MS2 - GI - Questions Part 2

Question 1

A patient with hepatitis A is in the acute phase. The nurse plans for care for the patient based on the knowledge that

a. Pruritus is a common problem with jaundice in this phase
b. The patient is most likely to transmit the disease during this phase
c. Gastrointestinal symptoms are not as severe in hepatitis A as they are in hepatitis B
d. Extrahepatic manifestations of glomerulonephritis and polyarteritis are common in this phase

Answer 1

a. Pruritus is a common problem with jaundice in this phase

The acute phase of jaundice may be icteric or anicteric. Jaundice results when bilirubin diffuses into the tissues. Pruritus sometimes accompanies jaundice. Pruritus is the result of an accumulation of bile salts beneath the skin.

Question 2

A patient with acute hepatitis B is being discharged in 2 days. In the discharge teaching plan the nurse should include instructions to

a. Avoid alcohol for the first 3 weeks
b. Use a condom during sexual intercourse
c. Have family members get an injection of immunoglobulin
d. Follow a low-protein, moderate-carbohydrate, moderate-fat diet

Answer 2

b. Use a condom during sexual intercourse

Hepatitis B virus may be transmitted by mucosal exposure to infected blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Hepatitis B is a sexually transmitted disease that is acquired through unprotected sex with an infected person. Condom use should be taught to patients to prevent transmission of hepatitis B.

Question 3

A patient has been told that she has elevated liver enzymes caused by nonalcoholic fatty liver disease (NAFLD). The nursing teaching plan should include

a. Having genetic testing done
b. Recommending a heart-healthy diet
c. The necessity to reduce weight rapidly
d. Avoiding alcohol until liver enzymes return to normal

Answer 3

b. Recommending a heart-healthy diet

Nonalcoholic fatty liver disease (NAFLD) can progress to liver cirrhosis. There is no definitive treatment, and therapy is directed at reduction of risk factors, which include treatment of diabetes, reduction in body weight, and elimination of harmful medications. For patients who are overweight, weight reduction is important. Weight loss improves insulin sensitivity and reduces liver enzyme levels. No specific dietary therapy is recommended. However, a heart-healthy diet as recommended by the American Heart Association is appropriate.

Question 4

The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse’s response is based on the knowledge that

a. A lack of clotting factors promotes the collection of blood in the abdominal cavity
b. Portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space
c. Decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel
d. Bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing bowel of fluid

Answer 4

b. Portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space

Ascites is the accumulation of serous fluid in the peritoneal or abdominal cavity and is a common manifestation of cirrhosis. With portal hypertension, proteins shift from the blood vessels through the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, those substances leak through the liver capsule into the peritoneal cavity. Osmotic pressure of the proteins pulls additional fluid into the peritoneal cavity.

A second mechanism of ascites formation is hypoalbuminemia, which results from the inability of the liver to synthesize albumin. Hypoalbuminemia results in decreased colloidal oncotic pressure. A third mechanism is hyperaldosteronism, which occurs when aldosterone is not metabolized by damaged hepatocytes. The increased level of aldosterone causes increases in sodium reabsorption by the renal tubules. Sodium retention and an increase in antidiuretic hormone levels cause additional water retention.

Question 5

In planning care for a patient with metastatic liver cancer, the nurse should include interventions that

a. Focus primarily on symptomatic and comfort measures
b. Reassure the patient that chemotherapy offers a good prognosis
c. Promote the patient’s confidence that surgical excision of the tumor will be successful
d. Provide ingormation necessary for the patient to make decisions regarding liver transplantation

Answer 5

a. Focus primarily on symptomatic and comfort measures

Nursing intervention for a patient with liver cancer focuses on keeping the patient as comfortable as possible. The prognosis for patients with liver cancer is poor. The cancer grows rapidly, and death may occur within 4 to 7 months as a result of hepatic encephalopathy or massive blood loss from gastrointestinal (GI) bleeding.

Question 6

Nursing management of the patient with acute pancreatitis includes (select all that apply)

a. Checking for signs of hypocalcemia
b. Providing a diet low in carbohydrates
c. Giving insulin based on a sliding scale
d. Observing stools for signs of steatorrhea
e. Monitoring for infection, particularly respiratory tract infection

Answer 6

a. Checking for signs of hypocalcemia
e. Monitoring for infection, particularly respiratory tract infection

During the acute phase, it is important to monitor vital signs. Hemodynamic stability may be compromised by hypotension, fever, and tachypnea. Intravenous fluids are ordered, and the response to therapy is monitored. Fluid and electrolyte balances are closely monitored. Frequent vomiting, along with gastric suction, may result in decreased levels of chloride, sodium, and potassium.

Because hypocalcemia can occur in acute pancreatitis, the nurse should observe for symptoms of tetany, such as jerking, irritability, and muscular twitching. Numbness or tingling around the lips and in the fingers is an early indicator of hypocalcemia. The patient should be assessed for Chvostek’s sign or Trousseau’s sign. A patient with acute pancreatitis should be observed for fever and other manifestations of infection. Respiratory infections are common because the retroperitoneal fluid raises the diaphragm, which causes the patient to take shallow, guarded abdominal breaths.

Question 7

A patient with pancreatic cancer is admitted to the hospital for evaluation of possible treatment options. The patients asks the nurse to explain the Whipple procedure that the surgeon has described. The explanation includes the information that a Whipple procedure involves

a. Creating a bypass around the obstruction caused by the tumor by joining the gallbladder
b. Resection of the entire pancreas and the distal portion of the stomach, with anastomosis of the common bile duct and the stomach into the duodenum
c. Removal of part of the pancreas, part of the stomach, the duodenum and the gallbladder, with joining the pancreatic duct, the common bile duct, and the stomach into the jejunum
d. Radical removal of the pancreas, the duodenum, and the spleen, and attachment of the to the jejunum anastomosis of the common bile duct and the stomach into the duodenum gallbladder, with joining the pancreatic duct, the common bile duct, and the stomach into the jejunum stomach to the jejunum, which requires oral supplementation of pancreatic digestive enzymes and insulin replacement therapy

Answer 7

c. Removal of part of the pancreas, part of the stomach, the duodenum and the gallbladder, with joining the pancreatic duct, the common bile duct, and the stomach into the jejunum

The classic operation for pancreatic cancer is a radical pancreaticoduodenectomy, or Whipple procedure. This entails resection of the proximal pancreas (i.e., proximal pancreatectomy), the adjoining duodenum (i.e., duodenectomy), the distal portion of the stomach (i.e., partial gastrectomy), and the distal segment of the common bile duct. The pancreatic duct, common bile duct, and stomach are anastomosed to the jejunum.

Question 8

The nursing management of the patient with cholecystitis associated with cholelithiasis is based on the knowledge that

a. Shock-wave therapy should be tried initially
b. Once gallstones are removed, they tend not to recur
c. The disorder that can be successfully treated with oral bile salts that dissolve gallstones
d. Laparoscopic cholecystectomy is the treatment of choice in most patients who are symptomatic

Answer 8

d. Laparoscopic cholecystectomy is the treatment of choice in most patients who are symptomatic

Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis.

Question 9

Teaching in relation to home management after a laparoscopic cholecystectomy should include

a. Keeping the bandages on the puncture sites for 48 hours
b. Reporting any bile-colored drainage or pus from any incision
c. Using OTC antiemetics if nausea and vomiting occur
d. Emptying and measuring the contents of the bile bag from the T tube every day

Answer 9

b. Reporting any bile-colored drainage or pus from any incision

The following discharge instructions are taught to the patient and caregiver after a laparoscopic cholecystectomy: First, remove the bandages on the puncture site the day after surgery and shower.

Second, notify the surgeon if any of the following signs and symptoms occur: redness, swelling, bile-
colored drainage or pus from any incision; and severe abdominal pain, nausea, vomiting, fever, or chills.

Third, gradually resume normal activities. Fourth, return to work within 1 week of surgery. Fifth, resume a usual diet, but a low-fat diet is usually better tolerated for several weeks after surgery.

Question 10

A patient is jaundiced and her stools are clay colored (gray). This is most likely related to

a. decreased bile flow into the intestine.
b. increased production of urobilinogen.
c. increased production of cholecystokinin.
d. increased bile and bilirubin in the blood.

Answer 10

a. decreased bile flow into the intestine.

Bile is produced by the hepatocytes and is stored and concentrated in the gallbladder. When bile is released from the common bile duct, it enters the duodenum. In the intestines, bilirubin is reduced to stercobilinogen and urobilinogen by bacterial action. Stercobilinogen accounts for the brown color of stool. Stools may be clay-colored if bile is not released from the common bile duct into the duodenum. Jaundice may result if the bilirubin level in the blood is elevated.

Question 11

The nurse is reviewing the home medication list for a 44-year-old man admitted with suspected hepatic failure. Which medication could cause hepatotoxicity?

a. Nitroglycerin
b. Digoxin (Lanoxin)
c. Ciprofloxacin (Cipro)
d. Acetaminophen (Tylenol)

Answer 11

d. Acetaminophen (Tylenol)

Many chemicals and drugs are potentially hepatotoxic (see Table 39-6) and result in significant patient harm unless monitored closely. For example, chronic high doses of acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) may be hepatotoxic

Question 12

The nurse is caring for a client who has suffered abdominal trauma in a motor vehicle crash. Which laboratory finding indicates that the client’s liver was injured?

a. Serum lipase, 49 U/L
b. Serum amylase, 68 IU/L
c. Serum creatinine, 0.8 mg/dL
d. Serum transaminase, 129 IU/L

Answer 12

d. Serum transaminase, 129 IU/L

The level of serum transaminase, a liver enzyme, is elevated with liver trauma. The other laboratory values are within normal limits and are not specific for the liver.

Question 13

The nurse is caring for a client who is brought to the emergency department following a motor vehicle crash. The nurse notes that the client has ecchymotic areas across the lower abdomen. Which is the priority action of the nurse?

a. Measure the client’s abdominal girth.
b. Assess for abdominal guarding or rigidity.
c. Check the client’s hemoglobin and hematocrit.
d. Ask whether the client was riding in the front or back seat of the car.

Answer 13

b. Assess for abdominal guarding or rigidity.

On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present; this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or asking about seating in the car is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity.

Question 14

The nurse is caring for a client who just had colon resection surgery with a new colostomy. Which teaching objective does the nurse include in the client’s plan of care?

a. Understanding colostomy care and lifestyle implications
b. Learning how to change the appliance independently
c. Demonstrating the correct way to change the appliance by discharge
d. Not being afraid to handle the ostomy appliance tomorrow

Answer 14

c. Demonstrating the correct way to change the appliance by discharge

Client learning goals must be measurable and objective with a time frame, so the nurse can determine whether they have been met. When the goal is to have the client demonstrate a particular skill, the nurse can easily determine whether the goal was met. The specific time frame of “by discharge” is easily measurable also. The other goals are all subjective and cannot be measured objectively. The first two options do not have time frames. “Tomorrow” is a vague time frame.

Question 15

The nurse is caring for a client who has been diagnosed with a bowel obstruction. Which assessment finding leads the nurse to conclude that the obstruction is in the small bowel?

a. Potassium of 2.8 mEq/L, with a sodium value of 121 mEq/L
b. Losing 15 pounds over the last month without dieting
c. Reports of crampy abdominal pain across the lower quadrants
d. High-pitched, hyperactive bowel sounds in all quadrants

Answer 15

a. Potassium of 2.8 mEq/L, with a sodium value of 121 mEq/L

Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range, 3.5 to 5.0 mEq/L) and hyponatremic (normal range, 136 to 145 mEq/L). Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched, hyperactive bowel sounds may be noted with large and small bowel obstructions. Crampy abdominal pain across the lower quadrants is associated with large bowel obstruction.

Question 16

A client post-hemorrhoidectomy feels the need to have a bowel movement. Which action by the nurse is best?

a. Have the client use the bedside commode.
b. Stay with the client, providing privacy.
c. Make sure toilet paper and the call light are in reach.
d. Plan to send a stool sample to the laboratory.

Answer 16

b. Stay with the client, providing privacy.

The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure needed items are within reach is an important nursing action too, but it does not take priority over client safety. The other two actions are not needed in this situation.

Question 17

A client is brought to the emergency department after being shot in the abdomen and is hemorrhaging heavily. Which action by the nurse is the priority?

a. Draw blood for type and crossmatch.
b. Start two large IVs for fluid resuscitation.
c. Obtain vital signs and assess skin perfusion.
d. Assess and maintain a patent airway.

Answer 17

d. Assess and maintain a patent airway.

All options are important nursing actions in the care of a trauma client. However, airway always comes first. The client must have a patent airway, or other interventions will not be helpful.

Question 18

A client with a mechanical bowel obstruction reports that abdominal pain, which was previously intermittent and colicky, is now more constant. Which is the priority action of the nurse?

a. Measure the abdominal girth.
b. Place the client in a knee-chest position.
c. Medicate the client with an opioid analgesic.
d. Assess for bowel sounds and rebound tenderness.

Answer 18

d. Assess for bowel sounds and rebound tenderness.

A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse need not measure abdominal girth. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse should not medicate the client until the physician has been notified of the change in his or her condition.

Question 19

The nurse is teaching self-care measures for a client who has hemorrhoids. Which nursing intervention does the nurse include in the plan of care for the client?

a. Instruct the client to use dibucaine (Nupercainal) ointment whenever needed.
b. Teach the client to choose low-fiber foods to make bowels move more easily.
c. Tell the client to take his or her time on the toilet when needing to defecate.
d. Encourage the client to dab with moist wipes instead of wiping with toilet paper.

Answer 19

d. Encourage the client to dab with moist wipes instead of wiping with toilet paper.

The client should be instructed to use wet wipes and dab the anal area after defecating to avoid further irritation. Dibucaine can be used only for short periods of time because long-term use can mask worsening symptoms. Clients with hemorrhoids require high-fiber foods. The client should not be encouraged to strain at stool or to spend long periods of time on the toilet, because this increases pressure in the rectal area, which can make hemorrhoids worse.

Question 20

A client who has had a colostomy placed in the ascending colon expresses concern that the effluent collected in the colostomy pouch has remained liquid for 2 weeks after surgery. Which is the nurse’s best response?

a. “This is normal for your type of colostomy.”
b. “I will let the health care provider know, so that it can be assessed.”
c. “You should add extra fiber to your diet to stop the diarrhea.”
d. “Your stool will become firmer over the next few weeks.”

Answer 20

a. “This is normal for your type of colostomy.”

The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. The provider may be notified, but this is not the best response from the nurse. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client’s diet or with the passage of time.

Question 21

A middle-aged male client has irritable bowel syndrome that has not responded well to diet changes and bulk-forming laxatives. He asks the nurse about the new drug lubiprostone (Amitiza). What information does the nurse provide him?

a. “This drug is investigational right now for irritable bowel syndrome.”
b. “Unfortunately, this drug is approved only for use in women.”
c. “Lubiprostone works well only in a small fraction of irritable bowel cases.”
d. “Let’s talk to your health care provider about getting you a trial prescription.”

Answer 21

b. “Unfortunately, this drug is approved only for use in women.”

Lubiprostone (Amitiza) is approved only for use in women. The other statements are not accurate.

Question 22

The nurse conducts a physical assessment for a client with abdominal pain. Which finding leads the nurse to suspect appendicitis?

a. Severe, steady right lower quadrant (RLQ) pain
b. Abdominal pain that started a day after vomiting began
c. Abdominal pain that increases with knee flexion
d. Marked peristalsis and hyperactive bowel sounds

Answer 22

a. Severe, steady right lower quadrant (RLQ) pain

Right lower quadrant pain, specifically at McBurney’s point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has a gastroenteritis. Abdominal pain due to appendicitis decreases with knee flexion. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis.

Question 23

The nurse conducts a physical assessment for a client with severe right lower quadrant (RLQ) abdominal pain. The nurse notes that the abdomen is rigid and the client’s temperature is 101.1° F (38.4° C). Which laboratory value does the nurse bring to the attention of the health care provider as a priority?

a. A “left shift” in the white blood cell count
b. White blood cell count, 22,000/mm3
c. Serum sodium, 149 mEq/L
d. Serum creatinine, 0.7 mg/dL

Answer 23

b. White blood cell count, 22,000/mm3

This client may have appendicitis based on RLQ pain. A white blood cell count of 22,000/mm3 is severely elevated and could indicate a perforated appendix, as could the fever. The nurse should bring these findings to the provider’s attention as soon as possible. A left shift would be expected in uncomplicated appendicitis. The sodium reading is only slightly high; this could be due to hemoconcentration from vomiting or from decreased intake. The creatinine level is normal.

Question 24

The nurse is caring for an older client with Salmonella food poisoning. Which is the priority action of the nurse?

a. Monitor vital signs.
b. Maintain IV fluids.
c. Provide perineal care.
d. Initiate Isolation Precautions.

Answer 24

b. Maintain IV fluids.

Dehydration can occur quickly in older clients with Salmonella food poisoning caused by diarrhea, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions, but are of lower priority than fluid replacement. Contact Isolation is not regularly instituted for Salmonella infection. Standard Precautions are usually sufficient.

Question 25

The nurse is caring for a client who has acute viral gastroenteritis. Which dietary instruction does the nurse provide to the client?

a. “Drink plenty of fluids to prevent dehydration.”
b. “You can have only clear liquids to drink.”
c. “Milk products will give you extra protein.”
d. “You can have sips of cola or tea to relieve nausea.”

Answer 25

a. “Drink plenty of fluids to prevent dehydration.”

The client should drink plenty of fluids to prevent dehydration. Clients are not necessarily restricted to clear liquids. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.

Question 26

The nurse is caring for a client who is hospitalized with exacerbation of Crohn’s disease. What does the nurse expect to find during the physical assessment?

a. Positive Murphy’s sign with rebound tenderness
b. Dullness in the lower abdominal quadrants
c. High-pitched, rushing bowel sounds in the right lower quadrant
d. Abdominal cramping that the client says is worse at night

Answer 26

c. High-pitched, rushing bowel sounds in the right lower quadrant

The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn’s disease. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohn’s disease. Nightly worsening of abdominal cramping is not consistent with Crohn’s disease. A positive Murphy’s sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis.

Question 27

A female client is admitted with an exacerbation of ulcerative colitis. Which laboratory value does the nurse correlate with this condition?

a. Potassium, 5.5 mEq/L
b. Hemoglobin, 14.2 g/dL
c. Sodium, 144 mEq/L
d. Erythrocyte sedimentation rate (ESR), 55 mm/hr

Answer 27

d. Erythrocyte sedimentation rate (ESR), 55 mm/hr

The erythrocyte sedimentation rate (ESR) is an indicator of inflammation, which is elevated during an exacerbation of ulcerative colitis. The normal range for the ESR is 0 to 33 mm/hr. Diarrhea caused by ulcerative colitis will result in loss of potassium and hypokalemia with levels lower than 3.5 mEq/L. Bloody diarrhea will lead to anemia, with hemoglobin levels lower than 12 g/dL in females. The sodium level is normal.

Question 28

The nurse is teaching a client how to care for a new ileostomy. Which client statement indicates that additional teaching is needed?

a. “I will consult the pharmacist before filling any new prescriptions.”
b. “I will empty the ostomy pouch when it is half-filled with stool or gas.”
c. “I will wash my hands with antibacterial soap before and after ostomy care.”
d. “I will call my health care provider if I have not had ostomy drainage for 3 hours.”

Answer 28

d. “I will call my health care provider if I have not had ostomy drainage for 3 hours.”

A client with an ileostomy should call the provider if no drainage has come from the ostomy in 6 to 12 hours. The other statements indicate good understanding of self-management.

Question 29

The nurse is caring for a client who had ileostomy surgery 10 days ago. The client verbalizes concerns that the effluent has not become formed and is still liquid green. Which is the nurse’s best response?

a. “I will call your health care provider right away because the stool should be semi-solid by now.”
b. “Your stools will firm up in a few weeks as your body gets used to the ileostomy.”
c. “You should eat a high-fiber diet to help make the stool bulkier and more solid.”
d. “You can add buttermilk or yogurt to your diet and avoid carbonated soft drinks.”

Answer 29

b. “Your stools will firm up in a few weeks as your body gets used to the ileostomy.”

Effluent from an ileostomy will become less liquid (but not solid) over time as the body adapts to loss of the large bowel. This process takes time and the client should be reassured of this. Clients with a new ileostomy should avoid high-fiber diets for the first few weeks because blockage of the bowel may occur. Buttermilk, yogurt, and carbonated drinks will not affect this process.

Question 30

The nurse is caring for a client with severe ulcerative colitis who has been prescribed adalimumab (Humira). Which client statement indicates that additional teaching about the medication is needed?

a. “I will avoid large crowds and people who are sick.”
b. “I will take this medication with food or milk.”
c. “Nausea and vomiting are common side effects.”
d. “I will wash my hands after I play with my dog.”

Answer 30

b. “I will take this medication with food or milk.”

Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing.

Question 31

The nurse is caring for an older client with gastroenteritis. Which order does the nurse consult with the health care provider about?

a. IV 0.45% NS at 50 mL/hr
b. Clear liquids as tolerated
c. Diphenoxylate hydrochloride/atropine sulfate (Lomotil) orally, after each loose stool
d. Acetaminophen (Tylenol), 325-650 mg orally every 4 hr PRN pain

Answer 31

c. Diphenoxylate hydrochloride/atropine sulfate (Lomotil) orally, after each loose stool

Lomotil can cause drowsiness and can increase the older client’s risk for falls. The nurse should consult with the provider to see if this medication is really necessary and, if an antidiarrheal medication is warranted, what other options might be available. The other orders are appropriate, although the nurse would have to monitor the client’s total 24-hour Tylenol dosage to ensure that the client did not receive more than 4000 mg/24 hr.

Question 32

The nurse is caring for a client who is taking mesalamine (5-aminosalicylic acid) (Asacol, Rowasa) for ulcerative colitis. The client has trouble swallowing the pill. Which action by the nurse is most appropriate?

a. Crush the pill carefully and administer it to the client in applesauce or pudding.
b. Empty the contents of the capsule into applesauce or pudding for administration.
c. Contact the client’s health care provider to request an order for Asacol suspension.
d. Contact the client’s health care provider to request an order for Rowasa enemas instead.

Answer 32

d. Contact the client’s health care provider to request an order for Rowasa enemas instead.

Asacol is enteric coated and should not be crushed, chewed, or broken. If the client is unable to swallow the Asacol pill, Rowasa enemas may be administered instead, with a provider’s order. Asacol is not available as a suspension or elixir.

Question 33

The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the highest priority?

a. Skin integrity
b. Blood pressure
c. Heart rate and rhythm
d. Abdominal percussion

Answer 33

c. Heart rate and rhythm

Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Abdominal percussion is an important part of physical assessment but has lower priority for this client than heart rate and rhythm.

Question 34

The nurse is caring for a client with Crohn’s disease and colonic strictures. Which assessment finding requires the nurse to consult the health care provider immediately?

a. Distended abdomen
b. Temperature of 100.0° F (37.8° C)
c. Traces of blood in the stool
d. Crampy lower abdominal pain

Answer 34

a. Distended abdomen

The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the client’s provider should be notified right away. Low-grade fever, bloody diarrhea, and crampy abdominal pain are common symptoms of Crohn’s disease.

Question 35

The nurse is caring for a client with Crohn’s disease who has developed a fistula. Which nursing intervention is the highest priority?

a. Monitor the client’s hematocrit and hemoglobin.
b. Position the client to allow gravity drainage of the fistula.
c. Check and record blood glucose levels every 6 hours.
d. Encourage the client to consume a diet high in protein and calories.

Answer 35

d. Encourage the client to consume a diet high in protein and calories.

The client with Crohn’s disease is already at risk for malabsorption and malnutrition. Malnutrition impairs healing of the fistula and immune responses. Therefore, maintaining adequate nutrition is a priority for this client. The client will require 3000 calories per day to promote healing of the fistula. Monitoring the client’s blood sugar and hemoglobin levels is important, but less so than encouraging nutritional intake. The client need not be positioned to facilitate gravity drainage of the fistula, because fistulas often are found in the abdominal cavity.

Question 36

A client with Crohn’s disease has a draining fistula. Which finding leads the nurse to intervene most rapidly?

a. Serum potassium of 2.6 mEq/L
b. The client not wanting to eat anything
c. White blood cell count of 8200/mm3
d. The client losing 3 pounds in a week

Answer 36

a. Serum potassium of 2.6 mEq/L

Fistulas place the client with Crohn’s disease at risk for hypokalemia, which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium takes priority.

Question 37

The nurse reviews a health teaching for a client with Crohn’s disease. Which instruction does the nurse provide for the client?

a. “You should have a colonoscopy every few years.”
b. “You should eat a diet that is high in protein and fiber.”
c. “You should avoid heavy lifting and tight-fitting clothes.”
d. “You should take the Asacol whenever you have loose stools.”

Answer 37

a. “You should have a colonoscopy every few years.”

Long-term inflammatory bowel disease increases the risk of colon cancer, so regular colonoscopies are recommended. A high-fiber diet is not recommended for clients with Crohn’s disease because fiber can further irritate the inner lining of the bowel. Asacol (mesalamine [5-aminosalicylic acid]) should be taken daily, not as needed. Avoiding heavy lifting and tight-fitting clothes is not necessary.

Question 38

A client has an anorectal abscess. Which teaching topic does the nurse address as the priority?

a. Perineal hygiene
b. Comfort measures
c. Nutrition therapy
d. Antibiotic use

Answer 38

a. Perineal hygiene

The priority intervention for a client with an anorectal abscess focuses on maintaining meticulous perineal hygiene to prevent infection. Comfort measures are also important, but are not as high a priority. Nutrition management and antibiotic teaching may or may not be needed.

Question 39

A nurse is caring for a client hospitalized with botulism. The nurse obtains the following vital signs: temperature—99.8° F (37.6° C), pulse—100, respiratory rate—10 and shallow, and blood pressure—100/62 mm Hg. What action by the nurse is most appropriate?

a. Allow the client rest periods without interruption.
b. Stay with the client while another nurse calls the physician.
c. Check the client’s IV rate and document all findings.
d. Help the client order appropriate food items from the menu.

Answer 39

b. Stay with the client while another nurse calls the physician.

A client with botulism is at risk for respiratory failure. This client’s respiratory rate is slow and shallow, which could indicate impending respiratory distress or failure. The nurse should remain with the client while another nurse notifies the provider. Nothing is allowed by mouth until all respiratory function and swallowing are normal. The nurse should monitor and document the IV infusion per protocol, but this does not take priority. Allowing the client to rest and ordering food items are not appropriate actions.

Question 40

The nurse is preparing a client with diverticulitis for discharge from the hospital. Which statement by the client indicates that additional teaching is needed?

a. “I will ride my bike or take a long walk at least three times a week.”
b. “I will try to include at least 25 g of fiber in my diet every day.”
c. “I will take a senna laxative at bedtime to avoid becoming constipated.”
d. “I will use my legs rather than my back muscles when I lift heavy objects.”

Answer 40

c. “I will take a senna laxative at bedtime to avoid becoming constipated.”

Laxatives are not recommended for clients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining.

Question 41

The nurse has taught self-care measures to a client with an anal fissure. Which action by the client requires the nurse to do additional teaching?

a. Taking warm sitz baths several times daily
b. Administering daily enemas to prevent constipation
c. Using bulk-producing agents to aid elimination
d. Self-administering anti-inflammatory suppositories

Answer 41

b. Administering daily enemas to prevent constipation

The client should not use enemas to promote elimination, but rather should rely on bulk-producing agents such as psyllium hydrophilic mucilloid (Metamucil). The other actions are appropriate.

Question 42

A client is brought to the emergency department with an abrupt onset of vomiting, abdominal cramping, and diarrhea 2 hours after eating food at a picnic. Which infectious microorganism does the nurse suspect as the probable cause?

a. Salmonella
b. Giardia lamblia
c. Staphylococcus aureus
d. Clostridium botulinum

Answer 42

c. Staphylococcus aureus

Staphylococcus can be found in meat and dairy products and can be transmitted to people. Food poisoning occurs, especially if foods are left unrefrigerated over a period of time. Symptoms of Staphylococcus food poisoning include sudden onset of vomiting, abdominal cramping, and diarrhea within 2 to 4 hours. The client’s symptoms are not consistent with infection by the other microorganisms.

Question 43

The nurse is caring for a client with Giardia lamblia infection. Which medication does the nurse anticipate teaching the client about?

a. Metronidazole (Flagyl)
b. Ciprofloxacin (Cipro)
c. Sulfasalazine (Azulfidine)
d. Ceftriaxone (Rocephin)

Answer 43

a. Metronidazole (Flagyl)

Flagyl is the drug of choice for Giardia lamblia infection. Cipro and Rocephin are antibiotics used for bacterial infections. Azulfidine is used for ulcerative colitis and Crohn’s disease.

Question 44

The nurse is caring for a client who has food poisoning that may be the result of Clostridium botulinum infection. Which is the priority nursing assessment for this client?

a. Heart rate and rhythm
b. Bowel sounds and heart tones
c. Fluid balance and urine output
d. Oxygen saturation and respiratory rate

Answer 44

d. Oxygen saturation and respiratory rate

Severe infection with Clostridium botulinum can lead to respiratory failure, so assessments of oxygen saturation and respiratory rate are of high priority for clients with suspected Clostridium botulinum infection. The other assessments may be completed after the respiratory system has been assessed.

Question 45

A patient is seeking emergency care after choking on a piece of steak. The nursing assessment reveals a history of alcoholism, cigarette smoking, and hemoptysis. Which diagnostic study is most likely to be performed on this patient?

a. Barium swallow
b. Endoscopic biopsy
c. Capsule endoscopy
d. Endoscopic ultrasonography

Answer 45

b. Endoscopic biopsy

Because of this patient’s history of excessive alcohol intake, smoking, hemoptysis, and the current choking episode, cancer may be present. A biopsy is necessary to make a definitive diagnosis of carcinoma, so an endoscope will be used to obtain a biopsy and observe other abnormalities as well. A barium swallow may show narrowing of the esophagus, but it is more diagnostic for achalasia. An endoscopic ultrasonography may be used to stage esophageal cancer. Capsule endoscopy can show alterations in the esophagus but is more often used for small intestine problems. A barium swallow, capsule endoscopy, and endoscopic ultrasonography cannot provide a definitive diagnosis for cancer when it is suspected.

Question 46

A 72-year-old patient was admitted with epigastric pain due to a gastric ulcer. Which patient assessment warrants an urgent change in the nursing plan of care?

a. Chest pain relieved with eating or drinking water
b. Back pain 3 or 4 hours after eating a meal
c. Burning epigastric pain 90 minutes after breakfast
d. Rigid abdomen and vomiting following indigestion

Answer 46

d. Rigid abdomen and vomiting following indigestion

A rigid abdomen with vomiting in a patient who has a gastric ulcer indicates a perforation of the ulcer, especially if the manifestations of perforation appear suddenly. Midepigastric pain is relieved by eating, drinking water, or antacids with duodenal ulcers, not gastric ulcers. Back pain 3-4 hours after a meal is more likely to occur with a duodenal ulcer. Burning epigastric pain 1-2 hours after a meal is an expected manifestation of a gastric ulcer related to increased gastric secretions and does not cause an urgent change in the nursing plan of care.

Question 47

The patient with chronic gastritis is being put on a combination of medications to eradicate H. pylori. Which drugs does the nurse know will probably be used for this patient?

a. Antibiotic(s), antacid, and corticosteroid
b. Antibiotic(s), aspirin, and antiulcer/protectant
c. Antibiotic(s), proton pump inhibitor, and bismuth
d. Antibiotic(s) and nonsteroidal antiinflammatory drugs (NSAIDs)

Answer 47

c. Antibiotic(s), proton pump inhibitor, and bismuth

To eradicate H. pylori, a combination of antibiotics, a proton pump inhibitor, and possibly bismuth (for quadruple therapy) will be used. Corticosteroids, aspirin, and NSAIDs are drugs that can cause gastritis and do not affect H. pylori.

Question 48

The patient is having an esophagoenterostomy with anastomosis of a segment of the colon to replace the resected portion. What initial postoperative care should the nurse expect when this patient returns to the nursing unit?

a. Turn, deep breathe, cough, and use spirometer every 4 hours.
b. Maintain an upright position for at least 2 hours after eating.
c. NG will have bloody drainage, and it should not be repositioned.
d. Keep in a supine position to prevent movement of the anastomosis.

Answer 48

c. NG will have bloody drainage, and it should not be repositioned.

The patient will have bloody drainage from the NG tube for 8 to 12 hours, and it should not be repositioned or reinserted without contacting the surgeon. Turning and deep breathing will be done every 2 hours, and the spirometer will be used more often than every 4 hours. Coughing would put too much pressure in the area and should not be done. Because the patient will have the NG tube, the patient will not be eating yet. The patient should be kept in a semi-Fowler’s or Fowler’s position, not supine, to prevent reflux and aspiration of secretions.

Question 49

The patient is having a gastroduodenostomy (Billroth I operation) for stomach cancer. What long-term complication is occurring when the patient reports generalized weakness, sweating, palpitations, and dizziness 15 to 30 minutes after eating?

a. Malnutrition
b. Bile reflux gastritis
c. Dumping syndrome
d. Postprandial hypoglycemia

Answer 49

c. Dumping syndrome

After a Billroth I operation, dumping syndrome may occur 15 to 30 minutes after eating because of the hypertonic fluid going to the intestine and additional fluid being drawn into the bowel. Malnutrition may occur but does not cause these symptoms. Bile reflux gastritis cannot happen when the stomach has been removed. Postprandial hypoglycemia occurs with similar symptoms, but 2 hours after eating.

Question 50

A 20-year-old man is admitted to the emergency department after a motor vehicle crash with suspected abdominal trauma. What assessment finding by the nurse is of highest priority?

a. Nausea and vomiting
b. Hyperactive bowel sounds
c. Firmly distended abdomen
d. Abrasions on all extremities

Answer 50

c. Firmly distended abdomen

Clinical manifestations of abdominal trauma are guarding and splinting of the abdominal wall; a hard, distended abdomen (indicating possible intraabdominal bleeding); decreased or absent bowel sounds; contusions, abrasions, or bruising over the abdomen; abdominal pain; pain over the scapula; hematemesis or hematuria; and signs of hypovolemic shock (tachycardia and decreased blood pressure).

Question 51

You would be most concerned about an order for a total parenteral nutrition (TPN) fat emulsion for a client with which condition?

1. Gastrointestinal (GI) obstruction
2. Severe anorexia nervosa
3. Chronic diarrhea and vomiting
4. Fractured femur

Answer 51

4. Fractured femur

Rationale:
A client with a fractured femur is at risk for fat embolism, so a fat emulsion should be used with caution. Vomiting may be a problem if the emulsion is infused too rapidly. TPN is commonly used in clients with GI obstruction, severe anorexia nervosa, and chronic diarrhea or vomiting.

Question 52

The postoperative care of a morbidly obese client is being planned. Which task best utilizes the expertise of the LPN/LVN?

1. Obtaining an oversized blood pressure cuff and a large-size bed
2. Setting up a reinforced trapeze bar
3. Assisting in the planning of toileting, turning, and ambulation
4. Assigning tasks to UAPs and other ancillary staff

Answer 52

3. Assisting in the planning of toileting, turning, and ambulation

Rationale:
The LPN/LVN can assist in the planning of interventions, but the RN should take ultimate responsibility for planning. The LPN/LVN can delegate and assign tasks to UAPs; however, if the RN is in charge, it is better if UAPs are not receiving instructions from multiple people. Obtaining equipment should be delegated to a UAP. A physical therapist should be contacted to set up specialized equipment.

Question 53

A client hospitalized with ulcerative colitis reports 10 to 20 small diarrhea stools per day, with abdominal pain before defecation. The client appears depressed and underweight and is uninterested in self-care or suggested therapies. What is the priority nursing diagnosis?

1. Diarrhea related to irritated bowel
2. Imbalanced Nutrition: Less Than Body Requirements related to nutrient loss
3. Acute Pain related to increased GI motility
4. Ineffective Self-Health Management related to treatment plan

Answer 53

1. Diarrhea related to irritated bowel

Rationale:
The immediate problem is controlling the diarrhea. Addressing this problem is a step toward correcting the nutritional imbalance and decreasing the diarrheal cramping. Self-care and compliance with the treatment plan are important long-term goals that can be addressed when the client is feeling better physically.

Question 54

You are providing postoperative care for a client who underwent laparoscopic cholecystectomy. What should be reported immediately to the physician?

1. The client cannot void 5 hours postoperatively.
2. The client reports shoulder pain.
3. The client reports right upper quadrant pain.
4. Output does not equal input for the first few hours.

Answer 54

3. The client reports right upper quadrant pain.

Rationale:
Right upper quadrant pain is a sign of hemorrhage or bile leak. The ability to void should return within 6 hours postoperatively. Right shoulder pain is related to unabsorbed carbon dioxide and will be resolved by placing the client in Sims position. Output that does not equal input after surgery for the first several hours is expected.

Question 55

You are caring for a client with cirrhosis and portal hypertension. Which statement by the client concerns you the most?

1. “I’m very constipated and have been straining during bowel movements.”
2. “I can’t button my pants anymore because my belly is so swollen.”
3. “I have a tight sensation in my lower legs when I forget to put my feet up.”
4. “When I sleep, I have to sit in a recliner so that I can breathe more easily.”

Answer 55

1. “I’m very constipated and have been straining during bowel movements.”

Rationale:
There is a potential for sudden rupture of fragile blood vessels with massive hemorrhage from straining that increases thoracic or abdominal pressure. The client could have fluid accumulation in the abdomen (ascites) that can be mild and hard to detect or severe enough to cause orthopnea. Dependent peripheral edema can also be observed but is less urgent.

Question 56

A client underwent an exploratory laparotomy 2 days ago. The physician should be called immediately for which physical assessment finding?

1. Abdominal distention and rigidity
2. Intentional displacement of the NG tube by the client
3. Absent or hypoactive bowel sounds
4. Nausea and occasional vomiting

Answer 56

1. Abdominal distention and rigidity

Rationale:
Distention and rigidity can signal hemorrhage or peritonitis. The physician may also decide that these symptoms require a medication to stimulate peristalsis. Absence of bowel sounds is expected within the first 24 to 48 hours. Nausea and vomiting are not uncommon and are usually self-limiting, and an “as needed” (PRN) order for an antiemetic is usually part of the routine postoperative orders. The reason for displacement of the NG tube should be assessed and the tube secured as necessary.

Question 57

You are caring for a client who was recently admitted for severe diverticulitis. Which task is appropriate to delegate for the care of this client?

1. Tell the unit secretary to call radiology and schedule a barium enema.
2. Instruct the LPN/LVN to give PRN laxatives when the client reports constipation.
3. Advise the nursing student to help the client ambulate up and down the hall.
4. Tell the UAP that a stool specimen must be saved to test for occult blood.

Answer 57

4. Tell the UAP that a stool specimen must be saved to test for occult blood.

Rationale:
Diverticulitis can cause chronic or severe bleeding, so if there is no obvious blood in the stool, the stool may be tested for occult blood. A barium enema is not usually ordered because of the danger of perforation. Laxatives and ambulation increase intestinal motility and are to be avoided in the initial phase of treatment. If a barium enema, PRN laxative, or ambulation is ordered, question the orders before delegating these interventions.

Question 58

You are caring for a client who was admitted for advanced cirrhosis. The client has massive ascites, peripheral dependent edema in the lower extremities, nausea and vomiting, and dyspnea related to pressure on the diaphragm. For the nursing diagnosis of Excess Fluid Volume, which indicator is the most reliable for tracking fluid retention?

1. Auscultating the lung fields for crackles every day
2. Measuring the abdominal girth every morning
3. Performing daily weights with the same amount of clothing
4. Checking the extremities for pitting edema and comparing to baseline

Answer 58

3. Performing daily weights with the same amount of clothing

Rationale:
All of these measures should be performed for total care of the client; however weighing the client every day is considered the single best indicator of fluid volume.

Question 59

You are supervising a nursing student who is caring for a client who had a cholecystectomy. There is a T-tube in place. You would intervene if the student performs which action?

1. Maintains the client in a semi-Fowler position
2. Checks the amount, color, and consistency of the drainage
3. Gently aspirates the drainage from the tube
4. Inspects the skin around the tube for redness or irritation

Answer 59

3. Gently aspirates the drainage from the tube

Rationale:
T-tubes should not be irrigated, aspirated, or clamped without a specific order from the physician. All of the other actions are appropriate in the care of this client.