MedSurge Success GI Comprehensive Exam

Question 1

The nurse is caring for the client with Clostridium difficile. Which intervention should the nurse implement to prevent nosocomial spread to other clients?

1. Wash hands with Betadine for two (2) minutes after giving care.
2. Wear nonsterile gloves when handling GI excretions.
3. Clean the perianal area with soap and water after each stool.
4. Flush the commode twice when disposing of stool.

Answer 1

Ans: 2. Wear nonsterile gloves when handling GI excretions.

1. The nurse should use soap and water for 15 to 30 seconds before and after caring for the client. Betadine is surgical scrub.
2. Clean gloves should be worn when pro- viding care to prevent the transfer of the bacteria found in the stool. This will prevent the spread of the bacteria to other clients in the health care facility (nosocomial). But this is not a substitute for good hand hygiene.
3. The nurse should clean the perianal area or instruct the client to clean the area, but this will not prevent the spread of the bacteria to other clients.
4. Flushing the commode twice is not neces- sary when disposing of stool and will not prevent a nosocomial infection.

Question 2

The client receiving antibiotic therapy complains of white, cheesy plaques in the mouth. Which intervention should the nurse implement?

1. Notify the health-care provider to obtain an antifungal medication.
2. Explain the patches will go away naturally in about two (2) weeks.
3. Instruct to rinse the mouth with diluted hydrogen peroxide and water daily.
4. Allow the client to verbalize feelings about having the plaques.

Answer 2

Ans: 1. Notify the health-care provider to obtain an antifungal medication.

1. Candidiasis, or thrush, presents as white, cheesy plaques which bleed when rubbed and is a side effect of antibiotic therapy. Candidiasis is treated with antifungal solution, swished around the mouth, held for at least one (1) minute, and then swallowed. Candidiasis can be prevented if Lactobacillus acidophilus is administered concurrently with antibiotic therapy.
2. White painless patches disappearing in ap- proximately two (2) weeks are leukoplakia, caused by tobacco use, which may be can- cerous and should be evaluated by an HCP.
3. A solution of hydrogen peroxide is not rec- ommended to treat candidiasis.
4. The nurse needs to treat the client’s mouth, not use therapeutic communication.

Question 3

Which instruction should be discussed with the client diagnosed with gastroesophageal reflux disease (GERD)?

1. Eat a low-carbohydrate, low-sodium diet.
2. Lie down for 30 minutes after eating.
3. Do not eat spicy foods or acidic foods.
4. Drink two (2) glasses of water before bedtime.

Answer 3

Ans: 3. Do not eat spicy foods or acidic foods.

1. The client should eat a low-fat, high-fiber diet.
2. The client should not lie down for at least two (2) hours after each meal to prevent gastric reflux.
3. The client should avoid irritants, such as spicy foods or acidic foods, as well as alcohol, caffeine, and tobacco, because they increase gastric secretions.
4. The client should avoid food or drink two (2) hours before bedtime or lying down after eating.

Question 4

Which data should the nurse report to the health-care provider when assessing the oral cavity of an elderly client?

1. The client’s tongue is rough and beefy red.
2. The client’s tonsils are +1 on a grading scale.
3. The client’s mucosa is pink and moist.
4. The client’s uvula rises with the mouth open.

Answer 4

Ans: 1. The client’s tongue is rough and beefy red.

1. A rough, beefy-red tongue may indicate the client has pernicious anemia and should be evaluated by the health-care provider.
2. A score of +1 on the tonsil grading scale shows the tonsils are extending to the pharyngopalatine arch, which is normal.
3. Mucosa should be pink and moist; there- fore, the nurse would not need to notify the health-care provider.
4. Symmetrical movement of the uvula is nor- mal and should not be reported to the health-care provider.

Question 5

Which complaint is significant for the nurse to assess in the adolescent male client who uses oral tobacco?

1. The client complains of clear to white sputum.
2. The client has an episodic blister on the upper lip.
3. The client complains of a nonhealing sore in the mouth.
4. The client has bilateral ducts at the second molars.

Answer 5

Ans: 3. The client complains of a nonhealing sore in the mouth.

1. Clear to white sputum is not significant in the client using oral tobacco.
2. Episodic blisters on the lips are herpes sim- plex 1 and are not specific to this client.
3. Presence of any nonhealing sore on the lips or mouth may be oral cancer. Oral cancer risk increases by using oral tobacco.
4. Bilateral Stensen’s ducts visible at the site of the second molars are normal assessment data.

Question 6

The client is diagnosed with ulcerative colitis. Which sign/symptom warrants immediate intervention by the nurse?

1. The client has 20 bloody stools a day.
2. The client’s oral temperature is 99.8 ̊F.
3. The client’s abdomen is hard and rigid.
4. The client complains of urinating when coughing.

Answer 6

Ans: 3. The client’s abdomen is hard and rigid.

1. The colon is ulcerated and unable to absorb water; 10 to 20 bloody diarrhea stools is the most common symptom of ulcerative colitis and does not warrant immediate intervention.
2. This is not an elevated temperature and does not warrant immediate intervention by the nurse.
3. A hard, rigid abdomen indicates peritoni- tis, a complication of ulcerative colitis, and warrants immediate intervention.
4. Stress incontinence is not a symptom of colitis and does not warrant immediate intervention.

Question 7

Which outcome should the nurse identify for the client diagnosed with aphthous stomatitis?

1. The client will be able to cope with perceived stress.
2. The client will consume a balanced diet.
3. The client will deny any difficulty swallowing.
4. The client will take antacids as prescribed.

Answer 7

Ans: 1. The client will be able to cope with perceived stress.

1. The cause of canker sores (aphthous stomatitis) is unknown. The small ulcerations of the soft oral tissue are linked to stress, trauma, allergies, viral infections, and metabolic disorders. Therefore, being able to cope with stress is a desired outcome.
2. The client with recurrent erythematous macule cankers will not have malnutrition; therefore, a balanced diet is not applicable to this client.
3. The client with cankers should not have difficulty swallowing.
4. Antacids are not a treatment for canker sores

Question 8

The nurse is administering a proton pump inhibitor to a client diagnosed with peptic ulcer disease. Which statement supports the rationale for administering this medication?

1. It prevents the final transport of hydrogen ions into the gastric lumen.
2. It blocks receptors controlling hydrochloric acid secretion by the parietal cells.
3. It protects the ulcer from the destructive action of the digestive enzyme pepsin.
4. It neutralizes the hydrochloric acid secreted by the stomach.

Answer 8

Ans: 1. It prevents the final transport of hydrogen ions into the gastric lumen.

1. This statement is the rationale for proton pump inhibitors.
2. This statement explains the rationale for histamine receptor antagonists.
3. This statement describes how mucosal protective agents work in the body.
4. This statement is the rationale for antacids.

Question 9

Which task should the nurse delegate to the unlicensed assistive personnel (UAP) to improve the desire to eat in a 14-year-old client diagnosed with anorexia?

1. Administer an antiemetic 30 minutes before the meal.
2. Provide mouth care with lemon-glycerin swabs prior to the meal.
3. Create a social atmosphere by interacting with the client.
4. Encourage the client’s parents to sit with the client during meals.

Answer 9

Ans: 3. Create a social atmosphere by interacting with the client.

1. ​Unlicensed assistive personnel (UAP) can- not administer medications, and this is not appropriate for a client with anorexia.
2. Mouth care should be provided before and after meals, but not with alcohol-based mouth wash and lemon-glycerin swabs, which can decrease the appetite.
3. The UAP assisting the client with meals should increase interaction to improve the client’s appetite and make it an enjoyable occasion.
4. Often the parents are the cause of the client’s stress and anxiety, which may have led to the client’s anorexia; therefore, the parents should not be asked to stay with the client.

Question 10

The client with a diagnosis of rule-out colon cancer is two (2) hours post–sigmoidoscopy procedure. Which assessment data warrant immediate intervention by the nurse?

1. The client has hyperactive bowel sounds.
2. The client is eating a hamburger the family brought.
3. The client is sleepy and wants to sleep.
4. The client’s BP is 96/60 and apical pulse is 108.

Answer 10

Ans: 4. The client’s BP is 96/60 and apical pulse is 108.

1. The client has been NPO and had laxatives; therefore, hyperactive bowel sounds do not warrant immediate intervention.
2. The client is able to eat after the procedure, so this does not warrant immediate intervention.
3. The client received sedation during the procedure and may have been up during the night having bowel movements, resulting in the client being exhausted and sleepy.
4. These are signs/symptoms of hypovolemic shock requiring immediate intervention by the nurse.

Question 11

The nurse identifies the client problem “alteration in gastrointestinal system” for the elderly client. Which statement reflects the most appropriate rationale for this problem?

1. Elderly clients have the ability to chew food more thoroughly with dentures.
2. Elderly clients have an increase in digestive enzymes, which helps with digestion.
3. Elderly clients have an increased need for laxatives because of a decrease in bile.
4. Elderly clients have an increase in bacteria in the GI system, resulting in diarrhea.

Answer 11

Ans: 4. Elderly clients have an increase in bacteria in the GI system, resulting in diarrhea.

1. Dentures are not an improvement over the client’s own teeth in mastication.
2. The secretion of digestive enzymes and bile is decreased in the elderly, resulting in an alteration in nutrition and elimination.
3. Bile does not affect motility of the intes- tines. The elderly client’s perception of the need for laxatives is caused by the client’s misunderstanding about normal bowel function.
4. When the motility of the gastrointestinal tract decreases, bacteria remain in the gut longer and multiply, which results in diarrhea.

Question 12

Which interventions should the nurse discuss regarding prevention of an acute exacerbation of diverticulosis? Select all that apply.

1. Eat a low-fiber diet.
2. Drink 2,500 mL of water daily.
3. Avoid eating foods with seeds.
4. Walk 30 minutes a day.
5. Take an antacid every two (2) hours.

Answer 12

Ans: 2, 3, 4

2. Drink 2,500 mL of water daily.
3. Avoid eating foods with seeds.
4. Walk 30 minutes a day.
5. A high-fiber diet will prevent constipation, the primary reason for diverticulosis/ diverticulitis. A low-fiber (residue) diet is prescribed for acute diverticulitis.
6. Increased fluids help to keep the stool soft and prevent constipation.
7. It is controversial if seeds cause an exacerbation of diverticulosis, but this is an appropriate intervention to teach until proven otherwise.
8. Exercise helps to prevent constipation, which can cause an exacerbation of diverticulitis.
9. There are no medications used to help pre- vent an acute exacerbation of diverticulosis/ diverticulitis. Antacids are used to neutral- ize hydrochloric acid in the stomach.

Question 13

The clinic nurse is caring for a client who is 67 inches tall and weighs 100 kg. The client complains of occasional pyrosis which resolves with standing or with taking antacids. Which treatment should the nurse expect the HCP to order?

1. Place the client on a weight loss program.
2. Instruct the client to eat three (3) balanced meals.
3. Tell the client to take an antiemetic before each meal.
4. Discuss the importance of decreasing alcohol intake.

Answer 13

Ans: 1. Place the client on a weight loss program.

1. Obesity increases the risk of pyrosis (heartburn); therefore, losing weight could help decrease the incidence.
2. Eating small, frequent meals along with decreased intake of spicy foods have been linked to the prevention of heartburn (pyrosis).
3. Antiemetics decrease nausea, which does not occur with heartburn. Antacids neu- tralize the acid of the stomach and are used to treat heartburn.
4. Drinking alcoholic beverages increases heartburn and should be avoided, not decreased.

Question 14

The client is being prepared for discharge after a laparoscopic cholecystectomy. Which intervention should the nurse implement?

1. Discuss the need to change the abdominal dressing daily.
2. Tell the client to check the T-tube output every eight (8) hours.
3. Include the significant other in the discharge teaching.
4. Instruct the client to stay off clear liquids for two (2) days.

Answer 14

Ans: 3. Include the significant other in the discharge teaching.

1. The client has three (3) to four (4) inci- sions with Band-Aids in the upper quad- rant, not an abdominal dressing.
2. The client will not have a T-tube with a laparoscopic cholecystectomy.
3. A laparoscopic cholecystectomy is done in day surgery. The nurse must make sure the significant others taking care of the client are knowledgeable of postoperative care.
4. The client will be on a regular diet after being discharged from the day surgery clinic.

Question 15

Which information should the nurse teach the client post–barium enema procedure?

1. The client should not eat or drink anything for four (4) hours.
2. The client should remain on bedrest until the sedative wears off.
3. The client should take a mild laxative to help expel the barium.
4. The client will have normal elimination color and pattern.

Answer 15

Ans: 3. The client should take a mild laxative to help expel the barium.

1. The client may resume the regular diet.
2. The client will not be sedated for this procedure; therefore, the client does not need to be on bedrest.
3. The nurse needs to teach the client to take a mild laxative to help evacuate the barium and return to the client’s normal bowel routine. Failure to pass the barium could cause constipation when the barium hardens.
4. The client can expect to pass white- or light-colored stools until the barium has completely been evacuated.

Question 16

The client diagnosed with a hiatal hernia is scheduled for a laparoscopic Nissen fundoplication. Which statement indicates the nurse’s teaching is effective?

1. “I will have four (4) to five (5) small incisions.”
2. “I will be in the hospital for at least one (1) week.”
3. “I will not have any pain because this is laparoscopic surgery.”
4. “I will be returning to work the day after my surgery.”

Answer 16

Ans: 1. “I will have four (4) to five (5) small incisions.”

1. In a laparoscopic Nissen fundoplication, there are four (4) to five (5) incisions approximately one (1) inch apart allowing for the passage of equipment to visualize the abdominal organs and perform the operation.
2. Many clients come through the day sur- gery department and go home the same day. Some clients may remain in the hospital for one (1) or two (2) days but not for a week.
3. All surgeries will result in pain for the client.
4. The client should not return to work the next day; the client should wait at least one (1) week before returning to work.

Question 17

The client is diagnosed with esophageal diverticula. Which lifestyle modification should be taught by the nurse?

1. Raise the foot of the bed to 45 degrees to increase peristalsis.
2. Eat the evening meal at least two (2) hours prior to bed.
3. Eat a low-fat, low-cholesterol, high-fiber diet.
4. Wear an abdominal binder to strengthen the abdominal muscles.

Answer 17

Ans: 2. Eat the evening meal at least two (2) hours prior to bed.

1. The client should elevate the head, not the foot, of the bed to prevent the reflux of stomach contents.
2. The evening meal should be eaten at least two (2) hours prior to retiring. Small, frequent meals and semisoft foods ease the passage of food, which decreases signs and symptoms of the disease process.
3. This diet is recommended for a client with coronary artery disease, not for esophageal diverticula.
4. Restrictive clothing should be avoided, and abdominal binders do not strengthen muscles and would not benefit this client.

Question 18

Which intervention should the nurse implement specifically for the client in end-stage liver failure who is experiencing hepatic encephalopathy?

1. Assess the client’s neurological status.
2. Prepare to administer a loop diuretic.
3. Check the client’s stool for blood.
4. Assess for an abdominal fluid wave.

Answer 18

Ans: 1. Assess the client’s neurological status.

1. The increased serum ammonia level associated with liver failure causes the hepatic encephalopathy, which, in turn, leads to neurological deficit.
2. Administering a loop diuretic is an appro- priate intervention for ascites and portal hypertension.
3. Checking the stool for bleeding is an ap- propriate intervention for esophageal varices and decreased vitamin K.
4. Assessing the abdominal fluid wave is an appropriate intervention for ascites and portal hypertension.

Question 19

Which priority teaching information should the nurse discuss with the client to help prevent contracting hepatitis B?

1. Explain the importance of good hand washing.
2. Recommend the client take the hepatitis B vaccine.
3. Tell the client not to ingest unsanitary food or water.
4. Discuss how to implement Standard Precautions.

Answer 19

Ans: 2. Recommend the client take the hepatitis B vaccine.

1. This intervention would be appropriate for prevention of hepatitis A.
2. The hepatitis B vaccine will prevent the client from contracting this disease.
3. This intervention would be appropriate for prevention of hepatitis A.
4. The nurse uses Standard Precautions, not the client.

Question 20

The emergency department nurse is working in a community hospital. During the past two (2) hours, 15 clients have been admitted with Salmonella food poisoning. Which information should the nurse discuss with clients?

1. Explain the incubation period is 48 to 72 hours.
2. Explain the source of this poisoning is contaminated water.
3. Explain sources of contamination are eggs and chicken.
4. Explain the bacterial contaminant came from canned foods.

Answer 20

Ans: 3. Explain sources of contamination are eggs and chicken.

1. The incubation period for Salmonella food poisoning is 8 to 48 hours.
2. Salmonellae bacteria are not transmitted to humans via water.
3. Eggs, poultry, and pet turtles are sources of the Salmonellae bacteria, which cause food poisoning.
4. Clostridium botulinum is transmitted via improperly canned food.

Question 21

Which intervention should the nurse include when discussing ways to prevent food poisoning?

1. Wash hands for ten (10) seconds after handling raw meat.
2. Clean all cutting boards between meats and fruits.
3. Maintain food temperatures at 140 ̊F during extended servings.
4. Explain fruits do not require washing prior to eating or preparing.

Answer 21

Ans: 3. Maintain food temperatures at 140 ̊F during extended servings.

1. Hand washing for 10 seconds is not long enough to remove any bacteria. Hands should be washed for at least 30 seconds before handling food or eating.
2. Cutting surfaces used for meats should be different from those used for fruits and vegetables to prevent contamination.
3. Foods being served for an extended time should be kept at 140 ̊F because food sitting at less than this temperature allows for bacterial growth.
4. All fruits and vegetables should be washed before eating or preparing.

Question 22

Which problem is most appropriate for the nurse to identify for the client with diarrhea?

1. Alteration in skin integrity.
2. Chronic pain perception.
3. Fluid volume excess.
4. Ineffective coping.

Answer 22

Ans: 1. Alteration in skin integrity.

1. When clients have multiple liquid stools, the rectal area can become irritated. The integrity of the skin can be impaired.
2. Pain experienced by this client would be acute, rather than chronic.
3. Fluid volume deficit is appropriate, rather than fluid volume excess.
4. Ineffective coping is a psychosocial prob- lem and is not appropriate for a client with diarrhea.

Question 23

The nurse is assessing a client complaining of abdominal pain. Which data support the diagnosis of a bowel obstruction?

1. Steady, aching pain in one specific area.
2. Sharp back pain radiating to the flank.
3. Sharp pain increases with deep breaths.
4. Intermittent colicky pain near the umbilicus.

Answer 23

Ans: 4. Intermittent colicky pain near the umbilicus.

1. Steady, aching pain is associated with a peritoneal inflammation, which may be secondary to a ruptured spleen or perfo- rated ulcer or other abdominal organ.
2. Sharp pain in the back and flank indicates kidney involvement.
3. Sharp pain increasing with deep breaths indicates muscular involvement.
4. Intermittent and colicky pain located near the umbilicus is indicative of a small bowel obstruction; lumbar pain is indicative of colon involvement.

Question 24

The nurse is caring for the client scheduled for an abdominal perineal resection for Stage IV colon cancer. Which client problem should the nurse include in the intraoperative care plan?

1. Fluid volume deficit.
2. Impaired tissue perfusion.
3. Infection of surgical site.
4. Risk for immunosuppression.

Answer 24

Ans: 2. Impaired tissue perfusion.

1. Fluid deficit is a potential problem, not an actual problem. The client’s fluid balance should be managed by intravenous fluids.
2. The perfusion of the surgical site is compromised as a result of the surgical incision, especially when a graft is used.
3. Infection is a potential problem, but not at the time of surgery.
4. After surgery, not during surgery, the client may require chemotherapy, which can cause immunosuppression.

Question 25

The nurse is assessing the client in end-stage liver failure who is diagnosed with portal hypertension. Which intervention should the nurse include in the plan of care?

1. Assess the abdomen for a tympanic wave.
2. Monitor the client’s blood pressure.
3. Percuss the liver for size and location.
4. Weigh the client twice each week.

Answer 25

Ans: 1. Assess the abdomen for a tympanic wave.

1. A client who has been diagnosed with portal hypertension should be assessed for a tympanic (fluid) wave to check for ascites.
2. High blood pressure is not the etiology of portal hypertension.
3. In portal hypertension, percussion is diffi- cult and will not provide pertinent infor- mation about the client’s condition.
4. Weighing the client should be done daily, not twice each week.

Question 26

The nurse is caring for the client diagnosed with ascites secondary to hepatic cirrhosis. Which information should the nurse report to the health-care provider?

1. A decrease in the client’s daily weight of one (1) pound.
2. An increase in urine output after administration of a diuretic.
3. An increase in abdominal girth of two (2) inches.
4. A decrease in the serum direct bilirubin to 0.6 mg/dL.

Answer 26

Ans: 3. An increase in abdominal girth of two (2) inches.

1. A decrease in weight indicates a loss in fluid and is not data necessary to report to the health-care provider.
2. An increase in urine output indicates the diuretic was effective.
3. An increase in abdominal girth indi- cates the ascites is increasing, meaning the client’s condition is becoming more serious, and should be reported to the health care provider.
4. The normal direct bilirubin value is 0.1 to 0.4 mg/dL; therefore, a decrease in the value, although it is still elevated, would not be reported.

Question 27

The nurse is caring for the client diagnosed with hepatic encephalopathy. Which sign and symptom indicate the disease is progressing?

1. The client has a decrease in serum ammonia level.
2. The client is not able to circle choices on the menu.
3. The client is able to take deep breaths as directed.
4. The client is able to eat previously restricted food items.

Answer 27

Ans: 2. The client is not able to circle choices on the menu.

1. An increase in serum ammonia levels is seen in clients diagnosed with hepatic en- cephalopathy and coma.
2. The inability to circle food items on the menu may indicate deterioration in the client’s cognitive status. The client’s neurological status is impaired with hepatic encephalopathy; the nurse should investigate this behavior.
3. The client being able to follow commands indicates the client’s neurological status is intact.
4. Consuming foods providing adequate nu- trition indicates the client is getting better and able to follow client teaching.

Question 28

The client is scheduled for a colostomy secondary to colon cancer, and the surgeon tells the client the stool will be a formed consistency. Where would the nurse teach the client the stoma will be located?

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

Answer 28

Ans: 4. D

1. Stools are liquid in the ascending colon.
2. Stools are mushy in the right transverse colon.
3. The left transverse colon has semi-mushy stool.
4. The sigmoid colon is located in the left lower quadrant, and the client expels solid feces.

Question 29

The nurse is facilitating a support group for clients diagnosed with Crohn’s disease. Which information is most important for the nurse to discuss with the clients?

1. Discuss coping skills to assist with adaptation to lifestyle modifications.
2. Teach about drug administration, dosages, and scheduled times.
3. Teach dietary changes necessary to control symptoms.
4. Explain the care of the ileostomy and necessary equipment.

Answer 29

Ans: 1. Discuss coping skills to assist with adaptation to lifestyle modifications.

1. The objectives for support groups are to help members cope with chronic diseases and help manage symptom control.
2. Drug administration, dosage, and sched- uled times should be discussed in the hospital prior to discharge or in the health- care provider’s office; therefore, this is not a priority at the support group meeting.
3. Dietary changes should be taught at the time the disease is diagnosed, but this is not a priority at the support group meeting.
4. An ileostomy may be the surgical option for clients who do not respond to medical treatment, but other nonsurgical treat- ments would be topics of discussions during support group meetings.

Question 30

The nurse is caring for a client diagnosed with ulcerative colitis. Which symptom(s) support this diagnosis?

1. Increased appetite and thirst.
2. Elevated hemoglobin.
3. Multiple bloody, liquid stools.
4. Exacerbations unrelated to stress.

Answer 30

Ans: 3. Multiple bloody, liquid stools.

1. Clients suffering from ulcerative colitis experience anorexia, not an increased appetite.
2. The hemoglobin and hematocrit are decreased, not elevated, as a result of blood loss.
3. Clients report as many as 10 to 20 liquid bloody stools in a day.
4. Stressful events have been linked to an in- crease in symptoms. The nurse needs to assess for perceived stress in the client’s life producing symptoms.

Question 31

The client is diagnosed with an acute exacerbation of inflammatory bowel disease (IBD). Which food selection would be the best choice for a meal?

1. Roast beef on wheat bread and a milk shake.
2. Hamburger, french fries, and a Coke.
3. Pepper steak, brown rice, and iced tea.
4. Roasted turkey, instant mashed potatoes, and water.

Answer 31

4. Roasted turkey, instant mashed potatoes, and water.
5. Wheat bread and whole grains should be avoided, and most clients cannot tolerate milk products.
6. Fried foods such as hamburger and french fries should be avoided. Raw fruits and vegetables such as lettuce and tomatoes are usually not tolerated.
7. Whole grains such as brown rice should be avoided. White rice can be eaten. Spicy meats and foods should be avoided.
8. Meats can be eaten if prepared by roasting, baking, or broiling. Vegeta- bles should be cooked, not raw, and skins should be removed. Instant mashed potatoes do not have the skin. A low-residue diet should be eaten.

Question 32

The nurse is caring for an elderly client diagnosed with acute gastritis. Which client problem is priority for this client?

1. Fluid volume deficit.
2. Altered nutrition: less than body requirements.
3. Impaired tissue perfusion.
4. Alteration in comfort.

Answer 32

Ans: 1. Fluid volume deficit.

1. Pediatric and geriatric clients have an increased risk for fluid volume and electrolyte imbalances. The nurse should always be alert to this possible complication.
2. Altered nutrition may be appropriate, de- pending on how long the client has been unable to eat, but it is not priority over fluid volume deficit.
3. Impaired tissue perfusion may be appro- priate if the mucosal lining of the stomach is unable to heal, but it is not priority over fluid volume deficit.
4. Alteration in comfort may be appropriate, but it is not priority over fluid volume deficit.

Question 33

The nurse is assessing the client diagnosed with chronic gastritis. Which symptom(s) support this diagnosis?

1. Rapid onset of midsternal discomfort.
2. Epigastric pain relieved by eating food.
3. Dyspepsia and hematemesis.
4. Nausea and projectile vomiting.

Answer 33

Ans: 2. Epigastric pain relieved by eating food.

1. Acute gastritis is characterized by sudden epigastric pain or discomfort, not midsternal chest pain.
2. Chronic pain in the epigastric area relieved by ingesting food is a sign of chronic gastritis.
3. Dyspepsia (heartburn) and hematemesis (vomiting blood) are frequent symptoms of acute gastritis.
4. Projectile vomiting is not a sign of chronic gastritis.

Question 34

The nurse identifies the problem of “fluid volume deficit” for a client diagnosed with gastritis. Which intervention should be included in the plan of care?

1. Obtain permission for a blood transfusion.
2. Prepare the client for total parenteral nutrition.
3. Monitor the client’s lung sounds every shift.
4. Assess the client’s intravenous site.

Answer 34

Ans: 4. Assess the client’s intravenous site.

1. There are no data to suggest the client needs a blood transfusion.
2. TPN is not a treatment for a client with fluid volume deficit. TPN provides calories for nutritional deficits, not fluid deficits.
3. If the client’s problem were fluid volume excess, assessing lung sounds would be appropriate.
4. Fluid administration is the medical treatment for dehydration, so the nurse must monitor and ensure the IV site is patent.

Question 35

The nurse working in a skilled nursing facility is collaborating with the dietitian concerning the meals of an immobile client. Which foods are most appropriate for this client?

1. Oatmeal and wheat toast.
2. Cream of wheat and biscuits.
3. Cottage cheese and canned peaches.
4. Tuna on a croissant and applesauce.

Answer 35

Ans: 1. Oatmeal and wheat toast.

1. Oatmeal and wheat toast are high-fiber foods and are recommended for clients who are immobile to help prevent constipation.
2. Cream of wheat and biscuits are low-fiber foods.
3. Cottage cheese and canned peaches are low-fiber foods.
4. Tuna is a good source of protein for the client, but croissants have a high fat con- tent and are a factor in weight gain if con- sistently eaten. Applesauce is low in fiber.

Question 36

Which intervention should the nurse implement when administering a potassium supplement?

1. Determine the client’s allergies.
2. Ask the client about leg cramps.
3. Monitor the client’s blood pressure.
4. Monitor the client’s complete blood count.

Answer 36

Ans: 2. Ask the client about leg cramps.

1. The nurse should inquire about drug allergies before administering all medications, not just potassium.
2. Leg cramps occur when serum potassium levels are too low or too high. If the client has leg cramps, this could indicate an imbalance, which could lead to cardiac dysrhythmias.
3. The blood pressure does not evaluate for dysrhythmias, a possible result of abnormal potassium levels.
4. The complete blood count does not include the potassium level; a chemistry panel is needed.

Question 37

The nurse is preparing the client for a fiberoptic colonoscopy for colon polyps. Which task can be delegated to the unlicensed assistive personnel (UAP)?

1. Administer the polyethylene glycol electrolyte lavage solution.
2. Explain to the client why this morning’s breakfast is withheld.
3. Start an intravenous site with 0.9% normal saline fluid.
4. Administer a cleansing enema until the return is clear.

Answer 37

Ans: 4. Administer a cleansing enema until the return is clear.

1. The polyethylene glycol electrolyte lavage solution is a medication and cannot be delegated.
2. Teaching is the responsibility of the nurse and cannot be delegated.
3. Starting an intravenous site and managing the delivery of the fluid is the responsibil- ity of the nurse and cannot be delegated.
4. The administration of enemas can be delegated to the unlicensed assistive personnel (UAP).

Question 38

The nurse is caring for the client who is one (1) day post–upper gastrointestinal (UGI) series. Which assessment data warrant intervention?

1. No bowel movement.
2. Oxygen saturation 96%.
3. Vital signs within normal baseline.
4. Intact gag reflex.

Answer 38

Ans: 1. No bowel movement.

1. The nurse should monitor the client for the first bowel movement to document elimination of barium, which should be eliminated within two (2) days. If the client does not have a bowel movement, a laxative may be needed to help the client to eliminate the barium before it becomes too hard to pass.
2. An oxygen saturation of 96% is acceptable and does not require intervention.
3. Vital signs should be monitored to recog- nize and treat complications before the client is in danger. Baseline is a desired outcome.
4. The client’s throat is not anesthetized for this procedure, so the gag reflex is not pertinent information in this procedure.

Question 39

The client is complaining of painful swallowing secondary to mouth ulcers. Which statement indicates the nurse’s teaching is effective?

1. “I will brush my teeth with a soft-bristle toothbrush.”
2. “I will rinse my mouth with Listerine mouthwash.”
3. “I will swish with antifungal solution and then swallow.”
4. “I will avoid spicy foods, tobacco, and alcohol.”

Answer 39

Ans: 4. “I will avoid spicy foods, tobacco, and alcohol.”

1. A soft-bristle toothbrush will not affect painful swallowing.
2. An alcohol-based mouthwash (Listerine) is irritating to the oral cavity and can increase pain.
3. An antifungal medication should be used with candidiasis and is not effective treat- ment for plain mouth ulcers.
4. Irritating substances should be avoided during the outbreaks of ulcers in the mouth. Spicy foods, alcohol, and tobacco are common irritants the client should avoid.

Question 40

The nurse is assessing the integumentary system of the client diagnosed with anorexia nervosa. Which finding supports the diagnosis?

1. Preoccupation with calories.
2. Thick body hair.
3. Sore tongue.
4. Dry, brittle hair.

Answer 40

Ans: 4. Dry, brittle hair.

1. The preoccupation with food, calories, and preparing meals are psychosocial behaviors suggesting the client has an eating disorder.
2. Clients who have anorexia nervosa have thin, fine body hair.
3. Iron-deficiency anemia causes clients to experience a sore tongue.
4. Thin, brittle hair occurs in clients with anorexia.

Question 41

The nurse is teaching the client diagnosed with colon cancer who is scheduled for a colostomy. Which behavior indicates the nurse is utilizing adult learning principles?

1. The nurse repeats the information as indicated by the client’s questions.
2. The nurse teaches in one session all the information the client needs.
3. The nurse uses a video so the client can hear the medical terms.
4. The nurse waits until the client asks questions about the surgery.

Answer 41

Ans: 1. The nurse repeats the information as indicated by the client’s questions.

1. The nurse should realize the client is anxious about the diagnosis of cancer and the impending surgery. Therefore, the nurse should be prepared to repeat information as necessary. The learning principle the nurse needs to consider is “anxiety decreases learning.”
2. Small manageable sessions increase learn- ing, especially when the client is anxious.
3. Videos are not the best teaching tool for adults. Short videos are useful for children.
4. The nurse should assess the client’s readi- ness and willingness to learn and not wait until the client asks questions about the surgery.

Question 42

The nurse is caring for the client one (1) day postoperative sigmoid colostomy. Which independent nursing intervention should the nurse implement?

1. Change the infusion rate of the intravenous fluid.
2. Encourage the client to ventilate feelings about body image.
3. Administer opioid narcotic medications for pain management.
4. Assist the client out of bed to sit in the chair twice daily.

Answer 42

Ans: 2. Encourage the client to ventilate feelings about body image.

1. The rate of the intravenous fluid is a col- laborative nursing intervention because it requires an order from the health-care provider.
2. Encouraging the client to verbalize feelings about body changes assists the client to accept these changes. This is an independent intervention not re- quiring a health-care provider’s order.
3. Medication administration is a collabora- tive intervention because it requires an order by the health-care provider.
4. Activity level immediately postoperative requires an order by the health-care provider.

Question 43

The nurse is caring for the client recovering from intestinal surgery. Which assessment finding requires immediate intervention?

1. Presence of thin pink drainage in the Jackson Pratt.
2. Guarding when the nurse touches the abdomen.
3. Tenderness around the surgical site during palpation.
4. Complaints of chills and feeling feverish.

Answer 43

Ans: 4. Complaints of chills and feeling feverish.

1. Thin pink drainage is expected in the Jackson Pratt (JP) bulb.
2. Guarding is a normal occurrence when touching a tender area on the abdomen and does not require immediate intervention.
3. Tenderness around the surgical site is a normal finding and does not require inter- vention.
4. Complaints of chills, sudden onset of fever, tachycardia, nausea, and hiccups are symptoms of peritonitis, which is a life-threatening complication.

Question 44

The nurse is caring for the client diagnosed with hemorrhoids. Which statement indicates further teaching is needed?

1. “I should increase fruits, bran, and fluids in my diet.”
2. “I will use warm compresses and take sitz baths daily.”
3. “I must take a laxative every night and have a stool daily.”
4. “I can use an analgesic ointment or suppository for pain.”

Answer 44

Ans: 3. “I must take a laxative every night and have a stool daily.”

1. Clients with hemorrhoids need to eat high-fiber diets and increase fluid intake to keep the stools soft and prevent consti- pation; therefore, the teaching is effective.
2. Warm compresses or sitz baths decrease pain; therefore, the teaching is effective.
3. Laxatives can be harsh to the bowel and are habit forming; they should not be taken daily. Stool softeners soften stool and can be taken daily.
4. Analgesic ointments, suppositories, and as- tringents can be used to decrease pain and decrease edema; therefore, the teaching has been effective.

Question 45

The nurse is preparing the postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?

1. Establish rapport with the client to decrease embarrassment of assessing site.
2. Encourage the client to lie in the lithotomy position twice a day.
3. Milk the tube inserted during surgery to allow the passage of flatus.
4. Digitally dilate the rectal sphincter to express old blood.

Answer 45

Ans: 1. Establish rapport with the client to decrease embarrassment of assessing site.

1. The site of the surgery can cause em- barrassment when the nurse assesses the site; therefore, the nurse should establish a positive relationship.
2. The lithotomy position is with the client’s legs in stirrups for procedures such as Pap smears and some surgeries such as transurethral resection of the prostate, not for the client who is postoperative hemor- rhoidectomy.
3. A tube is not placed in the client’s rectum after this surgery.
4. The rectal sphincter does not need to be digitally dilated.

Question 46

The client is diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?

1. Instruct the client to avoid drinking fluids with meals.
2. Explain the need to decrease intake of flatus-forming foods.
3. Teach the client how to perform gentle perianal care.
4. Encourage the client to attend a support group meeting.

Answer 46

Ans: 1. Instruct the client to avoid drinking fluids with meals.

1. Avoidance of fluids during meals will help prevent abdominal distention, which causes symptoms of IBS. Do not confuse inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS).
2. Avoidance of flatus (gas)-forming foods helps with the symptoms of IBD, not IBS.
3. Clients with IBS do have altered bowel habits such as diarrhea and constipation, but perianal care will not prevent IBS.
4. IBS does have a psychological component, but a client recently diagnosed should be taught other interventions before a psy- chologist is recommended.

Question 47

The nurse at the scene of a knife fight is caring for a young man who has a knife in his abdomen. Which action should the nurse implement?

1. Stabilize the knife.
2. Remove the knife gently.
3. Turn the client on the side.
4. Apply pressure to the insertion site.

Answer 47

Ans: 1. Stabilize the knife.

1. The nurse should not remove any pen- etrating object in the abdomen; removal could cause further internal damage.
2. Removal of the knife could cause further internal damage.
3. The client should be kept on the back and the knife should be stabilized.
4. The nurse should stabilize the knife and notify Emergency Medical Services as quickly as possible.

Question 48

The nurse writes the problem “risk for impaired skin integrity” for a client with a sigmoid colostomy. Which expected outcome would be appropriate for this client?

1. The client will have intact skin around the stoma.
2. The client will be able to change the ostomy bag.
3. The client will express anxiety about the body changes.
4. The client will maintain fluid balance.

Answer 48

Ans: 1. The client will have intact skin around the stoma.

1. Intact skin around the stoma is the most appropriate outcome for the problem of “impaired skin integrity.”
2. The client’s ability to change the ostomy bag is a goal for a knowledge-deficit problem or self-care.
3. Expressing anxiety about the body changes is a goal for an alteration in body image.
4. Maintaining a balance in fluid is a goal for a nursing diagnosis of risk for fluid deficit.

Question 49

The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright-red blood at home. Which interventions should the nurse implement? List in order of priority.

1. Assess the client’s vital signs.
2. Insert a nasogastric tube.
3. Begin iced saline lavage.
4. Start an IV with an 18-gauge needle.
5. Type and crossmatch for a blood transfusion.

Answer 49

Ans: In order of priority: 1, 4, 5, 2, 3.

1. The nurse should assess the vital signs to determine if the client is in hypov- olemic shock. The stem of the ques- tion does not provide information indi- cating the client is hypovolemic. The client’s perception of a large amount of blood may differ from the nurse’s assessment.
2. The nurse should start the IV line to replace fluid volume.
3. While the nurse is starting the IV, a blood sample for typing and cross- matching should be obtained and sent to the laboratory.
4. An N/G tube should be inserted so direct iced saline can be instilled to cause constriction, which will decrease the bleeding.
5. The iced saline lavage will help decrease bleeding.