low hemoglobin and hematocrit levels may be seen with both gastric and duodenal ulcers. Recurrence is more commonly seen with duodenal than gastric ulcers.
The nurse is caring for a client with congestive heart failure and chronic gastritis. The client tells the nurse that he takes 2 teaspoons of sodium bicarbonate every night before bed to prevent heartburn. Which is the nurse's best response? a. "You should let the doctor know right away if you develop stomach cramps." b. "I will let your doctor know so that a safer antacid can be prescribed for you." c. "Do not take the sodium bicarbonate with milk, because it can cause kidney stones." d. "Make sure that you mix the sodium bicarbonate with at least 8 ounces of water."
b. "I will let your doctor know so that a safer antacid can be prescribed for you." Sodium bicarbonate can cause fluid retention and edema, which can be dangerous for clients with congestive heart failure. The physician should be notified right away so that an alternative antacid can be prescribed.
Which statement indicates that the client understands the management of his or her hiatal hernia? a. "I will lie flat for 30 minutes after each meal." b. "I will remain upright for several hours after each meal." c. "I will have my blood count done in 2 weeks to check for anemia." d. "I will sleep at night lying on my left side to prevent nighttime reflux."
b. "I will remain upright for several hours after each meal." Clients with hiatal hernia experience GERD. Positioning is an important intervention. The client should be taught to sleep with the head of the bed elevated, to remain upright after meals for 2 to 3 hours, and to avoid straining or restrictive clothing.
The nurse is caring for a client who presents with chronic epigastric pain, heartburn, and anorexia. The client asks the nurse how the doctor can best determine if the symptoms are caused by gastritis. Which is the nurse's best response? a. "You will be asked to drink a barium solution while x-rays are taken of your stomach." b. "The doctor will take a look inside your stomach using a tube with a light on the end of it." c. "A CT scan of your abdomen will show if there is inflammation present in your stomach." d. "A blood sample will be sent to the laboratory to determine if you have a stomach infection or bleeding."
b. "The doctor will take a look inside your stomach using a tube with a light on the end of it." Endoscopy (esophagogastroduodenoscopy) with biopsy is the best method for diagnosing gastritis. Computed tomography (CT) scans, upper GI series, and blood samples are less accurate for making the diagnosis of gastritis.
The nurse is caring for a client with advanced gastric cancer who is scheduled for palliative surgery to relieve gastric outlet obstruction. The client asks the nurse why he should bother having the surgery because he will not be cured. Which is the nurse's best response? a. "The surgery will allow the doctors to determine more accurately how long you have to live." b. "The surgery will relieve the obstruction so you will be more comfortable and able to eat again." c. "The surgery will remove much of the tumor so that chemotherapy will be more effective." d. "The surgery will help prevent the tumor from spreading to other parts of your body."
b. "The surgery will relieve the obstruction so you will be more comfortable and able to eat again."
A client who has undergone a fundoplication wrap for hernia repair has returned from the postanesthesia care unit with a nasogastric tube draining dark brown fluid. Which is the nurse's priority action? a. Assessing the placement of the tube b. Documenting the finding and continuing to monitor c. Clamping the nasogastric tube for 30 minutes d. Irrigating the nasogastric tube with normal saline
b. Documenting the finding and continuing to monitor After fundoplication, drainage from the nasogastric tube is initially dark brown with old blood. This finding is expected and requires only documentation. The drainage should become yellow-green within 8 hours after surgery.
Which is the first intervention that the nurse will take for the client post-sliding hernia repair to prevent complications? a. Range-of-motion exercises to the lower extremities b. Elevation of the head of the bed to 30 degrees c. Monitoring of input and output d. Assessment of bowel sounds
b. Elevation of the head of the bed to 30 degrees The prevention of respiratory complications is the primary focus of postoperative care. The high incision makes taking deep breaths extremely painful for this client. By elevating the head of the bed to at least 30 degrees, the nurse promotes lung expansion in the client.
The nurse should assess for which complication in a client with Barrett's esophagus who is complaining of dysphasia? a. Achalasia b. Esophageal stricture c. Paraesophageal hernia d. Oropharyngeal dysphagia
b. Esophageal stricture
Which client response to the Bernstein test would confirm the diagnosis of esophagitis? a. Dysphagia during the test b. Heartburn during the test c. No symptoms during the test d. Painful swallowing during the test
b. Heartburn during the test Clients with esophagitis will experience heartburn as the acidic solution is infused, with a positive Bernstein test result.
Which referrals will the nurse make for an older adult client being discharged with esophageal cancer? (Select all that apply.) a. IV infusionist b. Home health aide c. Medicare or Medicaid d. Meals on Wheels e. Housecleaning service f. Transportation to and from treatment
b. Home health aide d. Meals on Wheels f. Transportation to and from treatment
A client with severe GERD is still having symptoms of reflux despite taking omeprazole, (Prilosec) 20 mg daily. What will the nurse do next? a. Document the finding as the only action. b. Obtain an order for omeprazole twice daily. c. Instruct the client to stop the medication immediately. d. Instruct the client to take an antacid in addition to the omeprazole.
b. Obtain an order for omeprazole twice daily. Omeprazole is a proton pump inhibitor that acts to reduce gastric acid secretion. If once-daily dosing fails to control the client's symptoms, the nurse should obtain an order for the client to take omeprazole twice daily for better symptom control.
A client with Zollinger-Ellison syndrome will be admitted to the medical unit. Which intervention will the nurse include in the client's nursing plan of care? a. Performing a urine test for ketones every morning before breakfast b. Performing perineal care with warm water and applying a moisture barrier twice daily c. Assessing the abdomen for fluid wave and shifting dullness every 8 hours and PRN d. Keeping 2 units of packed red blood cells on hold, transfusing if hemoglobin <8 g/dL
b. Performing perineal care with warm water and applying a moisture barrier twice daily Clients with Zollinger-Ellison syndrome often experience severe diarrhea and steatorrhea, so the nurse should include careful perineal care in the plan of care. Abdominal fluid wave testing and shifting dullness checks for ascites, which is not seen with Zollinger-Ellison syndrome. The client's physician is responsible for ordering transfusion of blood, not the nurse.
A client is admitted with progressive dysphagia. Which assessment finding does the nurse expect in this client? a. Headaches b. Weight loss c. Breathing difficulty d. Esophageal varices
b. Weight loss
Which finding alerts the nurse to a possible complication in a client with esophageal cancer receiving radiation therapy? a. Redness of the skin at the site of radiation b. Worsening of dysphagia or odynophagia c. Development of nausea or vomiting d. A profound feeling of tiredness
b. Worsening of dysphagia or odynophagia
Which discharge teaching is essential for the client who is postesophagogastrostomy? a. "Eat only three meals daily." b. "Lie flat after meals to prevent vomiting." c. "Drink fluids between, rather than with, meals." d. "Avoid high-protein foods because they are irritating."
c. "Drink fluids between, rather than with, meals." The client is taught to drink fluids between rather than with meals to prevent diarrhea resulting from vagotomy syndrome. The client also should sit upright during and after meals and eat a high-protein diet of six to eight meals daily.
The nurse is caring for a client who has recently undergone a Billroth I procedure. The nurse notes that the client's reflexes are slowed and the client reports tingling in his feet and hands. Which dietary recommendations will the nurse make for this client? a. "Avoid nuts and other legumes." b. "Avoid grapefruit and orange juices." c. "Eat more shellfish, beef, and salmon." d. "Eat more leafy, dark green vegetables."
c. "Eat more shellfish, beef, and salmon."
The nurse is caring for a client who will be discharged from the hospital following surgery for advanced gastric cancer. The client's daughter verbalizes the fear that she will not be able to manage her father's symptoms adequately at home. Which is the nurse's best response? a. "The nursing staff has taught you everything that you will need to know about the dressing changes and medications." b. "The dressing only needs to be changed once a day and the pain pills will keep him comfortable." c. "I will ask the social worker to arrange for a hospice nurse to help you care for your father at home." d. "I will ask the physician to review the postoperative care instructions with you again."
c. "I will ask the social worker to arrange for a hospice nurse to help you care for your father at home." Hospice nurses can assist family members with caring for clients who are terminally ill. The nurse should not belittle the daughter's concerns or ask the physician to review the discharge instructions again.
A client who has undergone a fundoplication wrap for hernia repair is preparing for discharge. Which intervention is essential for the nurse to include in discharge instructions? a. "Avoid taking stool softeners." b. "Eat three normal-sized meals daily." c. "Notify your physician if you develop symptoms of a cold." d. "Return to your former level of activity as soon as you are discharged."
c. "Notify your physician if you develop symptoms of a cold." The client is instructed to report cold or flulike symptoms, because persistent coughing associated with these conditions can cause dehiscence of the incision.
When initiating treatment for GERD with metoclopramide (Reglan), what is essential for the nurse to teach the client? a. "Take this medication 60 minutes before each meal." b. "This medication will promote healing of esophageal tissue if taken at regular intervals." c. "This medication can make you feel tired." d. "This medication can cause abdominal cramping and diarrhea."
c. "This medication can make you feel tired."
The nurse is caring for a client with gastritis who will undergo urea breath testing in the morning. Which instructions will the nurse provide for the client? a. "You will need to have an IV started just before the test." b. "You should drink eight glasses of water 3 hours before the test." c. "You may not have anything to eat or drink after midnight tonight." d. "You will be given a sedative, so you will need someone to drive you home."
c. "You may not have anything to eat or drink after midnight tonight."
Which is the most accurate method of diagnosing gastroesophageal reflux disease (GERD)? a. Endoscopy b. Schilling test c. 24-hour ambulatory pH monitoring d. Stool testing for occult blood
c. 24-hour ambulatory pH monitoring
Which factor would place a client at risk for esophageal cancer? a. A high-stress occupation b. A preference for high-fat foods c. A 20 pack-year smoking history d. A history of myocardial infarction
c. A 20 pack-year smoking history
A client with esophageal reflux who experiences regurgitation while lying flat is at risk for which complication? a. Erosion b. Bleeding c. Aspiration d. Odynophagia
c. Aspiration
Which is the priority intervention in the care of a client with esophageal cancer? a. Maintaining nutritional intake b. Allowing grieving c. Preventing aspiration d. Managing pain relief
c. Preventing aspiration
The nurse is caring for a client who takes magnesium hydroxide with aluminum hydroxide (Maalox) at home to control epigastric pain. Which finding from the client's health history leads the nurse to recommend taking aluminum hydroxide (Amphojel) instead? a. The client takes 81 mg of aspirin every day. b. The client has a history of chronic constipation. c. The client has a history of chronic kidney disease. d. The client takes omeprazole (Prilosec) 40 mg daily at bedtime.
c. The client has a history of chronic kidney disease. Poor renal perfusion caused by heart failure can cause retention of magnesium by the kidneys, leading to toxicity. Maalox can be taken safely with Prilosec and aspirin. Chronic constipation does not contraindicate the use of Maalox.
The nurse is caring for a client who has recently undergone Billroth II surgery. The client asks the nurse which foods would be best for him to have for breakfast. Which menu items will the nurse recommend for the client? (Select all that apply.) a. Blueberry pancakes with maple syrup b. A half-grapefruit with a blueberry muffin c. Whole-wheat bagel with low-fat cream cheese d. Raisin bran with milk and artificial sweetener e. Scrambled eggs with cheese and a slice of bacon f. One half-cup of cottage cheese with half an apple g. Strawberry nonfat yogurt with a slice of whole-wheat toast
c. Whole-wheat bagel with low-fat cream cheese e. Scrambled eggs with cheese and a slice of bacon f. One half-cup of cottage cheese with half an apple Clients who have undergone Billroth II surgery are at risk for dumping syndrome after meals. To help avoid dumping syndrome, clients should avoid concentrated sweets and fluids at mealtimes. Clients should choose foods that are relatively high in protein and fat, with relatively low carbohydrate content.
Which instruction will the nurse give the client to prevent nighttime reflux? a. "Sleep in the right lateral decubitus position." b. "Have a light evening snack before bedtime." c. "Have alcoholic beverages early in the evening." d. "Elevate the head of the bed 6 to 8 inches for sleep."
d. "Elevate the head of the bed 6 to 8 inches for sleep."
The nurse is caring for a client who reports persistent epigastric pain, heartburn, and nausea, despite faithfully taking ranitidine (Zantac), aluminum hydroxide (Amphojel), and metronidazole (Flagyl) as prescribed. Which is the nurse's best response? a. "Is your pain better or worse after you eat?" b. "Have you tried elevating the head of your bed at night?" c. "Have you been taking the Amphojel and Flagyl together?" d. "Have you been experiencing foul-smelling diarrhea lately?"
d. "Have you been experiencing foul-smelling diarrhea lately?" Peptic ulcer disease (PUD) symptoms that are not alleviated by medications may indicate Zollinger-Ellison syndrome, a similar condition that is often refractory to treatment. A hallmark of Zollinger-Ellison syndrome is diarrhea and steatorrhea, with frothy, foul-smelling diarrhea.
The nurse is performing an assessment of a client with suspected esophageal cancer. Which statement made by the client is indicative of advanced disease? a. "I have difficulty swallowing solids, particularly meat." b. "I usually have a sticking feeling in my throat." c. "I have difficulty swallowing soft foods." d. "I have difficulty swallowing liquids."
d. "I have difficulty swallowing liquids."
A client who has undergone Nissen fundoplication for GERD is ready for discharge home. Which statement made by the client indicates understanding of the disease? a. "I will no longer need any medication." b. "I will avoid spicy foods because they can irritate the suture line." c. "I should take antireflux medications when I eat a large meal." d. "I will need to continue to watch my diet and take my medication."
d. "I will need to continue to watch my diet and take my medication."
The nurse is caring for a client who has recently undergone a Billroth II procedure. The client states that whenever he eats, he becomes dizzy and sweaty, with heart palpitations. The client tells the nurse that he is now afraid to eat anything. Which is the nurse's best response? a. "You should drink at least 6 ounces of fluid before each meal." b. "You should go back to a clear liquid diet for the next few days." c. "You might be lactose-intolerant now. Try avoiding dairy products." d. "You should avoid eating foods that contain large amounts of sugar."
d. "You should avoid eating foods that contain large amounts of sugar." The client's symptoms are consistent with dumping syndrome, which can be minimized by avoiding intake of foods with high sugar content. A clear liquid or lactose-free diet is not appropriate for this client. Clients should avoid drinking fluids with meals to prevent dumping syndrome.
What is the pH range of the distal esophagus? a. 1.5-2.0 b. 3.0-4.5 c. 4.5-6.0 d. 6.0-7.0
d. 6.0-7.0
A client has undergone an esophagogastrostomy for cancer of the esophagus. How will the nurse best support the client's respiratory status? a. Assessing the client's breath sounds every 4 hours b. Performing chest physiotherapy every 6 hours c. Maintaining the client in a supine position d. Administering analgesia regularly
d. Administering analgesia regularly
A client with esophageal cancer and dysphagia states that it has become more difficult to swallow, and the client has experienced several choking episodes during meals. Which strategy would the nurse recommend to assist this client in obtaining adequate nutrition? a. Monitor caloric intake. b. Instruct the client to drink only clear liquids. c. Tell the client that artificial feeding will now be required. d. Encourage the client to eat semisoft foods and thickened liquids.
d. Encourage the client to eat semisoft foods and thickened liquids.
A client 2 hours post-esophageal dilation develops chest and shoulder pain. Which is the best action of the nurse? a. Administering an analgesic b. Documenting the finding as the only action c. Repositioning the client d. Further assessing the client for perforation
d. Further assessing the client for perforation Chest and shoulder pain may be indicative of bleeding or perforation and require immediate intervention. Administration of an analgesic should not be done until the problem is diagnosed.
Which characteristic puts a client at risk for gastroesophageal reflux disease? a. Drinking decaffeinated beverages b. Losing weight c. Taking oral hypoglycemic agents d. Nasogastric tube
d. Nasogastric tube A nasogastric tube keeps the cardiac sphincter open, allowing acidic contents from the stomach to enter the esophagus.
The nurse notes frank red blood in the drainage container from the nasogastric (NG) tube of a client who is 2 days postesophagogastrostomy. Which is the nurse's priority intervention? a. Irrigating the NG tube b. Documenting the drainage c. Repositioning the tube in the opposite nostril d. Notifying the physician that the suture line is bleeding
d. Notifying the physician that the suture line is bleeding The initial nasogastric drainage appears bloody, but should turn a yellow-green color by the end of the first postoperative day. If the bloody color continues, it may indicate bleeding at the suture line. If the tube is draining, there is no need to irrigate it. Repositioning the tube will not change the drainage.
Which symptom indicates a need for immediate intervention in the client with a rolling hernia? a. Reflux b. Vomiting c. Pneumonia d. Obstruction
d. Obstruction
A client is admitted with a chemical injury to the esophagus after ingestion of an alkaline substance. The nurse assesses for which potential complication? a. Infection b. Stricture c. Aspiration d. Perforation
d. Perforation Although all these complications are possible, ingestion of alkaline substances is dangerous because of their potential to penetrate the esophagus fully, leading to perforation.
