GI, GI and more GI

Question 1

The Nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms?

A. Hypocalcemia
B. Elevated ammonia level
C. Hypokalemia
D. Nutritional imbalance

Answer 1

A. Hypocalcemia

Question 2

A Client with a history of Crohn’s disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should review the client’s laboratory reports to determine which potential complication of the client’s symptom?

A. Hyperalbuminemia
B. Thrombocytopenia
C. Hypokalemia
D. Hypercalcemeia

Answer 2

C. Hypokalemia

Question 3

A client who had a Cholecystectomy with a billary drainage tube in place. What color of the drainage is expected?

A. Pinkish red
B. Dark yellow-light green
C. Clear
D. Green-Coffee

Answer 3

B. Dark yellow-light green

Question 4

The client is admitted with a 2-day history of vomiting and diarrhea, accompanied by abdominal pain. The health care provider diagnoses the client with gastroenteritis. There is no single room available. What type of room assignment should the nurse make for the client?

A. The client should be assigned a double room with a client with cardiomyopathy.
B. The client should be assigned to a double room with another client having the same diagnosis and same organism.
C. The client should be assigned to a telemetry bed because the client has lost a lot of fluids and is probably dehydrated.
D. The client should be maintained in contact isolation, the roommate does not need to be maintained in an isolation.

Answer 4

B. The client should be assigned to a double room with another client having the same diagnosis and same organism.

Question 5

A client progresses to a regular diet after a gastrectomy for gastric cancer. After eating lunch, the client becomes diaphoretic and has palpitations. The nurse recognizes that the probable response is:
A. Intolerance to fatty food.
B. Dehiscence of the surgical incision
C. Extracellular fluid shift into the bowel
D. Diminished peristalsis in the small intestine

Answer 5

C. Extracellular fluid shift into the bowel

Question 6

The nurse is caring for a client 24-hour post-cholecystectomy. Which assessment finding does the nurse prioritize as requiring notification of the health care provider?
A. Temperature 100 F
B. Right upper quadrant pain 6/10
C. Clay colored stools
D. Dark brown colored stools

Answer 6

C. Clay colored stools

Question 7

A nurse is caring for a client with symptoms of epigastric pain. When teaching the action of gastric contents related to functioning of the body, which actions occur in the stomach? (SATA)
A. Secreted Vitamin B12
B. Emulsifying fats
C. Killing microorganisms
D. Activating the enzyme pepsin

Answer 7

C. Killing microorganisms
D. Activating the enzyme pepsin

Question 8

A client undergoes Billiroth II gastrectomy. Several hours after surgery, the nurse notes that the Client’s nasogastric tube has stopped draining. How should the nurse respond?
A. Check bowel sounds for all four quadrants first.
B. Reposition the tube gently
C. Irrigate with normal saline very slowly
D. Notify the physician

Answer 8

D. Notify the physician

Question 9

When obtaining a nursing history on a client with a suspected duodenal ulcer, which signs, and symptoms should the nurse assess? (SATA)
A. Epigastric pain at night
B. Relief of epigastric pain after eating
C. Frequent vomiting after meals
D. Hematemesis
E. Melena

Answer 9

A. Epigastric pain at night
B. Relief of epigastric pain after eating
E. Melena

Question 10

A client comes to the emergency department with suspected cholecystitis. Which data collection findings are characteristic of this diagnosis? (SATA)
A. Transient epigastric pain radiating to the back and left shoulder
B. Burning in the chest after eating fried foods
C. Flatulence and ecchymosis around right flank area
D. Nausea
E. Uremic factor

Answer 10

B. Burning in the chest after eating fried foods
D. Nausea

Question 11

A client is at risk for development of metabolic alkalosis because of persistent vomiting. The nurse should assess the client specifically for which symptom?
A. Kussmaul respirations
B. Irritable
C. Diarrhea
D. Pitting Edema

Answer 11

B. Irritable

Question 12

A nurse is assessing a client who underwent ERCP (Endoscopic retrograde cholangiopancreatography for postoperative complications. Which sign or symptom would indicate a potential complication of this procedure?
A. Shortness of breath
B. High fever
C. Absent gag reflex
D. Abdominal discomfort

Answer 12

D. Abdominal discomfort

Question 13

The nurse enters the room of an adult woman who has just returned from the operating room after undergoing incisional cholecystectomy. Which finding requires prompt action by the nurse?
A. The abdominal dressing has a 2x2 inch area of serous sanguineous drainage
B. The IV solution is infusing at 100 ml/hr and has 75 ml of fluid remaining
C. The bed is elevated at the knee, and the knee is bent 45 degrees on the bed
D. The client’s indwelling urinary catheter is taped to the inner thigh

Answer 13

C. The bed is elevated at the knee, and the knee is bent 45 degrees on the bed

Question 14

The nurse is providing discharge instructions to a client with cirrhosis. Which statement best indicates that the client has understood the teaching?
A. “I should eat a high protein, high carbohydrate diet to provide energy.”
B. “It is safer for me to take acetaminophen for pain instead of aspirin.”
C. “If I cut off my drink and get enough rest, my cirrhosis will be cured.”
D. “I should take a high fiber diet for each meal when I get home.”

Answer 14

D. “I should take a high fiber diet for each meal when I get home.”

Question 15

A nurse is assessing a client who has a history of a bleeding peptic ulcer. What assessment findings should the nurse report immediately?
A. Warm, dry skin, hypotension, bounding regular pulse
B. Abdominal cramping slow, weak pulses, warm, pale skin
C. Strong, irregular pulse; lower abdominal pain; cool, dry skin
D. Abdominal distension; cool, clammy skin; weak, thready pulse

Answer 15

D. Abdominal distension; cool, clammy skin; weak, thready pulse

Question 16

A client recovering from multiple trauma is started on total parenteral nutrition therapy. The nurse determines that which of the following is a major goal of this therapy?
A. Ensure client receives needed essential vitamins
B. Provide adequate hydration
C. Maintain a high urine output
D. Prevent a negative nitrogen balance in the body

Answer 16

D. Prevent a negative nitrogen balance in the body

Question 17

A client was admitted to the hospital with cholelithiais the previous day, Which of the following new assessment findings indicates to the nurse that the stone has probably obstructed the common bile duct?
A. Elevated cholesterol level
B. High urobilinogen level in blood
C. Left upper quadrant pain
D. High conjugated bilirubin level in blood

Answer 17

D. High conjugated bilirubin level in blood

Question 18

The post-cholecystectomy client asks the nurse when the T-tube will be removed. Which of the following responses by the nurse would be appropriate?
A. “When your stool returns to a normal brown color, the tube can be removed.”
B. “The tube will be removed at the same time as your staples.”
C. “When the tube stops draining, it will be removed.”
D. “The tube is usually removed the day after surgery.”

Answer 18

A. “When your stool returns to a normal brown color, the tube can be removed.”

Question 19

When caring for a client who had cirrhosis, the nurse notices flapping tremors of the wrist and fingers. How should the nurse chart this finding?
A. Trousseau’s sign noted
B. Caput medusa noted
C. Fetor hepaticus noted
D. Asterixis noted

Answer 19

D. Asterixis noted

Question 20

A nurse is calling report to the medical-surgical floor staff regarding a client with acute diverticulitis. Which symptoms does the nurse anticipate? (SATA)
A. Esophagitis
B. Cramping pain in the left lower abdominal area
C. Bowel irregularity
D. Persistent constipation
E. Fever

Answer 20

B. Cramping pain in the left lower abdominal area
C. Bowel irregularity
E. Fever

Question 21

A client is given hepatitis B immune globulin (HBIG) after having Unprotected sexual contact with a person diagnosed with Hepatitis B. the nurse explains to the client that the HBIG is given for which purpose?
A. Prevent other sexual transmitted infections
B. Stimulate the immune system to develop antibodies to hepatitis
C. Prevent the client from contracting hepatitis
D. Temporarily increase the client’s resistance to hepatitis

Answer 21

D. Temporarily increase the client’s resistance to hepatitis

Question 22

A client receives the first injection in a series of hepatitis B vaccine. The nurse understands this vaccine offers which type of protection?
A. Natural passive acquired immunity
B. Artificial passive acquired immunity
C. Natural active acquired immunity
D. Artificial active acquired immunity

Answer 22

D. Artificial active acquired immunity

Question 23

The nurse provides care for a client after a laparoscopic cholecystectomy. which information does the nurse include when discharging the client?
A. There may be sharp pain in shoulder area after surgery
B. Clamp to T tube for four hours after meals
C. Observe the surgical dressing every 12 hours for bile leakage
D. Expect a temperature elevation to 103 F

Answer 23

A. There may be sharp pain in shoulder area after surgery

Question 24

The nurse understands which factor is the most likely source of hepatitis D?
A. Eating infected shellfish
B. Overly exerting oneself
C. Practicing poor hygiene
D. Receiving a blood transfusion

Answer 24

D. Receiving a blood transfusion

Question 25

After an open cholecystectomy, a client is returned to the unit with a nasogastric tube connected to low intermittent suction, a T-tube in place, and a Penrose drain. what is the purpose of the Penrose drain?
A. Removes accumulated bile and blood from the surgical site
B. Permits irrigation of the peritoneum
C. Remove spile from common bile duct
D. Create a route for alimentation

Answer 25

A. Removes accumulated bile and blood from the surgical site

Question 26

The nurse provides care for a client diagnosed with cholelithiasis. it is most important for the nurse to instruct the client to avoid which foods? SATA
A. Apples
B. Cheese
C. Lettuce
D. Bacon
E. Carrots

Answer 26

B. Cheese
D. Bacon

Question 27

The nurse provides care for a client admitted with symptoms of jaundice, nausea and diarrhea. The client is diagnosed with hepatitis A and placed on contact isolation. The nurse intervenes in the client’s care if which observation is made?
A. The staff providing direct care for the client wear a gown and gloves.
B. The client washes hands thoroughly after using the bathroom.
C. The client is on bed rest and ambulates to the bathroom in the client’s room.
D. The clients spouse puts on a mask, gloves and gown to visit the client.

Answer 27

D. The clients spouse puts on a mask, gloves and gown to visit the client.

Question 28

The nurse provides care for clients in the outpatient clinic. The nurse obtains a history on a client reporting diarrhea. It is most important for the nurse to follow up on which client statement?
A. “I eat a lot of processed foods”
B. “I have been taking Cephalexin (Keflex) for the last 2 weeks”
C. “I eat small meals four to six times per day”
D. “I prefer to eat my food cold”

Answer 28

B. “I have been taking Cephalexin (Keflex) for the last 2 weeks”

Question 29

The nurse instructs a client about the bowel preparation required prior to a sigmoidoscopy. the nurse identifies teaching is successful if the client makes which statement?
A. “I can eat a regular diet prior to the test”
B. “I will be asleep when this test is performed”
C. “I will have an enema the morning of the test”
D. “I will have nasogastric suction decompression”

Answer 29

C. “I will have an enema the morning of the test”

Question 30

The nurse cares for a client diagnosed with a bowel obstruction who has been receiving parenteral nutrition. The nurse reviews the clients medical record and notes the parenteral nutrition rate is to be slowly decreased until the parenteral nutrition infusion is discontinued. Why must the rate be tapered before the infusion is discontinued?
A. To decrease the risk of infection
B. To avoid hypoglycemia
C. To minimize discomfort
D. To stabilize electrolytes in extracellular space

Answer 30

B. To avoid hypoglycemia

Question 31

A client has a gastroscopy performed and a gastric aspirate taken for analysis. the nurse understands the purpose of a gastric aspirate includes which reason?
A. Assess acid secretion and bacterial activity in the stomach
B. Inhibit acid secretion in the stomach
C. Assess the mucus producing capacity of the stomach
D. Introduce gastric imitation substances

Answer 31

A. Assess acid secretion and bacterial activity in the stomach

Question 32

A client with a history of cirrhosis has a new prescription for Lactulose (Constulose) 30 ml four times a day. what does the nurse explain to the client about this medication?
A. It will decrease intestinal absorption of ammonia
B. It will facilitate diuresis of excess fluid
C. It will promote renal excretion of bilirubin
D. It will reduce portal pressure contributing to esophageal varices

Answer 32

A. It will decrease intestinal absorption of ammonia

Question 33

The health care provider prescribes the H2 antagonist famotidine (Pepcid) 20 mg in the morning and at bedtime. what statement regarding the action of H2 antagonists offers the correct rationale for administering the medication at bedtime?
A. Gastric acid secreted at night is buffered, preventing pepsin formation
B. Hydrochloric acid secreted during the night-time is blocked
C. The drug relaxes stomach muscles at night to reduce acid
D. Ingestion of the medication at night offers a sedative effect, promoting sleep

Answer 33

B. Hydrochloric acid secreted during the night-time is blocked

Question 34

The nurse is reviewing the laboratory results for a patient with acute pancreatitis. Which findings does the nurse expect to find in the report? SATA
A. Increase in platelet count
B. Decrease in albumin level
C. Increase in serum calcium level
D. Increase in serum glucose level
E. Increase in blood urea nitrogen

Answer 34

B. Decrease in albumin level
D. Increase in serum glucose level
E. Increase in blood urea nitrogen

Question 35

The nurse is teaching a patient about caring for an ileostomy at home. Which statement by the patient indicates a correct understanding of the teaching?
A. “I will change the pouch within an hour after meals and as necessary.”
B. “I may use a bulk forming laxative if I have not had a stool in six to 12 hours.”
C. “I should use skin barrier and skin prep to prevent skin irritation.”
D. “I should empty the ileostomy pouch when it is 2/3 full.”

Answer 35

C. “I should use skin barrier and skin prep to prevent skin irritation.”

Question 36

A nurse is caring for a patient who has undergone surgical resection of a malignant gastric tumor. The patient reports Vertigo , tachycardia, syncope, pallor, and increased perspiration within 30 minutes of food intake. Which nursing intervention is the best in this situation?
A. Encouraging the patient to lie down.
B. Encouraging the patient to drink more water during meals.
C. Encouraging the patient to take high protein and high fat diet.
D. Encouraging the patient to do aggressive pulmonary exercise.

Answer 36

A. Encouraging the patient to lie down.

Question 37

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

Answer 37

D. It protects the stomach’s lining

Question 38

What is a symptom of late dumping syndrome seen 2 hours after eating?
A. Abdominal discomfort with full sensation
B. Vertigo
C. Confusion
D. Vomiting

Answer 38

C. Confusion

Question 39

Which of the following drugs works as a gastric pump inhibitors to suppress acid secretion by inhibiting H+, K+, ATPase?
A. Aciphex (Rabeprazole)
B. Ranitidine (Zantac)
C. Carafat (Sucralfate)
D. Aphogel (Aluminum)

Answer 39

A. Aciphex (Rabeprazole)

Question 40

The nurse is planning the diet of a patient with dumping syndrome. Which food is excluded from the patient’s diet?
A. Whole wheat bread with multi nuts
B. Steamed carrot
C. Coffee cake
D. Broiled chicken

Answer 40

C. Coffee cake

Question 41

Mr. Bell Has recently been diagnosed with chronic pancreatitis. The physician has prescribed Creon (Pancrease) one capsule three times per day. The nurse will recognize that Mr. Bell understands his medication regimen when he states:
A. “I will take this medication with a glass of milk”
B. “If my stools appear bulk with a severe foul odor, I will call my doctor.”
C. “I will take my medication with some antacid so it will not bother my stomach’s mucosa.”
D. “I will be sure to thoroughly chew the capsule contents before swallowing the medication.”

Answer 41

B. “If my stools appear bulk with a severe foul odor, I will call my doctor.”

Question 42

Which of the following medications would the nurse question for a client with acute pancreatitis?
A. Lasix (Furosemide)
B. Primaxin (Imipenem)
C. Morphine Sulfate
D. Sandostatin (Octreotide acetate)

Answer 42

A. Lasix (Furosemide)

Question 43

A client with bleeding esophageal varices is to be treated via infusion of medication through an intravenous line. which medication should the nurse anticipate to reduce esophageal varices?
A. Lansoprazole (Prevacid)
B. Vasopressin (Pitressin)
C. Nitroglycerin (Nitrates)
D. Warfarin (Coumadin)

Answer 43

B. Vasopressin (Pitressin)

Question 44

Spironolactone (Aldactone) Is prescribed for a client with chronic cirrhosis and ascites. the nurse should monitor the client on telemetry for which of the following arrhythmia related to side effects?
A. Present U wave
B. ST segment elevation
C. Shortened QT interval
D. Tall T wave

Answer 44

D. Tall T wave

Question 45

A positive Murphy’s sign exsist when the patient’s:
A. Pain is relieved by the intake of milk or antacids
B. Pain increases and temporary inspiratory arrest occurs
C. Symptoms disappear completely within 48 hours of onset
D. Pain increases when compression relieved suddenly on abdomen

Answer 45

B. Pain increases and temporary inspiratory arrest occurs

Question 46

Important nursing interventions for a client who has continuously feeding via jejunostomy tube include: SATA
A. Change feeding bag daily
B. Check residual every shift
C. Check blood sugar every shift
D. Weigh the client three times per week
E. Confirm for placement by checking gastric pH every shift prior to feeding

Answer 46

A. Change feeding bag daily
C. Check blood sugar every shift
D. Weigh the client three times per week

Question 47

A client’s lab results show: HBs Ag-negative, HBs AB-positive, HBc AB-negative, How do you read this lab results?
A. This client is vaccinated
B. The client is resolved from hepatitis B infection
C. The client needs vaccination
D. The client is presently infected

Answer 47

A. This client is vaccinated

Question 48

A first day post-operative client on PCA pump reports that the pain control is inadequate. What is the first action you should take?
A. Deliver the bolus dose per standing order
B. Ask the client how many times he pushed the button of PCA
C. Check long sounds for any crackles
D. Assess the pain for location, quality and intensity

Answer 48

D. Assess the pain for location, quality and intensity

Question 49

The patient is to receive heparin 15,000 unit in 100 milliliters of 5% dextrose water. The medication is to infuse in 50 minutes. What rate of infusion would the nurse set the infusion pump?

Answer 49

Answer: 120

Question 50

The physician orders dopamine at 15 mcg/kg/min. the concentration is dopamine 2 gb in 250 ml of 0.9% NS solution. the patient’s weight is 80 Kg. how many ml per hour do you need to set up on IV pump?

Answer 50

Answer: 9

Question 51

After billroth two surgery a client experiences weakness diaphoresis anxiety and palpitations 2 hours after a high carbohydrate meal a nurse should interpret that these symptoms indicate the development of
A. Steatorrhea
B. duodenal reflux
C. hypervolemic fluid overload
D. postprandial hypoglycemia

Answer 51

D. postprandial hypoglycemia

Question 52

A nurse is discharging a client after billroth II surgery. To assist the client to control dumping syndrome, the client’s discharge instructions should include:

a. Drinking fluids with meals
b. Eating a high carbohydrate, low protein diet
c. Waiting at least 5 hours between meals
d. Lying down for 20 minutes after meals

Answer 52

d. Lying down for 20 minutes after meals

Question 53

An experienced nurse explains to a new nurse that the definitive diagnosis of peptic ulcer disease involves
A. a urea breath test
B. upper gastrointestinal endoscopy with biopsy
C. barium contrast studies
D. the shilling test

Answer 53

B. upper gastrointestinal endoscopy with biopsy

Question 54

In preparation for providing care to a client immediately after a whipple procedure a nurse should anticipate that the nursing care plan must include
A. monitoring the blood glucose levels
B. administering internal feedings
C. irrigating the nasogastric tube with 30 milliliters of Saline every four hours
D. assisting the client to the commode to promote bowel elimination within the first 8

Answer 54

A. monitoring the blood glucose levels

Question 55

A client recovering from acute pancreatitis that has been NPO ask a nurse when he can begin eating again which response is most accurate
A. As soon as you start to feel hungry you can eat again
B. when you have active bowel sounds and you are passing flatus
C. when your pain is controlled and your serum light pace level becomes normal
D. oral intake stimulates the pancreas so you will need to be NPO for at least three weeks

Answer 55

B. when you have active bowel sounds and you are passing flatus

Question 56

a male client has just been diagnosed with Hepatitis A. on assessment what should the nurse expect to find?
A. Severe diffused abdominal pain radiating to the shoulder
B. anorexia nausea and vomiting weight loss
C. Abdominals ascites
D. Ecchymosis on the abdomen an eructation

Answer 56

B. anorexia nausea and vomiting weight loss

Question 57

A nurse is evaluating a client’s understanding of sigmoid colostomy care the nurse should recognize the need for additional teaching when the client makes which statement.
A. by carrying stoma and taking well balanced diet, I may not need to wear a fecal collection device at all times
B. If I injured the stoma during irrigation, I will know because it will be painful
C. I know I need to examine the condition of the skin around the stoma every time I change the appliance
D. I know that my stoma should be odor free if I properly apply and make sure the pouch is sealed

Answer 57

B. If I injured the stoma during irrigation, I will know because it will be painful

Question 58

While conducting a home visit with a client who has a partial resection of the ileum for Crohn’s disease four weeks previously a nurse become concerned when the client says
A. my stools float and seem to have fat in them
B. I have gained 5 pounds since I left the hospital
C. I am still avoiding milk products
D. I only have 2 formed stools per day

Answer 58

A. my stools float and seem to have fat in them

Question 59

While discharging a 24 year old female client after a small bowel resection for Crohn’s disease a nurse overhears the client talking to her husband and realized that the client needs more education when the client says
A. I am so glad I will not ever need any more surgeries
B. I will need to continue to monitor my weight
C. if I have another acerbation, I know they will probably put me back on hydrocortisone
D. I will probably have to take vitamin supplements all my life

Answer 59

A. I am so glad I will not ever need any more surgeries

Question 60

Which of the following selections would be best for a client with gallbladder disease?
A. A Peanut Butter and jelly sandwich, an apple, and milk
B. Roast beef sandwich, a pickle spear, and iced tea
C. Sliced chicken breast, Cole slaw, fruit gelatin and coffee
D. Baked fish, peas and carrots, sponge cake, and skim milk

Answer 60

D. Baked fish, peas and carrots, sponge cake, and skim milk

Question 61

A trans jugular intrahepatic portosystemic shunt (TIP) is performed for which condition
A. Portal Hypertension
B. Ruptured esophageal Varices
C. Jugular venous distension
D. Abdominal Aortic aneurysm

Answer 61

A. Portal Hypertension

Question 62

A client diagnosed with gastric ulcer has been prescribed sucralfate (Carafate). The nurse explains that this medication will have which of the following beneficial effects for the client?
A. It will reduce GI spasms
B. It will protect the eroded ulcer surface from stomach acid
C. It will help relieve Nausea and vomiting as well as belching
D. It will act as an anticholinergic effect

Answer 62

B. It will protect the eroded ulcer surface from stomach acid

Question 63

A 26-year-old female client comes to the clinic for an annual health examination. She has been taking misoprostol (Cytotec) for several years following a gastric ulcer. She is getting married in a month. What is the priority nursing intervention for this client?
A. Discuss whether or not to continue taking her oral contraceptives
B. Discuss family planning
C. Ask the client about the need for sexually transmitted disease counseling
D. Explain the risks of using misoprostol during pregnancy

Answer 63

D. Explain the risks of using misoprostol during pregnancy

Question 64

The nurse cares for a client who is diagnosed with methicillin resistant Staphylococcus aureus (MRSA) and is placed in isolation. The nurse needs to perform and assessment of the client’s wound and administer prescribed medications to the client. The nurse should wear which PPE?
A. Gown and gloves
B. Gloves, gown and N95 mask
C. Gown, mask and gloves
D. Gloves, goggle and N99 mask

Answer 64

A. Gown and gloves

Question 65

The nurse is planning the care of a client who has had an abdominal perineal resection for cancer of the colon. Which intervention should the nurse implement? (SATA)
A. Provide meticulous skincare to the stoma.
B. Maintain the indwelling catheter.
C. Position the client in semi-Fowler’s position.
D. Check for Penrose drainage in the peritoneal area.
E. Irrigate the drainage system

Answer 65

A. Provide meticulous skincare to the stoma.
C. Position the client in semi-Fowler’s position.
D. Check for Penrose drainage in the peritoneal area.

Question 66

A client had a resection of the terminal ileum three years ago. While obtaining a health history and physical assessment the nurse finds the client has weakness, shortness of breath and a sore tongue which additional information from the client indicates the need for client education?
A. I have been gargling with warm salt water for my sore tongue
B. I take vitamin B12 tablets every day
C. I feel tired all the time
D. I have not been exercising enough

Answer 66

B. I take vitamin B12 tablets every day

Question 67

Clients suffering from profound malnutrition may experience the refeeding syndrome when first initiating total parenteral nutrition. To determine if this occurs, the nurse should do which of the following?
A. Monitor potassium, phosphorus and magnesium levels closely.
B. Observed client for increase in blood pressure.
C. Watch for a decrease in HR
D. Monitor ABGs

Answer 67

A. Monitor potassium, phosphorus and magnesium levels closely.

Question 68

A client has a Jackson Pratt drainage tube in place the first day after surgical repair of a ruptured diverticulum. The client asked the nurse the purpose of the drain. What should the nurse tell the client? The drain is used to prevent:
A. bleeding into the peritoneal cavity
B. Infection in the peritoneal cavity
C. Ascites
D. Blood loss through hemorrhage

Answer 68

B. Infection in the peritoneal cavity

Question 69

A nurse is assessing a client who has a potential diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? (SATA)
A. excessive alcohol use
B. Gallstones
C. abdominal trauma
D. Hyperlipidemia with Triglycerides
E. Family history

Answer 69

A. excessive alcohol use
B. Gallstones
C. abdominal trauma
D. Hyperlipidemia with Triglycerides

Question 70

The nurse is careful to ensure that when a client’s total parenteral nutrition infusion is discontinued, it is done gradually. The client questions why gradual tapering is necessary. The nurse responds that this measure will prevent which of the following?
A. rebound hyperglycemia
B. rebound hypoglycemia
C. refeeding syndrome
D. Dumping syndrome

Answer 70

B. rebound hypoglycemia

Question 71

A client progresses to a regular diet after a gastrectomy for gastric cancer. After eating lunch the client becomes diaphoretic and has palpitations. The nurse recognizes that the probable cause of this response is.
A. Extracellular fluid shift into the bowel
B. Rapid change in blood pressure
C. Rapid fluid loss
D. Orthostatic hypotension

Answer 71

A. Extracellular fluid shift into the bowel

Question 72

A client is taking cimetidine to treat hiatal hernia. The nurse should evaluate the client to determine that the drug has been effective in preventing which health problems?
A. laryngeal edema
B. esophagitis
C. gastric ulcer
D. esophagitis

Answer 72

D. esophagitis

Question 73

The nurse is giving preoperative instructions to a client who will have a reversal of a colostomy. What should the nurse prepare the client to expect during the immediate postoperative period? (SATA)
A. Calculation of intake and output for every shift
B. Administration of IV fluids
C. Assessment of vital signs every eight hours
D. NG tube attached to low intermittent suction
E. Changing if colostomy bag every 4 hrs

Answer 73

A. Calculation of intake and output for every shift
B. Administration of IV fluids
D. NG tube attached to low intermittent suction

Question 74

A client recovering from multiple traumas Is started on total parenteral nutrition. The nurse determines that we should the following is a goal for this treatment?
A. Prevent a negative nitrogen balance in the body
B. Ensure a client receives necessary vitamins
C. Weight gain
D. Maintain glucose levels

Answer 74

A. Prevent a negative nitrogen balance in the body

Question 75

A nurse is assessing a client who underwent esophagogastroduodenoscopy (EGD) for postoperative complications. Which sign or symptom would indicate a potential complication of this procedure?

a. High Fever
b. Severe abdominal pain
c. Tingling in Extremities
d. Diaphoresis

Answer 75

b. Severe abdominal pain

Question 76

A client was admitted to the hospital with Cholelithiasis the previous day. Which of the following new assessment findings indicates to the nurse that the stone has probably obstructed the common bile duct?
A. High conjugated bilirubin level in the blood
B. High Unconjugated bilirubin level in the blood (hemolytic)
C. Low conjugated bilirubin level in the blood
D. Low Unconjugated biliverdin

Answer 76

A. High conjugated bilirubin level in the blood

Question 77

In caring for the client two days post-cholecystectomy, the nurse notices that the drainage from the T tube is 400 ML in 24 hours. Which is the appropriate action by the nurse?
A. Notify the physician
B. Irrigate the tube
C. Nothing this is a normal finding
D. Assess drainage characteristics and record output each shift

Answer 77

D. Assess drainage characteristics and record output each shift

Question 78

The nurse is caring for a client 24 hours post cholecystectomy. Which assessment finding does the nurse prioritize as requiring notification of the healthcare provider?
A. Blood pressure 148/85 mmHg
B. Clay colored stool
C. Temperature of 100
D. Pruritus

Answer 78

B. Clay colored stool

Question 79

A client who has a history of Crohn’s disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should review the client’s laboratory reports to determine which potential complication of the client’s symptom?
A. Hypokalemia
B. Hypernatremia
C. Hypoglycemia
D. Infection

Answer 79

A. Hypokalemia

Question 80

A client seeks medical attention after developing acute abdominal pain. Which action by the nurse helps ensure accurate auscultation of the client’s bowel sounds?
A. Making sure the clients bladder is empty before auscultating
B. Listening with the bell of the stethoscope
C. Palpating beforehand
D. Making sure the client is supine

Answer 80

A. Making sure the clients bladder is empty before auscultating

Question 81

A client who had a cholecystectomy with a biliary drainage tube in place. What color of the drainage is expected?
A. Bright red
B. Cloudy and thick
C. Dark yellow light green
D. Serosanguinous

Answer 81

C. Dark yellow light green

Question 82

A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. What should the nurse do?
A. Use a diluted formula, gradually increasing the volume and concentration
B. Slow the administration rate
C. Change the feeding apparatus every 24 hours
D. Use a lactose-free formula for intolerance
E. Heat the feeding solution

Answer 82

A. Use a diluted formula, gradually increasing the volume and concentration
B. Slow the administration rate
C. Change the feeding apparatus every 24 hours
D. Use a lactose-free formula for intolerance

Question 83

A nurse is assessing a client who has a history of bleeding peptic ulcer. What assessment findings should the nurse report immediately?
A. Abdominal Distention, cool clammy skin, weak thready pulse
B. Nausea & Vomiting

Answer 83

A. Abdominal Distention, cool clammy skin, weak thready pulse

Question 84

A client is at risk for development of metabolic alkalosis because of persistent vomiting. The nurse should assess the client specifically for which symptom?/
A. Diarrhea
B. Irritability
C. Diaphoresis
D. Increase in temperature

Answer 84

B. Irritability

Question 85

The nurse is instructing a client who has had an ileostomy about the diet following surgery. The nurse should tell the client:
A. Drink plenty of fluids each day
B. Maintain a low fiber diet
C. There is no restrictions

Answer 85

A. Drink plenty of fluids each day

Question 86

A client with a diagnosis of severe ulcerative colitis is admitted to the hospital. The nurse should assess for which items?
A. Nausea vomiting and leg and stomach cramps
B. Extreme muscle weakness and tachycardia

Answer 86

B. Extreme muscle weakness and tachycardia