Med/Surg II PrepU for Exam 2 – Flashcards

question
A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The physician has ordered a visualization of the small intestine via a capsule endoscopy. Which of the following will the nurse include in the client education about this procedure?
answer
"You will need to swallow a capsule."
question
A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?
answer
"I'll avoid eating or drinking anything 6 to 8 hours before the test."
question
Which of the following is an enzyme secreted by the gastric mucosa?
answer
Pepsin
question
A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing is:
answer
"Has he had any recent forceful vomiting?"
question
Following ingestion of carrots or beets, the nurse would expect which alteration in stool color?
answer
Red
question
When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are
answer
Normal
question
A nurse assesses the abdomen of a newly admitted client. Which finding would necessitate further investigation?
answer
Asymmetrical upper abdomen
question
A nursing instructor tells the class that review of oral hygiene is an important component during assessment of the gastrointestinal system. One of the students questions this statement. Which of the following explanations from the nurse educator is most appropriate?
answer
"Injury to oral mucosa or tooth decay can lead to difficulty in chewing food."
question
Which of the following would indicate to the nurse that a client who has received three cleansing enemas in preparation for a barium enema is experiencing dehydration?
answer
Signs of dizziness and confusion
question
A client is scheduled for an esophagogastroduodenoscopy (EGD) to detect lesions in the gastrointestinal tract. The nurse would observe for which of the following while assessing the client during the procedure?
answer
Pain and discomfort tolerance
question
Which of the following is an enzyme that begins the digestion of starches?
answer
Ptyalin
question
A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered?
answer
Permit to drink only clear liquids
question
A nurse is providing postprocedure instructions for a client who had an esophagogastroduodenoscopy. The nurse should perform which action?
answer
Review instructions with the person assisting the client home
question
A few hours after eating hot and spicy chicken wings, a client presents with lower chest pain. He wonders if he is having a heart attack. How should the nurse proceed first?
answer
Investigate the initial complaint
question
The nurse is preparing to examine the abdomen of a client complaining of a change in his bowel pattern. The nurse would place the client in which position?
answer
Supine with knees flexed
question
Which of the following is an age-related change of the gastrointestinal system?
answer
Weakened gag reflex
question
A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test?
answer
Encourage fluid intake
question
A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor?
answer
Ultrasound before GI procedure
question
A few hours after eating hot and spicy chicken wings, a client presents with lower chest pain. He wonders if he is having a heart attack. How should the nurse proceed first?
answer
Further investigate the initial complaint
question
A client is scheduled for several diagnostic tests to evaluate her gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when she identifies which test as not requiring the use of a contrast medium?
answer
Colonoscopy
question
A client is scheduled for the following tests: barium enema, small bowel series, enteroclysis enema, and an oral cholecystogram. Which test would the nurse expect the client to undergo first?
answer
Oral cholecystogram
question
The nurse is talking with a client who is scheduled for a computed tomography (CT) colonography. Which client statement would indicate to the nurse that the client needs additional teaching about this procedure?
answer
My doctor will be able to remove any polyps he finds
question
A client presents to the emergency department, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances?
answer
Metabolic alkalosis and hypokalemia
question
A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing is:
answer
"Has your partner had recent forceful vomiting?"
question
Which of the following is the primary function of the small intestine?
answer
Absorption
question
The nurse is assessing a client following laparoscopy. The client states that his stomach looks bloated and asks if this is normal. How will the nurse respond?
answer
"Yes, your abdomen may appear larger as a result of the injection of carbon dioxide for visualization."
question
A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The physician has ordered a visualization of the small intestine via a capsule endoscopy. Which of the following will the nurse include in the client education about this procedure?
answer
"You will need to swallow a capsule."
question
A client with diabetes begins to have digestive problems and is told by the physician that they are a complication of the diabetes. Which of the following explanations from the nurse is most accurate?
answer
The pancreas secretes digestive enzymes
question
Which of the following is an enzyme secreted by the gastric mucosa?
answer
Pepsin
question
A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?
answer
"I'll avoid eating or drinking anything 6 to 8 hours before the test."
question
Which of the following diagnostics is used to identify malignant cells associated with esophageal cancer?
answer
PET
question
A nurse is performing health assessment with a client during an outpatient clinic visit. The most concerning client statement to the nurse is:
answer
"Food seems to be getting stuck in my throat"
question
Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery?
answer
Vagus
question
A group of students is reviewing the medications that may be used to treat esophageal reflux. The students demonstrate understanding of the information when they identify which of the following as an example of a proton-pump inhibitor?
answer
Prilosec
question
A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. The best nursing intervention is to
answer
Instruct the client to swish prescribed nystatin (Mycostatin) solution for 1 minute.
question
The most common symptom of esophageal disease is
answer
Dysphagia
question
Which of the following is an accurate statement regarding cancer of the esophagus?
answer
Chronic irritation of the esophagus is a known risk factor
question
Which of the following is the primary symptom of achalasia?
answer
Difficulty swallowing
question
A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge?
answer
The client is free from esophagitis and achalasia.
question
A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?
answer
The client lying in a lateral position, with the head of bed flat
question
Postoperatively, a patient with a radical neck dissection should be placed in which position?
answer
Fowler's
question
A client with esophageal cancer has difficulty in swallowing. Which of the following would be appropriate to help the client achieve improved nutrition?
answer
Give high-protein, semiliquid foods
question
A client with a disorder of the oral cavity cannot tolerate tooth brushing or flossing. Which of the following strategies can the nurse employ to assist this client?
answer
Provide the client with an irrigating solution of baking soda and warm water.
question
Cancer of the esophagus is most often diagnosed by which of the following?
answer
Esophagogastroduodenoscopy (EGD) with biopsy and brushings
question
A client has a new order for metoclorpramide (Reglan). The nurse knows that this medication should not be used long term and only in cases where all other options have been exhausted. This is because this medication has the potential for extrapyramidal side effects. Extrapyramidal side effects include which of the following?
answer
Uncontrollable movement of the face and limbs
question
Halitosis and a sour taste in the mouth are clinical manifestations associated most directly with
answer
esophageal diverticula.
question
Which of the following is one of the first clinical manifestations of esophageal cancer?
answer
Increasing difficulty is swallowing
question
A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?
answer
Take long, slow breaths
question
An elderly client states, "I don't understand why I have so many caries in my teeth." The nurse assesses the following as placing the client at risk:
answer
Exhibiting hemoglobin A1C 8.2
question
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:
answer
maintaining a patent airway
question
Which of the following terms is used to describe stone formation in a salivary gland, usually the submandibular gland?
answer
Sialolithiasis
question
A client with GERD develops espophagitis. Which diagnostic test would the nurse expect the physician to order to confirm the diagnosis?
answer
Upper endoscopy with biopsy
question
A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. The first activity of the nurse is to:
answer
Assess lung sounds bilaterally
question
Which of the following is the primary symptom of achalasia?
answer
Difficulty swallowing
question
The term for a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis is a
answer
Chancre
question
Regarding oral cancer, the nurse provides health teaching to inform the patient that
answer
many oral cancers produce no symptoms in the early stages.
question
The client is postoperative following a graft reconstruction of the neck. It is most important for the nurse to
answer
Assess the graft for color and temperature
question
For a patient with salivary calculi, which of the following procedures uses shock waves to disintegrate the stone?
answer
Lithotripsy
question
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?
answer
Avoid coffee and alcoholic beverages
question
When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as:
answer
Chancre sore of the oral soft tissues
question
A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?
answer
Take slow, deep breaths
question
A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment?
answer
"I'll eat frequent, small, bland meals that are high in fiber."
question
Which of the following would be an intervention for a patient with a chemical burn to the esophagus?
answer
Insertion of nasogastric tube
question
Which of the following mouth conditions are associated with HIV infection?
answer
Karposi's Sarcoma
question
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?
answer
Metoclopramide (Reglan)
question
The client has a chancre on his lips. The nurse instructs the client to
answer
Take measures to prevent spreading to others
question
A client with cancer has a neck dissection and laryngectomy. An intervention that the nurse will do is:
answer
Make a notation in the call light system that the patient cannot speak
question
A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. The nurse instructs the client to
answer
Brush and floss daily
question
A client has a new order for metoclorpramide (Reglan). The nurse identifies that this medication can be safely administered for which conditon?
answer
GERD
question
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?
answer
Reglan
question
Which of the following is the most common symptom of gastrointestinal (GI) problems in general?
answer
Nausea
question
A nurse is assessing a client with a family history of cancer. Which finding requires immediate follow-up?
answer
A client states he feels a lump in his throat
question
A client with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by
answer
Assess lung sounds
question
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:
answer
Maintaining patent airway
question
A nurse is providing discharge instructions for a client who fell from a bicycle, resulting in a fractured jaw. The client underwent surgical intervention with rigid fixation. The nurse includes in the instruction
answer
Ways to obtain supplemental nutrition
question
Hickman and Groshong are examples of which type of central venous access devices?
answer
Tunneled central catheters
question
The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance?
answer
260 mL
question
A client has a gastrointestinal tube that enters the stomach through a surgically created opening in the abdominal wall. The nurse documents this as which of the following?
answer
Gastrostomy tube
question
A patient has a gastric sump tube inserted and attached to low intermittent suction. The physician has ordered the tube to be irrigated with 30 mL of normal saline every 6 hours. When reviewing the patient's intake and output record for the past 24 hours, the nurse would expect to note that the patient received how much fluid with the irrigation?
answer
120 mL
question
A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is
answer
Inserted into the lungs
question
Which of the following surgical procedures for obesity utilizes a prosthetic device to restrict oral intake?
answer
Gastric banding
question
Symptoms of progressive gastric cancer include which of the following?
answer
Bloating after meals
question
A nurse is monitoring a client with peptic ulcer disease. Which of the following assessment findings would most likely indicate perforation of the ulcer? Choose all that apply.
answer
• Tachycardia • Hypotension • A rigid, board-like abdomen
question
Which of the following medications is classified as a proton pump inhibitor (PPI)?
answer
Omeprazole
question
A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
answer
Drink liquids only between meals
question
A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. The nurse suspects:
answer
Vasomotor symptoms associated with dumping syndrome
question
A nurse is teaching a client with gastritis about the need to avoid the intake of caffeinated beverages. The client asks why this is so important. Which of the following explanations from the nurse would be most accurate?
answer
"Caffeine stimulates the central nervous system and thus gastric activity and secretions, which need to be minimized to promote recovery."
question
A client reports to the clinic, stating that she rapidly developed headache, abdominal pain, nausea, hiccuping, and fatigue about 2 hours ago. For dinner, she ate buffalo chicken wings and beer. Which of the following medical conditions is most consistent with the client's presenting problems?
answer
Acute gastritis
question
A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake?
answer
Six small meals daily with 120 mL fluid between meals
question
Which of the following is the most successful treatment for gastric cancer?
answer
Removal of the tumor
question
Which of the following is an enzyme secreted by the gastric mucosa?
answer
Pepsin
question
Symptoms associated with pyloric obstruction include all of the following except:
answer
Diarrhea
question
Which of the following would be an intervention for a patient with a chemical burn to the esophagus?
answer
Insert NG tube
question
A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. The nurse instructs the client to
answer
Brush and floss daily
question
A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?
answer
NPO
question
Why are antacids administered regularly, rather than as needed, in peptic ulcer disease?
answer
To maintain gastric pH at 3.0-3.5
question
A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?
answer
Take long, slow breaths
question
The nurse is caring for a man who has experienced a spinal cord injury. Throughout his recovery, the client expects to gain control of his bowels. The nurse's best response to this client would be which of the following?
answer
"Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact."
question
A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The physician has ordered a visualization of the small intestine via a capsule endoscopy. Which of the following will the nurse include in the client education about this procedure?
answer
"you will need to swallow a capsule"
question
The nurse inserts a nasoduodenal tube for feeding of the client. To check best for placement, the nurse
answer
Abdominal x-ray
question
A nurse administered a full strength feeding with an increased osmolality through a jejunostomy tube to a client. Immediately following the feeding, the client expelled a large amount of liquid brown stool and exhibited a blood pressure of 86/58 and pulse rate of 112 beats/min. The nurse
answer
Consult physician regarding decreasing to half-strength
question
As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach?
answer
4
question
The nurse determines that teaching for the client with peptic ulcer disease has been effective when the client states:
answer
"I have learned some relaxation strategies that decrease my stress."
question
A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?
answer
Intrinsic factor
question
A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, and labored breathing; the client also appears to be confused. Which of the following complications has the client most likely developed?
answer
Hemorrhage
question
Which diagnostic produces images of the body by detecting the radiation emitted from radioactive substances?
answer
PET Scan
question
A client with a feeding tube is to receive medication. The medication supplied is an enteric-coated tablet. Which of the following would be most appropriate?
answer
Check with pharmacist to see if liquid form is available
question
Which of the following appears to be a significant factor in the development of gastric cancer?
answer
Diet
question
Morbid obesity is defined as being how many pounds over the person's ideal body weight?
answer
100 lbs
question
Which of the following would be the highest priority, immediate nursing intervention for a client just diagnosed with acute gastritis?
answer
Provide physical and emotional support
question
The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, would the nurse question?
answer
Indocin
question
The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also complains of unpleasant tastes and odors. Which of the following measures should be included in the client's plan of care?
answer
Provide frequent mouth care
question
Which of the following medications requires the nurse to contact the pharmacist in consultation when the patient receives all oral medications by feeding tube?
answer
Enteric coated tablets
question
A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. It is best for the nurse to
answer
Notify the surgeon about the tube's removal
question
A nurse is teaching a client who has experienced an episode of acute gastritis and knows further education is necessary when the client makes the following statement:
answer
"My appetite should come back tomorrow"
question
Initially, which diagnostic should be completed following placement of a NG tube?
answer
x-ray
question
The following appears on the medical record of a male patient receiving parenteral nutrition: WBC: 6500/cu mm Potassium 4.3 mEq/L Magnesium 2.0 mg/dL Calcium 8.8 mg/dL Glucose 190 mg/dL Which finding would alert the nurse to a problem?
answer
Glucose level
question
A client is prescribed tetracycline to treat peptic ulcer disease. Which of the following instructions would the nurse give the client?
answer
"Be sure to wear sunscreen when taking this medication"
question
A client with peptic ulcer disease must begin triple medication therapy. For how long will the client follow this regimen?
answer
10-14 days
question
A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to
answer
Auscultate lungs every 4 hours
question
The patient is on a continuous tube feeding. The tube placement should be checked every
answer
Shift
question
A client has been receiving intermittent tube feedings for several days at home. The nurse notes the findings as shown in the accompanying documentation. The nurse reports the following as an adverse reaction to the tube feeding:
answer
Blood glucose level
question
When caring for a client with an acute exacerbation of a peptic ulcer, the nurse finds the client doubled up in bed with severe pain to his right shoulder. The intial appropriate action by the nurse is to
answer
Assess abdomen and vitals
question
The nurse is caring for a client who underwent a subtotal gastrectomy 36 hours ago. The client has a nasogastric (NG) tube. The nurse knows to do the following with the NG:
answer
Irrigate the NG tube with NS if ordered
question
Which of the following is caused by improper catheter placement and inadvertent puncture of the pleura?
answer
Pneumothorax
question
Clients with Type O blood are at higher risk for which of the following GI disorders?
answer
Duodenal ulcers
question
The nurse is to discontinue a nasogastric tube that had been used for decompression. The first thing the nurse does is
answer
Flush with 10 mL of water
question
A client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond?
answer
Notify the physician
question
A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
answer
Drink liquids only between meals
question
A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply.
answer
• Remove gas and fluids from the stomach • Diagnose gastrointestinal motility disorders • Flush ingested toxins from the stomach • Administer nutritional substances
question
A client newly diagnosed with acute lymphocytic leukemia has a right subclavian central venous catheter in place. The nurse who's caring for the client is teaching a graduate nurse about central venous catheter care. The nurse should instruct the graduate nurse to change the central venous catheter dressing every:
answer
48 hours
question
Rebleeding may occur from a peptic ulcer and often warrants surgical interventions. Signs of bleeding include which of the following?
answer
Mental confusion
question
When assessing whether a patient is a candidate for home parenteral nutrition, which of the following would be important to address? Select all that apply.
answer
• Health status • Family support • Motivation for learning • Telephone access
question
To ensure patency of central venous line ports, diluted heparin flushes are used in which of the following situations?
answer
Daily, when not in use
question
A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and makes a recommendation when noting the following:
answer
No land line; cell phone available and taken by family member during working hours
question
A nurse measures the residual gastric volume of a patient receiving intermittent tube feedings. The patient's last residual volume was 250 mL. Which finding would lead the nurse to notify the physician?
answer
225 mL
question
A client who underwent abdominal surgery and has a nasogastric (NG) tube in place begins to complain of abdominal pain that he describes as "feeling full and uncomfortable." Which assessment should the nurse perform first?
answer
Assess patency of the NG tube
question
When a central venous catheter dressing becomes moist or loose, what should a nurse do first?
answer
Remove the dressing, clean the site, and apply a new dressing.
question
A nurse is preparing to administer a 500 mL bolus tube feeding to a patient. The nurse anticipates administering this feeding over which time frame?
answer
10-15 minutes
question
A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate?
answer
Hang a solution of dextrose 10% and water until the new solution is available.
question
Which of the following venous access devices can be used for less than 6 weeks in patients requiring parenteral nutrition?
answer
Non-tunneled catheter
question
A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. She should:
answer
turn the client on his left side and place the bed in Trendelenburg's position.
question
A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely?
answer
Excess fluid volume
question
A client with a nasogastric tube set to low intermittent suction is receiving D51/2NS at 100 mL/hr. The nurse has identified a nursing diagnosis of deficient fluid volume. Which of the following are data that support this diagnosis? Select all that apply.
answer
• Urine output that decreased from 60 to 40 mL/hr • Heart rate that increased from 82 to 98 beats/min within 2 hours • Fluid output of 2150 mL and total fluid intake of 2000 mL for the past 24 hours
question
A client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement (select all options that apply):
answer
Checks the pH of the gastric contents • Compares exposed tube length with original measurement • Visually assesses the color of the aspirate
question
A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for:
answer
diaphoresis, vomiting, and diarrhea.
question
A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube.
answer
Sit the client in an upright position Apply gloves to the nurse's hands Measure the length of the tube that will be inserted Apply water-soluble lubricant to the tip of the tube Tilt the client's nose upward Instruct the client to lower the head and swallow
question
A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. The nurse does all of the following. Select all that apply.
answer
• Ensures availability of an infusion pump • Ensures completion of baseline monitoring of the complete blood count (CBC) and chemistry panel • Places a 1.5-micron filter on the tubing
question
Which of the following is a nasoenteric feeding tube?
answer
Dobhoff
question
If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?
answer
Clamp the catheter
question
The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department for chest pain. The client was diagnosed as having gastroesophageal reflux disease. The nurse notes in the client's record that the client is taking carbidopa/levodopa (Sinemet). The nurse questions the physician's order for
answer
metoclopramide
question
The primary source of microorganisms for catheter-related infections are the skin and which of the following?
answer
Catheter hub
question
Which of the following is an age-related change of the gastrointestinal system?
answer
Weakened gag reflex
question
A client admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. Discharge teaching should include which instruction?
answer
"Continue to take antacids even if your symptoms subside."
question
A nurse is performing discharge teaching with a client who had a total gastrectomy. Which statement indicates the need for further teaching?
answer
"I will have to take vitamin B12 shots up to 1 year after surgery."
question
Which of the following venous access devices can be used for less than 6 weeks in patients requiring parenteral nutrition?
answer
Nontunneled catheter
question
A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered?
answer
Permit the client to drink only clear liquids.
question
A client has a new order for metoclorpramide (Reglan). The nurse identifies that this medication should not be used long term and only in cases where all other options have been exhausted. This is because this medication has what type of potential side effect?
answer
Extrapyramidal
question
Rebound hypoglycemia is a complication of parental nutrition caused by which of the following?
answer
Feedings stopped too abruptly
question
A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use?
answer
30 mL
question
A client with a peptic ulcer is diagnosed with Heliobacter pylori infection. The nurse is teaching the client about the medications prescribed, including metronidazole (Flagyl), omeprazole (Prilosec), and clarithromycin (Biaxin). Which statement by the client indicates the best understanding of the medication regimen?
answer
"The medications will kill the bacteria and stop the acid production."
question
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?
answer
Reglan
question
When gastric analysis testing reveals excess secretion of gastric acid, which of the following medical diagnoses is supported?
answer
Duodenal ulcer
question
A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate?
answer
"It is a vent that prevents backflow of the secretions."
question
A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube.
answer
Sit the client in an upright position Apply gloves to the nurse's hands Measure the length of the tube that will be inserted Apply water-soluble lubricant to the tip of the tube Tilt the client's nose upward Instruct the client to lower the head and swallow
question
When describing the role of the pancreas to a client with a pancreatic dysfunction, the nurse would identify which substance as being acted on by pancreatic lipase?
answer
Triglycerides
question
A physician suspects that a client has peptic ulcer disease. With which of the following diagnostic procedures would the nurse most likely prepare to assist?
answer
Endoscopy
question
Which of the following are functions of saliva? Select all that apply.
answer
• Lubrication • Digestion • Protection against harmful bacteria
question
Which of the following ulcers is associated with extensive burn injury?
answer
Curling's Ulcer
question
A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours?
answer
80-120 mL
question
Which of the following is the most common presenting symptom of colon cancer?
answer
Change in bowel habits
question
Which type of jaundice seen in adults is the result of increased destruction of red blood cells?
answer
Hemolytic
question
A client with complaints of right lower quadrant pain is admitted to the emergency department. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the physician immediately?
answer
White blood cell (WBC) count 22.8/mm3
question
In what location would the nurse palpate for the liver?
answer
Right upper quadrant
question
Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction?
answer
Sudden, sustained abdominal pain
question
Which of the following enzymes aids in the digestion of fats?
answer
Lipase
question
A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma?
answer
"At first, the stoma may bleed slightly when touched."
question
A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?
answer
Relieving abdominal pain
question
A critical care nurse is caring for a client with pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system?
answer
Maintain the client in a semi-Fowler's position.
question
A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?
answer
Liver biopsy
question
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?
answer
Take a stool softener such as docusate sodium (Colace) daily.
question
Which client requires immediate nursing intervention? The client who:
answer
presents with a rigid, boardlike abdomen.
question
Patients with chronic liver dysfunction have problems with insufficient vitamin intake. Which of the following may occur as a result of vitamin C deficiency?
answer
Scurvy
question
A nurse is preparing a client for surgery. During preoperative teaching, the client asks where is bile stored. The nurse knows that bile is stored in the:
answer
Gallbladder
question
The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?
answer
Purpura and petechiae
question
The mode of transmission of hepatitis A virus (HAV) includes which of the following?
answer
Fecal-oral
question
Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?
answer
Hot roast beef sandwich with gravy
question
A 67-year-old client is returning for a follow-up appointment to the primary care group where you practice nursing. At his last appointment, he received the diagnosis of portal hypertension and the physician instituted interventions to begin treatment of this condition. What is the primary aim of portal hypertension treatment? Choose all correct options.
answer
• Reduce fluid accumulation • Reduce venous pressure
question
Which of the following would be most appropriate for a client who is experiencing biliary colic?
answer
Ensure that the client rests.
question
The nurse is assessing a patient for constipation. Which of the following is the first review that the nurse should conduct in order to identify the cause of constipation?
answer
Usual pattern of elimination
question
When interviewing a client with internal hemorrhoids, which of the following would the nurse expect the client to report?
answer
Rectal Bleeding
question
Which of the following is a true statement regarding regional enteritis (Crohn's disease)?
answer
The clusters of ulcers take on a cobblestone appearance.
question
A client is being treated for diverticulosis. Which of the following points should the nurse include in this client's teaching plan? Choose all correct options.
answer
• Drink at least 8 to 10 large glasses of fluid every day. • Do not suppress the urge to defecate.
question
In women, which of the following types of cancer exceeds colorectal cancer?
answer
Breast
question
Which of the following will the nurse observe as symptoms of perforation in a client with intestinal obstruction? Choose all that apply.
answer
• Sudden, sustained abdominal pain • Abdominal distention
question
A longitudinal tear or ulceration in the lining of the anal canal is termed a (an)
answer
Anal fissure
question
The nurse is assessing a patient for constipation. Which of the following is the first review that the nurse should conduct in order to identify the cause of constipation?
answer
Usual pattern of elimination
question
Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction?
answer
Sudden, sustained abdominal pain
question
A 68-year-old resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. She receives nutrition via a PEG tube. The client remains physically and socially active and has adapted well to the tube feedings. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. Which of the following is the most likely cause of this client's constipation?
answer
Lack of free water intake
question
The nurse is assessing a client for constipation. Which of the following is the first review that the nurse should conduct in order to identify the cause of constipation? Choose the correct option.
answer
Review the client's usual pattern of elimination
question
A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care?
answer
Test for occult blood
question
The nurse is caring for a patient diagnosed with abdominal perforation. Which of the following is a clinical manifestation of this disease process?
answer
Hypotension
question
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?
answer
Take a stool softener such as docusate sodium (Colace) daily.
question
Vomiting results in which of the following acid-base imbalances?
answer
Metabolic alkalosis
question
A client with anorexia complains of constipation. Which of the following nursing measures would be most effective in helping the client reduce constipation?
answer
Assist client to increase dietary fiber.
question
Which of the following is the most common symptom of a polyp?
answer
Rectal bleeding
question
Which client requires immediate nursing intervention? The client who:
answer
presents with a rigid, boardlike abdomen.
question
A client is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult?
answer
"I didn't eat anything I shouldn't have; I just ate roast beef on rye bread."
question
A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma?
answer
"At first, the stoma may bleed slightly when touched."
question
A patient with an ileostomy should avoid which of the following?
answer
Enteric coated tablets
question
Pharmacologic therapy frequently is used to dissolve small gallstones. It takes about how many months of medication with UDCA or CDCA for stones to dissolve?
answer
6-12 months
question
A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?
answer
Loss of 1 kg in 24 hours
question
When caring for a patient with cirrhosis, which of the following symptoms should the nurse report immediately?
answer
Change in mental status
question
Which of the following is clinical manifestation of cholelithiasis?
answer
Clay colored stools
question
A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?
answer
A client's hepatic function is decreasing
question
A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions?
answer
Hepatic encephalopathy
question
A critical care nurse is caring for a client with acute pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system?
answer
Maintain patient in Semi-Fowlers position
question
A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?
answer
Liver biopsy
question
A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:
answer
Cirrhosis
question
Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia?
answer
Hypotension
question
When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function?
answer
Irritability and drowsiness
question
The nursing student has just reviewed material in the course textbook regarding pancreatitis. The student knows that a major symptom of pancreatitis that causes the client to seek medical care is:
answer
Severe abdominal pain
question
A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?
answer
Acute pain r/t biliary spasms
question
Which of the following medications would the nurse expect the physician to order for a client with cirrhosis who develops portal hypertension?
answer
Aldactone
question
When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?
answer
Measure abdominal girth according to a set routine.
question
When reviewing the history of a client with pancreatic cancer, the nurse would identify which of the following as a possible risk factor?
answer
History of pancreatitis
question
Which of the following is the most effective strategy to prevent hepatitis B infection?
answer
Vaccine
question
Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes melitus. Which of the following explains the cause of this secondary diabetes?
answer
Dysfunction of the pancreatic islet cells
question
The digestion of carbohydrates is aided by
answer
Amylase
question
A nurse is preparing a client for surgery. During preoperative teaching, the client asks where is bile stored. The nurse knows that bile is stored in the:
answer
Gallbladder
question
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?
answer
Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
question
Patients diagnosed with malabsorption syndrome may have vitamin and mineral deficiency. Patient who easily bleed have which of the following deficiencies?
answer
Vitamin K
question
Which of the following is considered a bulk-forming laxative?
answer
Metamucil
question
A nurse is preparing a presentation for a local community group of older adults about colon cancer. Which of the following would the nurse include as the primary characteristic associated with this disorder?
answer
A change in bowel habits
question
A patient with an ileostomy should avoid which of the following?
answer
Enteric coated tablets
question
Which outcome indicates effective client teaching to prevent constipation?
answer
The client reports engaging in a regular exercise regimen.
question
Which of the following is one of the primary symptoms of Irritable Bowel Syndrome (IBS)?
answer
Diarrhea
question
An elderly patient diagnosed with diarrhea is taking digoxin (Lanoxin). Which of the following electrolyte imbalances should the nurse be alert to?
answer
Hypokalemia
question
Which of the following is a true statement regarding regional enteritis (Crohn's disease)?
answer
The clusters of ulcers take on a cobblestone appearance.
question
A 68-year-old resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. She receives nutrition via a PEG tube. The client remains physically and socially active and has adapted well to the tube feedings. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. Which of the following is the most likely cause of this client's constipation?
answer
Lack of free water intake
question
A client is being treated for diverticulosis. Which of the following points should the nurse include in this client's teaching plan? Choose all correct options.
answer
• Drink at least 8 to 10 large glasses of fluid every day. • Do not suppress the urge to defecate.
question
A client with a pilonidal sinus undergoes surgery. Which of the following would the nurse include in the client's postoperative plan of care?
answer
Repacking the surgical wound
question
When interviewing a client with internal hemorrhoids, which of the following would the nurse expect the client to report?
answer
Rectal bleeding
question
Which of the following is considered a stimulant laxative?
answer
Dulcolax
question
A client with appendicitis is experiencing excruciating abdominal pain. An abdominal X-ray film reveals intraperitoneal air. The nurse should prepare the client for:
answer
Surgery
question
A patient underwent a continent ileostomy. Within which timeframe should the patient expect to empty the reservoir?
answer
Every 4 to 6 hours
question
A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of:
answer
increasing fluid intake to prevent dehydration.
question
A patient is being treated for diverticulosis. Which of the following information should the nurse include in this patient's teaching plan?
answer
Drink at least 8 to 10 large glasses of fluid every day
question
After teaching a group of students about irritable bowel syndrome and antidiarrheal agents, the instructor determines that the teaching was effective when the students identify which of the following as an example of an opiate-related antidiarrheal agent?
answer
Immodium
question
A home health nurse who sees a client with diverticulitis is evaluating teaching about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching?
answer
"I should increase my intake of fresh fruits and vegetables during remissions."
question
Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?
answer
Hot roast beef sandwich with gravy
question
The digestion of carbohydrates is aided by
answer
Amylase
question
A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?
answer
Acute pain related to biliary spasms
question
The nurse is caring for a client with hepatitis. Which of the following would lead the nurse to suspect that the client is in the prodromal phase?
answer
Rash
question
Which of the following enzymes aids in the digestion of fats?
answer
Lipase
question
Which type of deficiency results in macrocytic anemia?
answer
Folic Acid
question
This example of cholesterol gallstones (left side of picture) is the result of decreased bile acid synthesis and increased cholesterol synthesis in the liver, which in turn, form stones. Cholesterol stones account for what percentage of cases of gallbladder disease in the United States?
answer
75%
question
A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client?
answer
Vasopressin (Pitressin)
question
When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?
answer
Measuring abdominal girth
question
A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?
answer
Liver biopsy
question
A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:
answer
Yellow sclerae
question
A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?
answer
The client's hepatic function is decreasing.
question
A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk?
answer
Use incentive spirometry every hour.
question
A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client?
answer
Vitamin A
question
A nurse has admitted a client suspected of having acute pancreatitis. The nurse knows that mild acute pancreatitis is characterized by:
answer
Edema and inflammation
question
A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions?
answer
Hepatic encephalopathy
question
Which type of jaundice seen in adults is the result of increased destruction of red blood cells?
answer
Hemolytic
question
A student nurse is preparing a plan of care for a client with chronic pancreatitis. What nursing diagnosis related to the care of a client with chronic pancreatitis is the priority?
answer
Impaired nutrition: less than body requirements
question
The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?
answer
Purpura and petechiae
question
A patient has undergone a liver biopsy. Which of the following postprocedure positions is appropriate?
answer
On the right side
question
A 72-year-old client seeks help for chronic constipation. Constipation is a common problem for elderly clients because of several factors related to aging, including:
answer
decreased abdominal strength.
question
A nurse is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, blood pressure of 100/80 mm Hg, pulse rate of 88 beats/minute, respiratory rate of 20 breaths/minute, temperature 100° F (37.8° C). The nurse suspects the client will be diagnosed with:
answer
IBD
question
A client realizes that regular use of laxatives has greatly improved his bowel pattern. However, the nurse cautions this client against the prolonged use of laxatives for which reason?
answer
The client's natural bowel function may become sluggish.
question
Celiac sprue is an example of which category of malabsorption?
answer
Mucosal disorders causing generalized malabsorption
question
Vomiting results in which of the following acid-base imbalances?
answer
Metabolic alkalosis
question
Which of the following is the most effective strategy to prevent hepatitis B infection?
answer
Vaccine
question
A client with cirrhosis has been referred to hospice care. Assessment data reveal a need to discuss nutrition with the client. What is the nurse's priority intervention?
answer
Discuss meals that include low-fat high-carbohydrate content.
question
A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions?
answer
Hepatic encephalopathy
question
A patient has undergone a liver biopsy. Which of the following postprocedure positions is appropriate?
answer
on the right side
question
A mother brings her teenage son to the clinic, where tests show that he has hepatitis A virus (HAV). They ask the nurse how this could have happened. Which of the following explanations would the nurse correctly identify as possible causes? Select all that apply.
answer
• Infection at school • Suboptimal sanitary habits • Consumption of sewage-contaminated water or shellfish • Sexual activity
question
A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?
answer
Liver biopsy
question
A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations?
answer
Hepatic encephalopathy
question
A 67-year-old client is returning for a follow-up appointment to the primary care group where you practice nursing. At his last appointment, he received the diagnosis of portal hypertension and the physician instituted interventions to begin treatment of this condition. What is the primary aim of portal hypertension treatment? Choose all correct options.
answer
• Reduce venous pressure • Reduce fluid accumulation
question
A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal?
answer
Albumin
question
A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is:
answer
subnormal serum glucose and elevated serum ammonia levels.
question
Which of the following would the nurse expect to assess in a client with hepatic encephalopathy?
answer
Asterixis
question
Which of the following laboratory test results would the nurse associate with obstructive jaundice?
answer
Increased direct bilirubin
question
A client with cirrhosis is at risk for developing esophageal varices. Which of the following instructions should a nurse provide the client to minimize such risk?
answer
Minimize alcohol use
question
Which of the following terms describes the involuntary flapping movements of the hands associated with metabolic liver dysfunction?
answer
Asterixis
question
Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following?
answer
Ammonia
question
When caring for a client with cirrhosis, which of the following should a nurse notify immediately? Choose all correct options.
answer
• Change in mental status • Signs of GI bleeding
question
A physician has ordered a liver biopsy for a client whose condition is deteriorating. Which of the following places the client at high risk due to her altered liver function during the biopsy?
answer
Low platelet count
question
While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the possibility of liver problems? Select all that apply.
answer
• Ecchymoses • Jaundice • Petechiae
question
Gynecomastia is a common side effect of which of the following diuretics?
answer
Spironolactone (Aldactone)
question
A client is given a diagnosis of hepatic cirrhosis. The client asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? Select all that apply.
answer
• Enlarged liver size • Ascites • Hemorrhoids
question
After undergoing a liver biopsy, a client should be placed in which position?
answer
Right lateral decubitus position
question
A 67-year-old client is returning for a follow-up appointment to the primary care group where you practice nursing. At his last appointment, he received the diagnosis of portal hypertension and the physician instituted interventions to begin treatment of this condition. What is the primary aim of portal hypertension treatment? Choose all correct options.
answer
• Reduce venous pressure • Reduce fluid accumulation
question
A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should:
answer
wash her hands after touching the client.
question
Which of the following the are early manifestations of liver cancer? Select all that apply.
answer
• Pain • Continuous aching in the back
question
Which type of positioning should be utilized for a patient undergoing a paracentesis?
answer
Upright at the edge of the bed
question
A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client?
answer
Vasopressin
question
A nurse is taking health history data from a client. Use of which of the following medications would especially alert the nurse to an increased risk of hepatic dysfunction and disease in this client? Select all that apply.
answer
• Acetaminophen • Ketoconazole • Valproic acid
question
Which of the following medications are used to decrease portal pressure, halting bleeding of esophageal varices?
answer
Vasopressin
question
A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should the nurse administer to the client before surgery?
answer
Packed RBCs
question
A nursing student has learned about many collaborative interventions to achieve pain relief for clients with acute pancreatitis. Which of the following are appropriate? Choose all that apply.
answer
• Encourage bed rest to decrease the client's metabolic rate. • Teach the client about the correlation between alcohol intake and pain. • Withhold oral feedings to limit the release of secretin.
question
A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find?
answer
Elevated urine amylase levels
question
The nurse would expect to observe which of the following when assessing a client with cholelithiasis?
answer
Urine that appears dark brown
question
A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should the nurse include in her teaching plan?
answer
Increase respiratory effectiveness
question
The nurse should assess for an important early indicator of acute pancreatitis, which is a prolonged and elevated level of:
answer
Serum lipase
question
A nurse is caring for a client in the emergency department who is complaining of severe abdominal pain. The client is diagnosed with acute pancreatitis. Which laboratory value requires immediate intervention?
answer
Troponin of 2.3 mcg/L
question
Which of the following is the major cause of morbidity and mortality in patients with acute pancreatitis?
answer
Pancreatic necrosis
question
The nurse knows that the client with cholelithiasis can have a nutritional deficiency. The obstruction of bile flow due to cholelitiasis can interfere with the absorption of
answer
Vitamin A
question
A nursing instructor is lecturing to a class about chronic pancreatitis. Which of the following does the instructor list as major causes?
answer
Alcohol consumption and smokig
question
A client with pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate?
answer
Reserving an antecubital site for a peripherally inserted central catheter (PICC)
question
A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct?
answer
"Maintain a high-carbohydrate, low-fat diet."
question
What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
answer
Deficient fluid volume
question
A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk?
answer
Reposition q 2hrs
question
Which of the following is a gerontological consideration associated with the pancreas?
answer
Increase in fibrous material
1 of

Unlock all answers in this set

Unlock answers
question
A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The physician has ordered a visualization of the small intestine via a capsule endoscopy. Which of the following will the nurse include in the client education about this procedure?
answer
"You will need to swallow a capsule."
question
A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?
answer
"I'll avoid eating or drinking anything 6 to 8 hours before the test."
question
Which of the following is an enzyme secreted by the gastric mucosa?
answer
Pepsin
question
A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing is:
answer
"Has he had any recent forceful vomiting?"
question
Following ingestion of carrots or beets, the nurse would expect which alteration in stool color?
answer
Red
question
When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are
answer
Normal
question
A nurse assesses the abdomen of a newly admitted client. Which finding would necessitate further investigation?
answer
Asymmetrical upper abdomen
question
A nursing instructor tells the class that review of oral hygiene is an important component during assessment of the gastrointestinal system. One of the students questions this statement. Which of the following explanations from the nurse educator is most appropriate?
answer
"Injury to oral mucosa or tooth decay can lead to difficulty in chewing food."
question
Which of the following would indicate to the nurse that a client who has received three cleansing enemas in preparation for a barium enema is experiencing dehydration?
answer
Signs of dizziness and confusion
question
A client is scheduled for an esophagogastroduodenoscopy (EGD) to detect lesions in the gastrointestinal tract. The nurse would observe for which of the following while assessing the client during the procedure?
answer
Pain and discomfort tolerance
question
Which of the following is an enzyme that begins the digestion of starches?
answer
Ptyalin
question
A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered?
answer
Permit to drink only clear liquids
question
A nurse is providing postprocedure instructions for a client who had an esophagogastroduodenoscopy. The nurse should perform which action?
answer
Review instructions with the person assisting the client home
question
A few hours after eating hot and spicy chicken wings, a client presents with lower chest pain. He wonders if he is having a heart attack. How should the nurse proceed first?
answer
Investigate the initial complaint
question
The nurse is preparing to examine the abdomen of a client complaining of a change in his bowel pattern. The nurse would place the client in which position?
answer
Supine with knees flexed
question
Which of the following is an age-related change of the gastrointestinal system?
answer
Weakened gag reflex
question
A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test?
answer
Encourage fluid intake
question
A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor?
answer
Ultrasound before GI procedure
question
A few hours after eating hot and spicy chicken wings, a client presents with lower chest pain. He wonders if he is having a heart attack. How should the nurse proceed first?
answer
Further investigate the initial complaint
question
A client is scheduled for several diagnostic tests to evaluate her gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when she identifies which test as not requiring the use of a contrast medium?
answer
Colonoscopy
question
A client is scheduled for the following tests: barium enema, small bowel series, enteroclysis enema, and an oral cholecystogram. Which test would the nurse expect the client to undergo first?
answer
Oral cholecystogram
question
The nurse is talking with a client who is scheduled for a computed tomography (CT) colonography. Which client statement would indicate to the nurse that the client needs additional teaching about this procedure?
answer
My doctor will be able to remove any polyps he finds
question
A client presents to the emergency department, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances?
answer
Metabolic alkalosis and hypokalemia
question
A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing is:
answer
"Has your partner had recent forceful vomiting?"
question
Which of the following is the primary function of the small intestine?
answer
Absorption
question
The nurse is assessing a client following laparoscopy. The client states that his stomach looks bloated and asks if this is normal. How will the nurse respond?
answer
"Yes, your abdomen may appear larger as a result of the injection of carbon dioxide for visualization."
question
A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The physician has ordered a visualization of the small intestine via a capsule endoscopy. Which of the following will the nurse include in the client education about this procedure?
answer
"You will need to swallow a capsule."
question
A client with diabetes begins to have digestive problems and is told by the physician that they are a complication of the diabetes. Which of the following explanations from the nurse is most accurate?
answer
The pancreas secretes digestive enzymes
question
Which of the following is an enzyme secreted by the gastric mucosa?
answer
Pepsin
question
A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?
answer
"I'll avoid eating or drinking anything 6 to 8 hours before the test."
question
Which of the following diagnostics is used to identify malignant cells associated with esophageal cancer?
answer
PET
question
A nurse is performing health assessment with a client during an outpatient clinic visit. The most concerning client statement to the nurse is:
answer
"Food seems to be getting stuck in my throat"
question
Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery?
answer
Vagus
question
A group of students is reviewing the medications that may be used to treat esophageal reflux. The students demonstrate understanding of the information when they identify which of the following as an example of a proton-pump inhibitor?
answer
Prilosec
question
A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. The best nursing intervention is to
answer
Instruct the client to swish prescribed nystatin (Mycostatin) solution for 1 minute.
question
The most common symptom of esophageal disease is
answer
Dysphagia
question
Which of the following is an accurate statement regarding cancer of the esophagus?
answer
Chronic irritation of the esophagus is a known risk factor
question
Which of the following is the primary symptom of achalasia?
answer
Difficulty swallowing
question
A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge?
answer
The client is free from esophagitis and achalasia.
question
A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?
answer
The client lying in a lateral position, with the head of bed flat
question
Postoperatively, a patient with a radical neck dissection should be placed in which position?
answer
Fowler's
question
A client with esophageal cancer has difficulty in swallowing. Which of the following would be appropriate to help the client achieve improved nutrition?
answer
Give high-protein, semiliquid foods
question
A client with a disorder of the oral cavity cannot tolerate tooth brushing or flossing. Which of the following strategies can the nurse employ to assist this client?
answer
Provide the client with an irrigating solution of baking soda and warm water.
question
Cancer of the esophagus is most often diagnosed by which of the following?
answer
Esophagogastroduodenoscopy (EGD) with biopsy and brushings
question
A client has a new order for metoclorpramide (Reglan). The nurse knows that this medication should not be used long term and only in cases where all other options have been exhausted. This is because this medication has the potential for extrapyramidal side effects. Extrapyramidal side effects include which of the following?
answer
Uncontrollable movement of the face and limbs
question
Halitosis and a sour taste in the mouth are clinical manifestations associated most directly with
answer
esophageal diverticula.
question
Which of the following is one of the first clinical manifestations of esophageal cancer?
answer
Increasing difficulty is swallowing
question
A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?
answer
Take long, slow breaths
question
An elderly client states, "I don't understand why I have so many caries in my teeth." The nurse assesses the following as placing the client at risk:
answer
Exhibiting hemoglobin A1C 8.2
question
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:
answer
maintaining a patent airway
question
Which of the following terms is used to describe stone formation in a salivary gland, usually the submandibular gland?
answer
Sialolithiasis
question
A client with GERD develops espophagitis. Which diagnostic test would the nurse expect the physician to order to confirm the diagnosis?
answer
Upper endoscopy with biopsy
question
A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. The first activity of the nurse is to:
answer
Assess lung sounds bilaterally
question
Which of the following is the primary symptom of achalasia?
answer
Difficulty swallowing
question
The term for a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis is a
answer
Chancre
question
Regarding oral cancer, the nurse provides health teaching to inform the patient that
answer
many oral cancers produce no symptoms in the early stages.
question
The client is postoperative following a graft reconstruction of the neck. It is most important for the nurse to
answer
Assess the graft for color and temperature
question
For a patient with salivary calculi, which of the following procedures uses shock waves to disintegrate the stone?
answer
Lithotripsy
question
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?
answer
Avoid coffee and alcoholic beverages
question
When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as:
answer
Chancre sore of the oral soft tissues
question
A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?
answer
Take slow, deep breaths
question
A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment?
answer
"I'll eat frequent, small, bland meals that are high in fiber."
question
Which of the following would be an intervention for a patient with a chemical burn to the esophagus?
answer
Insertion of nasogastric tube
question
Which of the following mouth conditions are associated with HIV infection?
answer
Karposi's Sarcoma
question
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?
answer
Metoclopramide (Reglan)
question
The client has a chancre on his lips. The nurse instructs the client to
answer
Take measures to prevent spreading to others
question
A client with cancer has a neck dissection and laryngectomy. An intervention that the nurse will do is:
answer
Make a notation in the call light system that the patient cannot speak
question
A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. The nurse instructs the client to
answer
Brush and floss daily
question
A client has a new order for metoclorpramide (Reglan). The nurse identifies that this medication can be safely administered for which conditon?
answer
GERD
question
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?
answer
Reglan
question
Which of the following is the most common symptom of gastrointestinal (GI) problems in general?
answer
Nausea
question
A nurse is assessing a client with a family history of cancer. Which finding requires immediate follow-up?
answer
A client states he feels a lump in his throat
question
A client with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by
answer
Assess lung sounds
question
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:
answer
Maintaining patent airway
question
A nurse is providing discharge instructions for a client who fell from a bicycle, resulting in a fractured jaw. The client underwent surgical intervention with rigid fixation. The nurse includes in the instruction
answer
Ways to obtain supplemental nutrition
question
Hickman and Groshong are examples of which type of central venous access devices?
answer
Tunneled central catheters
question
The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance?
answer
260 mL
question
A client has a gastrointestinal tube that enters the stomach through a surgically created opening in the abdominal wall. The nurse documents this as which of the following?
answer
Gastrostomy tube
question
A patient has a gastric sump tube inserted and attached to low intermittent suction. The physician has ordered the tube to be irrigated with 30 mL of normal saline every 6 hours. When reviewing the patient's intake and output record for the past 24 hours, the nurse would expect to note that the patient received how much fluid with the irrigation?
answer
120 mL
question
A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is
answer
Inserted into the lungs
question
Which of the following surgical procedures for obesity utilizes a prosthetic device to restrict oral intake?
answer
Gastric banding
question
Symptoms of progressive gastric cancer include which of the following?
answer
Bloating after meals
question
A nurse is monitoring a client with peptic ulcer disease. Which of the following assessment findings would most likely indicate perforation of the ulcer? Choose all that apply.
answer
• Tachycardia • Hypotension • A rigid, board-like abdomen
question
Which of the following medications is classified as a proton pump inhibitor (PPI)?
answer
Omeprazole
question
A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
answer
Drink liquids only between meals
question
A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. The nurse suspects:
answer
Vasomotor symptoms associated with dumping syndrome
question
A nurse is teaching a client with gastritis about the need to avoid the intake of caffeinated beverages. The client asks why this is so important. Which of the following explanations from the nurse would be most accurate?
answer
"Caffeine stimulates the central nervous system and thus gastric activity and secretions, which need to be minimized to promote recovery."
question
A client reports to the clinic, stating that she rapidly developed headache, abdominal pain, nausea, hiccuping, and fatigue about 2 hours ago. For dinner, she ate buffalo chicken wings and beer. Which of the following medical conditions is most consistent with the client's presenting problems?
answer
Acute gastritis
question
A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake?
answer
Six small meals daily with 120 mL fluid between meals
question
Which of the following is the most successful treatment for gastric cancer?
answer
Removal of the tumor
question
Which of the following is an enzyme secreted by the gastric mucosa?
answer
Pepsin
question
Symptoms associated with pyloric obstruction include all of the following except:
answer
Diarrhea
question
Which of the following would be an intervention for a patient with a chemical burn to the esophagus?
answer
Insert NG tube
question
A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. The nurse instructs the client to
answer
Brush and floss daily
question
A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?
answer
NPO
question
Why are antacids administered regularly, rather than as needed, in peptic ulcer disease?
answer
To maintain gastric pH at 3.0-3.5
question
A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?
answer
Take long, slow breaths
question
The nurse is caring for a man who has experienced a spinal cord injury. Throughout his recovery, the client expects to gain control of his bowels. The nurse's best response to this client would be which of the following?
answer
"Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact."
question
A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The physician has ordered a visualization of the small intestine via a capsule endoscopy. Which of the following will the nurse include in the client education about this procedure?
answer
"you will need to swallow a capsule"
question
The nurse inserts a nasoduodenal tube for feeding of the client. To check best for placement, the nurse
answer
Abdominal x-ray
question
A nurse administered a full strength feeding with an increased osmolality through a jejunostomy tube to a client. Immediately following the feeding, the client expelled a large amount of liquid brown stool and exhibited a blood pressure of 86/58 and pulse rate of 112 beats/min. The nurse
answer
Consult physician regarding decreasing to half-strength
question
As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach?
answer
4
question
The nurse determines that teaching for the client with peptic ulcer disease has been effective when the client states:
answer
"I have learned some relaxation strategies that decrease my stress."
question
A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?
answer
Intrinsic factor
question
A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, and labored breathing; the client also appears to be confused. Which of the following complications has the client most likely developed?
answer
Hemorrhage
question
Which diagnostic produces images of the body by detecting the radiation emitted from radioactive substances?
answer
PET Scan
question
A client with a feeding tube is to receive medication. The medication supplied is an enteric-coated tablet. Which of the following would be most appropriate?
answer
Check with pharmacist to see if liquid form is available
question
Which of the following appears to be a significant factor in the development of gastric cancer?
answer
Diet
question
Morbid obesity is defined as being how many pounds over the person's ideal body weight?
answer
100 lbs
question
Which of the following would be the highest priority, immediate nursing intervention for a client just diagnosed with acute gastritis?
answer
Provide physical and emotional support
question
The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, would the nurse question?
answer
Indocin
question
The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also complains of unpleasant tastes and odors. Which of the following measures should be included in the client's plan of care?
answer
Provide frequent mouth care
question
Which of the following medications requires the nurse to contact the pharmacist in consultation when the patient receives all oral medications by feeding tube?
answer
Enteric coated tablets
question
A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. It is best for the nurse to
answer
Notify the surgeon about the tube's removal
question
A nurse is teaching a client who has experienced an episode of acute gastritis and knows further education is necessary when the client makes the following statement:
answer
"My appetite should come back tomorrow"
question
Initially, which diagnostic should be completed following placement of a NG tube?
answer
x-ray
question
The following appears on the medical record of a male patient receiving parenteral nutrition: WBC: 6500/cu mm Potassium 4.3 mEq/L Magnesium 2.0 mg/dL Calcium 8.8 mg/dL Glucose 190 mg/dL Which finding would alert the nurse to a problem?
answer
Glucose level
question
A client is prescribed tetracycline to treat peptic ulcer disease. Which of the following instructions would the nurse give the client?
answer
"Be sure to wear sunscreen when taking this medication"
question
A client with peptic ulcer disease must begin triple medication therapy. For how long will the client follow this regimen?
answer
10-14 days
question
A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to
answer
Auscultate lungs every 4 hours
question
The patient is on a continuous tube feeding. The tube placement should be checked every
answer
Shift
question
A client has been receiving intermittent tube feedings for several days at home. The nurse notes the findings as shown in the accompanying documentation. The nurse reports the following as an adverse reaction to the tube feeding:
answer
Blood glucose level
question
When caring for a client with an acute exacerbation of a peptic ulcer, the nurse finds the client doubled up in bed with severe pain to his right shoulder. The intial appropriate action by the nurse is to
answer
Assess abdomen and vitals
question
The nurse is caring for a client who underwent a subtotal gastrectomy 36 hours ago. The client has a nasogastric (NG) tube. The nurse knows to do the following with the NG:
answer
Irrigate the NG tube with NS if ordered
question
Which of the following is caused by improper catheter placement and inadvertent puncture of the pleura?
answer
Pneumothorax
question
Clients with Type O blood are at higher risk for which of the following GI disorders?
answer
Duodenal ulcers
question
The nurse is to discontinue a nasogastric tube that had been used for decompression. The first thing the nurse does is
answer
Flush with 10 mL of water
question
A client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond?
answer
Notify the physician
question
A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
answer
Drink liquids only between meals
question
A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply.
answer
• Remove gas and fluids from the stomach • Diagnose gastrointestinal motility disorders • Flush ingested toxins from the stomach • Administer nutritional substances
question
A client newly diagnosed with acute lymphocytic leukemia has a right subclavian central venous catheter in place. The nurse who's caring for the client is teaching a graduate nurse about central venous catheter care. The nurse should instruct the graduate nurse to change the central venous catheter dressing every:
answer
48 hours
question
Rebleeding may occur from a peptic ulcer and often warrants surgical interventions. Signs of bleeding include which of the following?
answer
Mental confusion
question
When assessing whether a patient is a candidate for home parenteral nutrition, which of the following would be important to address? Select all that apply.
answer
• Health status • Family support • Motivation for learning • Telephone access
question
To ensure patency of central venous line ports, diluted heparin flushes are used in which of the following situations?
answer
Daily, when not in use
question
A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and makes a recommendation when noting the following:
answer
No land line; cell phone available and taken by family member during working hours
question
A nurse measures the residual gastric volume of a patient receiving intermittent tube feedings. The patient's last residual volume was 250 mL. Which finding would lead the nurse to notify the physician?
answer
225 mL
question
A client who underwent abdominal surgery and has a nasogastric (NG) tube in place begins to complain of abdominal pain that he describes as "feeling full and uncomfortable." Which assessment should the nurse perform first?
answer
Assess patency of the NG tube
question
When a central venous catheter dressing becomes moist or loose, what should a nurse do first?
answer
Remove the dressing, clean the site, and apply a new dressing.
question
A nurse is preparing to administer a 500 mL bolus tube feeding to a patient. The nurse anticipates administering this feeding over which time frame?
answer
10-15 minutes
question
A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate?
answer
Hang a solution of dextrose 10% and water until the new solution is available.
question
Which of the following venous access devices can be used for less than 6 weeks in patients requiring parenteral nutrition?
answer
Non-tunneled catheter
question
A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. She should:
answer
turn the client on his left side and place the bed in Trendelenburg's position.
question
A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely?
answer
Excess fluid volume
question
A client with a nasogastric tube set to low intermittent suction is receiving D51/2NS at 100 mL/hr. The nurse has identified a nursing diagnosis of deficient fluid volume. Which of the following are data that support this diagnosis? Select all that apply.
answer
• Urine output that decreased from 60 to 40 mL/hr • Heart rate that increased from 82 to 98 beats/min within 2 hours • Fluid output of 2150 mL and total fluid intake of 2000 mL for the past 24 hours
question
A client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement (select all options that apply):
answer
Checks the pH of the gastric contents • Compares exposed tube length with original measurement • Visually assesses the color of the aspirate
question
A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for:
answer
diaphoresis, vomiting, and diarrhea.
question
A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube.
answer
Sit the client in an upright position Apply gloves to the nurse's hands Measure the length of the tube that will be inserted Apply water-soluble lubricant to the tip of the tube Tilt the client's nose upward Instruct the client to lower the head and swallow
question
A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. The nurse does all of the following. Select all that apply.
answer
• Ensures availability of an infusion pump • Ensures completion of baseline monitoring of the complete blood count (CBC) and chemistry panel • Places a 1.5-micron filter on the tubing
question
Which of the following is a nasoenteric feeding tube?
answer
Dobhoff
question
If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?
answer
Clamp the catheter
question
The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department for chest pain. The client was diagnosed as having gastroesophageal reflux disease. The nurse notes in the client's record that the client is taking carbidopa/levodopa (Sinemet). The nurse questions the physician's order for
answer
metoclopramide
question
The primary source of microorganisms for catheter-related infections are the skin and which of the following?
answer
Catheter hub
question
Which of the following is an age-related change of the gastrointestinal system?
answer
Weakened gag reflex
question
A client admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. Discharge teaching should include which instruction?
answer
"Continue to take antacids even if your symptoms subside."
question
A nurse is performing discharge teaching with a client who had a total gastrectomy. Which statement indicates the need for further teaching?
answer
"I will have to take vitamin B12 shots up to 1 year after surgery."
question
Which of the following venous access devices can be used for less than 6 weeks in patients requiring parenteral nutrition?
answer
Nontunneled catheter
question
A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered?
answer
Permit the client to drink only clear liquids.
question
A client has a new order for metoclorpramide (Reglan). The nurse identifies that this medication should not be used long term and only in cases where all other options have been exhausted. This is because this medication has what type of potential side effect?
answer
Extrapyramidal
question
Rebound hypoglycemia is a complication of parental nutrition caused by which of the following?
answer
Feedings stopped too abruptly
question
A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use?
answer
30 mL
question
A client with a peptic ulcer is diagnosed with Heliobacter pylori infection. The nurse is teaching the client about the medications prescribed, including metronidazole (Flagyl), omeprazole (Prilosec), and clarithromycin (Biaxin). Which statement by the client indicates the best understanding of the medication regimen?
answer
"The medications will kill the bacteria and stop the acid production."
question
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?
answer
Reglan
question
When gastric analysis testing reveals excess secretion of gastric acid, which of the following medical diagnoses is supported?
answer
Duodenal ulcer
question
A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate?
answer
"It is a vent that prevents backflow of the secretions."
question
A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube.
answer
Sit the client in an upright position Apply gloves to the nurse's hands Measure the length of the tube that will be inserted Apply water-soluble lubricant to the tip of the tube Tilt the client's nose upward Instruct the client to lower the head and swallow
question
When describing the role of the pancreas to a client with a pancreatic dysfunction, the nurse would identify which substance as being acted on by pancreatic lipase?
answer
Triglycerides
question
A physician suspects that a client has peptic ulcer disease. With which of the following diagnostic procedures would the nurse most likely prepare to assist?
answer
Endoscopy
question
Which of the following are functions of saliva? Select all that apply.
answer
• Lubrication • Digestion • Protection against harmful bacteria
question
Which of the following ulcers is associated with extensive burn injury?
answer
Curling's Ulcer
question
A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours?
answer
80-120 mL
question
Which of the following is the most common presenting symptom of colon cancer?
answer
Change in bowel habits
question
Which type of jaundice seen in adults is the result of increased destruction of red blood cells?
answer
Hemolytic
question
A client with complaints of right lower quadrant pain is admitted to the emergency department. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the physician immediately?
answer
White blood cell (WBC) count 22.8/mm3
question
In what location would the nurse palpate for the liver?
answer
Right upper quadrant
question
Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction?
answer
Sudden, sustained abdominal pain
question
Which of the following enzymes aids in the digestion of fats?
answer
Lipase
question
A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma?
answer
"At first, the stoma may bleed slightly when touched."
question
A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?
answer
Relieving abdominal pain
question
A critical care nurse is caring for a client with pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system?
answer
Maintain the client in a semi-Fowler's position.
question
A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?
answer
Liver biopsy
question
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?
answer
Take a stool softener such as docusate sodium (Colace) daily.
question
Which client requires immediate nursing intervention? The client who:
answer
presents with a rigid, boardlike abdomen.
question
Patients with chronic liver dysfunction have problems with insufficient vitamin intake. Which of the following may occur as a result of vitamin C deficiency?
answer
Scurvy
question
A nurse is preparing a client for surgery. During preoperative teaching, the client asks where is bile stored. The nurse knows that bile is stored in the:
answer
Gallbladder
question
The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?
answer
Purpura and petechiae
question
The mode of transmission of hepatitis A virus (HAV) includes which of the following?
answer
Fecal-oral
question
Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?
answer
Hot roast beef sandwich with gravy
question
A 67-year-old client is returning for a follow-up appointment to the primary care group where you practice nursing. At his last appointment, he received the diagnosis of portal hypertension and the physician instituted interventions to begin treatment of this condition. What is the primary aim of portal hypertension treatment? Choose all correct options.
answer
• Reduce fluid accumulation • Reduce venous pressure
question
Which of the following would be most appropriate for a client who is experiencing biliary colic?
answer
Ensure that the client rests.
question
The nurse is assessing a patient for constipation. Which of the following is the first review that the nurse should conduct in order to identify the cause of constipation?
answer
Usual pattern of elimination
question
When interviewing a client with internal hemorrhoids, which of the following would the nurse expect the client to report?
answer
Rectal Bleeding
question
Which of the following is a true statement regarding regional enteritis (Crohn's disease)?
answer
The clusters of ulcers take on a cobblestone appearance.
question
A client is being treated for diverticulosis. Which of the following points should the nurse include in this client's teaching plan? Choose all correct options.
answer
• Drink at least 8 to 10 large glasses of fluid every day. • Do not suppress the urge to defecate.
question
In women, which of the following types of cancer exceeds colorectal cancer?
answer
Breast
question
Which of the following will the nurse observe as symptoms of perforation in a client with intestinal obstruction? Choose all that apply.
answer
• Sudden, sustained abdominal pain • Abdominal distention
question
A longitudinal tear or ulceration in the lining of the anal canal is termed a (an)
answer
Anal fissure
question
The nurse is assessing a patient for constipation. Which of the following is the first review that the nurse should conduct in order to identify the cause of constipation?
answer
Usual pattern of elimination
question
Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction?
answer
Sudden, sustained abdominal pain
question
A 68-year-old resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. She receives nutrition via a PEG tube. The client remains physically and socially active and has adapted well to the tube feedings. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. Which of the following is the most likely cause of this client's constipation?
answer
Lack of free water intake
question
The nurse is assessing a client for constipation. Which of the following is the first review that the nurse should conduct in order to identify the cause of constipation? Choose the correct option.
answer
Review the client's usual pattern of elimination
question
A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care?
answer
Test for occult blood
question
The nurse is caring for a patient diagnosed with abdominal perforation. Which of the following is a clinical manifestation of this disease process?
answer
Hypotension
question
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?
answer
Take a stool softener such as docusate sodium (Colace) daily.
question
Vomiting results in which of the following acid-base imbalances?
answer
Metabolic alkalosis
question
A client with anorexia complains of constipation. Which of the following nursing measures would be most effective in helping the client reduce constipation?
answer
Assist client to increase dietary fiber.
question
Which of the following is the most common symptom of a polyp?
answer
Rectal bleeding
question
Which client requires immediate nursing intervention? The client who:
answer
presents with a rigid, boardlike abdomen.
question
A client is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult?
answer
"I didn't eat anything I shouldn't have; I just ate roast beef on rye bread."
question
A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma?
answer
"At first, the stoma may bleed slightly when touched."
question
A patient with an ileostomy should avoid which of the following?
answer
Enteric coated tablets
question
Pharmacologic therapy frequently is used to dissolve small gallstones. It takes about how many months of medication with UDCA or CDCA for stones to dissolve?
answer
6-12 months
question
A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?
answer
Loss of 1 kg in 24 hours
question
When caring for a patient with cirrhosis, which of the following symptoms should the nurse report immediately?
answer
Change in mental status
question
Which of the following is clinical manifestation of cholelithiasis?
answer
Clay colored stools
question
A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?
answer
A client's hepatic function is decreasing
question
A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions?
answer
Hepatic encephalopathy
question
A critical care nurse is caring for a client with acute pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system?
answer
Maintain patient in Semi-Fowlers position
question
A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?
answer
Liver biopsy
question
A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:
answer
Cirrhosis
question
Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia?
answer
Hypotension
question
When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function?
answer
Irritability and drowsiness
question
The nursing student has just reviewed material in the course textbook regarding pancreatitis. The student knows that a major symptom of pancreatitis that causes the client to seek medical care is:
answer
Severe abdominal pain
question
A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?
answer
Acute pain r/t biliary spasms
question
Which of the following medications would the nurse expect the physician to order for a client with cirrhosis who develops portal hypertension?
answer
Aldactone
question
When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?
answer
Measure abdominal girth according to a set routine.
question
When reviewing the history of a client with pancreatic cancer, the nurse would identify which of the following as a possible risk factor?
answer
History of pancreatitis
question
Which of the following is the most effective strategy to prevent hepatitis B infection?
answer
Vaccine
question
Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes melitus. Which of the following explains the cause of this secondary diabetes?
answer
Dysfunction of the pancreatic islet cells
question
The digestion of carbohydrates is aided by
answer
Amylase
question
A nurse is preparing a client for surgery. During preoperative teaching, the client asks where is bile stored. The nurse knows that bile is stored in the:
answer
Gallbladder
question
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?
answer
Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
question
Patients diagnosed with malabsorption syndrome may have vitamin and mineral deficiency. Patient who easily bleed have which of the following deficiencies?
answer
Vitamin K
question
Which of the following is considered a bulk-forming laxative?
answer
Metamucil
question
A nurse is preparing a presentation for a local community group of older adults about colon cancer. Which of the following would the nurse include as the primary characteristic associated with this disorder?
answer
A change in bowel habits
question
A patient with an ileostomy should avoid which of the following?
answer
Enteric coated tablets
question
Which outcome indicates effective client teaching to prevent constipation?
answer
The client reports engaging in a regular exercise regimen.
question
Which of the following is one of the primary symptoms of Irritable Bowel Syndrome (IBS)?
answer
Diarrhea
question
An elderly patient diagnosed with diarrhea is taking digoxin (Lanoxin). Which of the following electrolyte imbalances should the nurse be alert to?
answer
Hypokalemia
question
Which of the following is a true statement regarding regional enteritis (Crohn's disease)?
answer
The clusters of ulcers take on a cobblestone appearance.
question
A 68-year-old resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. She receives nutrition via a PEG tube. The client remains physically and socially active and has adapted well to the tube feedings. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. Which of the following is the most likely cause of this client's constipation?
answer
Lack of free water intake
question
A client is being treated for diverticulosis. Which of the following points should the nurse include in this client's teaching plan? Choose all correct options.
answer
• Drink at least 8 to 10 large glasses of fluid every day. • Do not suppress the urge to defecate.
question
A client with a pilonidal sinus undergoes surgery. Which of the following would the nurse include in the client's postoperative plan of care?
answer
Repacking the surgical wound
question
When interviewing a client with internal hemorrhoids, which of the following would the nurse expect the client to report?
answer
Rectal bleeding
question
Which of the following is considered a stimulant laxative?
answer
Dulcolax
question
A client with appendicitis is experiencing excruciating abdominal pain. An abdominal X-ray film reveals intraperitoneal air. The nurse should prepare the client for:
answer
Surgery
question
A patient underwent a continent ileostomy. Within which timeframe should the patient expect to empty the reservoir?
answer
Every 4 to 6 hours
question
A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of:
answer
increasing fluid intake to prevent dehydration.
question
A patient is being treated for diverticulosis. Which of the following information should the nurse include in this patient's teaching plan?
answer
Drink at least 8 to 10 large glasses of fluid every day
question
After teaching a group of students about irritable bowel syndrome and antidiarrheal agents, the instructor determines that the teaching was effective when the students identify which of the following as an example of an opiate-related antidiarrheal agent?
answer
Immodium
question
A home health nurse who sees a client with diverticulitis is evaluating teaching about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching?
answer
"I should increase my intake of fresh fruits and vegetables during remissions."
question
Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?
answer
Hot roast beef sandwich with gravy
question
The digestion of carbohydrates is aided by
answer
Amylase
question
A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?
answer
Acute pain related to biliary spasms
question
The nurse is caring for a client with hepatitis. Which of the following would lead the nurse to suspect that the client is in the prodromal phase?
answer
Rash
question
Which of the following enzymes aids in the digestion of fats?
answer
Lipase
question
Which type of deficiency results in macrocytic anemia?
answer
Folic Acid
question
This example of cholesterol gallstones (left side of picture) is the result of decreased bile acid synthesis and increased cholesterol synthesis in the liver, which in turn, form stones. Cholesterol stones account for what percentage of cases of gallbladder disease in the United States?
answer
75%
question
A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client?
answer
Vasopressin (Pitressin)
question
When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?
answer
Measuring abdominal girth
question
A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?
answer
Liver biopsy
question
A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:
answer
Yellow sclerae
question
A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?
answer
The client's hepatic function is decreasing.
question
A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk?
answer
Use incentive spirometry every hour.
question
A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client?
answer
Vitamin A
question
A nurse has admitted a client suspected of having acute pancreatitis. The nurse knows that mild acute pancreatitis is characterized by:
answer
Edema and inflammation
question
A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions?
answer
Hepatic encephalopathy
question
Which type of jaundice seen in adults is the result of increased destruction of red blood cells?
answer
Hemolytic
question
A student nurse is preparing a plan of care for a client with chronic pancreatitis. What nursing diagnosis related to the care of a client with chronic pancreatitis is the priority?
answer
Impaired nutrition: less than body requirements
question
The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?
answer
Purpura and petechiae
question
A patient has undergone a liver biopsy. Which of the following postprocedure positions is appropriate?
answer
On the right side
question
A 72-year-old client seeks help for chronic constipation. Constipation is a common problem for elderly clients because of several factors related to aging, including:
answer
decreased abdominal strength.
question
A nurse is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, blood pressure of 100/80 mm Hg, pulse rate of 88 beats/minute, respiratory rate of 20 breaths/minute, temperature 100° F (37.8° C). The nurse suspects the client will be diagnosed with:
answer
IBD
question
A client realizes that regular use of laxatives has greatly improved his bowel pattern. However, the nurse cautions this client against the prolonged use of laxatives for which reason?
answer
The client's natural bowel function may become sluggish.
question
Celiac sprue is an example of which category of malabsorption?
answer
Mucosal disorders causing generalized malabsorption
question
Vomiting results in which of the following acid-base imbalances?
answer
Metabolic alkalosis
question
Which of the following is the most effective strategy to prevent hepatitis B infection?
answer
Vaccine
question
A client with cirrhosis has been referred to hospice care. Assessment data reveal a need to discuss nutrition with the client. What is the nurse's priority intervention?
answer
Discuss meals that include low-fat high-carbohydrate content.
question
A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions?
answer
Hepatic encephalopathy
question
A patient has undergone a liver biopsy. Which of the following postprocedure positions is appropriate?
answer
on the right side
question
A mother brings her teenage son to the clinic, where tests show that he has hepatitis A virus (HAV). They ask the nurse how this could have happened. Which of the following explanations would the nurse correctly identify as possible causes? Select all that apply.
answer
• Infection at school • Suboptimal sanitary habits • Consumption of sewage-contaminated water or shellfish • Sexual activity
question
A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?
answer
Liver biopsy
question
A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations?
answer
Hepatic encephalopathy
question
A 67-year-old client is returning for a follow-up appointment to the primary care group where you practice nursing. At his last appointment, he received the diagnosis of portal hypertension and the physician instituted interventions to begin treatment of this condition. What is the primary aim of portal hypertension treatment? Choose all correct options.
answer
• Reduce venous pressure • Reduce fluid accumulation
question
A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal?
answer
Albumin
question
A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is:
answer
subnormal serum glucose and elevated serum ammonia levels.
question
Which of the following would the nurse expect to assess in a client with hepatic encephalopathy?
answer
Asterixis
question
Which of the following laboratory test results would the nurse associate with obstructive jaundice?
answer
Increased direct bilirubin
question
A client with cirrhosis is at risk for developing esophageal varices. Which of the following instructions should a nurse provide the client to minimize such risk?
answer
Minimize alcohol use
question
Which of the following terms describes the involuntary flapping movements of the hands associated with metabolic liver dysfunction?
answer
Asterixis
question
Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following?
answer
Ammonia
question
When caring for a client with cirrhosis, which of the following should a nurse notify immediately? Choose all correct options.
answer
• Change in mental status • Signs of GI bleeding
question
A physician has ordered a liver biopsy for a client whose condition is deteriorating. Which of the following places the client at high risk due to her altered liver function during the biopsy?
answer
Low platelet count
question
While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the possibility of liver problems? Select all that apply.
answer
• Ecchymoses • Jaundice • Petechiae
question
Gynecomastia is a common side effect of which of the following diuretics?
answer
Spironolactone (Aldactone)
question
A client is given a diagnosis of hepatic cirrhosis. The client asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? Select all that apply.
answer
• Enlarged liver size • Ascites • Hemorrhoids
question
After undergoing a liver biopsy, a client should be placed in which position?
answer
Right lateral decubitus position
question
A 67-year-old client is returning for a follow-up appointment to the primary care group where you practice nursing. At his last appointment, he received the diagnosis of portal hypertension and the physician instituted interventions to begin treatment of this condition. What is the primary aim of portal hypertension treatment? Choose all correct options.
answer
• Reduce venous pressure • Reduce fluid accumulation
question
A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should:
answer
wash her hands after touching the client.
question
Which of the following the are early manifestations of liver cancer? Select all that apply.
answer
• Pain • Continuous aching in the back
question
Which type of positioning should be utilized for a patient undergoing a paracentesis?
answer
Upright at the edge of the bed
question
A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client?
answer
Vasopressin
question
A nurse is taking health history data from a client. Use of which of the following medications would especially alert the nurse to an increased risk of hepatic dysfunction and disease in this client? Select all that apply.
answer
• Acetaminophen • Ketoconazole • Valproic acid
question
Which of the following medications are used to decrease portal pressure, halting bleeding of esophageal varices?
answer
Vasopressin
question
A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should the nurse administer to the client before surgery?
answer
Packed RBCs
question
A nursing student has learned about many collaborative interventions to achieve pain relief for clients with acute pancreatitis. Which of the following are appropriate? Choose all that apply.
answer
• Encourage bed rest to decrease the client's metabolic rate. • Teach the client about the correlation between alcohol intake and pain. • Withhold oral feedings to limit the release of secretin.
question
A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find?
answer
Elevated urine amylase levels
question
The nurse would expect to observe which of the following when assessing a client with cholelithiasis?
answer
Urine that appears dark brown
question
A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should the nurse include in her teaching plan?
answer
Increase respiratory effectiveness
question
The nurse should assess for an important early indicator of acute pancreatitis, which is a prolonged and elevated level of:
answer
Serum lipase
question
A nurse is caring for a client in the emergency department who is complaining of severe abdominal pain. The client is diagnosed with acute pancreatitis. Which laboratory value requires immediate intervention?
answer
Troponin of 2.3 mcg/L
question
Which of the following is the major cause of morbidity and mortality in patients with acute pancreatitis?
answer
Pancreatic necrosis
question
The nurse knows that the client with cholelithiasis can have a nutritional deficiency. The obstruction of bile flow due to cholelitiasis can interfere with the absorption of
answer
Vitamin A
question
A nursing instructor is lecturing to a class about chronic pancreatitis. Which of the following does the instructor list as major causes?
answer
Alcohol consumption and smokig
question
A client with pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate?
answer
Reserving an antecubital site for a peripherally inserted central catheter (PICC)
question
A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct?
answer
"Maintain a high-carbohydrate, low-fat diet."
question
What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
answer
Deficient fluid volume
question
A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk?
answer
Reposition q 2hrs
question
Which of the following is a gerontological consideration associated with the pancreas?
answer
Increase in fibrous material