MedSurge Success GI Practice Questions

Question 1

The male client tells the nurse he has been experiencing “heartburn” at night that awakens him. Which assessment question should the nurse ask?

1. “How much weight have you gained recently?”
2. “What have you done to alleviate the heartburn?”
3. “Do you consume many milk and dairy products?”
4. “Have you been around anyone with a stomach virus?”

Answer 1

Ans: 2. “What have you done to alleviate the heartburn?”

1. Clients with heartburn are frequently diagnosed as having GERD. GERD can occasionally cause weight loss, but not weight gain.
2. Most clients with GERD have been self- medicating with over-the-counter med- ications prior to seeking advice from a health-care provider. It is important to know what the client has been using to treat the problem.
3. Milk and dairy products contain lactose, which are important if considering lactose intolerance, but are not important for “heartburn.”
4. Heartburn is not a symptom of a viral illness.

Question 2

The nurse caring for a client diagnosed with GERD writes the client problem of “behavior modification.” Which intervention should be included for this problem?

1. Teach the client to sleep with a foam wedge under the head.
2. Encourage the client to decrease the amount of smoking.
3. Instruct the client to take over-the-counter medication for relief of pain.
4. Discuss the need to attend Alcoholics Anonymous to quit drinking.

Answer 2

Ans: 1. Teach the client to sleep with a foam wedge under the head.

1. The client should elevate the head of the bed on blocks or use a foam wedge to use gravity to help keep the gastric acid in the stomach and prevent reflux into the esophagus. Behavior modification is changing one’s behavior.
2. The client should be encouraged to quit smoking altogether. Referral to support groups for smoking cessation should be made.
3. The nurse should be careful when recom- mending OTC medications. This is not the most appropriate intervention for a client with GERD.
4. The client should be instructed to discon- tinue using alcohol, but the stem does not indicate the client is an alcoholic.

Question 3

The nurse is preparing a client diagnosed with GERD for discharge following an esophagogastroduodenoscopy. Which statement indicates the client understands the discharge instructions?

1. “I should not eat for at least one (1) day following this procedure.”
2. “I can lie down whenever I want after a meal. It won’t make a difference.”
3. “The stomach contents won’t bother my esophagus but will make me nauseous.”
4. “I should avoid orange juice and eating tomatoes until my esophagus heals.”

Answer 3

Ans: 4. “I should avoid orange juice and eating tomatoes until my esophagus heals.”

1. The client is allowed to eat as soon as the gag reflex has returned.
2. An esophagogastroduodenoscopy is a diag- nostic procedure, not a cure. Therefore, the client still has GERD and should be in- structed to stay in an upright position for two (2) to three (3) hours after eating.
3. Stomach contents are acidic and will erode the esophageal lining.
4. Orange juice and tomatoes are acidic, and the client diagnosed with GERD should avoid acidic foods until the esophagus has had a chance to heal.

Question 4

The nurse is planning the care of a client diagnosed with lower esophageal sphincter dysfunction. Which dietary modifications should be included in the plan of care?

1. Allow any of the client’s favorite foods as long as the amount is limited.
2. Have the client perform eructation exercises several times a day.
3. Eat four (4) to six (6) small meals a day and limit fluids during mealtimes.
4. Encourage the client to consume a glass of red wine with one (1) meal a day.

Answer 4

Ans: 3. Eat four (4) to six (6) small meals a day and limit fluids during mealtimes.

1. The client is instructed to avoid spicy and acidic foods and any food producing symptoms.
2. Eructation means belching, which is a symptom of GERD.
3. Clients should eat small, frequent meals and limit fluids with the meals to prevent reflux into the esophagus from a distended stomach.
4. Clients are encouraged to forgo all alco- holic beverages because alcohol relaxes the lower esophageal sphincter and increases the risk of reflux.

Question 5

The nurse is caring for a client diagnosed with GERD. Which nursing interventions should be implemented?

1. Place the client prone in bed and administer nonsteroidal anti-inflammatory medications.
2. Have the client remain upright at all times and walk for 30 minutes three (3) times a week.
3. Instruct the client to maintain a right lateral side-lying position and take antacids before meals.
4. Elevate the head of the bed 30 degrees and discuss lifestyle modifications with the client.

Answer 5

Ans: 4. Elevate the head of the bed 30 degrees and discuss lifestyle modifications with the client.

1. The client is encouraged to lie with the head of the bed elevated, but this is difficult to achieve when on the stomach. NSAIDs inhibit prostaglandin synthesis in the stomach, which places the client at risk for developing gastric ulcers. The client is already experiencing gastric acid difficulty.
2. The client will need to lie down at some time, and walking will not help with GERD.
3. If lying on the side, the left side-lying position, not the right side, will allow less chance of reflux into the esophagus. Antacids are taken one (1) and three (3) hours after a meal.
4. The head of the bed should be elevated to allow gravity to help in preventing reflux. Lifestyle modifications of losing weight, making dietary modifications, attempting smoking cessation, discon- tinuing the use of alcohol, and not stooping or bending at the waist all help to decrease reflux.

Question 6

The nurse is caring for an adult client diagnosed with GERD. Which condition is the most common comorbid disease associated with GERD?

1. Adult-onset asthma.
2. Pancreatitis.
3. Peptic ulcer disease.
4. Increased gastric emptying.

Answer 6

Ans: 1. Adult-onset asthma.

1. Of adult-onset asthma cases, 80% to 90% are caused by gastroesophageal reflux disease (GERD).
2. Pancreatitis is not related to GERD.
3. Peptic ulcer disease is related to H. pylori bacterial infections and can lead to in- creased levels of gastric acid, but it is not related to reflux.
4. GERD is not related to increased gastric emptying. Increased gastric emptying would be a benefit to a client with decreased functioning of the lower esophageal sphincter.

Question 7

The nurse is administering morning medications at 0730. Which medication should have priority?

1. A proton pump inhibitor.
2. A nonnarcotic analgesic.
3. A histamine receptor antagonist.
4. A mucosal barrier agent.

Answer 7

Ans: 4. A mucosal barrier agent.

1. Proton pump inhibitors can be adminis- tered at routine dosing times, usually0900 or after breakfast.
2. Pain medication is important, but a nonnar- cotic medication, such as Tylenol, can be administered after a medication which must be timed.
3. A histamine receptor antagonist can be administered at routine dosing times.
4. A mucosal barrier agent must be admin- istered on an empty stomach for the medication to coat the stomach.

Question 8

The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the HCP?

1. The client’s Bernstein esophageal test was positive.
2. The client’s abdominal x-ray shows a hiatal hernia.
3. The client’s WBC count is 14,000/mm3.
4. The client’s hemoglobin is 13.8 g/dL.

Answer 8

Ans: 3. The client’s WBC count is 14,000/mm3.

1. In a Bernstein test, acid is instilled into the distal esophagus, causing immediate heart- burn for a client diagnosed with GERD. This would not warrant notifying the HCP.
2. Hiatal hernias are frequently the cause of GERD; therefore, this finding would not warrant notifying the HCP.
3. The client’s WBC count is elevated, indicating a possible infection, which warrants notifying the HCP.
4. This is a normal hemoglobin result and would not warrant notifying the HCP.

Question 9

The charge nurse is making assignments. Staffing includes a registered nurse with five (5) years of medical-surgical experience, a newly graduated registered nurse, and two (2) unlicensed assistive personnel (UAPs). Which client should be assigned to the most experienced nurse?

1. The 39-year-old client diagnosed with lower esophageal dysfunction who is complaining of pyrosis.
2. The 54-year-old client diagnosed with Barrett’s esophagus who is scheduled to have an endoscopy this morning.
3. The 46-year-old client diagnosed with gastroesophageal reflux disease who has wheezes in all five (5) lobes.
4. The 68-year-old client who is three (3) days postoperative for hiatal hernia and needs to be ambulated four (4) times today.

Answer 9

Ans: 3. The 46-year-old client diagnosed with gastroesophageal reflux disease who has wheezes in all five (5) lobes.

1. Pyrosis is heartburn and is expected in a client diagnosed with GERD. The new graduate can care for this client.
2. Barrett’s esophagus is a complication of GERD; new graduates can prepare a client for a diagnostic procedure.
3. This client is exhibiting symptoms of asthma, a complication of GERD. This client should be assigned to the most experienced nurse.
4. This client can be cared for by the new graduate, and ambulating can be delegated to the unlicensed assistive personnel (UAP).

Question 10

Which statement made by the client indicates to the nurse the client may be experiencing GERD?

1. “My chest hurts when I walk up the stairs in my home.”
2. “I take antacid tablets with me wherever I go.”
3. “My spouse tells me I snore very loudly at night.”
4. “I drink six (6) to seven (7) soft drinks every day.”

Answer 10

Ans: 2. “I take antacid tablets with me wherever I go.”

1. Pain in the chest when walking up stairs indicates angina.
2. Frequent use of antacids indicates an acid reflux problem.
3. Snoring loudly could indicate sleep apnea, but not GERD.
4. Carbonated beverages increase stomach pressure. Six (6) to seven (7) soft drinks a day would not be tolerated by a client with GERD.

Question 11

The nurse is performing an admission assessment on a client diagnosed with GERD. Which signs and symptoms would indicate GERD?

1. Pyrosis, water brash, and flatulence.
2. Weight loss, dysarthria, and diarrhea.
3. Decreased abdominal fat, proteinuria, and constipation.
4. Midepigastric pain, positive H. pylori test, and melena.

Answer 11

Ans: 1. Pyrosis, water brash, and flatulence.

1. Pyrosis is heartburn, water brash is the feeling of saliva secretion as a result of reflux, and flatulence is gas—all symptoms of GERD.
2. Gastroesophageal reflux disease does not cause weight loss.
3. There is no change in abdominal fat, no proteinuria (the result of a filtration prob- lem in the kidney), and no alteration in bowel elimination for the client diagnosed with GERD.
4. Midepigastric pain, a positive H. pylori test, and melena are associated with gastric ulcer disease.

Question 12

Which disease is the client diagnosed with GERD at greater risk for developing?

1. Hiatal hernia.
2. Gastroenteritis.
3. Esophageal cancer.
4. Gastric cancer.

Answer 12

Ans: 3. Esophageal cancer.

1. A hiatal hernia places the client at risk for GERD; GERD does not predispose the client for developing a hiatal hernia.
2. Gastroenteritis is an inflammation of the stomach and intestine, usually caused by a virus.
3. Barrett’s esophagus results from long- term erosion of the esophagus as a result of reflux of stomach contents secondary to GERD. This is a precursor to esophageal cancer.
4. The problems associated with GERD result from the reflux of acidic stomach contents into the esophagus, which is not a precursor to gastric cancer.

Question 13

Which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis?

1. Twenty bloody stools a day.
2. Oral temperature of 102 ̊F.
3. Hard, rigid abdomen.
4. Urinary stress incontinence.

Answer 13

Ans: 1. Twenty bloody stools a day.

1. The colon is ulcerated and unable to absorb water, resulting in bloody diar- rhea. Ten (10) to 20 bloody diarrhea stools is the most common symptom of ulcerative colitis.
2. Inflammation usually causes an elevated temperature but is not expected in the client with ulcerative colitis.
3. A hard, rigid abdomen indicates peritoni- tis, which is a complication of ulcerative colitis but not an expected symptom.
4. Stress incontinence is not a symptom of colitis.

Question 14

The client with type 2 diabetes is prescribed prednisone, a steroid, for an acute exacerbation of inflammatory bowel disease. Which intervention should the nurse discuss with the client?

1. Take this medication on an empty stomach.
2. Notify the HCP if experiencing a moon face.
3. Take the steroid medication as prescribed.
4. Notify the HCP if the blood glucose is over 160.

Answer 14

Ans: 3. Take the steroid medication as prescribed.

1. Steroids can cause erosion of the stomach and should be taken with food.
2. A moon face is an expected side effect of steroids.
3. This medication must be tapered off to prevent adrenal insufficiency; therefore, the client must take this medication as prescribed.
4. Steroids may increase the client’s blood glucose, but diabetic medication regimens are usually not altered for the short period of time the client with an acute exacerba- tion is prescribed steroids.

Question 15

The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first?

1. Notify the health-care provider.
2. Assess the client for muscle weakness.
3. Request telemetry for the client.
4. Prepare to administer potassium IV.

Answer 15

Ans: 2. Assess the client for muscle weakness.

1. The HCP should be notified so potassium supplements can be ordered, but this is not the first intervention.
2. Muscle weakness may be a sign of hypokalemia; hypokalemia can lead to cardiac dysrhythmias and can be life threatening. Assessment is priority for a potassium level just below normal level, which is 3.5 to 5.5 mEq/L.
3. Hypokalemia can lead to cardiac dysrhyth- mias; therefore, requesting telemetry is appropriate, but it is not the first intervention.
4. The client will need potassium to correct the hypokalemia, but it is not the first intervention.

Question 16

The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement?

1. Provide a low-residue diet.
2. Rest the client’s bowel.
3. Assess vital signs daily.
4. Administer antacids orally.

Answer 16

Ans: 2. Rest the client’s bowel.

1. The client’s bowel should be placed on rest and no foods or fluids should be introduced into the bowel.
2. Whenever a client has an acute exacer- bation of a gastrointestinal disorder, the first intervention is to place the bowel on rest. The client should be NPO with intravenous fluids to prevent dehydration.
3. The vital signs must be taken more often than daily in a client who is having an acute exacerbation of ulcerative colitis.
4. The client will receive anti-inflammatory and antidiarrheal medications, not antacids, which are used for gastroenteritis.

Question 17

The client diagnosed with IBD is prescribed total parental nutrition (TPN). Which intervention should the nurse implement?

1. Check the client’s glucose level.
2. Administer an oral hypoglycemic.
3. Assess the peripheral intravenous site.
4. Monitor the client’s oral food intake.

Answer 17

Ans: 1. Check the client’s glucose level.

1. TPN is high in dextrose, which is glucose; therefore, the client’s blood glucose level must be monitored closely.
2. The client may be on sliding-scale regular insulin coverage for the high glucose level.
3. The TPN must be administered via a sub- clavian line because of the high glucose level.
4. The client is NPO to put the bowel at rest, which is the rationale for adminis- tering the TPN.

Question 18

The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement first?

1. Weigh the client daily and document in the client’s chart.
2. Teach coping strategies such as dietary modifications.
3. Record the frequency, amount, and color of stools.
4. Monitor the client’s oral fluid intake every shift.

Answer 18

Ans: 3. Record the frequency, amount, and color of stools.

1. Weighing the client daily will help identify if the client is experiencing malnutrition, but it is not the priority intervention during an acute exacerbation.
2. Coping strategies help develop healthy ways to deal with this chronic disease, which has remissions and exacerbations, but it is not the priority intervention.
3. The severity of the diarrhea helps determine the need for fluid replacement. The liquid stool should be measured as part of the total output.
4. The client will be NPO when there is an acute exacerbation of IBD to allow the bowel to rest.

Question 19

The client diagnosed with Crohn’s disease is crying and tells the nurse, “I can’t take it anymore. I never know when I will get sick and end up here in the hospital.” Which statement is the nurse’s best response?

1. “I understand how frustrating this must be for you.”
2. “You must keep thinking about the good things in your life.”
3. “I can see you are very upset. I’ll sit down and we can talk.”
4. “Are you thinking about doing anything like committing suicide?”

Answer 19

Ans: 3. “I can see you are very upset. I’ll sit down and we can talk.”

1. The nurse should never tell a client he or she understands what the client is going through.
2. Telling the client to think about the good things is not addressing the client’s feelings.
3. The client is crying and is expressing feelings of powerlessness; therefore, the nurse should allow the client to talk.
4. The client is crying and states “I can’t take it anymore,” but this is not a suicidal comment or situation.

Question 20

The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy?

1. “My stoma should be pink and moist.”
2. “I will irrigate my ileostomy every morning.”
3. “If I get a red, bumpy, itchy rash I will call my HCP.”
4. “I will change my pouch if it starts leaking.”

Answer 20

Ans: 2. “I will irrigate my ileostomy every morning.”

1. A pink and moist stoma indicates viable tissue and adequate circulation. A purple stoma indicates necrosis.
2. An ileostomy will drain liquid all the time and should not routinely be irri- gated. A sigmoid colostomy may need daily irrigation to evacuate feces.
3. A red, bumpy, itchy rash indicates infec- tion with the yeast Candida albicans, which should be treated with medication.
4. The ileostomy drainage has enzymes and bile salts, which are irritating and harsh to the skin; therefore, the pouch should be changed if any leakage occurs.

Question 21

The client diagnosed with IBD is prescribed sulfasalazine (Asulfidine), a sulfonamide antibiotic. Which statement best describes the rationale for administering this medication?

1. It is administered rectally to help decrease colon inflammation.
2. This medication slows gastrointestinal motility and reduces diarrhea.
3. This medication kills the bacteria causing the exacerbation.
4. It acts topically on the colon mucosa to decrease inflammation.

Answer 21

Ans: 4. It acts topically on the colon mucosa to decrease inflammation.

1. Asulfidine cannot be administered rectally. Corticosteroids may be administered by enema for the local effect of decreasing in- flammation while minimizing the systemic effects.
2. Antidiarrheal agents slow the gastroin- testinal motility and reduce diarrhea.
3. IBD is not caused by bacteria.
4. Asulfidine is poorly absorbed from the gastrointestinal tract and acts topically on the colonic mucosa to inhibit the inflammatory process.

Question 22

The client is diagnosed with Crohn’s disease, also known as regional enteritis. Which statement by the client supports this diagnosis?

1. “My pain goes away when I have a bowel movement.”
2. “I have bright red blood in my stool all the time.”
3. “I have episodes of diarrhea and constipation.”
4. “My abdomen is hard and rigid and I have a fever.”

Answer 22

Ans: 1. “My pain goes away when I have a bowel movement.”

1. The terminal ileum is the most com- mon site for regional enteritis, which causes right lower quadrant pain that is relieved by defecation.
2. Stools are liquid or semiformed and usually do not contain blood.
3. Episodes of diarrhea and constipation may be a sign/symptom of colon cancer, not Crohn’s disease.
4. A fever and hard rigid abdomen are signs/ symptoms of peritonitis, a complication of Crohn’s disease.

Question 23

The client diagnosed with ulcerative colitis is prescribed a low-residue diet. Which meal selection indicates the client understands the diet teaching?

1. Grilled hamburger on a wheat bun and fried potatoes.
2. A chicken salad sandwich and lettuce and tomato salad.
3. Roast pork, white rice, and plain custard.
4. Fried fish, whole grain pasta, and fruit salad.

Answer 23

Ans: 3. Roast pork, white rice, and plain custard.

1. Fried potatoes, along with pastries and pies, should be avoided.
2. Raw vegetables should be avoided because this is roughage.
3. A low-residue diet is a low-fiber diet. Products made of refined flour or finely milled grains, along with roasted, baked, or broiled meats,are recommended.
4. Fried foods should be avoided, and whole grain is high in fiber. Nuts and fruits with peels should be avoided.

Question 24

The client with ulcerative colitis is scheduled for an ileostomy. The nurse is aware the client’s stoma will be located in which area of the abdomen?

1. A
2. B
3. C
4. D

Answer 24

Ans: 1. A

1. The cure for ulcerative colitis is a total colectomy, which is removing the entire large colon and bringing the terminal end of the ileum up to the ab- domen in the right lower quadrant. This is an ileostomy.
2. This site is the left-lower quadrant
3. This site is the transverse colon.
4. This site is the right upper quadrant.

Question 25

Which assessment data support to the nurse the client’s diagnosis of gastric ulcer? 1. Presence of blood in the client’s stool for the past month. 2. Reports of a burning sensation moving like a wave. 3. Sharp pain in the upper abdomen after eating a heavy meal. 4. Complaints of epigastric pain 30 to 60 minutes after ingesting food.

Answer 25

Ans: 4. Complaints of epigastric pain 30 to 60 minutes after ingesting food. 1. The presence of blood does not specifically indicate diagnosis of an ulcer. The client could have hemorrhoids or cancer resulting in the presence of blood. 2. A wavelike burning sensation is a symptom of gastroesophageal reflux. 3. Sharp pain in the upper abdomen after eating a heavy meal is a symptom of gallbladder disease. 4. ***In a client diagnosed with a gastric ulcer, pain usually occurs 30 to 60 minutes after eating, but not at night. In contrast, a client with a duodenal ulcer has pain during the night often relieved by eating food. Pain occurs 1 to 3 hours after meals.***

Question 26

The nurse is caring for a client diagnosed with rule-out peptic ulcer disease. Which test confirms this diagnosis? 1. Esophagogastroduodenoscopy. 2. Magnetic resonance imaging. 3. Occult blood test. 4. Gastric acid stimulation.

Answer 26

Ans: 1. Esophagogastroduodenoscopy. 1. ***The esophagogastroduodenoscopy (EGD) is an invasive diagnostic test which visualizes the esophagus, stomach, and duodenum to accurately diagnose an ulcer and evaluate the effectiveness of the client’s treatment.*** 2. Magnetic resonance imaging (MRI) shows cross-sectional images of tissue or blood flow. 3. An occult blood test shows the presence of blood, but not the source. 4. A gastric acid stimulation test is used to understand the pathophysiology of ulcer disease, but it has limited usefulness.

Question 27

Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease? 1. History of side effects experienced from all medications. 2. Use of nonsteroidal anti-inflammatory drugs (NSAIDs). 3. Any known allergies to drugs and environmental factors. 4. Medical histories of at least three (3) generations.

Answer 27

Ans: 2. Use of nonsteroidal anti-inflammatory drugs (NSAIDs). 1. A history of problems the client has expe- rienced with medications is taken during the admission interview. This information does not specifically address peptic ulcer disease. 2. ***Use of NSAIDs places the client at risk for peptic ulcer disease and hem- orrhage. NSAIDs suppress the produc- tion of prostaglandin in the stomach, which is a protective mechanism to prevent damage from hydrochloric acid.*** 3. Allergies are included for safety, but this is not specific for peptic ulcer disease. 4. Information needs to be obtained about past generations so the nurse can analyze any potential health problems, but this is not specific for peptic ulcer disease.

Question 28

Which physical examination should the nurse implement first when assessing the client diagnosed with peptic ulcer disease? 1. Auscultate the client’s bowel sounds in all four quadrants. 2. Palpate the abdominal area for tenderness. 3. Percuss the abdominal borders to identify organs. 4. Assess the tender area progressing to nontender.

Answer 28

Ans: 1. Auscultate the client’s bowel sounds in all four quadrants. 1. ***Auscultation should be used prior to palpation or percussion when assessing the abdomen. Manipulation of the abdomen can alter bowel soundsand give false information.*** 2. Palpation gives appropriate information the nurse needs to collect, but if done prior to auscultation, the sounds will be altered. 3. Percussion of the abdomen does not give specific information about peptic ulcer disease. 4. Tender areas should be assessed last to prevent guarding and altering the assess- ment. This includes palpation, which should be done after auscultation.

Question 29

Which problems should the nurse include in the plan of care for the client diagnosed with peptic ulcer disease to observe for physiological complications? 1. Alteration in bowel elimination patterns. 2. Knowledge deficit in the causes of ulcers. 3. Inability to cope with changing family roles. 4. Potential for alteration in gastric emptying.

Answer 29

Ans: 4. Potential for alteration in gastric emptying. 1. There is no indication from the question there is a problem or potential problem with bowel elimination. 2. Knowledge deficit does not address physi- ological complications. 3. This client may have problems from changing roles within the family, but the question asks for potential physiological complications, not psychosocial problems. 4. ***Potential for alteration in gastric emp- tying is caused by edema or scarring associated with an ulcer, which may cause a feeling of “fullness,” vomiting of undigested food, or abdominal distention.***

Question 30

The nurse is caring for a client diagnosed with hemorrhaging duodenal ulcer. Which collaborative interventions should the nurse implement? **Select all that apply.** 1. Perform a complete pain assessment. 2. Assess the client’s vital signs frequently. 3. Administer a proton pump inhibitor intravenously. 4. Obtain permission and administer blood products. 5. Monitor the intake of a soft, bland diet.

Answer 30

Ans: 3. Administer a proton pump inhibitor intravenously. 4. Obtain permission and administer blood products. 1. A pain assessment is an independent intervention the nurse should implement frequently. 2. Evaluating vital signs is an independent intervention the nurse should implement. If the client is able, BPs should be taken lying, sitting, and standing to assess for orthostatic hypotension. 3. ***This is a collaborative intervention the nurse should implement. It requires an order from the HCP.*** 4. ***Administering blood products is collabo- rative, requiring an order from the HCP.*** 5. The diet requires an order by the health- care provider, but a diet will not be or- dered since the client is NPO.

Question 31

Which expected outcome should the nurse include for a client diagnosed with peptic ulcer disease? 1. The client’s pain is controlled with the use of NSAIDs. 2. The client maintains lifestyle modifications. 3. The client has no signs and symptoms of hemoptysis. 4. The client takes antacids with each meal.

Answer 31

Ans: 2. The client maintains lifestyle modifications. 1. Use of NSAIDs increases and causes prob- lems associated with peptic ulcer disease. 2. ***Maintaining lifestyle changes such as following an appropriate diet and re- ducing stress indicate the client is complying with the medical regimen. Compliance is the goal of treatment to prevent complications.*** 3. Hemoptysis is coughing up blood, which is not a sign or symptom of peptic ulcer disease. This would not be an expected outcome. 4. Antacids should be taken one (1) to three (3) hours after meals, not with each meal

Question 32

The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data require further intervention? 1. Bowel sounds auscultated fifteen (15) times in one (1) minute. 2. Belching after eating a heavy and fatty meal late at night. 3. A decrease in systolic BP of 20 mm Hg from lying to sitting. 4. A decreased frequency of distress located in the epigastric region.

Answer 32

Ans: 3. A decrease in systolic BP of 20 mm Hg from lying to sitting. 1. The range for normoactive bowel sounds is from five (5) to 35 times per minute. This would require no intervention. 2. Belching after a heavy, fatty meal is a symptom of gallbladder disease. Eating late at night may cause symptoms of esophageal disorders. 3. ***A decrease of 20 mm Hg in blood pres- sure after changing position from lying, to sitting, to standing is orthostatic hypotension. This could indicate the client is bleeding.*** 4. A decrease in the quality and quantity of discomfort shows an improvement in the client’s condition. This would not require further intervention.

Question 33

Which oral medication should the nurse question before administering to the client with peptic ulcer disease? 1. E-mycin, an antibiotic. 2. Prilosec, a proton pump inhibitor. 3. Flagyl, an antimicrobial agent. 4. Tylenol, a nonnarcotic analgesic.

Answer 33

Ans: 1. E-mycin, an antibiotic. 1. ***E-mycin is irritating to stomach, and its use in a client with peptic ulcer disease should be questioned.*** 2. Prilosec, a proton pump inhibitor, de- creases gastric acid production, and its use should not be questioned by the nurse. Flagyl, an antimicrobial, is administered to treat peptic ulcer disease secondary to 3. H. pylori bacteria. 4. Tylenol can be safely administered to a client with peptic ulcer disease.

Question 34

The nurse has administered an antibiotic, a proton pump inhibitor, and Pepto-Bismol for peptic ulcer disease secondary to H. pylori. Which data would indicate to the nurse the medications are effective? 1. A decrease in alcohol intake. 2. Maintaining a bland diet. 3. A return to previous activities. 4. A decrease in gastric distress.

Answer 34

Ans: 4. A decrease in gastric distress. 1. Decreasing the alcohol intake indicates the client is making some lifestyle changes. 2. The client with PUD is prescribed a regu- lar diet, but the type of diet does not determine if the medication is effective. 3. The return to previous activities indicates the client has not adapted to the lifestyle changes and has returned to the previous behaviors which precipitated the peptic ul- cer disease. 4. ***Antibiotics, proton pump inhibitors, and Pepto-Bismol are administered to decrease the irritation of the ulcerative area and cure the ulcer. A decrease in gastric distress indicates the medica- tion is effective.***

Question 35

Which assessment data indicate to the nurse the client’s gastric ulcer has perforated? 1. Complaints of sudden, sharp, substernal pain. 2. Rigid, boardlike abdomen with rebound tenderness. 3. Frequent, clay-colored, liquid stool. 4. Complaints of vague abdominal pain in the right upper quadrant.

Answer 35

Ans: 2. Rigid, boardlike abdomen with rebound tenderness. 1. Sudden sharp pain felt in the substernal area indicates angina or myocardial infarction. 2. ***A rigid, boardlike abdomen with rebound tenderness is the classic sign/symptom of peritonitis, which is a complication of a perforated gastric ulcer.*** 3. Clay-colored stools indicate liver disorders, such as hepatitis. 4. Clients with gallbladder disease report vague to sharp abdominal pain in the right upper quadrant.

Question 36

The client with a history of peptic ulcer disease is admitted into the intensive care unit with frank gastric bleeding. Which priority intervention should the nurse implement? 1. Maintain a strict record of intake and output. 2. Insert a nasogastric tube and begin saline lavage. 3. Assist the client with keeping a detailed calorie count. 4. Provide a quiet environment to promote rest.

Answer 36

Ans: 2. Insert a nasogastric tube and begin saline lavage. 1. Maintaining a strict record of intake and output is important to evaluate the pro- gression of the client’s condition, but it is not the most important intervention. 2. ***Inserting a nasogastric tube and lavaging the stomach with saline is the most important intervention because this directly stops the bleeding.*** 3. A calorie count is important information assisting in the prevention and treatment of a nutritional deficit, but this interven- tion does not address the client’s immedi- ate and life-threatening problem. 4. Promoting a quiet environment aids in the reduction of stress, which can cause further bleeding, but this will not stop the bleeding.

Question 37

The occupational health nurse is preparing a presentation to a group of factory workers about preventing colon cancer. Which information should be included in the presentation? 1. Wear a high-filtration mask when around chemicals. 2. Eat several servings of cruciferous vegetables daily. 3. Take a multiple vitamin every day. 4. Do not engage in high-risk sexual behaviors.

Answer 37

Ans: 2. Eat several servings of cruciferous vegetables daily. 1. Some cancers have a higher risk of devel- opment when the client is occupationally exposed to chemicals, but cancer of the colon is not one of them. 2. ***Cruciferous vegetables, such as broc- coli, cauliflower, and cabbage, are high in fiber. One of the risks for cancer of the colon is a high-fat, low-fiber, and high-protein diet. The longer the tran- sit time (the time from ingestion of the food to the elimination of the waste products), the greater the chance of developing cancer of the colon.*** 3. A multiple vitamin may improve immune system function, but it does not prevent colon cancer. 4. High-risk sexual behavior places the client at risk for sexually transmitted diseases. A history of multiple sexual partners and ini- tial sexual experience at an early age does increase the risk for the development of cancer of the cervix in females.

Question 38

The nurse is admitting a client to a medical floor with a diagnosis of adenocarcinoma of the rectosigmoid colon. Which assessment data support this diagnosis? 1. The client reports up to 20 bloody stools per day. 2. The client has a feeling of fullness after a heavy meal. 3. The client has diarrhea alternating with constipation. 4. The client complains of right lower quadrant pain.

Answer 38

Ans: 3. The client has diarrhea alternating with constipation. 1. Frequent bloody stools are a symptom of inflammatory bowel disease (IBD). IBD is a risk factor for cancer of the colon, but the symptoms are different when the colon becomes cancerous. 2. Most people have a feeling of fullness after a heavy meal; this does not indicate cancer. 3. ***The most common symptom of colon cancer is a change in bowel habits, specifically diarrhea alternating with constipation.*** 4. Lower right quadrant pain with rebound tenderness would indicate appendicitis.

Question 39

The 85-year-old male client diagnosed with cancer of the colon asks the nurse, “Why did I get this cancer?” Which statement is the nurse’s best response? 1. “Research shows a lack of fiber in the diet can cause colon cancer.” 2. “It is not common to get colon cancer at your age; it is usually in young people.” 3. “No one knows why anyone gets cancer, it just happens to certain people.” 4. “Women usually get colon cancer more often than men but not always.”

Answer 39

Ans: 1. “Research shows a lack of fiber in the diet can cause colon cancer.” 1. ***A long history of low-fiber, high-fat, and high-protein diets results in a pro- longed transit time. This allows the carcinogenic agents in the waste prod- ucts to have a greater exposure to the lumen of the colon.*** 2. The older the client, the greater the risk of developing cancer of the colon. 3. Risk factors for cancer of the colon in- clude increasing age; family history of colon cancer or polyps; history of IBD; genital or breast cancer; and eating a high-fat, high-protein, low-fiber diet. 4. Males have a slightly higher incidence of colon cancers than do females.

Question 40

The nurse is planning the care of a client who has had an abdominal–perineal resection for cancer of the colon. Which interventions should the nurse implement? **Select all that apply.** 1. Provide meticulous skin care to stoma. 2. Assess the flank incision. 3. Maintain the indwelling catheter. 4. Irrigate the JP drains every shift. 5. Position the client semirecumbent.

Answer 40

Ans: 1. Provide meticulous skin care to stoma. 3. Maintain the indwelling catheter. 5. Position the client semirecumbent. 1. ***Colostomy stomas are openings through the abdominal wall into the colon, through which feces exit the body. Feces can be irritating to the abdominal skin, so careful and thorough skin care is needed.*** 2. There are midline and perineal incisions, not flank incisions. 3. ***Because of the perineal wound, the client will have an indwelling catheter to keep urine out of the incision.*** 4. Jackson Pratt drains are emptied every shift, but they are not irrigated. 5. ***The client should not sit upright because this causes pressure on the perineum.***

Question 41

The client who has had an abdominal perineal resection is being discharged. Which discharge information should the nurse teach? 1. The stoma should be a white, blue, or purple color. 2. Limit ambulation to prevent the pouch from coming off. 3. Take pain medication when the pain level is at an “8.” 4. Empty the pouch when it is one-third to one-half full.

Answer 41

Ans: 4. Empty the pouch when it is one-third to one-half full. 1. The stoma should be light to a medium pink, the color of the intestines. A blue or purple color indicates a lack of circulation to the stoma and is a medical emergency. 2. The stoma should be pouched securely for the client to be able to participate in nor- mal daily activities. The client should be encouraged to ambulate to aid in recovery. 3. Pain medication should be taken before the pain level reaches a “5.” Delaying tak- ing medication will delay the onset of pain relief and the client will not receive full benefit from the medication. 4. ***The pouch should be emptied when it is one-third to one-half full to prevent the contents from becoming too heavy for the seal to hold and to prevent leakage from occurring.***

Question 42

The nurse caring for a client one (1) day postoperative sigmoid resection notes a moderate amount of dark reddish brown drainage on the midline abdominal incision. Which intervention should the nurse implement first? 1. Mark the drainage on the dressing with the time and date. 2. Change the dressing immediately using sterile technique. 3. Notify the health-care provider immediately. 4. Reinforce the dressing with a sterile gauze pad.

Answer 42

Ans: 1. Mark the drainage on the dressing with the time and date. 1. ***The nurse should mark the drainage on the dressing to determine if active bleeding is occurring, because dark reddish-brown drainage indicates old blood. This allows the nurse to assess what is actually happening.*** 2. Surgical dressings are initially changed by the surgeon; the nurse should not remove the dressing until the surgeon orders the dressing change to be done by the nurse. 3. The nurse should assess the situation before notifying the HCP. 4. The nurse may need to reinforce the dressing if the dressing becomes saturated, but this would be after a thorough assess- ment is completed.

Question 43

The client complains to the nurse of unhappiness with the health-care provider. Which intervention should the nurse implement next? 1. Call the HCP and suggest he or she talk with the client. 2. Determine what about the HCP is bothering the client. 3. Notify the nursing supervisor to arrange a new HCP to take over. 4. Explain the client cannot request another HCP until after discharge.

Answer 43

Ans: 2. Determine what about the HCP is bothering the client. 1. The nurse should first assess the situation prior to informing the HCP of the client’s concerns and then allow the HCP and client to discuss the situation. 2. ***The nurse should determine what is concerning the client. It could be a mis- understanding or a real situation where the client’s care is unsafe or inadequate.*** 3. If a new HCP is to be arranged, it is the HCP’s responsibility to arrange for another HCP to assume responsibility for the care of the client. 4. The choice of HCP is ultimately the client’s. If the HCP cannot arrange for another HCP, the client may be dis- charged and obtain a new health-care provider.

Question 44

The client with a new colostomy is being discharged. Which statement made by the client indicates the need for further teaching? 1. “If I notice any skin breakdown, I will call the HCP.” 2. “I should drink only liquids until the colostomy starts to work.” 3. “I should not take a tub bath until the HCP okays it.” 4. “I should not drive or lift more than five (5) pounds.”

Answer 44

Ans: 2. “I should drink only liquids until the colostomy starts to work.” 1. If the tissue around the stoma becomes ex- coriated, the client will be unable to pouch the stoma adequately, resulting in discom- fort and leakage. The client understands the teaching. 2. ***The client should be on a regular diet, and the colostomy will have been working for several days prior to discharge. The client’s statement indi- cates the need for further teaching.*** 3. Until the incision is completely healed, the client should not sit in bath water because of the potential contamination of the wound by the bath water. The client understands the teaching. 4. The client has had major surgery and should limit lifting to minimal weight. The client understands the teaching.

Question 45

The nurse is preparing to hang a new bag of total parental nutrition for a client with an abdominal perineal resection. The bag has 1,500 mL of 50% dextrose, 10 mL of trace elements, 20 mL of multivitamins, 20 mL of potassium chloride, and 500 mL of lipids. The bag is to infuse over the next 24 hours. At what rate should the nurse set the pump? \_\_\_\_\_\_\_\_\_

Answer 45

**Ans: 85 mL/hr** First determine the total amount to be in- fused over 24 hours: 1500 + 500 + 20 + 20 = 2,040 mL over 24 hours Then, determine the rate per hour: 2,040 ÷ 24 = 85 mL/hr

Question 46

The nurse is caring for clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society’s recommendations for the early detection of colon cancer? 1. Beginning at age 60, a digital rectal examination should be done yearly. 2. After reaching middle age, a yearly fecal occult blood test should be done. 3. Have a colonoscopy at age 50 and then once every five (5) to 10 years. 4. A flexible sigmoidoscopy should be done yearly after age 40.

Answer 46

Ans: 3. Have a colonoscopy at age 50 and then once every five (5) to 10 years. 1. A digital rectal examination is done to detect prostate cancer and should be started at age 40 years. 2. “Middle age” is a relative term; specific ages are used for recommendation. 3. ***The American Cancer Society recom- mends a colonoscopy at age 50 and every five (5) to 10 years thereafter, and a flexible sigmoidoscopy and a barium enema every five (5) years.*** 4. A flexible sigmoidoscopy should be done at five (5)-year intervals between the colonoscopy.

Question 47

The nurse writes a psychosocial problem of “risk for altered sexual functioning related to new colostomy.” Which intervention should the nurse implement? 1. Tell the client there should be no intimacy for at least three (3) months. 2. Ensure the client and significant other are able to change the ostomy pouch. 3. Demonstrate with charts possible sexual positions for the client to assume. 4. Teach the client to protect the pouch from becoming dislodged during sex.

Answer 47

Ans: 4. Teach the client to protect the pouch from becoming dislodged during sex. 1. Intimacy involves more than sexual inter- course. The client can be sexually active whenever the wounds are healed suffi- ciently to not cause pain. 2. This is an appropriate nursing interven- tion for home care, but it has nothing to do with sexual activity. 3. The nurse is not a sexual counselor who would have these types of charts. The nurse should address sexuality with the client but would not be considered an expert capable of explaining the advantages and disadvan- tages of sexual positioning. 4. ***A pouch that becomes dislodged during the sexual act would cause embarrass- ment for the client, whose body image has already been dealt a blow.***

Question 48

The client presents with a complete blockage of the large intestine from a tumor. Which health-care provider’s order would the nurse question? 1. Obtain consent for a colonoscopy and biopsy. 2. Start an IV of 0.9% saline at 125 mL/hr. 3. Administer 3 liters of GoLYTELY. 4. Give tap water enemas until it is clear.

Answer 48

Ans: 3. Administer 3 liters of GoLYTELY. 1. The client will need to have diagnostic tests, so this is an appropriate intervention. 2. The client who has an intestinal blockage will need to be hydrated. 3. ***This client has an intestinal blockage from a solid tumor blocking the colon. Although the client needs to be cleaned out for the colonoscopy, GoLYTELY could cause severe cramping without a reasonable benefit to the client and could cause a medical emergency.*** 4. Tap water enemas until clear would be in- stilling water from below the tumor to try to rid the colon of any feces. The client can expel this water.

Question 49

The client diagnosed with diverticulitis is complaining of severe pain in the left lower quadrant and has an oral temperature of 100.6 ̊F. Which intervention should the nurse implement first? 1. Notify the health-care provider. 2. Document the findings in the chart. 3. Administer an oral antipyretic. 4. Assess the client’s abdomen.

Answer 49

Ans: 4. Assess the client’s abdomen. 1. These are classic signs/symptoms of diver- ticulitis; therefore, the HCP does not need to be notified. 2. These are normal findings for a client di- agnosed with diverticulitis, but on admission the nurse should assess the client and document the findings in the client’s chart. 3. The nurse should not administer any food or medications. 4. ***The nurse should assess the client to determine if the abdomen is soft and nontender. A rigid tender abdomen may indicate peritonitis.***

Question 50

The nurse is teaching the client diagnosed with diverticulosis. Which instruction should the nurse include in the teaching session? 1. Discuss the importance of drinking 1,000 mL of water daily. 2. Instruct the client to exercise at least three (3) times a week. 3. Teach the client about a eating a low-residue diet. 4. Explain the need to have daily bowel movements.

Answer 50

Ans: 4. Explain the need to have daily bowel movements. 1. The client should drink at least 3,000 mL of water daily to help prevent constipation. 2. The client should exercise daily to help prevent constipation. 3. The client should eat a high-fiber diet to help prevent constipation. 4. ***The client should have regular bowel movements, preferably daily. Constipation may cause diverticulitis, which is a potentially life-threatening complication of diverticulosis.***

Question 51

The client is admitted to the medical unit with a diagnosis of acute diverticulitis. Which health-care provider’s order should the nurse question? 1. Insert a nasogastric tube. 2. Start an IV with D5W at 125 mL/hr. 3. Put client on a clear liquid diet. 4. Place client on bedrest with bathroom privileges.

Answer 51

Ans: 3. Put client on a clear liquid diet. 1. The client will have a nasogastric tube because the client will be NPO, which will decompress the bowel and remove hydrochloric acid. 2. Preventing dehydration is a priority with the client who is NPO. 3. **The nurse should question a clear liquid diet because the bowel must be put on total rest, which means NPO.** 4. The client is in severe pain and should be on bedrest, which will help rest the bowel.

Question 52

The nurse is discussing the therapeutic diet for the client diagnosed with diverticulosis. Which meal indicates the client understands the discharge teaching? 1. Fried fish, mashed potatoes, and iced tea. 2. Ham sandwich, applesauce, and whole milk. 3. Chicken salad on whole-wheat bread and water. 4. Lettuce, tomato, and cucumber salad and coffee.

Answer 52

Ans: 3. Chicken salad on whole-wheat bread and water. 1. Fried foods increase cholesterol. Mashed potatoes do not have the peel, which is needed for increased fiber. 2. Applesauce does not have the peel, which is needed for increased fiber, and the op- tion does not identify which type of bread; whole milk is high in fat. 3. ***Chicken salad, which has vegetables such as celery, grapes, and apples, and whole-wheat bread are high in fiber, which is the therapeutic diet pre- scribed for clients with diverticulosis. An adequate intake of water helps pre- vent constipation.*** 4. Tomatoes and cucumbers have seeds, and many health-care providers recommend clients with diverticulosis avoid seeds because of the possibility of the seeds entering the diverticulum and becoming trapped, leading to peritonitis.

Question 53

The client is two (2) hours post-colonoscopy. Which assessment data warrant intermediate intervention by the nurse? 1. The client has a soft, nontender abdomen. 2. The client has a loose, watery stool. 3. The client has hyperactive bowel sounds. 4. The client’s pulse is 104 and BP is 98/60.

Answer 53

Ans: 4. The client’s pulse is 104 and BP is 98/60. 1. The client’s abdomen should be soft and nontender; therefore, this finding would not require immediate intervention. 2. The client had to clean the bowel prior to the colonoscopy; therefore, watery stool is expected. 3. The client was NPO and received bowel preparation prior to the colonoscopy; there- fore, hyperactive bowel sounds might occur and do not warrant immediate intervention. 4. ***Bowel perforation is a potential com- plication of a colonoscopy. Therefore, signs of hypotension—decreased BP and increased pulse—warrant immedi- ate intervention from the nurse.***

Question 54

The nurse is preparing to administer the initial dose of an aminoglycoside antibiotic to the client diagnosed with acute diverticulitis. Which intervention should the nurse implement? 1. Obtain a serum trough level. 2. Ask about drug allergies. 3. Monitor the peak level. 4. Assess the vital signs.

Answer 54

Ans: 2. Ask about drug allergies. 1. Peak and trough levels are drawn after the client has received at least three (3) to four (4) doses of medication, not on the initial dose because the client has just been admitted. 2. ***The nurse should always ask about allergies to medication when adminis- tering medications, but especially when administering antibiotics, which are notorious for allergic reactions.*** 3. The peak and trough levels are not drawn prior to the first dose; they are ordered after multiple doses. 4. The nurse should question when to administer the medication, but there is no vital sign preventing the nurse from administering an antibiotic.

Question 55

The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and T 102 ̊F. Which intervention should the nurse implement? 1. Notify the health-care provider. 2. Prepare to administer a Fleet’s enema. 3. Administer an antipyretic suppository. 4. Continue to monitor the client closely.

Answer 55

Ans: 1. Notify the health-care provider. 1. ***These are signs of peritonitis, which is life threatening. The health-care provider should be notified immediately.*** 2. A Fleet’s enema will not help a life- threatening complication of diverticulitis. 3. A medication administered to help decrease the client’s temperature will not help a life-threatening complication. 4. These are signs/symptoms indicating a possible life-threatening situation and require immediate intervention.

Question 56

The nurse is preparing to administer 250 mL of intravenous antibiotic to the client. The medication must infuse in one (1) hour. An intravenous pump is not available and the nurse must administer the medication via gravity with IV tubing at 10 gtts/min. At what rate should the nurse infuse the medication? \_\_\_\_\_\_\_\_\_

Answer 56

**Ans: 42 gtts/min.** The nurse must use the formula: amount to be infused × drops per minute minutes for infusion 250mL×10gtts 60 minutes or, 2,500 ÷ 60 minutes = 41.66 gtts/min, which should be rounded up to 42 gtts/min.

Question 57

The client with acute diverticulitis has a nasogastric tube draining green liquid bile. Which intervention should the nurse implement? 1. Document the findings as normal. 2. Assess the client’s bowel sounds. 3. Determine the client’s last bowel movement. 4. Insert the N/G tube at least 2 more inches.

Answer 57

Ans: 1. Document the findings as normal. 1. ***Green bile contains hydrochloric acid and should be draining from the N/G tube; therefore, the nurse should take no action and document the findings.*** 2. There is no reason for the nurse to assess the client’s bowel sounds because the drainage is normal. 3. The client’s last bowel movement would not affect the N/G drainage. 4. Bile draining from the N/G tube indicates the tube is in the stomach and there is no need to advance the tube further.

Question 58

The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis? Select all that apply. 1. Eat a high-fiber diet. 2. Increase fluid intake. 3. Elevate the HOB after eating. 4. Walk 30 minutes a day. 5. Take an antacid every two (2) hours.

Answer 58

Ans: 1, 2, 4 1. Eat a high-fiber diet. 2. Increase fluid intake. 4. Walk 30 minutes a day. 1. ***A high-fiber diet will help to prevent constipation, which is the primary reason for diverticulitis.*** 2. ***Increased fluids will help keep the stool soft and prevent constipation.*** 3. This will not do anything to help prevent diverticulitis. 4. ***Exercise will help prevent constipation.*** 5. No medications are prescribed to prevent an acute exacerbation of diverticulitis. Antacids are used to neutralize hydrochlo- ric acid in the stomach.

Question 59

The nurse is working in an outpatient clinic. Which client is most likely to have a diagnosis of diverticulosis? 1. A 60-year-old male with a sedentary lifestyle. 2. A 72-year-old female with multiple childbirths. 3. A 63-year-old female with hemorrhoids. 4. A 40-year-old male with a family history of diverticulosis.

Answer 59

Ans: 3. A 63-year-old female with hemorrhoids. 1. A sedentary lifestyle may lead to obesity and contribute to hypertension or heart disease but usually not to diverticulosis. 2. Multiple childbirths are not a risk factor for developing diverticulosis. 3. ***Hemorrhoids would indicate the client has chronic constipation, which is a strong risk factor for diverticulosis. Constipation increases the intraluminal pressure in the sigmoid colon, leading to weakness in the intestinal lining, which, in turn, causes outpouchings, or diverticula.*** 4. A family history is not a risk factor. Having daily bowel movements and pre- venting constipation will decrease the chance of developing diverticulosis.

Question 60

The client is admitted to the medical floor with acute diverticulitis. Which collaborative intervention should the nurse anticipate the health-care provider ordering? 1. Administer total parenteral nutrition. 2. Maintain NPO and nasogastric tube. 3. Maintain on a high-fiber diet and increase fluids. 4. Obtain consent for abdominal surgery.

Answer 60

Ans: 2. Maintain NPO and nasogastric tube. 1. Total parenteral nutrition is not an expected order for this client. 2. ***The bowel must be put at rest. There- fore, the nurse should anticipate orders for maintaining the client NPO and a nasogastric tube.*** 3. These orders would be instituted when the client is getting better and the bowel is not inflamed. 4. Surgery is not the first consideration when the client is admitted into the hospital.

Question 61

The client is four (4) hours postoperative open cholecystectomy. Which data warrant immediate intervention by the nurse? 1. Absent bowel sounds in all four (4) quadrants. 2. The T-tube has 60 mL of green drainage. 3. Urine output of 100 mL in the past three (3) hours. 4. Refusal to turn, deep breathe, and cough.

Answer 61

Ans: 4. Refusal to turn, deep breathe, and cough. 1. After abdominal surgery, it is not uncom- mon for bowel sounds to be absent. 2. This is a normal amount and color of drainage. 3. The minimum urine output is 30 mL/hr. 4. **Refusing to turn, deep breathe, and cough places the client at risk for pneumonia. This client needs immediate intervention to prevent complications.**

Question 62

The client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement? 1. Apply a heating pad to the abdomen for 15 to 20 minutes. 2. Administer morphine sulfate intravenously after diluting with saline. 3. Contact the surgeon for an order to x-ray the right shoulder. 4. Apply a sling to the right arm, which was injured during surgery.

Answer 62

Ans: 1. Apply a heating pad to the abdomen for 15 to 20 minutes. 1. ***A heating pad should be applied for 15 to 20 minutes to assist the migra- tion of the CO2 used to insufflate the abdomen. Shoulder pain is an expected occurrence.*** 2. Morphine sulfate does not affect the etiology of the pain. 3. The surgeon would not order an x-ray for this condition. 4. There is no indication an injury occurred during surgery. A sling would not benefit the migration of the CO2. Shoulder pain is expected.

Question 63

The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching is effective? 1. “I will take my lipid-lowering medicine at the same time each night.” 2. “I may experience some discomfort when I eat a high-fat meal.” 3. “I need someone to stay with me for about a week after surgery.” 4. “I should not splint my incision when I deep breathe and cough.”

Answer 63

Ans: 2. “I may experience some discomfort when I eat a high-fat meal.” 1. This surgery does not require lipid- lowering medications, but eating high-fat meals may cause discomfort. 2. ***After removal of the gallbladder, some clients experience abdominal discom- fort when eating fatty foods.*** 3. Laparoscopic cholecystectomy surgeries are performed in day surgery, and clients usually do not need assistance for a week. 4. Using a pillow to splint the abdomen pro- vides support for the incision and should be continued after discharge.

Question 64

Which signs and symptoms should the nurse report to the health-care provider for the client recovering from an open cholecystectomy? **Select all that apply.** 1. Clay-colored stools. 2. Yellow-tinted sclera. 3. Amber-colored urine. 4. Wound approximated. 5. Abdominal pain.

Answer 64

Ans: 1, 2, 5 1. Clay-colored stools. 2. Yellow-tinted sclera. 5. Abdominal pain. 1. ***Clay-colored stools are caused by recurring stricture of the common bile duct, which is a sign of post- cholecystectomy syndrome.*** 2. ***Yellow-tinted sclera and skin indicate residual effects of stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome.*** 3. Amber-colored urine is a normal finding for a client, so this does not warrant inter- vention by the nurse. 4. An approximated wound indicates the in- cision is intact and does not warrant inter- vention by the nurse. 5. ***Abdominal pain indicates a residual effect of a stricture of the common bile duct, inflammation, or calculi, which is a sign of post-cholecystectomy syndrome.***

Question 65

The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Check the abdominal dressings for bleeding. 2. Increase the IV fluid if the blood pressure is low. 3. Ambulate the client to the bathroom. 4. Auscultate the breath sounds in all lobes.

Answer 65

Ans: 3. Ambulate the client to the bathroom. 1. This is assessment and cannot be delegated. 2. This intervention would require nursing judgment, and increasing IV fluid is medication administration; neither task can be delegated. 3. **A day surgery client can be ambulated to the bathroom, so this task can be delegated to the UAP.** 4. This would require assessment and cannot be delegated.

Question 66

Which data should the nurse expect to assess in the client who had an upper gastrointestinal (UGI) series? 1. Chalky white stools. 2. Increased heart rate. 3. A firm hard abdomen. 4. Hyperactive bowel sounds.

Answer 66

Ans: 1. Chalky white stools. 1. ***A UGI series requires the client to swallow barium, which passes through the intestines, making the stools a chalky white color.*** 2. Increased heart rate is abnormal data and would be cause for further assessment. 3. A firm, hard abdomen is not expected from the UGI series. 4. Hyperactive bowel sounds is not an ex- pected sequela of a UGI series.

Question 67

The client is one (1) hour post–endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care? 1. Instruct the client to cough forcefully. 2. Encourage early ambulation. 3. Assess for return of a gag reflex. 4. Administer held medications.

Answer 67

Ans: 3. Assess for return of a gag reflex. 1. Asking the client to cough forcefully may irritate the client’s throat. 2. Early ambulation does not enhance safety since the client will be sedated. 3. ***The ERCP requires an anesthetic spray be used prior to insertion of the endo- scope. If medications, food, or fluid are given orally prior to the return of the gag reflex, the client may aspirate.*** 4. Medications are not administered until the gag reflex has returned

Question 68

Which outcome should the nurse identify for the client scheduled to have a cholecystectomy? 1. Decreased pain management. 2. Ambulate first day postoperative. 3. No break in skin integrity. 4. Knowledge of postoperative care.

Answer 68

Ans: 4. Knowledge of postoperative care. 1. The expected outcome is pain control for both preoperative and postoperative care. 2. Postoperative care includes ambulation. 3. Prevention of an additional impaired skin integrity is a desired postoperative out- come. The incision would be a break in skin integrity. 4. ***This would be an expected outcome for the client scheduled for surgery. This indicates preoperative teaching has been effective.***

Question 69

Which assessment data indicate to the nurse the client recovering from an open cholecystectomy may require pain medication? 1. The client’s pulse is 65 beats per minute. 2. The client has shallow respirations. 3. The client’s bowel sounds are 20 per minute. 4. The client uses a pillow to splint when coughing.

Answer 69

Ans: 2. The client has shallow respirations. 1. An increased pulse is expected in the client who is in acute pain. 2. ***An open cholecystecomy requires a large incision under the diaphragm. Deep breathing places pressure on the diaphragm and the incision, causing pain. Shallow respirations indicate in- adequate pain control, and the nurse should intervene.*** 3. Twenty bowel sounds a minute is normal data and does not require further action. 4. Splinting the abdomen allows the client to increase the strength of the cough by in- creasing comfort and does not indicate a need for pain medication.

Question 70

The charge nurse is monitoring client laboratory values. Which value is expected in the client with cholecystitis who has chronic inflammation? 1. An elevated white blood cell count. 2. A decreased lactate dehydrogenase. 3. An elevated alkaline phosphatase. 4. A decreased direct bilirubin level.

Answer 70

Ans: 1. An elevated white blood cell count. 1. ***The white blood cell count should be elevated in clients with chronic inflammation.*** 2. A decreased lactate dehydrogenase (LDH) indicates liver abnormalities. 3. An elevated alkaline phosphatase indicates liver abnormalities. 4. A decreased bilirubin indicates an obstruc- tive process.

Question 71

Which problem is highest priority for the nurse to identify in the client who had an open cholecystectomy surgery? 1. Alteration in nutrition. 2. Alteration in skin integrity. 3. Alteration in urinary pattern. 4. Alteration in comfort.

Answer 71

Ans: 4. Alteration in comfort. 1. Alteration in nutrition may be an appro- priate client problem, but it is not priority. 2. Alteration in skin integrity may be an ap- propriate client problem, but is not priority. 3. Alteration in urinary elimination may be an appropriate client problem, but is not priority. 4. ***Acute pain management is the highest priority client problem after surgery because pain may indicate a life-threatening problem.***

Question 72

The nurse assesses a large amount of red drainage on the dressing of a client who is six (6) hours postoperative open cholecystectomy. Which intervention should the nurse implement? 1. Measure the abdominal girth. 2. Palpate the lower abdomen for a mass. 3. Turn client onto side to assess for further drainage. 4. Remove the dressing to determine the source.

Answer 72

Ans: 3. Turn client onto side to assess for further drainage. 1. Measuring the abdominal girth helps fur- ther assess internal bleeding, not external bleeding. 2. Palpating the lower abdomen assesses the bladder, not bleeding. 3. ***Turning the client to the side to assess the amount of drainage and possible bleeding is important prior to contacting the surgeon.*** 4. The first dressing change is usually done by the surgeon; the nurse can reinforce the dressing.

Question 73

The client diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (Sengstaken- Blakemore). Which nursing intervention should the nurse implement for this treatment? 1. Assess the gag reflex every shift. 2. Stay with the client at all times. 3. Administer the laxative lactulose (Chronulac). 4. Monitor the client’s ammonia level.

Answer 73

Ans: 2. Stay with the client at all times. 1. The client’s throat is not anesthetized dur- ing the insertion of a nasogastric tube, so the gag reflex does not need to be assessed. 2. ***While the balloons are inflated, the client must not be left unattended in case they become dislodged and occlude the airway. This is a safety issue.*** 3. This laxative is administered to decrease the ammonia level, but the question does not say the client’s ammonia level is elevated. 4. Esophageal bleeding does not cause the ammonia level to be elevated.

Question 74

The client has had a liver biopsy. Which postprocedure intervention should the nurse implement? 1. Instruct the client to void immediately. 2. Keep the client NPO for eight (8) hours. 3. Place the client on the right side. 4. Monitor BUN and creatinine level.

Answer 74

Ans: 3. Place the client on the right side. 1. The client should empty the bladder im- mediately prior to the liver biopsy, not after the procedure. 2. Foods and fluids are usually withheld two (2) hours after the biopsy, after which the client can resume the usual diet. 3. ***Direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure.*** 4. Blood urea nitrogen (BUN) and creatinine levels are monitored for kidney function, not liver function, and the renal system is not affected with the liver biopsy.

Question 75

The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication? 1. Restrict sodium intake to 2 g/day. 2. Limit oral fluids to 1,500 mL/day. 3. Decrease the daily fat intake. 4. Reduce protein intake to 60 to 80 g/day.

Answer 75

Ans: 4. Reduce protein intake to 60 to 80 g/day. 1. Sodium is restricted to reduce ascites and generalized edema, not for hepatic encephalopathy. 2. Fluids are calculated based on diuretic therapy, urine output, and serum elec- trolyte values; fluids do not affect hepatic encephalopathy. 3. A diet high in calories and moderate in fat intake is recommended to promote healing. 4. ***Ammonia is a by-product of protein metabolism and contributes to hepatic encephalopathy. Reducing protein in- take should decrease ammonia levels.***

Question 76

The client diagnosed with end-stage renal failure and ascites is scheduled for a paracentesis. Which client teaching should the nurse discuss with the client? 1. Explain the procedure will be done in the operating room. 2. Instruct the client a Foley catheter will have to be inserted. 3. Tell the client vital signs will be taken frequently after the procedure. 4. Provide instructions on holding the breath when the HCP inserts the catheter.

Answer 76

Ans: 3. Tell the client vital signs will be taken frequently after the procedure. 1. The procedure is done in the client’s room, with the client seated either on the side of the bed or in a chair. 2. The client should empty the bladder prior to the procedure to avoid bladder puncture, but there is no need for an indwelling catheter to be inserted. 3. ***The client is at risk for hypovolemia; therefore, vital signs will be assessed frequently to monitor for signs of hemorrhaging.*** 4. The client does not have to hold the breath when the catheter is inserted into the peritoneum; this is done when obtain- ing a liver biopsy.

Question 77

The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse? 1. The UAP is assisting the client to take a hot soapy shower. 2. The UAP applies an emollient to the client’s legs and back. 3. The UAP puts mittens on both hands of the client. 4. The UAP pats the client’s skin dry with a clean towel.

Answer 77

Ans: 1. The UAP is assisting the client to take a hot soapy shower. 1. ***Hot water increases pruritus, and soap will cause dry skin, which increases pruritus; therefore, the nurse should discuss this with the UAP.*** 2. Applying emollient lotion will help pre- vent dry skin, which will help decrease pruritus; therefore, this would not require any intervention by the nurse. 3. Mittens will help prevent the client from scratching the skin and causing skin breakdown. This would not require interven- tion by the nurse. 4. The skin should be patted dry, not rubbed, because rubbing the skin will cause increased irritation. This action does not require intervention by the nurse.

Question 78

The nurse identifies the client problem “excess fluid volume” for the client in liver failure. Which short-term goal would be most appropriate for this problem? 1. The client will not gain more than two (2) kg a day. 2. The client will have no increase in abdominal girth. 3. The client’s vital signs will remain within normal limits. 4. The client will receive a low-sodium diet.

Answer 78

Ans: 2. The client will have no increase in abdominal girth. 1. Two (2) kg is more than four (4) pounds, which indicates severe fluid retention and is not an appropriate goal. 2. ***Excess fluid volume could be secondary to portal hypertension. Therefore, no increase in abdominal girth would be an appropriate short-term goal, indi- cating no excess of fluid volume.*** 3. Vital signs are appropriate to monitor, but they do not yield specific information about fluid volume status. 4. Having the client receive a low-sodium diet does not ensure the client will comply with the diet. The short-term goal must evaluate if the fluid volume is within normal limits.

Question 79

The client in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse implement? **Select all that apply.** 1. Avoid rectal temperatures. 2. Use only a soft toothbrush. 3. Monitor the platelet count. 4. Use small-gauge needles. 5. Assess for asterixis.

Answer 79

Ans: 1, 2, 3, 4 1. Avoid rectal temperatures. 2. Use only a soft toothbrush. 3. Monitor the platelet count. 4. Use small-gauge needles. 1. ***Vitamin K deficiency causes impaired coagulation; therefore, rectal thermometers should be avoided to prevent bleeding.*** 2. ***Soft-bristle toothbrushes will help prevent bleeding of the gums.*** 3. ***Platelet count, PTT/PT, and INR should be monitored to assess coagula- tion status.*** 4. ***Injections should be avoided, if at all possible, because the client is unable to clot, but if they are absolutely neces- sarily, the nurse should use small- gauge needles.*** 5. Asterixis is a flapping tremor of the hands when the arms are extended and indicates an elevated ammonia level not associated with vitamin K deficiency.

Question 80

Which gastrointestinal assessment data should the nurse expect to find when assessing the client in end-stage liver failure? 1. Hypoalbuminemia and muscle wasting. 2. Oligomenorrhea and decreased body hair. 3. Clay-colored stools and hemorrhoids. 4. Dyspnea and caput medusae.

Answer 80

Ans: 3. Clay-colored stools and hemorrhoids. 1. Hypoalbuminemia (decreased albumin) and muscle wasting are metabolic effects, not gastrointestinal effects. 2. Oligomenorrhea is no menses, which is a reproductive effect, and decreased body hair is an integumentary effect. 3. ***Clay-colored stools and hemorrhoids are gastrointestinal effects of liver failure.*** 4. Dyspnea is a respiratory effect, and caput medusae (dilated veins around the umbili- cus) is an integumentary effect, although it is on the abdomen.

Question 81

Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis? 1. “How many years have you been drinking alcohol?” 2. “Have you completed an advance directive?” 3. “When did you have your last alcoholic drink?” 4. “What foods did you eat at your last meal?”

Answer 81

Ans: 3. “When did you have your last alcoholic drink?” 1. It really doesn’t matter how long the client has been drinking alcohol. The diagnosis of alcoholic cirrhosis indicates the client has probably been drinking for many years. 2. An advance directive is important for the client who is terminally ill, but it is not the priority question. 3. ***The nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the phys- ical withdrawal from alcohol.*** 4. This is not a typical question asked by the nurse unless the client is malnour- ished, which is not information provided in the stem.

Question 82

The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy? 1. Gastrointestinal bleeding. 2. Hypoalbuminemia. 3. Splenomegaly. 4. Hyperaldosteronism.

Answer 82

Ans: 1. Gastrointestinal bleeding. 1. ***Blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy.*** 2. Decreased albumin causes the client to develop ascites. 3. An enlarged spleen increases the rate at which RBCs, WBCs, and platelets are destroyed, causing the client to develop anemia, leukopenia, and thrombocytope- nia, but not hepatic encephalopathy. 4. An increase in aldosterone causes sodium and water retention, resulting in the development of ascites and generalized edema.

Question 83

The client is diagnosed with end-stage liver failure. The client asks the nurse, “Why is my doctor decreasing the doses of my medications?” Which statement is the nurse’s best response? 1. “You are worried because your doctor has decreased the dosage.” 2. “You really should ask your doctor. I am sure there is a good reason.” 3. “You may have an overdose of the medications because your liver is damaged.” 4. “The half-life of the medications is altered because the liver is damaged.”

Answer 83

Ans: 3. “You may have an overdose of the medications because your liver is damaged.” 1. This is a therapeutic response and is used to encourage the client to verbalize feelings, but does not provide factual information. 2. This is passing the buck; the nurse should be able to answer this question. 3. ***This is the main reason the HCP decreases the client’s medication dose and is an explanation appropriate for the client.*** 4. This is the medical explanation as to why the medication dose is decreased, but it should not be used to explain to a layperson.

Question 84

The client is admitted with end-stage liver failure and is prescribed the laxative lactulose (Chronulac). Which statement indicates the client needs more teaching concerning this medication? 1. “I should have two to three soft stools a day.” 2. “I must check my ammonia level daily.” 3. “If I have diarrhea, I will call my doctor.” 4. “I should check my stool for any blood.”

Answer 84

Ans: 2. “I must check my ammonia level daily.” 1. Two to soft three stools a day indicates the medication is effective. 2. ***There is no instrument used at home to test daily ammonia levels. The am- monia level is a serum level requiring venipuncture and laboratory diagnostic equipment.*** 3. Diarrhea indicates an overdosage of the medication, possibly requiring the dosage to be decreased. The HCP needs to make this change in dosage, so the client under- stands the teaching. 4. The client should check the stool for bright-red blood as well as dark, tarry stool.

Question 85

The client is in the preicteric phase of hepatitis. Which signs/symptoms should the nurse expect the client to exhibit during this phase? 1. Clay-colored stools and jaundice. 2. Normal appetite and pruritus. 3. Being afebrile and left upper quadrant pain. 4. Complaints of fatigue and diarrhea.

Answer 85

Ans: 4. Complaints of fatigue and diarrhea. 1. Clay-colored stools and jaundice occur in the icteric phase of hepatitis. 2. Normal appetite and itching occur in the icteric phase of hepatitis. 3. Fever subsides in the icteric phase, and the pain is in the right upper quadrant. 4. ***“Flu-like” symptoms are the first com- plaints of the client in the preicteric phase of hepatitis, which is the initial phase and may begin abruptly or insidiously.***

Question 86

The public health nurse is teaching day-care workers. Which type of hepatitis is transmitted by the fecal–oral route via contaminated food, water, or direct contact with an infected person? 1. Hepatitis A. 2. Hepatitis B. 3. Hepatitis C. 4. Hepatitis D.

Answer 86

Ans: 1. Hepatitis A. 1. ***The hepatitis A virus is in the stool of infected people and takes up to two (2) weeks before symptoms develop.*** 2. Hepatitis B virus is spread through contact with infected blood and body fluids. 3. Hepatitis C virus is transmitted through infected blood and body fluids. 4. Hepatitis D virus only causes infection in people who are also infected with hepatitis B or C.

Question 87

Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? 1. Airborne Precautions. 2. Standard Precautions. 3. Droplet Precautions. 4. Exposure Precautions.

Answer 87

Ans: 2. Standard Precautions. 1. Airborne Precautions are required for transmission occurring by dissemination of either airborne droplet nuclei or dust particles containing the infectious agent. 2. ***Standard Precautions apply to blood, all body fluids, secretions, and excre- tions, except sweat, regardless of whether they contain visible blood.*** 3. Droplet transmission involves contact of the conjunctivae of the eyes or mucous membranes of the nose or mouth with large-particle droplets generated during coughing, sneezing, talking, or suctioning. 4. Exposure Precautions is not a designated isolation category.

Question 88

The school nurse is discussing methods to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the most important to teach the high school teachers? 1. Do not allow students to eat or drink after each other. 2. Drink bottled water as much as possible. 3. Encourage protected sexual activity. 4. Sing the happy birthday song while washing hands.

Answer 88

Ans: 4. Sing the happy birthday song while washing hands. 1. Eating after each other should be discour- aged, but it is not the most important intervention. 2. Only bottled water should be consumed in third world countries, but this precaution is not necessary in American high schools. 3. Hepatitis B and C, not hepatitis A, are transmitted by sexual activity. 4. ***Hepatitis A is transmitted via the fecal–oral route. Good hand washing helps to prevent its spread. Singing the happy birthday song takes approximately 30 seconds, which is how long an indi- vidual should wash his or her hands.***

Question 89

Which instruction should the nurse discuss with the client who is in the icteric phase of hepatitis C? 1. Decrease alcohol intake. 2. Encourage rest periods. 3. Eat a large evening meal. 4. Drink diet drinks and juices.

Answer 89

Ans: 2. Encourage rest periods. 1. The client must avoid alcohol altogether, not decrease intake, to prevent further liver damage and promote healing. 2. ***Adequate rest is needed for maintain- ing optimal immune function.*** 3. Clients are more often anorexic and nau- seated in the afternoon and evening; therefore, the main meal should be in the morning. 4. Diet drinks and juices provide few calo- ries, and the client needs an increased- calorie diet for healing.

Question 90

The public health nurse is discussing hepatitis B with a group in the community. Which health promotion activities should the nurse discuss with the group? Select all that apply. 1. Do not share needles or equipment. 2. Use barrier protection during sex. 3. Get the hepatitis B vaccine. 4. Obtain immune globulin injections. 5. Avoid any type of hepatotoxic medications.

Answer 90

Ans: 1, 2, 3 1. Do not share needles or equipment. 2. Use barrier protection during sex. 3. Get the hepatitis B vaccine. 1. ***Hepatitis B can be transmitted by sharing any type of needles, especially those used by drug abusers.*** 2. ***Hepatitis B can be transmitted through sexual activity; therefore, the nurse should recommend abstinence, mutual monogamy, or barrier protection.*** 3. ***Three doses of hepatitis B vaccine pro- vide immunity in 90% of healthy adults.*** 4. Immune globulin injections are adminis- tered as postexposure prophylaxis (after being exposed to hepatitis B), but encour- aging these injections is not a health promotion activity. 5. Hepatotoxic medications should be avoided in clients who have hepatitis or who have had hepatitis. The health-care provider prescribes medications, and the layperson does not know which medica- tions are hepatotoxic.

Question 91

The client with hepatitis asks the nurse, “I went to an herbalist, who recommended I take milk thistle. What do you think about the herb?” Which statement is the nurse’s best response? 1. “You are concerned about taking an herb.” 2. “The herb has been used to treat liver disease.” 3. “I would not take anything that is not prescribed.” 4. “Why would you want to take any herbs?”

Answer 91

Ans: 2. “The herb has been used to treat liver disease.” 1. This is a therapeutic response, and the nurse should provide factual information. 2. ***Milk thistle has an active ingredient, silymarin, which has been used to treat liver disease for more than 2,000 years. It is a powerful oxidant and promotes liver cell growth.*** 3. The nurse should not discourage comple- mentary therapies. 4. This is a judgmental statement, and the nurse should encourage the client to ask questions.

Question 92

The nurse writes the problem “imbalanced nutrition: less than body requirements” for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care? 1. Provide a high-calorie intake diet. 2. Discuss total parenteral nutrition (TPN). 3. Instruct the client to decrease salt intake. 4. Encourage the client to increase water intake.

Answer 92

Ans: 1. Provide a high-calorie intake diet. 1. ***Sufficient energy is required for heal- ing. Adequate carbohydrate intake can spare protein. The client should eat approximately 16 carbohydrate kilocalories for each kilogram of ideal body weight daily.*** 2. TPN is not routinely prescribed for the client with hepatitis; the client must lose a large of amount of weight and be unable to eat anything for TPN to be ordered. 3. Salt intake does not affect the healing of the liver. 4. Water intake does not affect healing of the liver, and the client should not drink so much water as to decrease caloric food intake.

Question 93

The female nurse sticks herself with a contaminated needle. Which action should the nurse implement first? 1. Notify the infection control nurse. 2. Cleanse the area with soap and water. 3. Request postexposure prophylaxis. 4. Check the hepatitis status of the client.

Answer 93

Ans: 2. Cleanse the area with soap and water. 1. The nurse must notify the infection con- trol nurse as soon as possible so treatment can start if needed, but this is not the first intervention. 2. ***The nurse should first clean the needle stick with soap and water and attempt stick bleed to help remove any virus injected into the skin.*** 3. Postexposure prophylaxis may be needed, but this is not the first action. 4. The infection control/employee health nurse will check the status of the client whom the needle was used on before the nurse stuck herself.

Question 94

The client diagnosed with liver problems asks the nurse, “Why are my stools clay- colored?” On which scientific rationale should the nurse base the response? 1. There is an increase in serum ammonia level. 2. The liver is unable to excrete bilirubin. 3. The liver is unable to metabolize fatty foods. 4. A damaged liver cannot detoxify vitamins.

Answer 94

Ans: 2. The liver is unable to excrete bilirubin. 1. The serum ammonia level is increased in liver failure, but it is not the cause of clay- colored stools. 2. ***Bilirubin, the by-product of red blood cell destruction, is metabolized in the liver and excreted via the feces, which causes the feces to be brown in color. If the liver is damaged, the bilirubin is excreted via the urine and skin.*** 3. The liver excretes bile into the gallbladder and the body uses the bile to digest fat, but it does not affect the feces. 4. Vitamin deficiency, resulting from the liver’s inability to detoxify vitamins, may cause steatorrhea, but it does not cause clay-colored stool.

Question 95

Which statement by the client diagnosed with hepatitis warrants immediate intervention by the clinic nurse? 1. “I will not drink any type of beer or mixed drink.” 2. “I will get adequate rest so I don’t get exhausted.” 3. “I had a big hearty breakfast this morning.” 4. “I took some cough syrup for this nasty head cold.”

Answer 95

Ans: 4. “I took some cough syrup for this nasty head cold.” 1. The client should avoid alcohol to pre- vent further liver damage and promote healing. 2. Rest is needed for healing of the liver and to promote optimum immune function. 3. Clients with hepatitis need increased caloric intake, so this is a good statement. 4. ***The client needs to understand some types of cough syrup have alcohol and all alcohol must be avoided to prevent further injury to the liver; therefore, this statement requires intervention.***

Question 96

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Draw the serum liver function test. 2. Evaluate the client’s intake and output. 3. Perform the bedside glucometer check. 4. Help the ward clerk transcribe orders.

Answer 96

Ans: 3. Perform the bedside glucometer check. 1. The laboratory technician draws serum blood studies, not the UAP. 2. The UAP can obtain the intake and out- put, but the nurse must evaluate the data to determine if the results are normal for the client’s disease process or condition. 3. ***The UAP can perform a bedside glucometer check, but the nurse must evaluate the result and determine any action needed.*** 4. The ward clerk has specific training that allows the transcribing of health-care provider orders.

Question 97

The female client came to the clinic complaining of abdominal cramping and at least 10 episodes of diarrhea every day for the last two (2) days. The client just returned from a trip to Mexico. Which intervention should the nurse implement? 1. Instruct the client to take a cathartic laxative daily. 2. Encourage the client to drink lots of Gatorade. 3. Discuss the need to increase protein in the diet. 4. Explain the client should weigh herself daily.

Answer 97

Ans: 2. Encourage the client to drink lots of Gatorade. 1. The client would be taking antidiarrheal medication, not medications to stimulate bowel movements. 2. **The client probably has traveler’s diarrhea, and oral rehydration is the preferred choice for replacing fluids lost as a result of diarrhea. An oral glucose electrolyte solution, such as Gatorade, All-Sport, or Pedialyte, is recommended.** 3. The client should be encouraged to stay on liquids and eat bland foods of all three (3) food groups—carbohydrates, proteins, and fats. 4. There is no need for the client to weigh herself daily. Symptoms usually resolve within two (2) to three (3) days without complications.

Question 98

Which intervention should the nurse include when discussing ways to help prevent potential episodes of gastroenteritis from Clostridium botulism? 1. Make sure all hamburger meat is well cooked. 2. Ensure all dairy products are refrigerated. 3. Discuss why campers should drink only bottled water. 4. Discard damaged canned goods.

Answer 98

Ans: 4. Discard damaged canned goods. 1. Well-cooked meat will help prevent gas- troenteritis secondary to staphylococcal food poisoning. 2. Refrigerating dairy products will help pre- vent gastroenteritis secondary to eating foods kept at room temperature, causing staphylococcal food poisoning. 3. Drinking bottled water will help prevent gastroenteritis secondary to Escherichia coli found in contaminated water. 4. ***Any discolored food, food from a dam- aged can or jar, or food from a can or jar not having a tight seal should be de- stroyed without tasting or touching it.***

Question 99

The client is diagnosed with salmonellosis secondary to eating some slightly cooked hamburger meat. Which clinical manifestations should the nurse expect the client to report? 1. Abdominal cramping, nausea, and vomiting. 2. Neuromuscular paralysis and dysphagia. 3. Gross amounts of explosive bloody diarrhea. 4. Frequent “rice water stool” with no fecal odor.

Answer 99

Ans: 1. Abdominal cramping, nausea, and vomiting. 1. ***Symptoms develop 8 to 48 hours after ingesting the Salmonella bacteria and include diarrhea, abdominal cramp- ing, nausea, and vomiting, along with low-grade fever, chills, and weakness.*** 2. Neuromuscular paralysis and dysphagia occur with botulism, a severe life- threatening form of food poisoning caused by Clostridium botulinum. 3. Gross explosive bloody diarrhea is a clinical manifestation of hemorrhagic colitis caused by Escherichia coli. 4. Gray-cloudy diarrhea with no fecal odor, blood, or pus is caused by cholera, which is endemic in parts of Asia, the Middle East, and Africa.

Question 100

The client is diagnosed with gastroenteritis. Which laboratory data warrant imme- diate intervention by the nurse? 1. A serum sodium level of 137 mEq/L. 2. Arterial blood gases of pH 7.37, PaO2 95, PaCO2 43, HCO3 24. 3. A serum potassium level of 3.3 mEq/L. 4. A stool sample positive for fecal leukocytes.

Answer 100

Ans: 3. A serum potassium level of 3.3 mEq/L. 1. The normal serum sodium level is 135 to 145 mEq/L; therefore, an intervention by the nurse is not needed. 2. These are normal arterial blood gas results; therefore, the nurse would not need to intervene. 3. ***In gastroenteritis, diarrhea often results in metabolic acidosis and loss of potassium. The normal serum potassium level is 3.5 to 5.5 mEq/L; therefore, a level of 3.3 mEq/L would require immediate intervention. Hypokalemia can lead to life-threatening cardiac dysrhythmias.*** 4. A stool specimen showing fecal leukocytes supports the diagnosis of gastroenteritis and does not warrant immediate intervention by the nurse.

Question 101

The client diagnosed with gastroenteritis is being discharged from the emergency department. Which intervention should the nurse include in the discharge teaching? 1. If diarrhea persists for more than 96 hours, contact the health-care provider. 2. Instruct the client to wash hands thoroughly before handling any type of food. 3. Explain the importance of decreasing steroids gradually as instructed. 4. Discuss how to collect all stool samples for the next 24 hours.

Answer 101

Ans: 2. Instruct the client to wash hands thoroughly before handling any type of food. 1. If the diarrhea persists more than 48 hours, the client should notify the HCP. Diarrhea for more than 96 hours could lead to metabolic acidosis, hypokalemia, and possible death. 2. ***Washing hands should be done by the client at all times, but especially when the client has gastroenteritis. The bacteria in feces may be transferred to other people via food if hands are not washed properly.*** 3. Steroids are not used in the treatment of gastroenteritis; antidiarrheal medication is usually prescribed. 4. The client may be asked to provide a stool specimen for culture, ova, parasites, and fecal leukocytes, but the client is not asked for a 24-hour stool collection.

Question 102

Which medication should the nurse expect the HCP to order to treat the client diagnosed with botulism secondary to eating contaminated canned goods? 1. An antidiarrheal medication. 2. An aminoglycoside antibiotic. 3. An antitoxin medication. 4. An ACE inhibitor medication.

Answer 102

Ans: 3. An antitoxin medication. 1. Antidiarrheal medications are contraindi- cated with botulism because the toxin needs to be expelled from the body. 2. Aminoglycoside antibiotics will not be or- dered because there is no bacterium with botulism; it is caused by a neurotoxin. 3. ***A botulism antitoxin neutralizes the circulating toxin and is prescribed for a client with botulism.*** 4. An angiotensin-converting enzyme (ACE) inhibitor is prescribed for a client diagnosed with cardiovascular disease.

Question 103

Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning? 1. Fluid volume deficit. 2. Nausea. 3. Risk for aspiration. 4. Impaired urinary elimination.

Answer 103

Ans: 1. Fluid volume deficit. 1. ***Fluid volume deficit secondary to diarrhea is the priority because of the potential for metabolic acidosis and hypokalemia, which are both life threatening, especially in the elderly.*** 2. Nausea may occur, but it is not priority. However, excessive vomiting could lead to potential complications. 3. Risk for aspiration could result from vomiting; however, vomiting does not usually occur in food poisoning, but it may be secondary to botulism. 4. Impaired urinary elimination is not a pri- ority. The client has diarrhea, not urine output problems.

Question 104

Which data should the nurse expect to assess in the client diagnosed with acute gastroenteritis? 1. Decreased gurgling sounds on auscultation of the abdominal wall. 2. A hard, firm, edematous abdomen on palpation. 3. Frequent, small melena-type liquid bowel movements. 4. Bowel assessment reveals loud, rushing bowel sounds.

Answer 104

Ans: 4. Bowel assessment reveals loud, rushing bowel sounds. 1. The client would have increased gur- gling sounds revealing hyperactive bowel movements. 2. A hard, firm, edematous abdomen is not expected in a client with gastroenteritis; this would indicate a possible complica- tion and require further assessment. 3. The client has increased liquid bowel movements (diarrhea) but should not have blood in the stool, which is the def- inition of melena. 4. ***Borborygmi, or loud, rushing bowel sounds, indicates increased peristalsis, which occurs in clients with diarrhea and is the primary clinical manifestation in a client diagnosed with acute gastroenteritis.***

Question 105

The 79-year-old client diagnosed with acute gastroenteritis is admitted to the medical unit. Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Evaluate the client’s intake and output. 2. Take the client’s vital signs. 3. Change the client’s intravenous solution. 4. Assess the client’s perianal area.

Answer 105

Ans: 2. Take the client’s vital signs. 1. The UAP can calculate the client’s intake and output, but the nurse must evaluate the data to determine if it is normal for the elderly client diagnosed with acute gastroenteritis. 2. ***The UAP can take the vital signs for a client who is stable; the nurse must interpret and evaluate the vital signs.*** 3. The UAP cannot administer medica- tions, and IV solutions are considered to be medications. 4. The nurse cannot delegate assessment. The client may have an excoriated peri- anal area secondary to diarrhea; there- fore, the nurse should assess the client.

Question 106

Which statement indicates to the emergency department nurse the client diagnosed with acute gastroenteritis understands the discharge teaching? 1. “I will probably have some leg cramps while I have gastroenteritis.” 2. “I should decrease my fluid intake until the diarrhea subsides.” 3. “I should reintroduce solid foods very slowly back into my diet.” 4. “I should only drink bottled water until the abdominal cramping stops.”

Answer 106

Ans: 3. “I should reintroduce solid foods very slowly back into my diet.” 1. Leg cramps could indicate hypokalemia, which is a potential complication of excessive diarrhea and should be re- ported to the health-care provider. 2. The client should increase the fluid in- take because oral rehydration is the pri- mary treatment for gastroenteritis to replace lost fluid as a result of diarrhea and to prevent dehydration. 3. ***Reintroducing solid foods slowly, in small amounts, will allow the bowel to rest and the mucosa to return to normal functioning after acute gastroenteritis.*** 4. Bottled water should be consumed when contaminated water is suspected, and an oral glucose–electrolyte solution, such as Gatorade or Pedialyte, should be recommended.

Question 107

Which nursing interventions should be included in the care plan for the 84-year- old client diagnosed with acute gastroenteritis? **Select all that apply.** 1. Assess the skin turgor on the back of the client’s hands. 2. Monitor the client for orthostatic hypotension. 3. Record the frequency and characteristics of sputum. 4. Use Standard Precautions when caring for the client. 5. Institute safety precautions when ambulating the client.

Answer 107

Ans: 2, 4, 5 2. Monitor the client for orthostatic hypotension.+ 4. Use Standard Precautions when caring for the client. 5. Institute safety precautions when ambulating the client. 1. The nurse should assess skin turgor over the sternum in the elderly client because loss of subcutaneous fat associated with aging makes skin turgor assessment on the arms less reliable. 2. ***Orthostatic hypotension indicates fluid volume deficit, which can occur in an elderly client who is having many episodes of diarrhea.*** 3. The nurse should record frequency and characteristics of stool, not sputum, in the client diagnosed with gastroenteritis. 4. ***Standard Precautions, including wear- ing gloves and hand washing, help prevent the spread of the infection to others.*** 5. ***The elderly client is at risk for ortho- static hypotension; therefore, safety precautions should be instituted to ensure the client doesn’t fall as a re- sult of a decrease in blood pressure.***

Question 108

The nurse has received the a.m. shift report. Which client should the nurse assess first? 1. The 44-year-old client diagnosed with peptic ulcer disease who is complaining of acute epigastric pain. 2. The 74-year-old client diagnosed with acute gastroenteritis who has had four (4) diarrhea stools during the night. 3. The 65-year-old client diagnosed with IBD who has tented skin turgor and dry mucous membranes. 4. The 15-year-old client diagnosed with food poisoning who has vomited several times during the night shift.

Answer 108

Ans: 3. The 65-year-old client diagnosed with IBD who has tented skin turgor and dry mucous membranes. 1. Epigastric pain is expected in a client diagnosed with peptic ulcer disease. 2. Four (4) diarrheal stools are not unusual in a client diagnosed with gastroenteritis. 3. ***Tented skin turgor and dry mucus membranes indicate dehydration, which warrants the nurse assessing this client first.*** 4. Vomiting is expected in a client diag- nosed with food poisoning.

Question 109

The male client had abdominal surgery and the nurse suspects the client has peri- tonitis. Which assessment data support the diagnosis of peritonitis? 1. Absent bowel sounds and potassium level of 3.9 mEq/L. 2. Abdominal cramping and hemoglobin of 14 g/dL. 3. Profuse diarrhea and stool specimen shows Campylobacter. 4. Hard, rigid abdomen and white blood cell count 22,000/mm3.

Answer 109

Ans: 4. Hard, rigid abdomen and white blood cell count 22,000/mm3. 1. Absent bowel sounds indicate a paralytic ileus, not peritonitis, and the potassium level is within normal limits (3.5 to 5.5 mEq/L). 2. Abdominal cramping would not make the nurse suspect peritonitis, and the hemoglobin is normal (13 to 17 g/dL). 3. Campylobacter is a cause of profuse diarrhea, but it does not support a diagnosis of peritonitis. 4. ***A hard, rigid abdomen indicates an inflamed peritoneum (abdominal wall cavity) resulting from an infection, which results in an elevated WBC level.***

Question 110

The client who had abdominal surgery tells the nurse, “I felt something give way in my stomach.” Which intervention should the nurse implement first? 1. Notify the surgeon immediately. 2. Instruct the client to splint the incision. 3. Assess the abdominal wound incision. 4. Administer pain medication intravenously.

Answer 110

Ans: 3. Assess the abdominal wound incision. 1. The nurse may notify the surgeon if warranted, but it is not the first intervention. 2. The nurse should instruct the client to splint the incision when coughing, then take further action. 3. ***Assessing the surgical incision is the first intervention because this may indicate the client has wound dehiscence.*** 4. The nurse should never administer pain medication without assessing for poten- tial complications.

Question 111

The client is one (1) day postoperative major abdominal surgery. Which client problem is priority? 1. Impaired skin integrity. 2. Fluid and electrolyte imbalance. 3. Altered bowel elimination. 4. Altered body image.

Answer 111

Ans: 2. Fluid and electrolyte imbalance. 1. The client has a surgical incision, which impairs the skin integrity, but it is not the priority because it is sutured under sterile conditions. 2. ***After abdominal surgery, thebody distributes fluids to the affected area as part of the healing process. These fluids are shifted from the intravascular compartment to the interstitial space, which causes potential fluid and electrolyte imbalance.*** 3. Bowel elimination is a problem, but after general anesthesia wears off, the bowel sounds will return, and this is not a life- threatening problem. 4. Psychosocial problems are not priority over actual physiological problems.

Question 112

The client has an eviscerated abdominal wound. Which intervention should the nurse implement? 1. Apply sterile normal saline dressing. 2. Use sterile gloves to replace protruding parts. 3. Place the client in reverse Trendelenburg position. 4. Administer intravenous antibiotic STAT.

Answer 112

Ans: 1. Apply sterile normal saline dressing. 1. ***Evisceration is a life-threatening condition in which the abdominal contents protrude through the ruptured incision. The nurse must protect the bowel from the environ- ment by placing a sterile normal saline gauze on it, which prevents the intestines from drying out and necrosing.*** 2. The nurse should not attempt to replace the protruding bowel. 3. This position places the client with the head of the bed elevated, which will make the situation worse. 4. Antibiotics will not protect the protrud- ing bowels, which must be priority. Antibiotics will be administered at a later time to prevent infection, but this is not urgent.

Question 113

The client is diagnosed with peritonitis. Which assessment data indicate to the nurse the client’s condition is improving? 1. The client is using more pain medication on a daily basis. 2. The client’s nasogastric tube is draining coffee-ground material. 3. The client has a decrease in temperature and a soft abdomen. 4. The client has had two (2) soft, formed bowel movements.

Answer 113

Ans: 3. The client has a decrease in temperature and a soft abdomen. 1. The client needing more pain medica- tion indicates the client’s condition is getting worse. 2. Coffee-ground material indicates old blood from the gastrointestinal system. 3. ***Because the signs of peritonitis are elevated temperature and rigid abdomen, a reversal of these signs indicates the client is getting better.*** 4. Two soft-formed bowel movements are normal, but this does not have anything to do with peritonitis.

Question 114

The client developed a paralytic ileus after abdominal surgery. Which intervention should the nurse include in the plan of care? 1. Administer a laxative of choice. 2. Encourage client to increase oral fluids. 3. Encourage client to take deep breaths. 4. Maintain a patent nasogastric tube.

Answer 114

Ans: 4. Maintain a patent nasogastric tube. 1. The client is NPO; therefore, no med- ication would be administered. 2. The client is NPO so no food or fluids are allowed. 3. Deep breathing will help prevent pul- monary complications, but does not ad- dress the client’s paralytic ileus. 4. ***A paralytic ileus is the absence of peristalsis; therefore, the bowel will be unable to process any oral intake. A nasogastric tube is inserted to decompress the bowel until surgical intervention or until bowel sounds return spontaneously.***

Question 115

The client who had an abdominal surgery has a Jackson Pratt (JP) drainage tube. Which assessment data warrant immediate intervention by the nurse? 1. The bulb is round and has 40 mL of fluid. 2. The drainage tube is taped to the dressing. 3. The JP insertion site is pink and has no drainage. 4. The JP bulb has suction and is sunken in.

Answer 115

Ans: 1. The bulb is round and has 40 mL of fluid. 1. ***The JP bulb should be depressed, which indicates suction is being ap- plied. A round bulb indicates the bulb is full and needs to be emptied and suction reapplied.*** 2. The tube should be taped to the dressing to prevent accidentally pulling the drain out of the insertion site. 3. The insertion site should be pink and without any signs of infection, which in- clude drainage, warmth, and redness. 4. The JP bulb should be sunken in or depressed, indicating suction is being applied.

Question 116

The post-anesthesia care nurse is caring for a client who had abdominal surgery and is complaining of nausea. Which intervention should the nurse implement first? 1. Medicate the client with a narcotic analgesic IVP. 2. Assess the nasogastric tube for patency. 3. Check the temperature for elevation. 4. Hyperextend the neck to prevent stridor.

Answer 116

Ans: 2. Assess the nasogastric tube for patency. 1. Medicating the client with an analgesic could increase the client’s nausea unless the nausea is caused by pain. The nurse should assess the etiology to determine the interventions. 2. ***A client who had abdominal surgery usually has a nasogastric (N/G) tube in place. If the N/G tube is not patent, this will cause nausea. Irrigat- ing the N/G tube may relieve nausea.*** 3. Checking the temperature will not treat the nausea. 4. Hyperextending the neck will assist the client to breathe but will not treat nausea.

Question 117

The nurse is assessing the client recovering from abdominal surgery who has a PCA pump. The client has shallow respirations and refuses to deep breathe. Which in- tervention should the nurse implement? 1. Insist the client take deep breaths. 2. Notify the surgeon to request a chest x-ray. 3. Determine the last time the client used the PCA pump. 4. Administer oxygen at 2 L/min via nasal cannula.

Answer 117

Ans: 3. Determine the last time the client used the PCA pump. 1. The nurse cannot force the client to do anything; this would be considered assault. 2. There are no data to support the need for a chest x-ray. 3. ***Shallow respirations and refusal to deep breathe could be the result of abdominal pain. The nurse should assess the client for pain and determine the last time the PCA pump was used.*** 4. Based on the information given, the client does not need oxygen.

Question 118

The client has a nasogastric tube. The health-care provider orders IV fluid replace- ment based on the previous hour’s output plus the baseline IV fluid ordered of 125 mL/hr. From 0800 to 0900 the client’s N/G tube drained 45 mL. At 0900, what rate should the nurse set for the IV pump? \_\_\_\_\_\_\_

Answer 118

**Ans: 170 mL/hr.** The N/G tube drainage of 45 mL must be added to the 125 mL/hr IV rate, which equals 170 (125 + 45 = 170). The nurse should infuse 170 mL in the next hour.

Question 119

The nurse is caring for clients on a surgical unit. Which client should the nurse assess first? 1. The client who had an inguinal hernia repair and has not voided in four (4) hours. 2. The client who was admitted with abdominal pain who suddenly has no pain. 3. The client four (4) hours postoperative abdominal surgery with no bowel sounds. 4. The client who is one (1) day postappendectomy and is being discharged.

Answer 119

Ans: 2. The client who was admitted with abdominal pain who suddenly has no pain. 1. A client who has not voided within four (4) hours after any surgery is not priority. This is an acceptable occurrence, but if the client hasn’t voided for eight (8) hours, then the nurse should assess further. 2. ***A sudden cessation of pain may indi- cate a ruptured appendix, which could lead to peritonitis, a life-threatening complication; therefore, the nurse should assess this client first.*** 3. Bowel sounds should return within 4. 24 hours after abdominal surgery. Absent bowel sounds at four (4) hours postoper- ative is not of great concern to the nurse. The client being discharged is stable and not a priority for the nurse.

Question 120

The 84-year-old client comes to the clinic complaining of right lower abdominal pain. Which question is most appropriate for the nurse to ask the client? 1. “When was your last bowel movement?” 2. “Did you have a high-fat meal last night?” 3. “Can you describe the type of pain?” 4. “Have you been experiencing any gas?”

Answer 120

Ans: 3. “Can you describe the type of pain?” 1. The last bowel movement does not help identify the cause of the client’s right lower abdominal pain. This might be appropriate for a client with left lower abdominal pain. 2. Information about a high-fat meal would be asked if the nurse suspected the client had a gallbladder problem. 3. ***An elderly client may experience a ruptured appendix with minimal pain; therefore, the nurse should assess the characteristics of the pain.*** 4. The passage of flatus (gas) does not help determine the cause of right lower ab- dominal pain.

Question 121

The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented? 1. Administer an antidiarrheal medication every day and PRN. 2. Perform bowel training every two (2) hours. 3. Administer an oil retention enema. 4. Prepare for an upper gastrointestinal (UGI) series x-ray.

Answer 121

Ans: 3. Administer an oil retention enema. 1. An antidiarrheal medication would slow down the peristalsis in the colon, worsening the problem. 2. The client has an immediate need to evacuate the bowel, not a need for bowel training. 3. ***Oil retention enemas will help to soften the feces and evacuatethe stool.*** 4. A UGI series adds barium to the already hardened stool in the colon. Barium ene- mas x-ray the colon; a UGI series x-rays the stomach and jejunum.

Question 122

The nurse is caring for a client who uses cathartics frequently. Which statement made by the client indicates an understanding of the discharge teaching? 1. “In the future I will eat a banana every time I take the medication.” 2. “I don’t have to have a bowel movement every day.” 3. “I should limit the fluids I drink with my meals.” 4. “If I feel sluggish, I will eat a lot of cheese and dairy products.”

Answer 122

Ans: 2. “I don’t have to have a bowel movement every day.” 1. Bananas are encouraged for clients with potassium loss from diuretics; a banana is not needed for harsh laxative (cathartic) use. Harsh laxatives should be discour- aged because they cause laxative depend- ence and a narrowing of the colon with long-term use. 2. ***It is not necessary to have a bowel movement every day to have normal bowel functioning.*** 3. Limiting fluids will increase the prob- lem; the client should be encouraged to increase the fluids in the diet. 4. If the client is feeling “sluggish” from not being able to have a bowel move- ment, these foods increase constipation because they are low in residue (fiber).

Question 123

The client has been experiencing difficulty and straining when expelling feces. Which intervention should the nurse discuss with the client? 1. Explain some blood in the stool will be normal for the client. 2. Instruct the client in manual removal of feces. 3. Encourage the client to use a cathartic laxative on a daily basis. 4. Place the client on a high-fiber diet.

Answer 123

Ans: 4. Place the client on a high-fiber diet. 1. Blood may indicate a hemorrhoid, but it is not normal to expel blood when having a bowel movement. 2. Nurses manually remove feces; it is not a self-care activity. 3. Cathartic use on a daily basis creates dependence and a narrowing of the lumen of the colon, creating a much more serious problem. 4. ***A high-fiber (residue) diet provides bulk for the colon to use in removing the waste products of metabolism. Bulk laxatives and fiber from vegeta- bles and bran assist the colon to work more effectively.***

Question 124

The client has dark, watery, and shiny-appearing stool. Which intervention should the nurse implement first? 1. Check for a fecal impaction. 2. Encourage the client to drink fluids. 3. Check the chart for sodium and potassium levels. 4. Apply a protective barrier cream to the perianal area.

Answer 124

Ans: 1. Check for a fecal impaction. 1. ***This is a symptom of diarrhea moving around an impaction higher up in the colon. The nurse should assess for an impaction when observing this finding.*** 2. Encouraging the client to drink fluids should be done, but not the first intervention. 3. The sodium level is usually not a prob- lem for clients experiencing diarrhea, but the potassium level may be checked. However, again, this is not the first intervention. 4. A protective cream can be applied to an excoriated perineum, but first the nurse should assess the situation.

Question 125

The charge nurse has just received the shift report. Which client should the nurse see first? 1. The client diagnosed with Crohn’s disease who had two (2) semiformed stools on the previous shift. 2. The elderly client admitted from another facility who is complaining of constipation. 3. The client diagnosed with AIDS who had a 200-mL diarrhea stool and has elastic skin tissue turgor. 4. The client diagnosed with hemorrhoids who had some spotting of bright red blood on the toilet tissue.

Answer 125

Ans: 2. The elderly client admitted from another facility who is complaining of constipation. 1. This client is improving; semiformed stools are better than diarrhea. 2. ***This client has just arrived, so the nurse does not know if the complaint is valid and needs intervention unless assessed. The elderly have difficulty with constipation as a result of de- creased gastric motility, medications, poor diet, and immobility.*** 3. The client has diarrhea, but only 200 mL, and has elastic tissue turgor indicating the client is not dehydrated. 4. This is not normal, but it is expected for a client with hemorrhoids

Question 126

The dietitian and the nurse in a long-term care facility are planning the menu for the day. Which foods should be recommended for the immobile clients for whom swallowing is not an issue? 1. Cheeseburger and milk shake. 2. Canned peaches and a sandwich on whole-wheat bread. 3. Mashed potatoes and mechanically ground red meat. 4. Biscuits and gravy with bacon.

Answer 126

2. Canned peaches and a sandwich on whole-wheat bread. 1. Cheeseburgers and milk shakes are low-residue foods and can make constipation worse. 2. ***Canned peaches are soft and can be chewed and swallowed easily while providing some fiber; whole-wheat bread is higher in fiber than white bread. These foods will be helpful for clients whose gastric motility is slowed as a result of lack of exercise or immobility.*** 3. Mashed potatoes and mechanically ground meat do not provide high fiber. 4. Biscuits, gravy, and bacon are refined flour foods or processed meat (fat). These will not help clients to prevent constipation.

Question 127

The client diagnosed with AIDS is experiencing voluminous diarrhea. Which inter- ventions should the nurse implement? **Select all that apply.** 1. Monitor diarrhea, charting amount, character, and consistency. 2. Assess the client’s tissue turgor every day. 3. Encourage the client to drink carbonated soft drinks. 4. Weigh the client daily in the same clothes and at the same time. 5. Assist the client with a warm sitz bath PRN.

Answer 127

Ans: 1, 4, 5 1. Monitor diarrhea, charting amount, character, and consistency. 4. Weigh the client daily in the same clothes and at the same time. 5. Assist the client with a warm sitz bath PRN. 1. ***It is important to keep track of the amounts, color, and other characteris- tics of body fluids excreted.*** 2. Skin turgor should be assessed at least every six (6) to eight (8) hours, not daily. 3. Carbonated soft drinks increase flatus in the GI tract, and the increased sugar will act as an osmotic laxative and increase diarrhea. 4. ***Daily weights are the best method of determining fluid loss and gain.*** 5. ***Sitz baths will assist in keeping the client’s perianal area clean without having to rub. The warm water is soothing, providing comfort***

Question 128

The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task would be most appropriate to assign to the LPN? 1. Assist the UAP to learn to perform blood glucose checks. 2. Monitor the potassium levels of a client with diarrhea. 3. Administer a bulk laxative to a client diagnosed with constipation. 4. Assess the abdomen of a client who has had complaints of pain.

Answer 128

Ans: 3. Administer a bulk laxative to a client diagnosed with constipation. 1. The nurse will be responsible for signing off on the UAP as to being competent to perform the blood glucose. The nurse should do this to determine the compe- tency of the UAP. 2. The laboratory values may require the nurse to interpret and act on the results. The nurse cannot delegate tasks requir- ing professional judgment. 3. **The LPN can administer medications such as a laxative.** 4. The nurse cannot delegate assessment.

Question 129

The client is placed on percutaneous endoscopic gastrostomy (PEG) tube feedings. Which occurrence warrants immediate intervention by the nurse? 1. The client tolerates the feedings being infused at 50 mL/hr. 2. The client pulls the nasogastric feeding tube out. 3. The client complains of being thirsty. 4. The client has green, watery stool.

Answer 129

Ans: 4. The client has green, watery stool. 1. The client is tolerating the feeding change, so there is no need for an imme- diate action. 2. The client has a PEG tube inserted into the stomach through the abdominal wall. The client does not have a nasogastric feeding tube. 3. Complaints of being thirsty should be addressed; the client may require some ice chips in the mouth or oral care, but this is not priority over assessing the client’s ability to swallow. 4. ***This client needs to be cleaned im- mediately, the abdomen must be as- sessed, and a determination must be made regarding the type of feeding and the additives and medications being administered and skin damage occurring. This occurrence is priority.***

Question 130

The client presents to the emergency department experiencing frequent watery, bloody stools after eating some undercooked meat at a fast-food restaurant. Which intervention should be implemented first? 1. Obtain a stool sample from the client. 2. Initiate antibiotic therapy intravenously. 3. Have the laboratory draw a complete blood count. 4. Administer the antidiarrheal medication Lomotil.

Answer 130

Ans: 1. Obtain a stool sample from the client. 1. ***This client may have developed an in- fection from the undercooked meat. The nurse should obtain a stool spec- imen for the laboratory to analyze.*** 2. Antibiotic therapy is initiated in only the most serious cases of infectious diarrhea; the diarrhea must be assessed first. A specimen for culture should be obtained before beginning medication. 3. A complete blood count will provide an estimate of blood loss, but it is not the first intervention. 4. An antidiarrheal medication would be administered after the specimen collection.

Question 131

The clinic nurse is talking on the phone to a client who has diarrhea. Which inter- vention should the nurse discuss with the client? 1. Tell the client to measure the amount of stool. 2. Recommend the client come to the clinic immediately. 3. Explain the client should follow the BRAT diet. 4. Discuss taking an over-the-counter histamine-2 blocker.

Answer 131

Ans: 3. Explain the client should follow the BRAT diet. 1. The clinic nurse should not ask the client to measure stool at home; this is done in the acute care setting. 2. Unless the client has had diarrhea for longer than 48 hours, the client does not need to be seen in the clinic. 3. ***The BRAT (bananas, rice, applesauce, and toast) diet is recommended for a client with diarrhea because it is low residue and produces nutrition while not irritating the GI system.*** 4. Histamine-2 blockers decrease gastric acid production and would not be pre- scribed for a client with diarrhea.

Question 132

The nurse is caring for clients on a medical unit. Which client information should be brought to the attention of the HCP immediately? 1. A serum sodium of 128 mEq/L in a client diagnosed with obstipation. 2. The client diagnosed with fecal impaction who had two (2) hard formed stools. 3. A serum potassium level of 3.8 mEq/L in a client diagnosed with diarrhea. 4. The client with diarrhea who had two (2) semiliquid stools totaling 300 mL.

Answer 132

Ans: 1. A serum sodium of 128 mEq/L in a client diagnosed with obstipation. 1. ***Normal serum sodium levels are 135 to 152 mEq/L, so the client’s 128 mEq/L value requires intervention.*** 2. The client diagnosed with a fecal im- paction is beginning to move the stool; this indicates an improvement. 3. Normal potassium levels are 3.5 to 5.5 mEq/L. A level of 3.8 mEq/L is within normal limits and does not require intervention. 4. This client has been having diarrhea and now is having semiliquid stools, so this client is getting better.