Gi Reviewer

Download as doc, pdf, or txt
Download as doc, pdf, or txt
You are on page 1of 79

GI SYSTEM DISORDERS NLEX QUESTIONS

1. Nurse Berlinda is assigned to a 41-year-old client who has a diagnosis of chronic pancreatitis. The
nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level
of:

45 units/L

100 units/L

300 units/L

500 units/L

2. A male client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid
diet. The client is looking forward to the diet change because he has been “bored” with the clear liquid
diet. The nurse would offer which full liquid item to the client?

Tea

Gelatin

Custard

Popsicle

3. Nurse Juvy is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the
nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has
the best understanding of the dietary measures to follow if the client states an intension to increase the
intake of:

Pork

Milk

Chicken

Broccoli
4. Nurse Oliver checks for residual before administering a bolus tube feeding to a client with a
nasogastric tube and obtains a residual amount of 150 mL. What is appropriate action for the nurse to
take?

Hold the feeding

Reinstill the amount and continue with administering the feeding

Elevate the client’s head at least 45 degrees and administer the feeding

Discard the residual amount and proceed with administering the feeding

5. A nurse is inserting a nasogastric tube in an adult male client. During the procedure, the client begins
to cough and has difficulty breathing. Which of the following is the appropriate nursing action?

Quickly insert the tube

Notify the physician immediately

Remove the tube and reinsert when the respiratory distress subsides

Pull back on the tube and wait until the respiratory distress subsides

6. Nurse Ryan is assessing for correct placement of a nosogartric tube. The nurse aspirates the stomach
contents and check the contents for pH. The nurse verifies correct tube placement if which pH value is
noted?

3.5

7.0

7.35

7.5

7. A nurse is preparing to remove a nasogartric tube from a female client. The nurse should instruct the
client to do which of the following just before the nurse removes the tube?

Exhale

Inhale and exhale quickly


Take and hold a deep breath

Perform a Valsalva maneuver

8. Nurse Joy is preparing to administer medication through a nasogastric tube that is connected to
suction. To administer the medication, the nurse would:

Position the client supine to assist in medication absorption

Aspirate the nasogastric tube after medication administration to maintain patency

Clamp the nasogastric tube for 30 minutes following administration of the medication

Change the suction setting to low intermittent suction for 30 minutes after medication administration

9. A nurse is preparing to care for a female client with esophageal varices who has just has a Sengstaken-
Blakemore tube inserted. The nurse gathers supplies, knowing that which of the following items must be
kept at the bedside at all times?

An obturator

Kelly clamp

An irrigation set

A pair of scissors

10. Dr. Smith has determined that the client with hepatitis has contracted the infection form
contaminated food. The nurse understands that this client is most likely experiencing what type of
hepatitis?

Hepatitis A

Hepatitis B

Hepatitis C

Hepatitis D

11. A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this
diagnosis?

Elevated hemoglobin level


Elevated serum bilirubin level

Elevated blood urea nitrogen level

Decreased erythrocycle sedimentation rate

12. The nurse is reviewing the physician’s orders written for a male client admitted to the hospital with
acute pancreatitis. Which physician order should the nurse question if noted on the client’s chart?

NPO status

Nasogastric tube inserted

Morphine sulfate for pain

An anticholinergic medication

13. A female client being seen in a physician’s office has just been scheduled for a barium swallow the
next day. The nurse writes down which instruction for the client to follow before the test?

Fast for 8 hours before the test

Eat a regular supper and breakfast

Continue to take all oral medications as scheduled

Monitor own bowel movement pattern for constipation

14. The nurse is performing an abdominal assessment and inspects the skin of the abdomen. The nurse
performs which assessment technique next?

Palpates the abdomen for size

Palpates the liver at the right rib margin

Listens to bowel sounds in all for quadrants

Percusses the right lower abdominal quadrant


15. Polyethylene glycol-electrlyte solution (GoLYTELY) is prescribed for the female client scheduled for a
colonoscopy. The client begins to experience diarrhea following administration of the solution. What
action by the nurse is appropriate?

Start an IV infusion

Administer an enema

Cancel the diagnostic test

Explain that diarrhea is expected

16. The nurse is caring for a male client with a diagnosis of chronic gastritis. The nurse monitors the
client knowing that this client is at risk for which vitamin deficiency?

Vitamin A

Vitamin B12

Vitamin C

Vitamin E

17. The nurse is reviewing the medication record of a female client with acute gastritis. Which
medication, if noted on the client’s record, would the nurse question?

Digoxin (Lanoxin)

Furosemide (Lasix)

Indomethacin (Indocin)

Propranolol hydrochloride (Inderal)

18. The nurse is assessing a male client 24 hours following a cholecystectomy. The nurse noted that the
T tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is
appropriate?

Clamp the T tube

Irrigate the T tube


Notify the physician

Document the findings

19. The nurse is monitoring a female client with a diagnosis of peptic ulcer. Which assessment findings
would most likely indicate perforation of the ulcer?

Bradycardia

Numbness in the legs

Nausea and vomiting

A rigid, board-like abdomen

20. A male client with a peptic ulcer is scheduled for a vagotomy and the client asks the nurse about the
purpose of this procedure. Which response by the nurse best describes the purpose of a vagotomy?

Halts stress reactions

Heals the gastric mucosa

Reduces the stimulus to acid secretions

Decreases food absorption in the stomach

21. The nurse is caring for a female client following a Billroth II procedure. Which postoperative order
should the nurse question and verify?

Leg exercises

Early ambulation

Irrigating the nasogastric tube

Coughing and deep-breathing exercises

22. The nurse is providing discharge instructions to a male client following gastrectomy and instructs the
client to take which measure to assist in preventing dumping syndrome?
Ambulate following a meal

Eat high carbohydrate foods

Limit the fluid taken with meal

Sit in a high-Fowler’s position during meals

23. The nurse is monitoring a female client for the early signs and symptoms of dumping syndrome.
Which of the following indicate this occurrence?

Sweating and pallor

Bradycardia and indigestion

Double vision and chest pain

Abdominal cramping and pain

24. The nurse is preparing a discharge teaching plan for the male client who had umbilical hernia repair.
What should the nurse include in the plan?

Irrigating the drain

Avoiding coughing

Maintaining bed rest

Restricting pain medication

25. The nurse is instructing the male client who has an inguinal hernia repair how to reduce
postoperative swelling following the procedure. What should the nurse tell the client?

Limit oral fluid

Elevate the scrotum

Apply heat to the abdomen

Remain in a low-fiber diet

26. The nurse is caring for a hospitalized female client with a diagnosis of ulcerative colitis. Which
finding, if noted on assessment of the client, would the nurse report to the physician?
Hypotension

Bloody diarrhea

Rebound tenderness

A hemoglobin level of 12 mg/dL

27. The nurse is caring for a male client postoperatively following creation of a colostomy. Which nursing
diagnosis should the nurse include in the plan of care?

Sexual dysfunction

Body image, disturbed

Fear related to poor prognosis

Nutrition: more than body requirements, imbalanced

28. The nurse is reviewing the record of a female client with Crohn’s disease. Which stool characteristics
should the nurse expect to note documented in the client’s record?

Diarrhea

Chronic constipation

Constipation alternating with diarrhea

Stools constantly oozing form the rectum

29. The nurse is performing a colostomy irrigation on a male client. During the irrigation, the client
begins to complain of abdominal cramps. What is the appropriate nursing action?

Notify the physician

Stop the irrigation temporarily

Increase the height of the irrigation

Medicate for pain and resume the irrigation


30. The nurse is teaching a female client how to perform a colostomy irrigation. To enhance the
effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to
do?

Increase fluid intake

Place heat on the abdomen

Perform the irrigation in the evening

Reduce the amount of irrigation solution

31. A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient’s
blood pressure because of which change that is associated with the liver failure?

Hypoalbuminemia

Increased capillary permeability

Abnormal peripheral vasodilation

Excess rennin release from the kidneys

32. You’re assessing the stoma of a patient with a healthy, well-healed colostomy. You expect the stoma
to appear:

Pale, pink and moist

Red and moist

Dark or purple colored

Dry and black

33. You’re caring for a patient with a sigmoid colostomy. The stool from this colostomy is:

Formed

Semisolid

Semiliquid
Watery

34. You’re advising a 21 y.o. with a colostomy who reports problems with flatus. What food should you
recommend?

Peas

Cabbage

Broccoli

Yogurt

35. You have to teach ostomy self care to a patient with a colostomy. You tell the patient to measure
and cut the wafer:

To the exact size of the stoma.

About 1/16” larger than the stoma.

About 1/8” larger than the stoma.

About 1/4″ larger than the stoma.

36. You’re performing an abdominal assessment on Brent who is 52 y.o. In which order do you
proceed?

Observation, percussion, palpation, auscultation

Observation, auscultation, percussion, palpation

Percussion, palpation, auscultation, observation

Palpation, percussion, observation, auscultation

37. You’re doing preoperative teaching with Gertrude who has ulcerative colitis who needs surgery to
create an ileoanal reservoir. Which information do you include?

A reservoir is created that exits through the abdominal wall.

A second surgery is required 12 months after the first surgery.


A permanent ileostomy is created.

The surgery occurs in two stages.

38. You’re caring for Carin who has just had ileostomy surgery. During the first 24 hours post-op, how
much drainage can you expect from the ileostomy?

100 ml

500 ml

1500 ml

5000 ml

39. You’re preparing a teaching plan for a 27 y.o. named Jeff who underwent surgery to close a
temporary ileostomy. Which nutritional guideline do you include in this plan?

There is no need to change eating habits.

Eat six small meals a day.

Eat the largest meal in the evening.

Restrict fluid intake.

40. Arthur has a family history of colon cancer and is scheduled to have a sigmoidoscopy. He is crying as
he tells you, “I know that I have colon cancer, too.” Which response is most therapeutic?

“I know just how you feel.”

“You seem upset.”

“Oh, don’t worry about it, everything will be just fine.”

“Why do you think you have cancer?”

41. You’re caring for Beth who underwent a Billroth II procedure (surgical removal of the pylorus and
duodenum) for treatment of a peptic ulcer. Which findings suggest that the patient is developing
dumping syndrome, a complication associated with this procedure?
Flushed, dry skin.

Headache and bradycardia.

Dizziness and sweating.

Dyspnea and chest pain.

42. You’re developing the plan of care for a patient experiencing dumping syndrome after a Billroth II
procedure. Which dietary instructions do you include?

Omit fluids with meals.

Increase carbohydrate intake.

Decrease protein intake.

Decrease fat intake.

43. You’re caring for Lewis, a 67 y.o. patient with liver cirrhosis who develops ascites and requires
paracentesis. Relief of which symptom indicated that the paracentesis was effective?

Pruritus

Dyspnea

Jaundice

Peripheral Neuropathy

44. You’re caring for Jane, a 57 y.o. patient with liver cirrhosis who develops ascites and requires
paracentesis. Before her paracentesis, you instruct her to:

Empty her bladder.

Lie supine in bed.

Remain NPO for 4 hours.

Clean her bowels with an enema.

45. After abdominal surgery, your patient has a severe coughing episode that causes wound
evisceration. In addition to calling the doctor, which intervention is most appropriate?
Irrigate the wound & organs with Betadine.

Cover the wound with a saline soaked sterile dressing.

Apply a dry sterile dressing & binder.

Push the organs back & cover with moist sterile dressings.

46. You’re caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to
suspect hepatic encephalopathy in her?

Asterixis

Chvostek’s sign

Trousseau’s sign

Hepatojugular reflex

47. You are developing a careplan on Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the
following do you include?

Administering a lactulose enema as ordered.

Encouraging a protein-rich diet.

Administering sedatives, as necessary.

Encouraging ambulation at least four times a day.

48. You have a patient with achalasia (incomplete muscle relaxtion of the GI tract, especially sphincter
muscles). Which medications do you anticipate to administer?

Isosorbide dinitrate (Isordil)

Digoxin (Lanoxin)

Captopril (Capoten)

Propanolol (Inderal)
49. The student nurse is preparing a teaching care plan to help improve nutrition in a patient with
achalasia. You include which of the following:

Swallow foods while leaning forward.

Omit fluids at mealtimes.

Eat meals sitting upright.

Avoid soft and semisoft foods.

50. Britney, a 20 y.o. student is admitted with acute pancreatitis. Which laboratory findings do you
expect to be abnormal for this patient?

Serum creatinine and BUN

Alanine aminotransferase (ALT) and aspartate aminotransferase (AST)

Serum amylase and lipase

Cardiac enzymes

51. A patient with Crohn’s disease is admitted after 4 days of diarrhea. Which of the following urine
specific gravity values do you expect to find in this patient?

1.005

1.011

1.020

1.030

52. Your goal is to minimize David’s risk of complications after a heriorrhaphy. You instruct the patient
to:

Avoid the use of pain medication.

Cough and deep breathe Q2H.

Splint the incision if he can’t avoid sneezing or coughing.


Apply heat to scrotal swelling.

53. Janice is waiting for discharge instructions after her herniorrhaphy. Which of the following
instructions do you include?

Eat a low-fiber diet.

Resume heavy lifting in 2 weeks.

Lose weight, if obese.

Resume sexual activity once discomfort is gone.

54. Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which of the
following points do you include?

“You’ll need to lie on your stomach during the test.”

“You’ll need to lie on your right side after the test.”

“During the biopsy you’ll be asked to exhale deeply and hold it.”

“The biopsy is performed under general anesthesia.”

55. Stephen is a 62 y.o. patient that has had a liver biopsy. Which of the following groups of signs alert
you to a possible pneumothorax?

Dyspnea and reduced or absent breath sounds over the right lung

Tachycardia, hypotension, and cool, clammy skin

Fever, rebound tenderness, and abdominal rigidity

Redness, warmth, and drainage at the biopsy site

56. Michael, a 42 y.o. man is admitted to the med-surg floor with a diagnosis of acute pancreatitis. His
BP is 136/76, pulse 96, Resps 22 and temp 101. His past history includes hyperlipidemia and alcohol
abuse. The doctor prescribes an NG tube. Before inserting the tube, you explain the purpose to patient.
Which of the following is a most accurate explanation?

“It empties the stomach of fluids and gas.”


“It prevents spasms at the sphincter of Oddi.”

“It prevents air from forming in the small intestine and large intestine.”

“It removes bile from the gallbladder.”

57. Jason, a 22 y.o. accident victim, requires an NG tube for feeding. What should you immediately do
after inserting an NG tube for liquid enteral feedings?

Aspirate for gastric secretions with a syringe.

Begin feeding slowly to prevent cramping.

Get an X-ray of the tip of the tube within 24 hours.

Clamp off the tube until the feedings begin.

58. Stephanie, a 28 y.o. accident victim, requires TPN. The rationale for TPN is to provide:

Necessary fluids and electrolytes to the body.

Complete nutrition by the I.V. route.

Tube feedings for nutritional supplementation.

Dietary supplementation with liquid protein given between meals.

59. Type A chronic gastritis can be distinquished from type B by its ability to:

Cause atrophy of the parietal cells.

Affect only the antrum of the stomach.

Thin the lining of the stomach walls.

Decrease gastric secretions.

60. Matt is a 49 y.o. with a hiatal hernia that you are about to counsel. Health care counseling for Matt
should include which of the following instructions?

Restrict intake of high-carbohydrate foods.


Increase fluid intake with meals.

Increase fat intake.

Eat three regular meals a day.

61. Jerod is experiencing an acute episode of ulcerative colitis. Which is priority for this patient?

Replace lost fluid and sodium.

Monitor for increased serum glucose level from steroid therapy.

Restrict the dietary intake of foods high in potassium.

Note any change in the color and consistency of stools.

62. A 29 y.o. patient has an acute episode of ulcerative colitis. What diagnostic test confirms this
diagnosis?

Barium Swallow.

Stool examination.

Gastric analysis.

Sigmoidoscopy.

63. Eleanor, a 62 y.o. woman with diverticulosis is your patient. Which interventions would you expect
to include in her care?

Low-fiber diet and fluid restrictions.

Total parenteral nutrition and bed rest.

High-fiber diet and administration of psyllium.

Administration of analgesics and antacids.

64. Regina is a 46 y.o. woman with ulcerative colitis. You expect her stools to look like:

Watery and frothy.


Bloody and mucoid.

Firm and well-formed.

Alternating constipation and diarrhea.

65. Donald is a 61 y.o. man with diverticulitis. Diverticulitis is characterized by:

Periodic rectal hemorrhage.

Hypertension and tachycardia.

Vomiting and elevated temperature.

Crampy and lower left quadrant pain and low-grade fever.

66. Brenda, a 36 y.o. patient is on your floor with acute pancreatitis. Treatment for her includes:

Continuous peritoneal lavage.

Regular diet with increased fat.

Nutritional support with TPN.

Insertion of a T tube to drain the pancreas.

67. Glenda has cholelithiasis (gallstones). You expect her to complain of:

Pain in the right upper quadrant, radiating to the shoulder.

Pain in the right lower quadrant, with rebound tenderness.

Pain in the left upper quadrant, with shortness of breath.

Pain in the left lower quadrant, with mild cramping.

68. After an abdominal resection for colon cancer, Madeline returns to her room with a Jackson-Pratt
drain in place. The purpose of the drain is to:

Irrigate the incision with a saline solution.

Prevent bacterial infection of the incision.


Measure the amount of fluid lost after surgery.

Prevent accumulation of drainage in the wound.

69. Anthony, a 60 y.o. patient, has just undergone a bowel resection with a colostomy. During the first
24 hours, which of the following observations about the stoma should you report to the doctor?

Pink color.

Light edema.

Small amount of oozing.

Trickles of bright red blood.

70. Your teaching Anthony how to use his new colostomy. How much skin should remain exposed
between the stoma and the ring of the appliance?

1/16”

1/4″

1/2”

1”

71. Claire, a 33 y.o. is on your floor with a possible bowel obstruction. Which intervention is priority for
her?

Obtain daily weights.

Measure abdominal girth.

Keep strict intake and output.

Encourage her to increase fluids.

72. Your patient has a GI tract that is functioning, but has the inability to swallow foods. Which is the
preferred method of feeding for your patient?

TPN
PPN

NG feeding

Oral liquid supplements

73. You’re patient is complaining of abdominal pain during assessment. What is your priority?

Auscultate to determine changes in bowel sounds.

Observe the contour of the abdomen.

Palpate the abdomen for a mass.

Percuss the abdomen to determine if fluid is present.

74. Before bowel surgery, Lee is to administer enemas until clear. During administration, he complains
of intestinal cramps. What do you do next?

Discontinue the procedure.

Lower the height of the enema container.

Complete the procedure as quickly as possible.

Continue administration of the enema as ordered without making any adjustments.

75. Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best
indicates the treatment is effective?

There is no skin breakdown.

Her appetite improves.

She loses more than 10 lbs.

Stools are less fatty and decreased in frequency.

76. Ralph has a history of alcohol abuse and has acute pancreatitis. Which lab value is most likely to be
elevated?

Calcium
Glucose

Magnesium

Potassium

77. Anna is 45 y.o. and has a bleeding ulcer. Despite multiple blood transfusions, her HGB is 7.5g/dl and
HCT is 27%. Her doctor determines that surgical intervention is necessary and she undergoes partial
gastrectomy. Postoperative nursing care includes:

Giving pain medication Q6H.

Flushing the NG tube with sterile water.

Positioning her in high Fowler’s position.

Keeping her NPO until the return of peristalsis.

78. Sitty, a 66 y.o. patient underwent a colostomy for ruptured diverticulum. She did well during the
surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after
surgery. Which finding do you report to the doctor?

Blanched stoma

Edematous stoma

Reddish-pink stoma

Brownish-black stoma

79. Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease
the excessive accumulation of serous fluid in her peritoneal cavity?

Restrict fluids

Encourage ambulation

Increase sodium in the diet

Give antacids as prescribed

80. Katrina is diagnosed with lactose intolerance. To avoid complications with lack of calcium in the diet,
which food should be included in the diet?
Fruit

Whole grains

Milk and cheese products

Dark green, leafy vegetables

81. Nathaniel has severe pruritus due to having hepatitis B. What is the best intervention for his
comfort?

Give tepid baths.

Avoid lotions and creams.

Use hot water to increase vasodilation.

Use cold water to decrease the itching.

82. Rob is a 46 y.o. admitted to the hospital with a suspected diagnosis of Hepatitis B. He’s jaundiced
and reports weakness. Which intervention will you include in his care?

Regular exercise.

A low-protein diet.

Allow patient to select his meals.

Rest period after small, frequent meals.

83. You’re discharging Nathaniel with hepatitis B. Which statement suggests understanding by the
patient?

“Now I can never get hepatitis again.”

“I can safely give blood after 3 months.”

“I’ll never have a problem with my liver again, even if I drink alcohol.”

“My family knows that if I get tired and start vomiting, I may be getting sick again.”
84. Gail is scheduled for a cholecystectomy. After completion of preoperative teaching, Gail states,”If I
lie still and avoid turning after the operation, I’ll avoid pain. Do you think this is a good idea?” What is
the best response?

“You’ll need to turn from side to side every 2 hours.”

“It’s always a good idea to rest quietly after surgery.”

“The doctor will probably order you to lie flat for 24 hours.”

“Why don’t you decide about activity after you return from the recovery room?”

85. You’re caring for a 28 y.o. woman with hepatitis B. She’s concerned about the duration of her
recovery. Which response isn’t appropriate?

Encourage her to not worry about the future.

Encourage her to express her feelings about the illness.

Discuss the effects of hepatitis B on future health problems.

Provide avenues for financial counseling if she expresses the need.

86. Elmer is scheduled for a proctoscopy and has an I.V. The doctor wrote an order for 5mg of I.V.
diazepam(Valium). Which order is correct regarding diazepam?

Give diazepam in the I.V. port closest to the vein.

Mix diazepam with 50 ml of dextrose 5% in water and give over 15 minutes.

Give diazepam rapidly I.V. to prevent the bloodstream from diluting the drug mixture.

Question the order because I.V. administration of diazepam is contraindicated.

87. Annebell is being discharged with a colostomy, and you’re teaching her about colostomy care.
Which statement correctly describes a healthy stoma?

“At first, the stoma may bleed slightly when touched.”

“The stoma should appear dark and have a bluish hue.”


“A burning sensation under the stoma faceplate is normal.”

“The stoma should remain swollen away from the abdomen.”

88. A patient who underwent abdominal surgery now has a gaping incision due to delayed wound
healing. Which method is correct when you irrigate a gaping abdominal incision with sterile normal
saline solution, using a piston syringe?

Rapidly instill a stream of irrigating solution into the wound.

Apply a wet-to-dry dressing to the wound after the irrigation.

Moisten the area around the wound with normal saline solution after the irrigation.

Irrigate continuously until the solution becomes clear or all of the solution is used.

89. Hepatic encephalopathy develops when the blood level of which substance increases?

Ammonia

Amylase

Calcium

Potassium

90. Your patient recently had abdominal surgery and tells you that he feels a popping sensation in his
incision during a coughing spell, followed by severe pain. You anticipate an evisceration. Which supplies
should you take to his room?

A suture kit.

Sterile water and a suture kit.

Sterile water and sterile dressings.

Sterile saline solution and sterile dressings.

91. Findings during an endoscopic exam include a cobblestone appearance of the colon in your patient.
The findings are characteristic of which disorder?
Ulcer

Crohn’s disease

Chronic gastritis

Ulcerative colitis

92. What information is correct about stomach cancer?

Stomach pain is often a late symptom.

Surgery is often a successful treatment.

Chemotherapy and radiation are often successful treatments.

The patient can survive for an extended time with TPN.

93. Dark, tarry stools indicate bleeding in which location of the GI tract?

Upper colon.

Lower colon.

Upper GI tract.

Small intestine.

94. A patient has an acute upper GI hemorrhage. Your interventions include:

Treating hypovolemia.

Treating hypervolemia.

Controlling the bleeding source.

Treating shock and diagnosing the bleeding source.

95. You promote hemodynamic stability in a patient with upper GI bleeding by:

Encouraging oral fluid intake.


Monitoring central venous pressure.

Monitoring laboratory test results and vital signs.

Giving blood, electrolyte and fluid replacement.

96. You’re preparing a patient with a malignant tumor for colorectal surgery and subsequent colostomy.
The patient tells you he’s anxious. What should your initial step be in working with this patient?

Determine what the patient already knows about colostomies.

Show the patient some pictures of colostomies.

Arrange for someone who has a colostomy to visit the patient.

Provide the patient with written material about colostomy care.

97. Your patient, Christopher, has a diagnosis of ulcerative colitis and has severe abdominal pain
aggravated by movement, rebound tenderness, fever, nausea, and decreased urine output. This may
indicate which complication?

Fistula.

Bowel perforation.

Bowel obstruction.

Abscess.

98. A patient has a severe exacerbation of ulcerative colitis. Long-term medications will probably
include:

Antacids.

Antibiotics.

Corticosteroids.

Histamine2-receptor blockers.

99. The student nurse is teaching the family of a patient with liver failure. You instruct them to limit
which foods in the patient’s diet?
Meats and beans.

Butter and gravies.

Potatoes and pastas.

Cakes and pastries.

100. An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate
of 60ml/hr. Gastric residuals have been 30-40ml when monitored Q4H. You check the gastric residual
and aspirate 220ml. What is your first response to this finding?

Notify the doctor immediately.

Stop the feeding, and clamp the NG tube.

Discard the 220ml, and clamp the NG tube.

Give a prescribed GI stimulant such as metoclopramide (Reglan).

Answers and Rationales

Answer C. The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the
rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis,
the value may exceed five times the normal value. Options A and B are within normal limits. Option D is
an extremely elevated level seen in acute pancreatitis.

Answer C. Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk,
pudding and custard, soups that are strained, and strained vegetable juices. A clear liquid diet consists
of foods that are relatively transparent. The food items in options A, B, and D are clear liquids.

Answer A. The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a
variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good
food sources include nuts, whole grain cereals, and legumes. Milk contains vitamins A, D, and B2.
Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid

Answer A. Unless specifically indicated, residual amounts more than 100 mL require holding the feeding.
Therefore options B, C, and D are incorrect. Additionally, the feeding is not discarded unless its contents
are abnormal in color or characteristics.

Answer D. During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any
respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress
subsides. Options B and C are unnecessary. Quickly inserting the tube is not an appropriate action
because, in this situation, it may be likely that the tube has entered the bronchus.

Answer A. If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric
aspirates have acidic pH values and should be 3.5 or lower. Option B indicates a slightly acidic pH. Option
C indicates a neutral pH. Option D indicates an alkaline pH.

Answer C. When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep
breath. This will close the epiglottis. This allows for easy withdrawal through the esophagus into the
nose. The nurse removes the tube with one smooth, continuous pull.

Answer C. If a client has a nasogastric tube connected to suction, the nurse should wait up to 30 minutes
before reconnecting the tube to the suction apparatus to allow adequate time for medication
absorption. Aspirating the nasogastric tube will remove the medication just administered. Low
intermittent suction also will remove the medication just administered. The client should not be placed
in the supine position because of the risk for aspiration.

Answer D. When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the
client’s bedside at all times. The client needs to be observed for sudden respiratory distress, which
occurs if the gastric balloon ruptures and the entire tube moves upward. If this occurs, the nurse
immediately cuts all balloon lumens and removes the tube. An obturator and a Kelly clamp are kept at
the bedside of a client with a tracheostomy. An irrigation set may be kept at the bedside, but it is not
the priority item.

Answer A. Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food
handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.

Answer B. Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum
bilirubin levels, elevated erythrocyte sedimentation rates, and leukopenia. An elevated blood urea
nitrogen level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

Answer C. Meperidine (Demerol) rather than morphine sulfate is the medication of choice to treat pain
because morphine sulfate can cause spasms in the sphincter of Oddi. Options A, B, and D are
appropriate interventions for the client with acute pancreatitis.

Answer A. A barium swallow is an x-ray study that uses a substance called barium for contrast to
highlight abnormalities in the gastrointestinal tract. The client should fast for 8 to 12 hours before the
test, depending on physician instructions. Most oral medications also are withheld before the test. After
the procedure, the nurse must monitor for constipation, which can occur as a result of the presence of
barium in the gastrointestinal tract.

Answer C. The appropriate sequence for abdominal examination is inspection, auscultation, percussion,
and palpation. Auscultation is performed after inspection to ensure that the motility of the bowel and
bowel sounds are not altered by percussion or palpation. Therefore, after inspecting the skin on the
abdomen, the nurse should listen for bowel sounds.
Answer D. The solution GoLYTELY is a bowel evacuant used to prepare a client for a colonoscopy by
cleansing the bowel. The solution is expected to cause a mild diarrhea and will clear the bowel in 4 to 5
hours. Options A, B, and C are inappropriate actions.

Answer B. Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the
loss of the function of the parietal cells. The source of the intrinsic factor is lost, which results in the
inability to absorb vitamin B12. This leads to the development of pernicious anemia. The client is not at
risk for vitamin A, C, or E deficiency.

Answer C. Indomethacin (Indocin) is a nonsteroidal anti-inflammatory drug and can cause ulceration of
the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a client with
gastrointestinal disorders. Furosemide (Lasix) is a loop diuretic. Digoxin is a cardiac medication.
Propranolol (Inderal) is a β-adrenergic blocker. Furosemide, digoxin, and propranolol are not
contraindicated in clients with gastric disorders.

Answer D. Following cholecystectomy, drainage from the T tube is initially bloody and then turns to a
greenish-brown color. The drainage is measured as output. The amount of expected drainage will range
from 500 to 1000 mL/day. The nurse would document the output.

Answer D. Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp,


intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which
becomes rigid and board-like. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic
shock develops. Numbness in the legs is not an associated finding.

Answer C. A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation
of gastric secretion. Options A, B, and D are incorrect descriptions of a vagotomy.

Answer C. In a Billroth II procedure, the proximal remnant of the stomach is anastomosed to the
proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric
secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless
specifically ordered by the physician. In this situation, the nurse should clarify the order. Options A, B,
and D are appropriate postoperative interventions.

Answer C. Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that
occurs after eating, especially following a Billroth II procedure. Early manifestations usually occur within
30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the
desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals
and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low-Fowler’s
position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take
antispasmodics as prescribed.

Answer A. Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms
include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
Answer B. Coughing is avoided following umbilical hernia repair to prevent disruption of tissue integrity,
which can occur because of the location of this surgical procedure. Bed rest is not required following this
surgical procedure. The client should take analgesics as needed and as prescribed to control pain. A
drain is not used in this surgical procedure, although the client may be instructed in simple dressing
changes.

Answer B. Following inguinal hernia repair, the client should be instructed to elevate the scrotum and
apply ice packs while in bed to decrease pain and swelling. The nurse also should instruct the client to
apply a scrotal support when out of bed. Heat will increase swelling. Limiting oral fluids and a low-fiber
diet can cause constipation.

Answer C. Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in
ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level
may be lower than normal. Signs of peritonitis must be reported to the physician.

Answer B. Body image, disturbed relates to loss of bowel control, the presence of a stoma, the release
of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external
pouch). No data in the question support options A and C. Nutrition: less than body requirements,
imbalanced is the more likely nursing diagnosis.

Answer A. Crohn’s disease is characterized by nonbloody diarrhea of usually not more than four to five
stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options B, C,
and D are not characteristics of Crohn’s disease.

Answer B. If cramping occurs during a colostomy irrigation, the irrigation flow is stopped temporarily
and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too
much pressure. The physician does not need to be notified. Increasing the height of the irrigation will
cause further discomfort. Medicating the client for pain is not the appropriate action in this situation.

Answer A. To enhance effectiveness of the irrigation and fecal returns, the client is instructed to increase
fluid intake and to take other measures to prevent constipation. Options B, C and D will not enhance the
effectiveness of this procedure.

Answer A. Blood pressure decreases as the body is unable to maintain normal oncotic pressure with liver
failure, so patients with liver failure require close blood pressure monitoring. Increased capillary
permeability, abnormal peripheral vasodilation, and excess rennin released from the kidney’s aren’t
direct ramifications of liver failure.

Answer B. Good circulation causes tissues to be moist and red, so a healthy, well-healed stoma appears
red and moist.

Answer A. A colostomy in the sigmoid colon produces a solid, formed stool.

Answer D. High-fiber foods stimulate peristalsis, and a result, flatus. Yogurt reduces gas formation.
Answer B. A proper fit protects the skin, but doesn’t impair circulation. A 1/16” should be cut.

Answer B. Observation, auscultation, percussion, palpation

Answer D. An ileoanal reservoir is created in two stages. The two surgeries are about 2 to 3 months
apart. First, diseased intestines are removed and a temporary loop ileostomy is created. Second, the
loop ileostomy is closed and stool goes to the reservoir and out through the anus.

Answer C. The large intestine absorbs large amounts of water so the initial output from the ileostomy
may be as much as 1500 to 2000 ml/24 hours. Gradually, the small intestine absorbs more fluid and the
output decreases.

Answer B. To avoid overloading the small intestine, encourage the patient to eat six small, regularly
spaced meals.

Answer B. Making observations about what you see or hear is a useful therapeutic technique. This way,
you acknowledge that you are interested in what the patient is saying and feeling.

Answer C. After a Billroth II procedure, a large amount of hypertonic fluid enters the intestine. This
causes extracellular fluid to move rapidly into the bowel, reducing circulating blood volume and
producing vasomotor symptoms. Vasomotor symptoms produced by dumping syndrome include
dizziness and sweating, tachycardia, syncope, pallor, and palpitations.

Answer A. Gastric emptying time can be delayed by omitting fluids from your patient’s meal. A diet low
in carbs and high in fat & protein is recommended to treat dumping syndrome.

Answer B. Ascites puts pressure on the diaphragm. Paracentesis is done to remove fluid and reducing
pressure on the diaphragm. The goal is to improve the patient’s breathing. The others are signs of
cirrhosis that aren’t relieved by paracentesis.

Answer A. A full bladder can interfere with paracentesis and be punctured inadvertently.

Answer B. Cover the organs with a sterile, nonadherent dressing moistened with normal saline. Do this
to prevent infection and to keep the organs from drying out.

Answer A. Asterixis is an early neurologic sign of hepatic encephalopathy elicited by asking the patient to
hold her arms stretched out. Asterixis is present if the hands rapidly extend and flex.

Answer A. You may administer the laxative lactulose to reduce ammonia levels in the colon.

Answer A. Achalasia is characterized by incomplete relaxation of the LES, dilation of the lower
esophagus, and a lack of esophageal peristalsis. Because nitrates relax the lower esophageal sphincter,
expect to give Isordil orally or sublingually.

Answer C. Eating in the upright position aids in emptying the esophagus. Doing the opposite of the other
three also may be helpful.
Answer C. Pancreatitis involves activation of pancreatic enzymes, such as amylase and lipase. These
levels are elevated in a patient with acute pancreatitis.

Answer D. The normal range of specific gravity of urine is 1.010 to 1.025; a value of 1.030 may be seen
with dehydration.

Answer C. Teach the pt to avoid activities that increase intra-abdominal pressure such as coughing,
sneezing, or straining with a bowel movement.

Answer C. Because obesity weakens the abdominal muscles, advise weight loss for the patient who has
had a hernia repair.

Answer B. After a liver biopsy, the patient is placed on the right side to compress the liver and to reduce
the risk of bleeding or bile leakage.

Answer A. Signs and Symptoms of pneumothorax include dyspnea and decreased or absent breath
sounds over the affected lung (right lung).

Answer A. An NG tube is inserted into the patients stomach to drain fluid and gas.

Answer A. Aspirating the stomach contents confirms correct placement. If an X-ray is ordered, it should
be done immediately, not in 24 hours.

Answer B. TPN is given I.V. to provide all the nutrients your patient needs. TPN isn’t a tube feeding nor is
it a liquid dietary supplement.

Answer A. Type A causes changes in parietal cells.

Answer B. Increasing fluids helps empty the stomach. A high carb diet isn’t restricted and fat intake
shouldn’t be increased.

Answer A. Diarrhea d/t an acute episode of ulcerative colitis leads to fluid & electrolyte losses so fluid
replacement takes priority.

Answer D. Sigmoidoscopy allows direct observation of the colon mucosa for changes, and if needed,
biopsy.

Answer C. She needs a high-fiber diet and a psyllium (bulk laxative) to promote normal soft stools.

Answer B. Stools from ulcerative colitis are often bloody and contain mucus.

Answer D. One sign of acute diverticulitis is crampy lower left quadrant pain. A low-grade fever is
another common sign.

Answer C. With acute pancreatitis, you need to rest the GI tract by TPN as nutritional support.

Answer A. The gallbladder is located in the RUQ and a frequent sign of gallstones is pain radiating to the
shoulder.
Answer D. A Jackson-Pratt drain promotes wound healing by allowing fluid to escape from the wound.

Answer D. After creation of a colostomy, expect to see a stoma that is pink, slightly edematous, with
some oozing. Bright red blood, regardless of amount, indicates bleeding and should be reported to the
doctor.

Answer A. Only a small amount of skin should be exposed and more than 1/16” of skin allows the
excretement to irritate the skin.

Answer B. Measuring abdominal girth provides quantitative information about increases or decreases in
the amount of distention.

Answer C. Because the GI tract is functioning, feeding methods involve the enteral route which bypasses
the mouth but allows for a major portion of the GI tract to be used.

Answer B. The first step in assessing the abdomen is to observe its shape and contour, then auscultate,
palpate, and then percuss.

Answer B. Lowering the height decreases the amount of flow, allowing him to tolerate more fluid.

Answer D. Pancrelipase provides the exocrine pancreatic enzyme necessary for proper protein, fat, and
carb digestion. With increased fat digestion and absorption, stools become less frequent and normal in
appearance.

Answer B. Glucose level increases and diabetes mellitus may result d/t the pancreatic damage to the
islets of langerhans.

Answer D. After surgery, she remains NPO until peristaltic activity returns. This decreases the risk for
abdominal distention and obstruction.

Answer D. A brownish-black color indicates lack of blood flow, and maybe necrosis.

Answer A. Restricting fluids decrease the amount of body fluid and the accumulation of fluid in the
peritoneal space.

Answer D. Dark green, leafy vegetables are rich in calcium.

Answer A. For pruritus, care should include tepid sponge baths and use of emollient creams and lotions.

Answer D. Rest periods and small frequent meals is indicated during the acute phase of hepatitis B.

Answer D. Hepatitis B can recur. Patients who have had hepatitis are permanently barred from donating
blood. Alcohol is metabolized by the liver and should be avoided by those who have or had hepatitis B.

Answer A. To prevent venous stasis and improve muscle tone, circulation, and respiratory function,
encourage her to move after surgery.

Answer A. Telling her not to worry minimizes her feelings.


Answer A. Diazepam is absorbed by the plastic I.V. tubing and should be given in the port closest to the
vein.

Answer A. For the first few days to a week, slight bleeding normally occurs when the stoma is touched
because the surgical site is still new. She should report profuse bleeding immediately.

Answer D. To wash away tissue debris and drainage effectively, irrigate the wound until the solution
becomes clear or all the solution is used.

Answer A. Ammonia levels increase d/t improper shunting of blood, causing ammonia to enter systemic
circulation, which carries it to the brain.

Answer D. Saline solution is isotonic, or close to body fluids in content, and is used along with sterile
dressings to cover an eviscerated wound and keep it moist.

Answer B. Crohn’s disease penetrates the mucosa of the colon through all layers and destroys the colon
in patches, which creates a cobblestone appearance.

Answer A. Stomach pain is often a late sign of stomach cancer; outcomes are particularly poor when the
cancer reaches that point. Surgery, chemotherapy, and radiation have minimal positive effects. TPN may
enhance the growth of the cancer.

Answer C. Melena is the passage of dark, tarry stools that contain a large amount of digested blood. It
occurs with bleeding from the upper GI tract.

Answer A. A patient with an acute upper GI hemorrhage must be treated for hypovolemia and
hemorrhagic shock. You as a nurse can’t diagnose the problem. Controlling the bleeding may require
surgery or intensive medical treatment.

Answer D. To stabilize a patient with acute bleeding, NS or LR solution is given I.V. until BP rises and
urine output returns to 30ml/hr.

Answer A. Initially, you should assess the patient’s knowledge about colostomies and how it will affect
his lifestyle.

Answer B. An inflammatory condition that affects the surface of the colon, ulcerative colitis causes
friability and erosions with bleeding. Patients with ulcerative colitis are at increased risk for bowel
perforation, toxic megacolon, hemorrhage, cancer, and other anorectal and systemic complications.

Answer C. Medications to control inflammation such as corticosteroids are used for long-term
treatment.

Answer A. Meats and beans are high-protein foods. In liver failure, the liver is unable to metabolize
protein adequately, causing protein by-products to build up in the body rather than be excreted.
Answer B. A gastric residual greater than 2 hours worth of feeding or 100-150ml is considered too high.
The feeding should be stopped; NG tube clamped, and then allow time for the stomach to empty before
additional feeding is added.

1. During preparation for bowel surgery, a male client receives an antibiotic to reduce intestinal bacteria.
Antibiotic therapy may interfere with synthesis of which vitamin and may lead to
hypoprothrombinemia?

vitamin A

vitamin D

vitamin E

vitamin K

2. When evaluating a male client for complications of acute pancreatitis, the nurse would observe for:

increased intracranial pressure.

decreased urine output.

bradycardia.

hypertension.

3. A male client with a recent history of rectal bleeding is being prepared for a colonoscopy. How should
the nurse position the client for this test initially?

Lying on the right side with legs straight

Lying on the left side with knees bent

Prone with the torso elevated

Bent over with hands touching the floor

4. A male 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:

“Tell me about your husband’s alcohol usage.”

“Is your husband being treated for tuberculosis?”

“Has your husband recently fallen or injured his chest?”

“Describe spices and condiments your husband uses on food.”

5. Which of the following nursing interventions should the nurse perform for a female client receiving
enteral feedings through a gastrostomy tube?

Change the tube feeding solutions and tubing at least every 24 hours.

Maintain the head of the bed at a 15-degree elevation continuously.

Check the gastrostomy tube for position every 2 days.

Maintain the client on bed rest during the feedings.

6. A male client is recovering from a small-bowel resection. To relieve pain, the physician prescribes
meperidine (Demerol), 75 mg I.M. every 4 hours. How soon after administration should meperidine’s
onset of action occur?

5 to 10 minutes

15 to 30 minutes

30 to 60 minutes

2 to 4 hours

7. The nurse is caring for a male client with cirrhosis. Which assessment findings indicate that the client
has deficient vitamin K absorption caused by this hepatic disease?

Dyspnea and fatigue

Ascites and orthopnea


Purpura and petechiae

Gynecomastia and testicular atrophy

8. Which condition is most likely to have a nursing diagnosis of fluid volume deficit?

Appendicitis

Pancreatitis

Cholecystitis

Gastric ulcer

9. While a female client is being prepared for discharge, the nasogastric (NG) feeding tube becomes
clogged. To remedy this problem and teach the client’s family how to deal with it at home, what should
the nurse do?

Irrigate the tube with cola.

Advance the tube into the intestine.

Apply intermittent suction to the tube.

Withdraw the obstruction with a 30-ml syringe.

10. A male client with pancreatitis complains of pain. The nurse expects the physician to prescribe
meperidine (Demerol) instead of morphine to relieve pain because:

meperidine provides a better, more prolonged analgesic effect.

morphine may cause spasms of Oddi’s sphincter.

meperidine is less addictive than morphine.

morphine may cause hepatic dysfunction.

11. Mandy, an adolescent girl is admitted to an acute care facility with severe malnutrition. After a
thorough examination, the physician diagnoses anorexia nervosa. When developing the plan of care for
this client, the nurse is most likely to include which nursing diagnosis?
Hopelessness

Powerlessness

Chronic low self esteem

Deficient knowledge

12. Which diagnostic test would be used first to evaluate a client with upper GI bleeding?

Endoscopy

Upper GI series

Hemoglobin (Hb) levels and hematocrit (HCT)

Arteriography

13. A female client who has just been diagnosed with hepatitis A asks, “How could I have gotten this
disease?” What is the nurse’s best response?

“You may have eaten contaminated restaurant food.”

“You could have gotten it by using I.V. drugs.”

“You must have received an infected blood transfusion.”

“You probably got it by engaging in unprotected sex.”

14. When preparing a male client, age 51, 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?

Obstruction of the appendix may increase venous drainage and cause the appendix to rupture.

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the
appendix.

The appendix may develop gangrene and rupture, especially in a middle-aged client.

Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage.
15. A female client with hepatitis C develops liver failure and GI hemorrhage. The blood products that
would most likely bring about hemostasis in the client are:

whole blood and albumin.

platelets and packed red blood cells.

fresh frozen plasma and whole blood.

cryoprecipitate and fresh frozen plasma.

16. To prevent gastroesophageal reflux in a male client with hiatal hernia, the nurse should provide
which discharge instruction?

“Lie down after meals to promote digestion.”

“Avoid coffee and alcoholic beverages.”

“Take antacids with meals.”

“Limit fluid intake with meals.”

17. The nurse caring for a client with small-bowel obstruction would plan to implement which nursing
intervention first?

Administering pain medication

Obtaining a blood sample for laboratory studies

Preparing to insert a nasogastric (NG) tube

Administering I.V. fluids

18. A female client with dysphagia is being prepared for discharge. Which outcome indicates that the
client is ready for discharge?

The client doesn’t exhibit rectal tenesmus.

The client is free from esophagitis and achalasia.

The client reports diminished duodenal inflammation.


The client has normal gastric structures.

19. A male 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?

Notify the physician

Reposition the tube

Irrigate the tube

Increase the suction level

20. What laboratory finding is the primary diagnostic indicator for pancreatitis?

Elevated blood urea nitrogen (BUN)

Elevated serum lipase

Elevated aspartate aminotransferase (AST)

Increased lactate dehydrogenase (LD)

21. A male client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this
client, the nurse expects to note:

yellow sclerae.

light amber urine.

circumoral pallor.

black, tarry stools.

22. Nurse Hannah is teaching a group of middle-aged men about peptic ulcers. When discussing risk
factors for peptic ulcers, the nurse should mention:

a sedentary lifestyle and smoking.

a history of hemorrhoids and smoking.

alcohol abuse and a history of acute renal failure.


alcohol abuse and smoking.

23. While palpating a female client’s right upper quadrant (RUQ), the nurse would expect to find which
of the following structures?

Sigmoid colon

Appendix

Spleen

Liver

24. A male client has undergone a colon resection. While turning him, wound dehiscence with
evisceration occurs. The nurse’s first response is to:

call the physician.

place saline-soaked sterile dressings on the wound.

take a blood pressure and pulse.

pull the dehiscence closed.

25. The nurse is monitoring a female client receiving paregoric to treat diarrhea for drug interactions.
Which drugs can produce additive constipation when given with an opium preparation?

Antiarrhythmic drugs

Anticholinergic drugs

Anticoagulant drugs

Antihypertensive drugs

26. A male client is recovering from an ileostomy that was performed to treat inflammatory bowel
disease. During discharge teaching, the nurse should stress the importance of:

increasing fluid intake to prevent dehydration.

wearing an appliance pouch only at bedtime.


consuming a low-protein, high-fiber diet.

taking only enteric-coated medications.

27. The nurse is caring for a female client with active upper GI bleeding. What is the appropriate diet for
this client during the first 24 hours after admission?

Regular diet

Skim milk

Nothing by mouth

Clear liquids

28. A male client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:

severe abdominal pain radiating to the shoulder.

anorexia, nausea, and vomiting.

eructation and constipation.

abdominal ascites.

29. A female client with viral hepatitis A is being treated in an acute care facility. Because the client
requires enteric precautions, the nurse should:

place the client in a private room.

wear a mask when handling the client’s bedpan.

wash the hands after touching the client.

wear a gown when providing personal care for the client.

30. Which of the following factors can cause hepatitis A?

Contact with infected blood

Blood transfusions with infected blood


Eating contaminated shellfish

Sexual contact with an infected person

31. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?

Increase the I.V. infusion rate.

Use diversion activities.

Provide frequent mouth care.

Give ice chips every 15 minutes.

32. Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this
indicate?

He has fresh, active upper GI bleeding.

He needs immediate saline gastric lavage.

His gastric bleeding occurred 2 hours earlier.

He needs a transfusion of packed RBC’s.

33. A 53 y.o. patient has undergone a partial gastrectomy for adenocarcinoma of the stomach. An NG
tube is in place and is connected to low continuous suction. During the immediate postoperative period,
you expect the gastric secretions to be which color?

Brown.

Clear.

Red.

Yellow.

34. Your patient has a retractable gastric peptic ulcer and has had a gastric vagotomy. Which factor
increases as a result of vagotomy?

Peristalsis.
Gastric acidity.

Gastric motility.

Gastric pH.

35. Christina is receiving an enteral feeding that requires a concentration of 80ml of supplement mixed
with 20 ml of water. How much water do you mix with an 8 oz (240ml) can of feeding?

60 ml.

70 ml.

80 ml.

90 ml.

36. Which stoma would you expect a malodorous, enzyme-rich, caustic liquid output that is yellow,
green, or brown?

Ileostomy.

Ascending colostomy.

Transverse colostomy.

Descending colostomy.

37. George has a T tube in place after gallbladder surgery. Before discharge, what information or
instructions should be given regarding the T tube drainage?

“If there is any drainage, notify the surgeon immediately.”

“The drainage will decrease daily until the bile duct heals.”

“First, the drainage is dark green; then it becomes dark yellow.”

“If the drainage stops, milk the tube toward the puncture wound.”

38. Your patient Maria takes NSAIDS for her degenerative joint disease, has developed peptic ulcer
disease. Which drug is useful in preventing NSAID-induced peptic ulcer disease?
Calcium carbonate (Tums)

Famotidine (Pepcid)

Misoprostol (Cytotec)

Sucralfate (Carafate)

39. The student nurse is participating in colorectal cancer-screening program. Which patient has the
fewest risk factors for colon cancer?

Janice, a 45 y.o. with a 25-year history of ulcerative colitis

George, a 50 y.o. whose father died of colon cancer

Herman, a 60 y.o. who follows a low-fat, high-fiber diet

Sissy, a 72 y.o. with a history of breast cancer

40. You’re patient, post-op drainage of a pelvic abscess secondary to diverticulitis, begins to cough
violently after drinking water. His wound has ruptured and a small segment of the bowel is protruding.
What’s your priority?

Ask the patient what happened, call the doctor, and cover the area with a water-soaked bedsheet.

Obtain vital signs, call the doctor, and obtain emergency orders.

Have a CAN hold the wound together while you obtain vital signs, call the doctor and flex the patient’s
knees.

Have the doctor called while you remain with the patient, flex the patient’s knees, and cover the wound
with sterile towels soaked in sterile saline solution.

Answers and Rationales

Answer D. Intestinal bacteria synthesize such nutritional substances as vitamin K, thiamine, riboflavin,
vitamin B12, folic acid, biotin, and nicotinic acid. Therefore, antibiotic therapy may interfere with
synthesis of these substances, including vitamin K. Intestinal bacteria don’t synthesize vitamins A, D, or
E.
Answer B. Acute pancreatitis can cause decreased urine output, which results from the renal failure that
sometimes accompanies this condition. Intracranial pressure neither increases nor decreases in a client
with pancreatitis. Tachycardia, not bradycardia, usually is associated with pulmonary or hypovolemic
complications of pancreatitis. Hypotension can be caused by a hypovolemic complication, but
hypertension usually isn’t related to acute pancreatitis.

Answer B. For a colonoscopy, the nurse initially should position the client on the left side with knees
bent. Placing the client on the right side with legs straight, prone with the torso elevated, or bent over
with hands touching the floor wouldn’t allow proper visualization of the large intestine.

Answer A. A Mallory-Weiss tear is associated with massive bleeding after a tear occurs in the mucous
membrane at the junction of the esophagus and stomach. There is a strong relationship between
ethanol usage, resultant vomiting, and a Mallory-Weiss tear. The bleeding is coming from the stomach,
not from the lungs as would be true in some cases of tuberculosis. A Mallory-Weiss tear doesn’t occur
from chest injuries or falls and isn’t associated with eating spicy foods.

Answer A. Tube feeding solutions and tubing should be changed every 24 hours, or more frequently if
the feeding requires it. Doing so prevents contamination and bacterial growth. The head of the bed
should be elevated 30 to 45 degrees continuously to prevent aspiration. Checking for gastrostomy tube
placement is performed before initiating the feedings and every 4 hours during continuous feedings.
Clients may ambulate during feedings.

Answer B. Meperidine’s onset of action is 15 to 30 minutes. It peaks between 30 and 60 minutes and has
a duration of action of 2 to 4 hours.

Answer C. A hepatic disorder, such as cirrhosis, may disrupt the liver’s normal use of vitamin K to
produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of
bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea
are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased
estrogen metabolism by the diseased liver.

Answer B. Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis. The other
conditions are less likely to exhibit fluid volume deficit.

Answer A. The nurse should irrigate the tube with cola because its effervescence and acidity are suited
to the purpose, it’s inexpensive, and it’s readily available in most homes. Advancing the NG tube is
inappropriate because the tube is designed to stay in the stomach and isn’t long enough to reach the
intestines. Applying intermittent suction or using a syringe for aspiration is unlikely to dislodge the
material clogging the tube but may create excess pressure. Intermittent suction may even collapse the
tube.

Answer B. For a client with pancreatitis, the physician will probably avoid prescribing morphine because
this drug may trigger spasms of the sphincter of Oddi (a sphincter at the end of the pancreatic duct),
causing irritation of the pancreas. Meperidine has a somewhat shorter duration of action than
morphine. The two drugs are equally addictive. Morphine isn’t associated with hepatic dysfunction.

Answer C. Young women with Chronic low self esteem — are at highest risk for anorexia nervosa
because they perceive being thin as a way to improve their self-confidence. Hopelessness and
Powerlessness are inappropriate nursing diagnoses because clients with anorexia nervosa seldom feel
hopeless or powerless; instead, they use food to control their desire to be thin and hope that restricting
food intake will achieve this goal. Anorexia nervosa doesn’t result from a knowledge deficit, such as one
regarding good nutrition.

Answer A. Endoscopy permits direct evaluation of the upper GI tract and can detect 90% of bleeding
lesions. An upper GI series, or barium study, usually isn’t the diagnostic method of choice, especially in a
client with acute active bleeding who’s vomiting and unstable. An upper GI series is also less accurate
than endoscopy. Although an upper GI series might confirm the presence of a lesion, it wouldn’t
necessarily reveal whether the lesion is bleeding. Hb levels and HCT, which indicate loss of blood
volume, aren’t always reliable indicators of GI bleeding because a decrease in these values may not be
seen for several hours. Arteriography is an invasive study associated with life-threatening complications
and wouldn’t be used for an initial evaluation.

Answer A. Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming
food contaminated by infected food handlers. The virus isn’t transmitted by the I.V. route, blood
transfusions, or unprotected sex. Hepatitis B can be transmitted by I.V. drug use or blood transfusion.
Hepatitis C can be transmitted by unprotected sex.

Answer B. A client with appendicitis is at risk for infection related to inflammation, perforation, and
surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the
appendix and compressing venous outflow drainage. The pressure continues to rise with venous
obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation
and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in
gangrene and rupture. Geriatric, not middle-aged, clients are especially susceptible to appendix rupture.

Answer D. The liver is vital in the synthesis of clotting factors, so when it’s diseased or dysfunctional, as
in hepatitis C, bleeding occurs. Treatment consists of administering blood products that aid clotting.
These include fresh frozen plasma containing fibrinogen and cryoprecipitate, which have most of the
clotting factors. Although administering whole blood, albumin, and packed cells will contribute to
hemostasis, those products aren’t specifically used to treat hemostasis. Platelets are helpful, but the
best answer is cryoprecipitate and fresh frozen plasma.

Answer B. To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to
avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should
teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after
eating. The client need not limit fluid intake with meals as long as the fluids aren’t gastric irritants.
Answer D. I.V. infusions containing normal saline solution and potassium should be given first to
maintain fluid and electrolyte balance. For the client’s comfort and to assist in bowel decompression,
the nurse should prepare to insert an NG tube next. A blood sample is then obtained for laboratory
studies to aid in the diagnosis of bowel obstruction and guide treatment. Blood studies usually include a
complete blood count, serum electrolyte levels, and blood urea nitrogen level. Pain medication often is
withheld until obstruction is diagnosed because analgesics can decrease intestinal motility.

Answer B. Dysphagia may be the reason why a client with esophagitis or achalasia seeks treatment.
Dysphagia isn’t associated with rectal tenesmus, duodenal inflammation, or abnormal gastric structures.

Answer A. An NG tube that fails to drain during the postoperative period should be reported to the
physician immediately. It may be clogged, which could increase pressure on the suture site because fluid
isn’t draining adequately. Repositioning or irrigating an NG tube in a client who has undergone gastric
surgery can disrupt the anastomosis. Increasing the level of suction may cause trauma to GI mucosa or
the suture line.

Answer B. Elevation of serum lipase is the most reliable indicator of pancreatitis because this enzyme is
produced solely by the pancreas. A client’s BUN is typically elevated in relation to renal dysfunction; the
AST, in relation to liver dysfunction; and LD, in relation to damaged cardiac muscle.

Answer A. Yellow sclerae may be the first sign of jaundice, which occurs when the common bile duct is
obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don’t occur in
common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

Answer D. Risk factors for peptic (gastric and duodenal) ulcers include alcohol abuse, smoking, and
stress. A sedentary lifestyle and a history of hemorrhoids aren’t risk factors for peptic ulcers. Chronic
renal failure, not acute renal failure, is associated with duodenal ulcers.

Answer D. The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of
the colon, portions of the ascending and transverse colon, and a portion of the right kidney. The sigmoid
colon is located in the left lower quadrant; the appendix, in the right lower quadrant; and the spleen, in
the left upper quadrant.

Answer B. The nurse should first place saline-soaked sterile dressings on the open wound to prevent
tissue drying and possible infection. Then the nurse should call the physician and take the client’s vital
signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.

Answer B. Paregoric has an additive effect of constipation when used with anticholinergic drugs.
Antiarrhythmics, anticoagulants, and antihypertensives aren’t known to interact with paregoric.

Answer A. Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid
fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The
nurse should teach the client to wear a collection appliance at all times because ileostomy drainage is
incontinent, to avoid high-fiber foods because they may irritate the intestines, and to avoid enteric-
coated medications because the body can’t absorb them after an ileostomy
Answer C. Shock and bleeding must be controlled before oral intake, so the client should receive nothing
by mouth. A regular diet is incorrect. When the bleeding is controlled, the diet is gradually increased,
starting with ice chips and then clear liquids. Skim milk shouldn’t be given because it increases gastric
acid production, which could prolong bleeding. A liquid diet is the first diet offered after bleeding and
shock are controlled.

Answer B. Hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and
weakness. Abdominal pain may occur but doesn’t radiate to the shoulder. Eructation and constipation
are common in gallbladder disease, not hepatitis A. Abdominal ascites is a sign of advanced hepatic
disease, not an early sign of hepatitis A.

Answer C. To maintain enteric precautions, the nurse must wash the hands after touching the client or
potentially contaminated articles and before caring for another client. A private room is warranted only
if the client has poor hygiene — for instance, if the client is unlikely to wash the hands after touching
infective material or is likely to share contaminated articles with other clients. For enteric precautions,
the nurse need not wear a mask and must wear a gown only if soiling from fecal matter is likely.

Answer C. Hepatitis A can be caused by consuming contaminated water, milk, or food — especially
shellfish from contaminated water. Hepatitis B is caused by blood and sexual contact with an infected
person. Hepatitis C is usually caused by contact with infected blood, including receiving blood
transfusions.

Answer C. Frequent mouth care helps relieve dry mouth.

Answer C. Coffee-ground emesis occurs when there is upper GI bleeding that has undergone gastric
digestion. For blood to appear as coffee-ground emesis, it would have to be digested for approximately
2 hours.

Answer C. Normally, drainage is bloody for the first 24 hours after a partial gastrectomy; then it changes
to brown-tinged and then to yellow or clear.

Answer D. If the vagus nerve is cut as it enters the stomach, gastric acid secretion is decreased, but
intestinal motility is also decreased and gastric emptying is delayed. Because gastric acids are decreased,
gastric pH increases.

Answer A. Dosage problem. It’s 80/20 = 240/X. X=60.

Answer A. The output from an Ileostomy is described.

Answer B. As healing occurs from the bile duct, bile drains from the tube; the amount of bile should
decrease. Teach the patient to expect dark green drainage and to notify the doctor if drainage stops.

Answer C. Misoprostol restores prostaglandins that protect the stomach from NSAIDS, which diminish
the prostaglandins.

Answer C.
Answer D.

. The parents of a child, age 6, who will begin school in the fall ask the nurse for anticipatory guidance.
The nurse should explain that a child of this age:

Still depends on the parents

Rebels against scheduled activities

Is highly sensitive to criticism

Loves to tattle

2. While preparing to discharge an 8-month-old infant who is recovering from gastroenteritis and
dehydration, the nurse teaches the parents about their infant’s dietary and fluid requirements. The
nurse should include which other topic in the teaching session?

Nursery schools

Toilet Training

Safety guidelines

Preparation for surgery

3. Nurse Betina should begin screening for lead poisoning when a child reaches which age?

6 months

12 months

18 months

24 months

4. When caring for an 11-month-old infant with dehydration and metabolic acidosis, the nurse expects
to see which of the following?
A reduced white blood cell count

A decreased platelet count

Shallow respirations

Tachypnea

5. After the nurse provides dietary restrictions to the parents of a child with celiac disease, which
statement by the parents indicates effective teaching?

“Well follow these instructions until our child’s symptoms disappear.”

“Our child must maintain these dietary restrictions until adulthood.”

“Our child must maintain these dietary restrictions lifelong.”

“We’ll follow these instructions until our child has completely grown and developed.”

6. A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When palpating the
toddler’s fontanels, what should the nurse expects to find?

Closed anterior fontanel and open posterior fontanel

Open anterior and fontanel and closed posterior fontanel

Closed anterior and posterior fontanels

Open anterior and posterior fontanels

7. Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should
monitor this client’s fluid intake because fluid overload may cause:

Cerebral edema

Dehydration

Heart failure

Hypovolemic shock

8. An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most
appropriate for this infant?
Encouraging the infant to hold a bottle

Keeping the infant on bed rest to conserve energy

Rotating caregivers to provide more stimulation

Maintaining a consistent, structured environment

9. The mother of Gian, a preschooler with spina bifida tells the nurse that her daughter sneezes and
gets a rash when playing with brightly colored balloons, and that she recently had an allergic reaction
after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to:

Bananas

Latex

Kiwifruit

Color dyes

10. Cristina, a mother of a 4-year-old child tells the nurse that her child is a very poor eater. What’s the
nurse’s best recommendation for helping the mother increase her child’s nutritional intake?

Allow the child to feed herself

Use specially designed dishes for children – for example, a plate with the child’s favorite cartoon
character

Only serve the child’s favorite foods

Allow the child to eat at a small table and chair by herself

11. Nurse Roy is administering total parental nutrition (TPN) through a peripheral I.V. line to a school-
age child. What’s the smallest amount of glucose that’s considered safe and not caustic to small veins,
while also providing adequate TPN?

5% glucose

10% glucose

15% glucose
17% glucose

12. David, age 15 months, is recovering from surgery to remove Wilms’ tumor. Which findings best
indicates that the child is free from pain?

Decreased appetite

Increased heart rate

Decreased urine output

Increased interest in play

13. When planning care for a 8-year-old boy with Down syndrome, the nurse should:

Plan interventions according to the developmental level of a 7-year-old child because that’s the child’s
age

Plan interventions according to the developmental levels of a 5-year-old because the child will have
developmental delays

Assess the child’s current developmental level and plan care accordingly

Direct all teaching to the parents because the child can’t understand

14. Nurse Victoria is teaching the parents of a school-age child. Which teaching topic should take
priority?

Prevent accidents

Keeping a night light on to allay fears

Explaining normalcy of fears about body integrity

Encouraging the child to dress without help

15. The nurse is finishing her shift on the pediatric unit. Because her shift is ending, which intervention
takes top priority?

Changing the linens on the clients’ beds


Restocking the bedside supplies needed for a dressing change on the upcoming shift

Documenting the care provided during her shift

Emptying the trash cans in the assigned client room

16. Nurse Alice is providing cardiopulmonary resuscitation (CPR) to a child, age 4. the nurse should:

Compress the sternum with both hands at a depth of 1½ to 2” (4 to 5 cm)

Deliver 12 breaths/minute

Perform only two-person CPR

Use the heel of one hand for sternal compressions

17. A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which
nursing intervention has the highest priority?

Instituting droplet precautions

Administering acetaminophen (Tylenol)

Obtaining history information from the parents

Orienting the parents to the pediatric unit

18. Sheena, tells the nurse that she wants to begin toilet training her 22-month-old child. The most
important factor for the nurse to stress to the mother is:

Developmental readiness of the child

Consistency in approach

The mother’s positive attitude

Developmental level of the child’s peers

19. An infant who has been in foster care since birth requires a blood transfusion. Who is authorized to
give written, informed consent for the procedure?

The foster mother


The social worker who placed the infant in the foster home

The registered nurse caring for the infant

The nurse-manager

20. A child is undergoing remission induction therapy to treat leukemia. Allopurinol is included in the
regimen. The main reason for administering allopurinol as part of the client’s chemotherapy regimen is
to:

Prevent metabolic breakdown of xanthine to uric acid

Prevent uric acid from precipitating in the ureters

Enhance the production of uric acid to ensure adequate excretion of urine

Ensure that the chemotherapy doesn’t adversely affect the bone marrow

21. A 10-year-old client contracted severe acute respiratory syndrome (SARS) when traveling abroad
with her parents. The nurse knows she must put on personal protective equipment to protect herself
while providing care. Based on the mode of SARS transmission, which personal protective should the
nurse wear?

Gloves

Gown and gloves

Gown, gloves, and mask

Gown, gloves, mask, and eye goggles or eye shield

22. A tuberculosis intradermal skin test to detect tuberculosis infection is given to a high-risk
adolescent. How long after the test is administered should the result be evaluated?

Immediately

Within 24 hours

In 48 to 72 hours

After 5 days
23. Nurse Oliver s teaching a mother who plans to discontinue breast-feeding after 5 months. The
nurse should advise her to include which foods in her infant’s diet?

Iron-rich formula and baby food

Whole milk and baby food

Skim milk and baby food

Iron-rich formula only

24. Gracie, the mother of a 3-month-old infant calls the clinic and states that her child has a diaper
rash. What should the nurse advise?

“Switch to cloth diapers until the rash is gone”

“Use baby wipes with each diaper change.”

“Leave the diaper off while the infant sleeps.”

“Offer extra fluids to the infant until the rash improves.”

25. Nurse Kelly is teaching the parents of a young child how to handle poisoning. If the child ingests
poison, what should the parents do first?

Administer ipecac syrup

Call an ambulance immediately

Call the poison control center

Punish the child for being bad

26. A child has third-degree burns of the hands, face, and chest. Which nursing diagnosis takes
priority?

Ineffective airway clearance related to edema

Disturbed body image related to physical appearance

Impaired urinary elimination related to fluid loss


Risk for infection related to epidermal disruption

27. A 3-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour.
Which sign or symptom suggests excessive I.V. fluid intake?

Worsening dyspnea

Gastric distension

Nausea and vomiting

Temperature of 102°F (38.9° C)

28. Which finding would alert a nurse that a hospitalized 6-year-old child is at risk for a severe asthma
exacerbation?

Oxygen saturation of 95%

Mild work of breathing

Absence of intercostals or substernal retractions

History of steroid-dependent asthma

29. Nurse Mariane is caring for an infant with spina bifida. Which technique is most important in
recognizing possible hydrocephalus?

Measuring head circumference

Obtaining skull X-ray

Performing a lumbar puncture

Magnetic resonance imaging (MRI)

30. An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What should
the nurse do to help relieve the itching?

Apply cool air under the cast with a blow-dryer

Use sterile applicators to scratch the itch


Apply cool water under the cast

Apply hydrocortisone cream under the cast using sterile applicator.

Answers and Rationales

Answer C. In a 6-year-old child, a precarious sense of self causes overreaction to criticism and a sense of
inferiority. By age 6, most children no longer depend on the parents for daily tasks and love the routine
of a schedule. Tattling is more common at age 4 to 5, by age 6, the child wants to make friends and be a
friend.

Answer C. The nurse always should reinforce safety guidelines when teaching parents how to care for
their child. By giving anticipatory guidance the nurse can help prevent many accidental injuries. For
parents of a 9-month-old infant, it is too early to discuss nursery schools or toilet training. Because
surgery is not used gastroenteritis, this topic is inappropriate.

Answer C. The nurse should start screening a child for lead poisoning at age 18 months and perform
repeat screening at age 24, 30, and 36 months. High-risk infants, such as premature infants and formula-
fed infants not receiving iron supplementation, should be screened for iron-deficiency anemia at 6
months. Regular dental visits should begin at age 24 months.

Answer D. The body compensates for metabolic acidosis via the respiratory system, which tries to
eliminate the buffered acids by increasing alveolar ventilation through deep, rapid respirations, altered
white blood cell or platelet counts are not specific signs of metabolic imbalance.

Answer C. A patient with celiac disease must maintain dietary restrictions lifelong to avoid recurrence of
clinical manifestations of the disease. The other options are incorrect because signs and symptoms will
reappear if the patient eats prohibited foods.

Answer C. By age 18 months, the anterior and posterior fontanels should be closed. The diamond-
shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior
fontanel normally closes between ages 2 and 3 months.

Answer A. Because of the inflammation of the meninges, the client is vulnerable to developing cerebral
edema and increase intracranial pressure. Fluid overload won’t cause dehydration. It would be unusual
for an adolescent to develop heart failure unless the overhydration is extreme. Hypovolemic shock
would occur with an extreme loss of fluid of blood.

Answer D. The nurse caring for an infant with nonorganic failure to thrive should maintain a consistent,
structured environment that provides interaction with the infant to promote growth and development.
Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant
should receive social stimulation rather than be confined to bed rest. The number of caregivers should
be minimized to promote consistency of care.
Answer B. Children with spina bifida often develop an allergy to latex and shouldn’t be exposed to it. If a
child is sensitive to bananas, kiwifruit, and chestnuts, then she’s likely to be allergic to latex. Some
children are allergic to dyes in foods and other products but dyes aren’t a factor in a latex allergy.

Answer A. The best recommendation is to allow the child to feed herself because the child’s stage of
development is the preschool period of initiative. Special dishes would enhance the primary
recommendation. The child should be offered new foods and choices, not just served her favorite foods.
Using a small table and chair would also enhance the primary recommendation.

Answer B. The amount of glucose that’s considered safe for peripheral veins while still providing
adequate parenteral nutrition is 10%. Five percent glucose isn’t sufficient nutritional replacement,
although it’s sake for peripheral veins. Any amount above 10% must be administered via central venous
access.

Answer D. One of the most valuable clues to pain is a behavior change: A child who’s pain-free likes to
play. A child in pain is less likely to consume food or fluids. An increased heart rate may indicate
increased pain; decreased urine output may signify dehydration.

Answer C. Nursing care plan should be planned according to the developmental age of a child with
Down syndrome, not the chronological age. Because children with Down syndrome can vary from mildly
to severely mentally challenged, each child should be individually assessed. A child with Down syndrome
is capable of learning, especially a child with mild limitations.

Answer A. Accidents are the major cause of death and disability during the school-age years. Therefore,
accident prevention should take priority when teaching parents of school-age children. Preschool (not
school-age) children are afraid of the dark, have fears concerning body integrity, and should be
encouraged to dress without help (with the exception of tying shoes).

Answer C. Documentation should take top priority. Documentation is the only way the nurse can legally
claim that interventions were performed. The other three options would be appreciated by the nurses
on the oncoming shift but aren’t mandatory and don’t take priority over documentation.

Answer D. The nurse should use the heel of one hand and compress 1” to 1½ “. The nurse should use the
heels of both hands clasped together and compress the sternum 1½ “to 2” for an adult. For a small child,
two-person rescue may be inappropriate. For a child, the nurse should deliver 20 breaths/minute
instead of 12.

Answer A. Instituting droplet precautions is a priority for a newly admitted infant with meningococcal
meningitis. Acetaminophen may be prescribed but administering it doesn’t take priority over instituting
droplet precautions. Obtaining history information and orienting the parents to the unit don’t take
priority.

Answer A. If the child isn’t developmentally ready, child and parent will become frustrated. Consistency
is important once toilet training has already started. The mother’s positive attitude is important when
the child is ready. Developmental levels of children are individualized and comparison to peers isn’t
useful.

Answer A. When children are minors and aren’t emancipated, their parents or designated legal
guardians are responsible for providing consent for medical procedures. Therefore, the foster mother is
authorized to give consent for the blood transfusion. The social workers, the nurse, and the nurse-
manager have no legal rights to give consent in this scenario.

Answer A. The massive cell destruction resulting from chemotherapy may place the client at risk for
developing renal calculi; adding allopurinol decreases this risk by preventing the breakdown of xanthine
to uric acid. Allopurinol doesn’t act in the manner described in the other options.

Answer D. The transmission of SARS isn’t fully understood. Therefore, all modes of transmission must be
considered possible, including airborne, droplet, and direct contact with the virus. For protection from
contracting SARS, any health care worker providing care for a client with SARS should wear a gown,
gloves, mask, and eye goggles or an eye shield.

Answer C. Tuberculin skin tests of delayed hypersensitivity. If the test results are positive, a reaction
should appear in 48 to 72 hours. Immediately after the test and within 24 hours are both too soon to
observe a reaction. Waiting more than 5 days to evaluate the test is too long because any reaction may
no longer be visible.

Answer D. The American Academy of Pediatrics recommends that infants at age 5 months receive iron-
rich formula and that they shouldn’t receive solid food – even baby food – until age 6 months. The
Academy doesn’t recommend whole milk until age 12 months, and skim milk until after age 2 years.

Answer C. Leaving the diaper off while the infant sleeps helps to promote air circulation to the area,
improving the condition. Switching to cloth diapers isn’t necessary; in fact, that may make the rash
worse. Baby wipes contain alcohol, which may worsen the condition. Extra fluids won’t make the rash
better.

Answer C. Before interviewing in any way, the parents should call the poison control center for specific
directions. Ipecac syrup is no longer recommended. The parents may have to call an ambulance after
calling the poison control center. Punishment for being bad isn’t appropriate because the parents are
responsible for making the environment safe.

Answer A.Initially, when a preschool client is admitted to the hospital for burns, the primary focus is on
assessing and managing an effective airway. Body image disturbance, impaired urinary elimination, and
infection are all integral parts of burn management but aren’t the first priority.

Answer A. Dyspnea and other signs of respiratory distress signify fluid volume excess (overload), which
can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular
compartments. Gastric distention may suggest excessive oral fluid intake or infection. Nausea and
vomiting or an elevated temperature may indicate a fluid volume deficit.
Answer D. A history of steroid-dependent asthma, a contributing factor to this client’s high-risk status,
requires the nurse to treat the situation as a severe exacerbation regardless of the severity of the
current episode. An oxygen saturation of 95%, mild work of breathing, and absence of intercostals or
substernal retractions are all normal findings.

Answer A. Measuring head circumference is the most important assessment technique for recognizing
possible hydrocephalus, and is a key part of routine infant screening. Skull X-rays and MRI may be used
to confirm the diagnosis. A lumber puncture isn’t appropriate.

Answer A. Itching underneath a cast can be relieved by directing blow-dyer, set, on the cool setting,
toward the itchy area. Skin breakdown can occur if anything is placed under the cast. Therefore, the
client should be cautioned not to put any object down the cast in an attempt to scratch.

1. Which of the following conditions can cause a hiatal hernia?

Increased intrathoracic pressure

Weakness of the esophageal muscle

Increased esophageal muscle pressure

Weakness of the diaphragmic muscle

2. Risk factors for the development of hiatal hernias are those that lead to increased abdominal
pressure. Which of the following complications can cause increased abdominal pressure?

Obesity

Volvulus

Constipation

Intestinal obstruction

3. Which of the following symptoms is common with a hiatal hernia?

Left arm pain


Lower back pain

Esophageal reflux

Abdominal cramping

4. Which of the following tests can be performed to diagnose a hiatal hernia?

Colonoscopy

Lower GI series

Barium swallow

Abdominal x-rays

5. Which of the following measures should the nurse focus on for the client with esophageal varices?

Recognizing hemorrhage

Controlling blood pressure

Encouraging nutritional intake

Teaching the client about varices

6. Which of the following tests can be used to diagnose ulcers?

Abdominal x-ray

Barium swallow

Computed tomography (CT) scan

Esophagogastroduodenoscopy (EGD)

7. Which of the following best describes the method of action of medications, such as ranitidine
(Zantac), which are used in the treatment of peptic ulcer disease?

Neutralize acid

Reduce acid secretions


Stimulate gastrin release

Protect the mucosal barrier

8. The hospitalized client with GERD is complaining of chest discomfort that feels like heartburn
following a meal. After administering an ordered antacid, the nurse encourages the client to lie in which
of the following positions?

Supine with the head of the bed flat

On the stomach with the head flat

On the left side with the head of the bed elevated 30 degrees

On the right side with the head of the bed elevated 30 degrees.

9. The nurse is caring for a client following a Billroth II procedure. On review of the post-operative
orders, which of the following, if prescribed, would the nurse question and verify?

Irrigating the nasogastric tube

Coughing a deep breathing exercises

Leg exercises

Early ambulation

10. The nurse is providing discharge instructions to a client following gastrectomy. Which measure will
the nurse instruct the client to follow to assist in preventing dumping syndrome?

Eat high-carbohydrate foods

Limit the fluids taken with meals

Ambulate following a meal

Sit in a high-Fowlers position during meals

11. The nurse instructs the nursing assistant on how to provide oral hygiene for a client who cannot
perform this task for himself. Which of the following techniques should the nurse tell the assistant to
incorporate into the client’s daily care?
Assess the oral cavity each time mouth care is given and record observations

Use a soft toothbrush to brush the client’s teeth after each meal

Swab the client’s tongue, gums, and lips with a soft foam applicator every 2 hours.

Rinse the client’s mouth with mouthwash several times a day.

12. A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the
following assessments made after the procedure would indicate the development of a potential
complication?

The client complains of a sore throat

The client displays signs of sedation

The client experiences a sudden increase in temperature

The client demonstrates a lack of appetite

13. A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to undergo a
subtotal gastrectomy (Billroth II procedure). During pre-operative teaching, the nurse is reinforcing
information about the procedure. Which of the following explanations is most accurate?

The procedure will result in enlargement of the pyloric sphincter

The procedure will result in anastomosis of the gastric stump to the jejunum

The procedure will result in removal of the duodenum

The procedure will result in repositioning of the vagus nerve

14. After a subtotal gastrectomy, the nurse should anticipate that nasogastric tube drainage will be
what color for about 12 to 24 hours after surgery?

Dark brown

Bile green

Bright red

Cloudy white
15. After a subtotal gastrectomy, care of the client’s nasogastric tube and drainage system should
include which of the following nursing interventions?

Irrigate the tube with 30 ml of sterile water every hour, if needed.

Reposition the tube if it is not draining well

Monitor the client for N/V, and abdominal distention

Turn the machine to high suction of the drainage is sluggish on low suction.

16. Which of the following would be an expected nutritional outcome for a client who has undergone a
subtotal gastrectomy for cancer?

Regain weight loss within 1 month after surgery

Resume normal dietary intake of three meals per day

Control nausea and vomiting through regular use of antiemetics

Achieve optimal nutritional status through oral or parenteral feedings

17. The client with GERD complains of a chronic cough. The nurse understands that in a client with
GERD this symptom may be indicative of which of the following conditions?

Development of laryngeal cancer

Irritation of the esophagus

Esophageal scar tissue formation

Aspiration of gastric contents

18. Which of the following dietary measures would be useful in preventing esophageal reflux?

Eating small, frequent meals

Increasing fluid intake

Avoiding air swallowing with meals

Adding a bedtime snack to the dietary plan


19. A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding
duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric area along with a rigid,
boardlike abdomen. These clinical manifestations most likely indicate which of the following?

An intestinal obstruction has developed

Additional ulcers have developed

The esophagus has become inflamed

The ulcer has perforated

20. When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and
symptoms would the nurse expect to see? Select all that apply.

Epigastric pain at night

Relief of epigastric pain after eating

Vomiting

Weight loss

21. The nurse is caring for a client who has had a gastroscopy. Which of the following symptoms may
indicate that the client is developing a complication related to the procedure? Select all that apply.

The client complains of a sore throat

The client has a temperature of 100*F

The client appears drowsy following the procedure

The client complains of epigastric pain

The client experiences hematemesis

22. A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported
to his physician. Based on this information, which nursing diagnosis would be appropriate for this client?

Ineffective coping related to fear of diagnosis of chronic illness


Deficient knowledge related to unfamiliarity with significant signs and symptoms

Constipation related to decreased gastric motility

Imbalanced nutrition: Less than body requirements due to gastric bleeding

23. A client with a peptic ulcer reports epigastric pain that frequently awakens her at night, a feeling of
fullness in the abdomen, and a feeling of anxiety about her health. Based on this information, which
nursing diagnosis would be most appropriate?

Imbalanced Nutrition: Less than Body Requirements related to anorexia.

Disturbed Sleep Pattern related to epigastric pain

Ineffective Coping related to exacerbation of duodenal ulcer

Activity Intolerance related to abdominal pain

24. While caring for a client with peptic ulcer disease, the client reports that he has been nauseated
most of the day and is now feeling lightheaded and dizzy. Based upon these findings, which nursing
actions would be most appropriate for the nurse to take? Select all that apply.

Administering an antacid hourly until nausea subsides.

Monitoring the client’s vital signs

Notifying the physician of the client’s symptoms

Initiating oxygen therapy

Reassessing the client on an hour

25. A client is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer. The nurse
knows that the client understands proper drug administration of ranitidine when she says that she will
take the drug at which of the following times?

Before meals

With meals

At bedtime

When pain occurs


26. A client has been taking aluminum hydroxide 30 mL six times per day at home to treat his peptic
ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this
information, the nurse would determine that which of the following is the most likely cause of the
client’s constipation?

The client has not been including enough fiber in his diet

The client needs to increase his daily exercise

The client is experiencing a side effect of the aluminum hydroxide.

The client has developed a gastrointestinal obstruction.

27. A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best
indicates that the client understands how to correctly take the antacid?

“I should take my antacid before I take my other medications.”

“I need to decrease my intake of fluids so that I don’t dilute the effects of my antacid.”

“My antacid will be most effective if I take it whenever I experience stomach pains.”

“It is best for me to take my antacid 1 to 3 hours after meals.”

28. The nurse is caring for a client with chronic gastritis. The nurse monitors the client, knowing that this
client is at risk for which of the following vitamin deficiencies?

Vitamin A

Vitamin B12

Vitamin C

Vitamin E

29. 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?

Digoxin (Lanoxin)

Indomethacin (Indocin)
Furosemide (Lasix)

Propranolol hydrochloride (Inderal)

30. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-
tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate?

Notify the physician

Document the findings

Irrigate the T-tube

Clamp the T-tube

31. The nurse provides medication instructions to a client with peptic ulcer disease. Which statement, if
made by the client, indicates the best understanding of the medication therapy?

“The cimetidine (Tagamet) will cause me to produce less stomach acid.”

“Sucralfate (Carafate) will change the fluid in my stomach.”

“Antacids will coat my stomach.”

“Omeprazole (Prilosec) will coat the ulcer and help it heal.”

32. The client with peptic ulcer disease is scheduled for a pyloroplasty. The client asks the nurse about
the procedure. The nurse plans to respond knowing that a pyloroplasty involves:

Cutting the vagus nerve

Removing the distal portion of the stomach

Removal of the ulcer and a large portion of the cells that produce hydrochloric acid

An incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach
to the duodenum.

33. A client with a peptic ulcer is scheduled for a vagotomy. The client asks the nurse about the purpose
of this procedure. The nurse tells the client that the procedure:
Decreases food absorption in the stomach

Heals the gastric mucosa

Halts stress reactions

Reduces the stimulus to acid secretions

34. The nurse would assess the client experiencing an acute episode of cholecysitis for pain that is
located in the right

Upper quadrant and radiates to the left scapula and shoulder

Upper quadrant and radiates to the right scapula and shoulder

Lower quadrant and radiates to the umbilicus

Lower quadrant and radiates to the back

35. Which of the following tasks should be included in the immediate postoperative management of a
client who has undergone gastric resection?

Monitoring gastric pH to detect complications

Assessing for bowel sounds

Providing nutritional support

Monitoring for symptoms of hemorrhage

36. If a gastric acid perforates, which of the following actions should not be included in the immediate
management of the client?

Blood replacement

Antacid administration

Nasogastric tube suction

Fluid and electrolyte replacement

37. Mucosal barrier fortifiers are used in peptic ulcer disease management for which of the following
indications?
To inhibit mucus production

To neutralize acid production

To stimulate mucus production

To stimulate hydrogen ion diffusion back into the mucosa

38. When counseling a client in ways to prevent cholecystitis, which of the following guidelines is most
important?

Eat a low-protein diet

Eat a low-fat, low-cholesterol diet

Limit exercise to 10 minutes/day

Keep weight proportionate to height

39. Which of the following symptoms best describes Murphy’s sign?

Periumbilical eccymosis exists

On deep palpitation and release, pain in elicited

On deep inspiration, pain is elicited and breathing stops

Abdominal muscles are tightened in anticipation of palpation

40. Which of the following tests is most commonly used to diagnose cholecystitis?

Abdominal CT scan

Abdominal ultrasound

Barium swallow

Endoscopy

41. Which of the following factors should be the main focus of nursing management for a client
hospitalized for cholecystitis?
Administration of antibiotics

Assessment for complications

Preparation for lithotripsy

Preparation for surgery

42. A client being treated for chronic cholecystitis should be given which of the following instructions?

Increase rest

Avoid antacids

Increase protein in diet

Use anticholinergics as prescribed

43. The client with a duodenal ulcer may exhibit which of the following findings on assessment?

Hematemesis

Malnourishment

Melena

Pain with eating

44. The pain of a duodenal ulcer can be distinguished from that of a gastric ulcer by which of the
following characteristics?

Early satiety

Pain on eating

Dull upper epigastric pain

Pain on empty stomach

45. The client has orders for a nasogastric (NG) tube insertion. During the procedure, instructions that
will assist in the insertion would be:
Instruct the client to tilt his head back for insertion in the nostril, then flex his neck for the final insertion

After insertion into the nostril, instruct the client to extend his neck

Introduce the tube with the client’s head tilted back, then instruct him to keep his head upright for final
insertion

Instruct the client to hold his chin down, then back for insertion of the tube

46. The most important pathophysiologic factor contributing to the formation of esophageal varices is:

Decreased prothrombin formation

Decreased albumin formation by the liver

Portal hypertension

Increased central venous pressure

47. The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control
the bleeding. The most important assessment is for the nurse to:

Check that the hemostat is on the bedside

Monitor IV fluids for the shift

Regularly assess respiratory status

Check that the balloon is deflated on a regular basis

48. A female client complains of gnawing epigastric pain for a few hours after meals. At times, when the
pain is severe, vomiting occurs. Specific tests are indicated to rule out:

Cancer of the stomach

Peptic ulcer disease

Chronic gastritis

Pylorospasm

49. When a client has peptic ulcer disease, the nurse would expect a priority intervention to be:
Assisting in inserting a Miller-Abbott tube

Assisting in inserting an arterial pressure line

Inserting a nasogastric tube

Inserting an I.V.

50. A 40-year-old male client has been hospitalized with peptic ulcer disease. He is being treated with a
histamine receptor antagonist (cimetidine), antacids, and diet. The nurse doing discharge planning will
teach him that the action of cimetidine is to:

Reduce gastric acid output

Protect the ulcer surface

Inhibit the production of hydrochloric acid (HCl)

Inhibit vagus nerve stimulation

Answers and Rationales

D. A hiatal hernia is caused by weakness of the diaphragmic muscle and increased intra-abdominal—not
intrathoracic—pressure. This weakness allows the stomach to slide into the esophagus. The esophageal
supports weaken, but esophageal muscle weakness or increased esophageal muscle pressure isn’t a
factor in hiatal hernia.

A. Obesity may cause increased abdominal pressure that pushes the lower portion of the stomach into
the thorax.

C. Esophageal reflux is a common symptom of hiatal hernia. This seems to be associated with chronic
exposure of the lower esophageal sphincter to the lower pressure of the thorax, making it less effective.

C. A barium swallow with fluoroscopy shows the position of the stomach in relation to the diaphragm. A
colonoscopy and a lower GI series show disorders of the intestine.

A. Recognizing the rupture of esophageal varices, or hemorrhage, is the focus of nursing care because
the client could succumb to this quickly. Controlling blood pressure is also important because it helps
reduce the risk of variceal rupture. It is also important to teach the client what varices are and what
foods he should avoid such as spicy foods.

D. The EGD can visualize the entire upper GI tract as well as allow for tissue specimens and
electrocautery if needed. The barium swallow could locate a gastric ulcer. A CT scan and an abdominal x-
ray aren’t useful in the diagnosis of an ulcer.
B. Ranitidine is a histamine-2 receptor antagonist that reduces acid secretion by inhibiting gastrin
secretion.

C. The discomfort of reflux is aggravated by positions that compress the abdomen and the stomach.
These include lying flat on the back or on the stomach after a meal of lying on the right side. The left
side-lying position with the head of the bed elevated is most likely to give relief to the client.

A. In a Billroth II procedure the proximal remnant of the stomach is anastomased to the proximal
jejunum. Patency of the NG tube is critical for preventing the retention of gastric secretions. The nurse
should never irrigate or reposition the gastric tube after gastric surgery, unless specifically ordered by
the physician. In this situation, the nurse would clarify the order.

B. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high
carbohydrate foods including fluids such as fruit nectars; to assume a low-Fowler’s position during
meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmidocs as
prescribed.

B. A soft toothbrush should be used to brush the client’s teeth after each meal and more often as
needed. Mechanical cleaning is necessary to maintain oral health, simulate gingiva, and remove plaque.
Assessing the oral cavity and recording observations is the responsibility of the nurse, not the nursing
assistant. Swabbing with a safe foam applicator does not provide enough friction to clean the mouth.
Mouthwash can be a drying irritant and is not recommended for frequent use.

C. The most likely complication of an endoscopic procedure is perforation. A sudden temperature spike
with 1 to 2 hours after the procedure is indicative of a perforation and should be reported immediately
to the physician. A sore throat is to be anticipated after an endoscopy. Clients are given sedatives during
the procedure, so it is expected that they will display signs of sedation after the procedure is completed.
A lack of appetite could be the result of many factors, including the disease process.

B. A Billroth II procedure bypasses the duodenum and connects the gastric stump directly to the
jejunum. The pyloric sphincter is removed, along with some of the stomach fundus.

A. About 12 to 24 hours after a subtotal gastrectomy, gastric drainage is normally brown, which
indicates digested blood. Bile green or cloudy white drainage is not expected during the first 12 to 24
hours after a subtotal gastrectomy. Drainage during the first 6 to 12 hours contains some bright red
blood, but large amounts of blood or excessively bloody drainage should be reported to the physician
promptly.

C. Nausea, vomiting, or abdominal distention indicated that gas and secretions are accumulating within
the gastric pouch due to impaired peristalsis or edema at the operative site and may indicate that the
drainage system is not working properly. Saline solution is used to irrigate nasogastric tubes. Hypotonic
solutions such as water increase electrolyte loss. In addition, a physician’s order is needed to irrigate the
NG tube, because this procedure could disrupt the suture line. After gastric surgery, only the surgeon
repositions the NG tube because of the danger of rupturing or dislodging the suture line. The amount of
suction varies with the type of tube used and is ordered by the physician. High suction may create too
much tension on the gastric suture line.

D. An appropriate expected outcome is for the client to achieve optimal nutritional status through the
use of oral feedings or total parenteral nutrition (TPN). TPN may be used to supplement oral intake, or it
may be used alone if the client cannot tolerate oral feedings. The client would not be expected to regain
lost weight within 1 month after surgery or to tolerate a normal dietary intake of three meals per day.
Nausea and vomiting would not be considered an expected outcome of gastric surgery, and regular use
of antiemetics would not be anticipated.

D. Clients with GERD can develop pulmonary symptoms such as coughing, wheezing, and dyspnea that
are caused by the aspiration of gastric contents. GERD does not predispose the client to the
development of laryngeal cancer. Irritation of the esophagus and esophageal scar tissue formation can
develop as a result of GERD. However, GERD is more likely to cause painful and difficult swallowing.

A. Esophageal reflux worsens when the stomach is overdistended with food. Therefore, an important
measure is to eat small, frequent meals. Fluid intake should be decreased during meals to reduce
abdominal distention. Avoiding air swallowing does not prevent esophageal reflux. Food intake in the
evening should be strictly limited to reduce the incidence of nighttime reflux, so bedtime snacks are not
recommended.

D. The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results
in boardlike muscle rigidity, usually with extreme pain. Perforation is a medical emergency requiring
immediate surgical intervention because peritonitis develops quickly after perforation. An intestinal
obstruction would not cause midepigastric pain. Esophageal inflammation or the development of
additional ulcers would not cause a rigid, boardlike abdomen.

C and D. Vomiting and weight loss are common with gastric ulcers. Clients with a gastric ulcer are most
likely to complain of a burning epigastric pain that occurs about one hour after eating. Eating frequently
aggravates the pain. Clients with duodenal ulcers are more likely to complain about pain that occurs
during the night and is frequently relieved by eating.

B, D, and E. Following a gastroscopy, the nurse should monitor the client for complications, which
include perforation and the potential for aspiration. An elevated temperature, complaints of epigastric
pain, or the vomiting of blood (hematemesis) are all indications of a possible perforation and should be
reported promptly. A sore throat is a common occurrence following a gastroscopy. Clients are usually
sedated to decrease anxiety and the nurse would anticipate that the client will be drowsy following the
procedure.

B. Black, tarry stools are an important warning sign of bleeding in peptic ulcer disease. Digested blood in
the stomach causes it to be black. The odor of the stool is very stinky. Clients with peptic ulcer disease
should be instructed to report the incidence of black stools promptly to their physician.
B. Based on the data provided, the most appropriate nursing diagnosis would be Disturbed Sleep
pattern. A client with a duodenal ulcer commonly awakens at night with pain. The client’s feelings of
anxiety do not necessarily indicate that she is coping ineffectively.

B and C. The symptoms of nausea and dizziness in a client with peptic ulcer disease may be indicative of
hemorrhage and should not be ignored. The appropriate nursing actions at this time are for the nurse to
monitor the client’s vital signs and notify the physician of the client’s symptoms. To administer an
antacid hourly or to wait one hour to reassess the client would be inappropriate; prompt intervention is
essential in a client who is potentially experiencing a gastrointestinal hemorrhage. The nurse would
notify the physician of assessment findings and then initiate oxygen therapy if ordered by the physician.

C. Ranitidine blocks secretion of hydrochloric acid. Clients who take only one daily dose of ranitidine are
usually advised to take it at bedtime to inhibit nocturnal secretion of acid. Clients who take the drug
twice a day are advised to take it in the morning and at bedtime.

C. It is most likely that the client is experiencing a side effect of the antacid. Antacids with aluminum salt
products, such as aluminum hydroxide, form insoluble salts in the body. These precipitate and
accumulate in the intestines, causing constipation. Increasing dietary fiber intake or daily exercise may
be a beneficial lifestyle change for the client but is not likely to relieve the constipation caused by the
aluminum hydroxide. Constipation, in isolation from other symptoms, is not a sign of bowel obstruction.

D. Antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an antacid is taken
on an empty stomach, the duration of the drug’s action is greatly decreased. Taking antacids 1 to 3
hours after a meal lengthens the duration of action, thus increasing the therapeutic action of the drug.
Antacids should be administered about 2 hours after other medications to decrease the chance of drug
interactions. It is not necessary to decrease fluid intake when taking antacids.

B. Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of
the functioning parietal cells. The source of the intrinsic factor is lost, which results in the inability to
absorb vitamin B12. This leads to the development of pernicious anemia.

B. Indomethacin (Indocin) is a NSAID and can cause ulceration of the esophagus, stomach, duodenum,
or small intestine. Indomethacin is contraindicated in a client with GI disorders.

B. Following cholecystectomy, drainage from the T-tube is initially bloody and then turns to green-
brown. The drainage is measured as output. The amount of expected drainage will range from 500 to
1000 ml per day. The nurse would document the output.

A. Cimetidine (Tagamet), a histamine H2 receptor antagonist, will decrease the secretion of gastric acid.
Sucralfate (Carafate) promotes healing by coating the ulcer. Antacids neutralize acid in the stomach.
Omeprazole (Prilosec) inhibits gastric acid secretion.

D. An incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the
stomach to the duodenum describes the procedure for a pyloroplasty. A vagotomy involves cutting the
vagus nerve. A subtotal gastrectomy involves removing the distal portion of the stomach. A Billroth II
procedure involves removal of the ulcer and a large portion of the tissue that produces hydrochloric
acid.

D. A vagotomy, or cutting the vagus nerve, is done to eliminate parasympathetic stimulation of gastric
secretion.

B. During an acute “gallbladder attack,” the client may complain of severe right upper quadrant pain
that radiates to the right scapula and shoulder. This is governed by the pattern on dermatones in the
body.

D. The client should be monitored closely for signs and symptoms of hemorrhage, such as bright red
blood in the nasogastric tube suction, tachycardia, or a drop in blood pressure. Gastric pH may be
monitored to evaluate the need for histamine-2 receptor antagonists. Bowel sounds may not return for
up to 72 hours postoperatively. Nutritional needs should be addressed soon after surgery.

B. Antacids aren’t helpful in perforation. The client should be treated with antibiotics as well as fluid,
electrolyte, and blood replacement. NG tube suction should also be performed to prevent further
spillage of stomach contents into the peritoneal cavity.

C. The mucosal barrier fortifiers stimulate mucus production and prevent hydrogen ion diffusion back
into the mucosa, resulting in accelerated ulcer healing. Antacids neutralize acid production.

D. Obesity is a known cause of gallstones, and maintaining a recommended weight will help protect
against gallstones. Excessive dietary intake of cholesterol is associated with the development of
gallstones in many people. Dietary protein isn’t implicated in cholecystitis. Liquid protein and low-calorie
diets (with rapid weight loss of more than 5 lb [2.3kg] per week) are implicated as the cause of some
cases of cholecystitis. Regular exercise (30 minutes/three times a week) may help reduce weight and
improve fat metabolism. Reducing stress may reduce bile production, which may also indirectly
decrease the chances of developing cholecystitis.

C. Murphy’s sign is elicited when the client reacts to pain and stops breathing. It’s a common finding in
clients with cholecystitis. Periumbilical ecchymosis, Cullen’s sign, is present in peritonitis. Pain on deep
palpation and release is rebound tenderness. Tightening up abdominal muscles in anticipation of
palpation is guarding.

B. An abdominal ultrasound can show if the gallbladder is enlarged, if gallstones are present, if the
gallbladder wall is thickened, or if distention of the gallbladder lumen is present. An abdominal CT scan
can be used to diagnose cholecystitis, but it usually isn’t necessary. A barium swallow looks at the
stomach and the duodenum. Endoscopy looks at the esophagus, stomach, and duodenum.

B. The client with acute cholecystitis should first be monitored for perforation, fever, abscess, fistula,
and sepsis. After assessment, antibiotics will be administered to reduce the infection. Lithotripsy is used
only for a small percentage of clients. Surgery is usually done after the acute infection has subsided.
D. Conservative therapy for chronic cholecystitis includes weight reduction by increasing physical
activity, a low-fat diet, antacid use to treat dyspepsia, and anticholinergic use to relax smooth muscles
and reduce ductal tone and spasm, thereby reducing pain.

C. The client with a duodenal ulcer may have bleeding at the ulcer site, which shows up as melena (black
tarry poop). The other findings are consistent with a gastric ulcer.

D. Pain on empty stomach is relieved by taking foods or antacids. The other symptoms are those of a
gastric ulcer.

A. NG insertion technique is to have the client first tilt his head back for insertion into the nostril, then to
flex his neck forward and swallow. Extension of the neck will impede NG tube insertion.

C. As the liver cells become fatty and degenerate, they are no longer able to accommodate the large
amount of blood necessary for homeostasis. The pressure in the liver increases and causes increased
pressure in the venous system. As the portal pressure increases, fluid exudes into the abdominal cavity.
This is called ascites.

C. The respiratory system can become occluded if the balloon slips and moves up the esophagus, putting
pressure on the trachea. This would result in respiratory distress and should be assessed frequently.
Scissors should be kept at the bedside to cut the tube if distress occurs. This is a safety intervention.

B. Peptic ulcer disease is characteristically gnawing epigastric pain that may radiate to the back.
Vomiting usually reflects pyloric spasm from muscular spasm or obstruction. Cancer would not evidence
pain or vomiting unless the pylorus was obstructed.

C. An NG tube insertion is the most appropriate intervention because it will determine the presence of
active GI bleeding. A Miller-Abbott tube is a weighted, mercury-filled ballooned tube used to resolve
bowel obstructions. There is no evidence of shock or fluid overload in the client; therefore, an arterial
line is not appropriate at this time and an IV is optional.

A. These drugs inhibit action of histamine on the H2 receptors of parietal cells, thus reducing gastric acid
output.

You might also like