Practice Test 3 NURS327
An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom?
Esophageal tumor
A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. The first activity of the nurse is to:
Assess lung sounds bilaterally
The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease?
Avoid eating or drinking 2 hours before bedtime
A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate?
Hang a solution of dextrose 110% and water until the new solution is available
After teaching a client who has had a Roux-en-Y gastric bypass, which client statement indicates the need for additional teaching?
I need to drink 8 ox of water before eating
A positive Rovsing's sign is indicative of appendicitis. A nurse knows to assess for this indicator by palpating the:
Left lower quadrant
The physician orders the insertion of a single lumen nasogastric tube. When gathering the equipment for the insertion, the nurse would select which of the following?
Levin tube
A client has symptoms suggestive of peritonitis. Nursing management would not include:
Limiting analgesics to avoid the formation of paralytic ileus
A client comes to the clinic reporting pain in the epigastric region. What statement by the client suggests the presence of a duodenal ulcer?
My pain resolves when I have something to eat
A patient has been taking a 10-day course of antibiotics for pneumonia. The patient has been having white patches that look like milk curds in the mouth. What treatment will the nurse educate the patient about?
Nystatin
A patient complains about an inflamed salivary gland below his right ear. The nurse documents probable inflammation of which gland?
Parotid
A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply.
Remove gas and fluids from the stomach Diagnose gastrointestinal motility disorders Flush ingested toxins from the stomach Administer nutritional substances
Which nursing instruction is correct to provide the client following a barium enema?
The stools may be white or clay colored
A middle-aged obese female presents to the ED with severe radiating right-sided flank pain, nausea, vomiting, and fever. A likely cause of these symptoms is:
Acute cholecystitis
The nurse should assess for an important early indicator of acute pancreatitis. What prolonged and elevated level would the nurse determine is an early indicator?
Serum lipase
The nurse administers a tube feeding to a client via the intermittent gravity drip method. The nurse should administer the feeding over at least which period of time?
30 minutes
A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use?
30-ml
The nurse is conducting a community education session on the prevention of oral cancers. The nurse includes which cancer as being a type of premalignant squamous cell skin cancer?
Actinic cheilitis
A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms?
An absence of blood in the stool
The client is postoperative following a graft reconstruction of the neck. It is most important for the nurse to
Assess the graft for color and temperature
The client has just had a central line inserted for parenteral nutrition. The client is awaiting transport to the Radiology Department for catheter placement verification. The client reports feeling anxious. Respirations are 28 breaths/minute. The first action of the nurse is
Auscultate lung sounds
A patient is scheduled for a fiberoptic colonoscopy. What does the nurse know that fiberoptic colonoscopy is most frequently used to diagnose?
Cancer
A nurse is preparing to administer a client's scheduled parenteral nutrition (PN). Upon inspecting the bag, the nurse notices that small amounts of white precipitate are present in the bag. What is the nurse's best action?
Contact the pharmacy to obtain a new bag of PN
A nurse is assessing a patient receiving tube feedings and suspects dumping syndrome. Which of the following would lead the nurse to suspect this? Select all that apply.
Diaphoresis Diarrhea Tachycardia
The nurse is caring for an older adult who reports xerostomia. The nurse evaluates for use of which medication?
Diuretics
During a nursing assessment, the nurse knows that the most common symptom in patients with GI dysfunction is which of the following?
Dyspepsia
A nurse cares for a client who is postoperative bariatric surgery and has experienced frequent episodes of dumping syndrome. The client now reports anorexia. What is the primary reason for the client's report of anorexia?
Fear of eating
The nurse is caring for a client with a suspected megacolon. The nurse anticipates that one of the findings of assessment will be
Fecal incontinence
The nurse is to discontinue a nasogastric tube that had been used for decompression. The first thing the nurse does is
Flush with 10 ml of water
A nurse is assessing the abdomen of a client just admitted to the unit with a suspected GI disease. Inspection reveals several diverse lesions on the client's abdomen. How should the nurse best interpret this assessment finding?
GI diseases often produce skin changes
The nurse is conducting a community education program on peptic ulcer disease prevention. The nurse includes that the most common cause of peptic ulcers is:
Gram-negative bacteria
After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching?
I'll have to wear an external collection pouch for the rest of my life
The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon return to the nursing unit, what does the nurse identify as the client goal?
Increase the amount of fluids
The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly?
Keep the vent lumen about the patient's waist to prevent gastric content reflux
An elderly client comes into the emergency department reporting an earache. The client and has an oral temperature of 37.9° (100.2ºF) and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next?
Palpate the client's parotid glands to detect swelling and tenderness
A client is being treated for prolonged diarrhea. Which of the following foods should the nurse encourage the client to consume?
Potassium-rich foods
A nurse is preparing to discharge a client newly diagnosed with peptic ulcer disease. The client's diagnostic test results were positive for H. pylori bacteria. The doctor has ordered the "triple therapy" regimen. Which of the following is the correct representation of "triple therapy" refers?
Proton-pump inhibitor and two antibiotics
A client who is postoperative from bariatric surgery reports foul-smelling, fatty stools. What is the nurse's understanding of the primary reason for this finding?
Rapid gastric dumping
A client is treated for gastrointestinal problems related to chronic cholecystitis. What pathophysiological process related to cholecystitis does the nurse understand is the reason behind the client's GI problems?
Reduced or absent bile as a result of obstruction impacts digestion
The nurse advises the patient who has just been diagnosed with acute gastritis to:
Refrain from food until the GI symptoms subside
A nurse works in a bariatric clinic and cares for client with obesity who will or have undergone bariatric surgery. What is the nurse's understanding of how the procedure works?
Restricts the client's ability to eat
The nurse cares for a client after an endoscopic examination and prepares the client for discharge. The nurse includes which instruction?
Resume regular diet
The nurse observes the physician palpating the abdomen of a client that is suspected of having acute appendicitis. When the abdomen is pressed in the left lower quadrant the client complains of pain on the right side. What does the nurse understand this assessment technique is referred to?
Rovsing sign
A nurse cares for a client who is post op from bariatric surgery. Once able, the nurse encourages oral intake for what primary purpose?
Stimulate GI peristalsis
A client with peptic ulcer disease has been prescribed sucralfate. What health education should the nurse provide to this client?
Take the medication 2 hours before or after other medications
The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length?
The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process
A nurse is admitting a client diagnosed with late-stage gastric cancer. The client's family is distraught and angry that she was not diagnosed earlier in the course of her disease. What factor most likely contributed to the client's late diagnosis?
The early symptoms of gastric cancer are usually not alarming or highly unusual
A client with diabetes begins to have digestive problems and is told by the physician that they are a complication of the diabetes. Which of the following explanations from the nurse is most accurate
The pancreas secretes digestive enzymes
When preparing to insert a nasogastric tube, the nurse determines the length of the tube to be inserted. The nurse nurse places the distal tip of the tube at which location?
Tip of patient's nose
The nurse is admitting a client whose medication regimen includes regular injections of vitamin B12. The nurse should question the client about a history of:
Total gastrectomy
A nurse is creating a care plan for a client with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube?
Use a combination of at least two accepted methods for confirming placement
A client is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate?
Wash the area around the tube with soap and water daily
The client is receiving 50% dextrose parenteral nutrition with fat emulsion therapy through a peripherally inserted central catheter (PICC). The nurse has developed a care plan for the nursing diagnosis "Risk for infection related to contamination of the central catheter site or infusion line." The nurse includes the intervention
Wear a face mask during dressing changes
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 his health will be affected by the absence of an appendix. How should the nurse best respond?
Your appendix doesn't play a major role, so you won't notice any difference after your recovery from surgery
The nurse inspects a client's tongue. Which finding would the nurse evaluate as an indication of potential oral cancer?
red plaque on undersurface of tongue