TEST 5: The Client with Upper Gastrointestinal Tract Health Problems

Question 1

1. A nurse is caring for a client who has just returned from surgery to treat a fractured mandible.
Which of the following items should always be available at this client's bedside? Select all that
apply.
1. Nasogastric tube.
2. Wire cutters.
3. Oxygen cannula.
4. Suction equipment.
5. Code cart.

Answer 1

The Client with Disorders of the Oral Cavity
1. 2, 4. Following surgery for a fractured mandible, the client’s jaws will be wired. The nurse
should be prepared to intervene quickly in case the client develops respiratory distress or begins to
choke or vomit. Wire cutters or scissors should always be available in case the wires need to be cut
in a medical emergency. Suction equipment should be available to help clear the client’s airway if
necessary. It is not necessary to keep a nasogastric tube or oxygen cannula at the client’s bedside.
Cardiopulmonary arrest is unlikely, so a code cart is not needed at the bedside.
CN: Safety and infection control; CL: Apply

Question 2

2. Which of the following interventions is most appropriate for a client who has stomatitis?
3. Drinking hot tea at frequent intervals.
4. Gargling with antiseptic mouthwash.
5. Using an electric toothbrush.
6. Eating a soft, bland diet.

Answer 2

2. 4. Clients with stomatitis (inflammation of the mouth) have significant discomfort, which
      impacts their ability to eat and drink. They will be most comfortable eating soft, bland foods, and
      avoiding temperature extremes in their food and liquids. Gargling with an antiseptic mouthwash will
      be irritating to the mucosa. Mouth care should include gentle brushing with a soft toothbrush and
      flossing.
      CN: Basic care and comfort; CL: Synthesize2. 4. Clients with stomatitis (inflammation of the mouth) have significant discomfort, which
      impacts their ability to eat and drink. They will be most comfortable eating soft, bland foods, and
      avoiding temperature extremes in their food and liquids. Gargling with an antiseptic mouthwash will
      be irritating to the mucosa. Mouth care should include gentle brushing with a soft toothbrush and
      flossing.
      CN: Basic care and comfort; CL: Synthesize

Question 3

3. A client who has a history of a mitral valve prolapse is scheduled to get her teeth cleaned.
   Which of the following replies by the nurse is most appropriate?
4. “The physician will need to reevaluate the status of your heart condition before your dental
   appointment.”
5. “Be sure to remind your dentist that you have a heart condition.”
6. “It is important for you to care for your teeth because your heart condition makes you more
   susceptible to developing oral infections.”
7. “We will prescribe a prophylactic antibiotic for you to take before getting your teeth cleaned.”

Answer 3

3. 4. Clients who are at risk for developing infective endocarditis due to cardiac conditions such
      as mitral valve prolapse must take prophylactic antibiotics before any dental procedure that may
      cause bleeding. The client is not more susceptible to developing oral infections. Rather, the client is
      more susceptible to developing endocarditis that results from oral bacteria that enter the circulation
      during the dental procedure. The physician does not necessarily need to re-evaluate the heart
      condition of a client who is stable, but antibiotics must be prescribed. It is not enough to simply
      remind the dentist about the heart condition.
      CN: Reduction of risk potential; CL: Synthesize

Question 4

4. Amoxicillin trihydrate (Amoxil) 300 mg PO has been prescribed for a client with an oral infection.
   The medication is available in a liquid suspension that is available as 250 mg/5 mL. How many
   milliliters should the nurse administer?
   ______________________ mL.

Answer 4

4. 6 mL. To administer 300 mg PO, the nurse will need to administer 6 mL. The following
   formula is used to calculate the correct dosage:
   CN: Pharmacological and parenteral therapies; CL: Apply

Question 5

5. During the assessment of a client’s mouth, the nurse notes the absence of saliva. The client
   reports having pain behind the ear. The client has been nothing-by-mouth (NPO) for several days, but
   now can have liquids. Based on these findings, the nurse should do which of the following?
6. Request a prescription for an antifungal mouthwash.
7. Instruct the client to brush the gums as well as the teeth.
8. Encourage the client to suck on hard candy.
9. Give the client a hydrogen peroxide–based mouthwash.

Answer 5

5. 3. The lack of saliva, pain near the area of the ear, and the prolonged NPO status of the client
      are indications that the client may be developing parotitis, or inflammation of the parotid gland.
      Parotitis usually develops with dehydration combined with poor oral hygiene or when clients have
      been NPO for an extended period. Preventive measures include the use of sugarless hard candy or
      gum to stimulate saliva production, adequate hydration, and frequent mouth care. The client does not
      have indications of stomatitis (inflammation of the mouth), which produces excessive salivation and a
      sore mouth. The client does not have indications of oral candidiasis (thrush), which causes bluishwhite mouth lesions, and the nurse does not need to request a prescription for an antifungal
      mouthwash. There are no indications that the client has gingivitis, which can be recognized by the
      inflamed gingiva and bleeding that occur during toothbrushing, and while the client should brush the
      teeth and gums, increasing salivation to prevent parotitis is the priority at this time.
      CN: Basic care and comfort; CL: Synthesize

Question 6

6. The nurse is preparing a community presentation on oral cancer. Which of the following is a
   primary risk factor for oral cancer that the nurse should include in the presentation?
7. Use of alcohol.
8. Frequent use of mouthwash.
9. Lack of vitamin B 12 .
10. Lack of regular teeth cleaning by a dentist.

Answer 6

6. 1. Chronic and excessive use of alcohol can lead to oral cancer. Smoking and use of smokeless
      tobacco are other significant risk factors. Additional risk factors include chronic irritation such as a
      broken tooth or ill-fitting dentures, poor dental hygiene, overexposure to sun (lip cancer), and
      syphilis. Use of mouthwash, lack of vitamin B 12 , and lack of regular teeth cleaning appointments have
      not been implicated as primary risk factors for oral cancer.
      CN: Health promotion and maintenance; CL: Analyze

Question 7

7. A client has entered a smoking cessation program to quit a two-pack-a-day cigarette habit. The
   client has not smoked a cigarette for 3 weeks, and tells the nurse about fears of starting smoking again
   because of current job pressures. What would be the most appropriate reply for the nurse to make in
   response to the client’s comments?
8. “Don’t worry about it. Everybody has difficulty quitting smoking, and you should expect to as
   well.”
9. “If you increase your self-control, I am sure you will be able to avoid smoking.”
10. “Try taking a couple of days of vacation to relieve the stress of your job.”
11. “It is good that you can talk about your concerns. Try calling a friend when you want to
    smoke.”

Answer 7

7. 4. It is important for individuals who are engaged in smoking cessation efforts to feel
      comfortable with sharing their fears of failure with others and seeking support. Although fewer than
      5% of smokers successfully quit on their first attempt, it is not helpful to tell a client to anticipate
      failure. Telling the client to exercise more self-control does not provide support. Taking a vacation to
      avoid job pressures does not address the issue of how to manage the desire to smoke when in a
      stressful situation.
      CN: Psychosocial adaptation; CL: Synthesize

Question 8

8. A client who was in a motor vehicle accident has a fractured mandible. Surgery has been
   performed to immobilize the injury by wiring the jaw. In the immediate postoperative phase, the nurse
   should:
9. Prevent nausea and vomiting.
10. Maintain a patent airway.
11. Provide frequent oral hygiene.
12. Establish a way for the client to communicate.

Answer 8

8. 2. The priority of care in the immediate postoperative phase is to maintain a patent airway. The
      nurse should observe the client carefully for signs of respiratory distress. If the client becomes
      nauseated, antiemetics should be administered to decrease the chance of vomiting with obstruction of
      the airway and aspiration of vomitus. Providing frequent oral hygiene and an alternative means of
      communication are important aspects of nursing care, but maintaining a patent airway is most
      important.
      CN: Physiological adaptation; CL: Synthesize

Question 9

9. A client has returned from surgery during which the jaws were wired as treatment for a
   fractured mandible. The client is in stable condition. The nurse is instructing the unlicensed nursing
   personnel (UAP) on how to properly position the client. Which instructions about positioning would
   be appropriate for the nurse to give the UAP?
10. Keep the client in a side-lying position with the head slightly elevated.
11. Do not reposition the client without the assistance of a registered nurse.
12. The client can assume any position that is comfortable.
13. Keep the client’s head elevated on two pillows at all times.

Answer 9

9. 1. Immediately after surgery, the client should be placed on the side with the head slightly
      elevated. This position helps facilitate removal of secretions and decreases the likelihood of
      aspiration should vomiting occur. A registered nurse does not need to be present to reposition the
      client, unless the client’s condition warrants the presence of the nurse. Although it is important to
      elevate the head, there is no need to keep the client’s head elevated on two pillows unless that
      position is comfortable for the client.
      CN: Reduction of risk potential; CL: Synthesize

Question 10

10. A client who has had the jaws wired begins to vomit. What should be the nurse’s first action?
11. Insert a nasogastric (NG) tube and connect it to suction.
12. Use wire cutters to cut the wire.
13. Suction the client’s airway as needed.
14. Administer an antiemetic intravenously.

Answer 10

10. 3. The nurse’s first action is to clear the client’s airway as necessary. Inserting an NG tube or
       administering an antiemetic may prevent future vomiting episodes, but these procedures are not
       helpful when the client is actually vomiting. Cutting the wires is done only as a last resort or in case
       of respiratory or cardiac arrest.
       CN: Physiological adaptation; CL: Synthesize

Question 11

The Client with Peptic Ulcer Disease
A nurse teaches a client experiencing heartburn to take 11⁄2 oz of Maalox when symptoms appear.
How many milliliters should the client take?
_________________________ mL.

Answer 11

The Client with Peptic Ulcer Disease
11. 45 mL
CN: Pharmacological and parenteral therapies; CL: Apply

Question 12

12. The nurse has been assigned to provide care for four clients. In what order should the nurse
    assess these clients?
13. A client awaiting surgery for a hiatal hernia repair at 11 AM .
14. A client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests.
15. A client with peptic ulcer disease experiencing a sudden onset of acute stomach pain.
16. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw.

Answer 12

12.
3. A client with peptic ulcer disease experiencing a sudden onset of acute stomach pain.
4. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw.
2. A client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests.
1. A client awaiting surgery for a hiatal hernia repair at 11 AM .
The client with peptic ulcer disease who is experiencing a sudden onset of acute stomach pain
should be assessed first by the nurse. The sudden onset of stomach pain could be indicative of a
perforated ulcer, which would require immediate medical attention. It is also important for the nurse
to thoroughly assess the nature of the client’s pain. The client with the fractured jaw is experiencing
pain and should be assessed next. The nurse should then assess the client who is NPO for tests to
ensure NPO status and comfort. Last, the nurse can assess the client before surgery.
CN: Management of care; CL: Synthesize

Question 13

13. The nurse is caring for a client who has just had an upper GI endoscopy. The client’s vital
    signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed
    nursing personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was
    previously afebrile, has developed a temperature of 101.8°F (38.8°C). What should the nurse do in
    response to these reported assessment data?
14. Promptly assess the client for potential perforation.
15. Tell the assistant to change thermometers and retake the temperature.
16. Plan to give the client acetaminophen (Tylenol) to lower the temperature.
17. Ask the UAP to bathe the client with tepid water.

Answer 13

13. 1. A sudden spike in temperature following an endoscopic procedure may indicate perforation
       of the GI tract. The nurse should promptly conduct a further assessment of the client, looking for
       further indicators of perforation, such as a sudden onset of acute upper abdominal pain; a rigid,
       boardlike abdomen; and developing signs of shock. Telling the assistant to change thermometers is not
       an appropriate action and only further delays the appropriate action of assessing the client. The nurse
       would not administer acetaminophen without further assessment of the client or without a physician’s
       prescription; a suspected perforation would require that the client be placed on nothing-by-mouth
       status. Asking the assistant to bathe the client before any assessment by the nurse is inappropriate.
       CN: Management of care; CL: Synthesize

Question 14

14. A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a
    bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along
    with a rigid, boardlike abdomen. The nurse should do which of the following first?
15. Administer pain medication as prescribed.
16. Raise the head of the bed.
17. Prepare to insert a nasogastric tube
18. Notify the physician.

Answer 14

14. 4. The client is experiencing a perforation of the ulcer, and the nurse should notify the
       physician immediately. The body reacts to perforation of an ulcer by immobilizing the area as much
       as possible. This results in boardlike abdominal rigidity, usually with extreme pain. Perforation is a
       medical emergency requiring immediate surgical intervention because peritonitis develops quickly
       after perforation. Administering pain medication is not the first action, although the nurse later should
       institute measures to relieve pain. Elevating the head of the bed will not minimize the perforation. A
       nasogastric tube may be used following surgery.
       CN: Physiological adaptation; CL: Synthesize

Question 15

15. When obtaining a nursing history from a client with a suspected gastric ulcer, which signs and
    symptoms should the nurse assess? Select all that apply.
16. Epigastric pain at night.
17. Relief of epigastric pain after eating.
18. Vomiting.
19. Weight loss.
20. Melena.

Answer 15

15. 3, 4, 5. Vomiting and weight loss are common with gastric ulcers. The client may also have
    blood in the stools (melena) from gastric bleeding. Clients with a gastric ulcer are most likely to have
    a burning epigastric pain that occurs about 1 hour after eating. Eating frequently aggravates the pain.
    Clients with duodenal ulcers are more likely to have pain that occurs during the night and is
    frequently relieved by eating.
    CN: Physiological adaptation; CL: Analyze

Question 16

16. The nurse is caring for a client who has had a gastroscopy. Which of the following may
    indicate that the client is developing a complication related to the procedure? Select all that apply.
17. The client has a sore throat.
18. The client has a temperature of 100°F (37.8°C).
19. The client appears drowsy following the procedure.
20. The client has epigastric pain.
21. The client experiences hematemesis.

Answer 16

16. 2, 4, 5. Following a gastroscopy, the nurse should monitor the client for complications, which
    include perforation and the potential for aspiration. An elevated temperature, epigastric pain, or the
    vomiting of blood (hematemesis) are all indications of a possible perforation and should be reported
    promptly. A sore throat is a common occurrence following a gastroscopy. Clients are usually sedated
    to decrease anxiety and the nurse would anticipate that the client will be drowsy following the
    procedure.
    CN: Reduction of risk potential; CL: Analyze

Question 17

17. A client admitted to the hospital with peptic ulcer disease tells the nurse about having black,
    tarry stools. The nurse should:
18. Encourage the client to increase fluid intake.
19. Advise the client to avoid iron-rich foods.
20. Place the client on contact precautions.
21. Report the finding to the health care provider.

Answer 17

17. 4. Black, tarry stools are an important warning sign of bleeding in peptic ulcer disease.
       Digested blood in the stool causes it to be black; the odor of the stool is very offensive. The nurse
       should instruct the client to report the incidence of black stools promptly to the primary health care
       provider. Increasing fluids or avoiding iron-rich foods will not change the stool color or consistency
       if the stools contain digested blood. Until other information is available, it is not necessary to initiate
       contact precautions.
       CN: Reduction of risk potential; CL: Synthesize

Question 18

18. A client with peptic ulcer disease is taking ranitidine. What is the expected outcome of this
drug?
1. Heal the ulcer.
2. Protect the ulcer surface from acids.
3. Reduce acid concentration.
4. Limit gastric acid secretion.

Answer 18

18. 4. Histamine-2 (H2) receptor antagonists, such as ranitidine, reduce gastric acid secretion.
       Antisecretory, or proton-pump inhibitors, such as omeprazole, help ulcers heal quickly in 4 to 8
       weeks. Cytoprotective drugs, such as sucralfate, protect the ulcer surface against acid, bile, and
       pepsin. Antacids reduce acid concentration and help reduce symptoms.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 19

19. A client with a peptic ulcer reports epigastric pain that frequently causes the client to wake
    up during the night. The nurse should instruct the client to do which activities? Select all that apply.
20. Obtain adequate rest to reduce stimulation.
21. Eat small, frequent meals throughout the day.
22. Take all medications on time as prescribed.
23. Sit up for 1 hour when awakened at night.
24. Stay away from crowded areas.

Answer 19

19. 1, 2, 3, 4. The nurse should encourage the client to reduce stimulation that may enhance gastric
    secretion. The nurse can also advise the client to utilize health practices that will prevent recurrences
    of ulcer pain, such as avoiding fatigue and elimination of smoking. Eating small, frequent meals helps
    to prevent gastric distention if not actively bleeding and decreases distension and release of gastrin.
    Medications should be administered promptly to maintain optimum levels. After awakening during the
    night, the client should eat a small snack and return to bed, keeping the head of the bed elevated for an
    hour after eating. It is not necessary to stay away from crowded areas.
    CN: Physiological adaptation; CL: Synthesize

Question 20

20. A client with peptic ulcer disease reports being nauseated most of the day and now feeling
    light-headed and dizzy. Based upon these findings, which nursing actions would be most appropriate
    for the nurse to take? Select all that apply.
21. Administering an antacid hourly until nausea subsides.
22. Monitoring the client’s vital signs.
23. Notifying the physician of the client’s symptoms.
24. Initiating oxygen therapy.
25. Reassessing the client in an hour.

Answer 20

20. 2, 3. The symptoms of nausea and dizziness in a client with peptic ulcer disease may be
    indicative of hemorrhage and should not be ignored. The appropriate nursing actions at this time are
    for the nurse to monitor the client’s vital signs and notify the physician of the client’s symptoms. To
    administer an antacid hourly or to wait 1 hour to reassess the client would be inappropriate; prompt
    intervention is essential in a client who is potentially experiencing a gastrointestinal hemorrhage. The
    nurse would notify the physician of assessment findings and then initiate oxygen therapy if prescribed
    by the physician.
    CN: Physiological adaptation; CL: Synthesize

Question 21

21. The nurse is preparing to teach a client with a peptic ulcer about the diet that should befollowed after discharge. The nurse should explain that the client should eat which of the following?
22. Bland foods.
23. High-protein foods.
24. Any foods that are tolerated.
25. A glass of milk with each meal

Answer 21

21. 3. Diet therapy for ulcer disease is a controversial issue. There is no scientific evidence that
       diet therapy promotes healing. Most clients are instructed to follow a diet that they can tolerate. There
       is no need for the client to ingest only a bland or high-protein diet. Milk may be included in the diet,
       but it is not recommended in excessive amounts.
       CN: Basic care and comfort; CL: Apply

Question 22

22. The nurse finds a client who has been diagnosed with a peptic ulcer surrounded by papers
    from a briefcase and arguing on the telephone with a coworker. The nurse’s response to observing
    these actions should be based on knowledge that:
23. Involvement with the job will keep the client from becoming bored.
24. A relaxed environment will promote ulcer healing.
25. Not keeping up with the job will increase the client’s stress level.
26. Setting limits on the client’s behavior is an important nursing responsibility.

Answer 22

22. 2. A relaxed environment is an essential component of ulcer healing. Nurses can help clientsunderstand the importance of relaxation and explore with them ways to balance work and family
       demands to promote healing. Being involved with his work may prevent boredom; however, this
       client is upset and argumentative. Not keeping up with his job will probably increase the client’s
       stress level, but the nurse’s response is best if it is based on the fact that a relaxed environment is an
       essential component of ulcer healing. Nurses cannot set limits on a client’s behavior; clients must
       make the decision to make lifestyle changes.
       CN: Basic care and comfort; CL: Apply

Question 23

23. A client with a peptic ulcer has been instructed to avoid intense physical activity and stress.
    Which strategy should the client incorporate into the home care plan?
24. Conduct physical activity in the morning in order to be able to rest in the afternoon.
25. Have the family agree to perform the necessary yard work at home.
26. Give up jogging and substitute a less demanding hobby.
27. Incorporate periods of physical and mental rest in the daily schedule.

Answer 23

23. 4. It would be most effective for the client to develop a health maintenance plan that
       incorporates regular periods of physical and mental rest in the daily schedule. Strategies should be
       identified to deal with the types of physical and mental stressors that the client needs to cope with in
       the home and work environments. Scheduling physical activity to occur only in the morning would not
       be restful or practical. There is no need for the client to avoid yard work or jogging if these activities
       are not stressful.
       CN: Psychosocial adaptation; CL: Synthesize

Question 24

24. A client is to take one daily dose of ranitidine (Zantac) at home to treat a peptic ulcer. The
    client understands proper drug administration of ranitidine when the client will take the drug at which
    of the following times?
25. Before meals.
26. With meals.
27. At bedtime.
28. When pain occurs.

Answer 24

24. 3. Ranitidine blocks secretion of hydrochloric acid. Clients who take only one daily dose of
       ranitidine are usually advised to take it at bedtime to inhibit nocturnal secretion of acid. Clients who
       take the drug twice a day are advised to take it in the morning and at bedtime. It is not necessary to
       take the drug before meals. The client should take the drug regularly, not just when pain occurs.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 25

25. A client has been taking aluminum hydroxide 30 mL six times per day at home to treat a
    peptic ulcer. The client has been unable to have a bowel movement for 3 days. Based on this
    information, the nurse would determine that which of the following is the most likely cause of the
    client’s constipation?
26. The client has not been including enough fiber in the diet.
27. The client needs to increase the daily exercise.
28. The client is experiencing an adverse effect of the aluminum hydroxide.
29. The client has developed a gastrointestinal obstruction.

Answer 25

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

Question 26

26. A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements
    best indicates that the client understands how to correctly take the antacid?
27. “I should take my antacid before I take my other medications.”
28. “I need to decrease my intake of fluids so that I don’t dilute the effects of my antacid.”
29. “My antacid will be most effective if I take it whenever I experience stomach pains.”
30. “It is best for me to take my antacid 1 to 3 hours after meals.”

Answer 26

26. 4. Antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an
       antacid is taken on an empty stomach, the duration of the drug’s action is greatly decreased. Taking
       antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the therapeutic
       action of the drug. Antacids should be administered about 2 hours after other medications to decrease
       the chance of drug interactions. It is not necessary to decrease fluid intake when taking antacids. If
       antacids are taken more frequently than recommended, the likelihood of developing adverse effects
       increases. Therefore, the client should not take antacids as often as desired to control pain.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 27

27. Which of the following would be an expected outcome for a client with peptic ulcer disease?
    The client will:
28. Demonstrate appropriate use of analgesics to control pain.2. Explain the rationale for eliminating alcohol from the diet.
29. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months.
30. Eliminate engaging in contact sports.

Answer 27

27. 2. Alcohol is a gastric irritant that should be eliminated from the intake of the client with
       peptic ulcer disease. Analgesics are not used to control ulcer pain; many analgesics are gastric
       irritants. The client’s hemoglobin and hematocrit typically do not need to be monitored every 3
       months, unless gastrointestinal bleeding is suspected. The client can maintain an active lifestyle and
       does not need to eliminate contact sports as long as they are not stress inducing.
       CN: Reduction of risk potential; CL: Evaluate

Question 28

The Client with Cancer of the Stomach
28. The nurse should assess the client who is being admitted to the hospital with upper GI
bleeding for which of the following? Select all that apply.
1. Dry, flushed skin.
2. Decreased urine output.
3. Tachycardia.
4. Widening pulse pressure.
5. Rapid respirations.
6. Thirst.

Answer 28

The Client with Cancer of the Stomach28. 2, 3, 5, 6. The client who is experiencing upper GI bleeding is at risk for developing
hypovolemic shock from blood loss. Therefore, the signs and symptoms the nurse should expect to
find are those related to hypovolemia, including decreased urine output, tachycardia, rapid
respirations, and thirst. The client’s skin would be cool and clammy, not dry and flushed. The client
would also be likely to develop hypotension, which would lead to a narrowing pulse pressure, not a
widening pulse pressure.
CN: Physiological adaptation; CL: Analyze

Question 29

29. A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the
    following assessments made after the procedure would indicate the development of a potential
    complication?
30. The client has a sore throat.
31. The client displays signs of sedation.
32. The client experiences a sudden increase in temperature.
33. The client demonstrates a lack of appetite.

Answer 29

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

Question 30

30. A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to undergo
    a subtotal gastrectomy (Billroth II procedure). During preoperative teaching, the nurse is reinforcing
    information about the surgical procedure. Which of the following explanations is most accurate?
31. The procedure will result in enlargement of the pyloric sphincter.
32. The procedure will result in anastomosis of the gastric stump to the jejunum.
33. The procedure will result in removal of the duodenum.
34. The procedure will result in repositioning of the vagus nerve.

Answer 30

30. 2. A Billroth II procedure bypasses the duodenum and connects the gastric stump directly to
       the jejunum. The pyloric sphincter is removed, along with some of the stomach fundus.
       CN: Physiological adaptation; CL: Apply

Question 31

31. Since the diagnosis of stomach cancer, the client has been having trouble sleeping and is
    frequently preoccupied with thoughts about how life will change. The client says, “I wish my life
    could stay the same.” Based on this information, the nurse should understand that the client:
32. Is having difficulty coping.
33. Has a sleep disorder.
34. Is grieving.
35. Is anxious.

Answer 31

31. 3. The information presented indicates the client is grieving about the changes that will occur
       as a result of the diagnosis of gastric cancer. The information does not indicate the client is having
       difficulty coping, or experiencing insomnia. The client is not demonstrating signs of anxiety.
       CN: Psychosocial adaptation; CL: Analyze

Question 32

32. After a subtotal gastrectomy, the nasogastric tube drainage will be what color for about 12 to
24 hours after surgery?
1. Dark brown.
2. Bile green.
3. Bright red.
4. Cloudy white.

Answer 32

32. 1. About 12 to 24 hours after a subtotal gastrectomy, gastric drainage is normally brown,
       which indicates digested blood. Bile green or cloudy white drainage is not expected during the first
       12 to 24 hours after a subtotal gastrectomy. Drainage during the first 6 to 12 hours contains some
       bright red blood, but large amounts of blood or excessive bloody drainage should be reported to the
       physician promptly.
       CN: Reduction of risk potential; CL: Apply

Question 33

33. A client has a nasogastric (NG) tube following a subtotal gastrectomy. The nurse should:
34. Irrigate the tube with 30 mL of sterile water every hour, if needed.
35. Reposition the tube if it is not draining well.
36. Monitor the client for nausea, vomiting, and abdominal distention.
37. Turn the machine to high suction if the drainage is sluggish on low suction.

Answer 33

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

Question 34

A client who is recovering from gastric surgery is receiving IV fluids to be infused at 100 mL/h. The
IV tubing delivers 15 gtt/mL. The nurse should infuse the solution at a flow rate of how many drops
per minute to ensure that the client receives 100 mL/h?
____________ gtt/min.

Answer 34

34. 25 gtt/min. To administer IV fluids at 100 mL/h using tubing that has a drip factor of 15
    gtt/mL, the nurse should use the following formula: 100 mL/60 minutes × 15 gtts/1 mL = 25 gtt/min.
    CN: Pharmacological and parenteral therapies; CL: Apply

Question 35

35. Following a gastrectomy, the nurse should position the client in which of the following
positions?
1. Prone.
2. Supine.
3. Low Fowler's.
4. Right or left Sims.

Answer 35

35. 3. A client who has had abdominal surgery is best placed in a low Fowler’s positionpostoperatively. This positioning relaxes abdominal muscles and provides for maximum respiratory
       and cardiovascular function. The prone, supine, or Sims position would not be tolerated by a client
       who has had abdominal surgery, nor do those positions support respiratory or cardiovascular
       functioning.
       CN: Physiological adaptation; CL: Synthesize

Question 36

36. After a subtotal gastrectomy, the nurse is developing a plan with the client to assist the client
    to gain weight. To help the client meet nutritional goals at home, the nurse should:
37. Instruct the client to increase the amount eaten at each meal.
38. Encourage the client to eat smaller amounts more frequently.
39. Explain that if vomiting occurs after a meal, nothing more should be eaten that day.
40. Inform the client that bland foods are typically less nutritional and should be used minimally.

Answer 36

36. 2. Because of the client’s reduced stomach capacity, frequent small feedings are
       recommended. Early satiety can result, and large quantities of food are not well tolerated. Each client
       should progress at his or her own pace, gradually increasing the amount of food eaten. The goal is
       three meals daily if possible, but this can take 6 months or longer to achieve. Nausea can be episodic
       and can result from eating too fast or eating too much at one time. Eating less and eating more slowly,
       rather than not eating at all, can be a solution. Bland foods are recommended as starting foods
       because they are easily digested and are less irritating to the healing mucosa. Bland foods are not less
       nutritional.
       CN: Basic care and comfort; CL: Create

Question 37

37. To reduce the risk of dumping syndrome, the nurse should teach the client to do which of the
    following?
38. Sit upright for 30 minutes after meals.
39. Drink liquids with meals, avoiding caffeine.
40. Avoid milk and other dairy products.
41. Decrease the carbohydrate content of meals.

Answer 37

37. 4. Carbohydrates are restricted, but protein, including meat and dairy products, is
       recommended because it is digested more slowly. Lying down for 30 minutes after a meal is
       encouraged to slow movement of the food bolus. Fluids are restricted to reduce the bulk of food.
       There is no need to avoid caffeine.
       CN: Basic care and comfort; CL: Synthesize

Question 38

38. A client who is recovering from a subtotal gastrectomy experiences dumping syndrome. The
    client asks the nurse, “When will I be able to eat three meals a day again like I used to?” Which of the
    following responses by the nurse is most appropriate?
39. “Eating six meals a day is time-consuming, isn’t it?”
40. “You will have to eat six small meals a day for the rest of your life.”
41. “You will be able to tolerate three meals a day before you are discharged.”
42. “Most clients can resume their normal meal patterns in about 6 to 12 months.”

Answer 38

38. 4. The symptoms related to dumping syndrome that occur after a gastrectomy usually
       disappear by 6 to 12 months after surgery. Most clients can begin to resume normal meal patterns
       after signs of the dumping syndrome have stopped. Acknowledging that eating six meals a day is time-
       consuming does not address the client’s question and makes an assumption about the client’s concerns.
       It is not necessarily true that a six-meal-a-day dietary pattern will be required for the rest of the
       client’s life. Clients will not be able to eat three meals a day before hospital discharge.
       CN: Physiological adaptation; CL: Synthesize

Question 39

39. What should the nurse teach a client about how to avoid the dumping syndrome? Select all
    that apply.
40. Consume three regularly spaced meals per day.
41. Eat a diet with high-carbohydrate foods with each meal.
42. Reduce fluids with meals, but take them between meals.
43. Obtain adequate amounts of protein and fat in each meal.
44. Eat in a relaxing environment.

Answer 39

39. 3, 4, 5. Dumping syndrome results in excessive, rapid emptying of gastric contents. The nurse
    should instruct the client to avoid dumping syndrome by eating small, frequent meals rather than three
    large meals, having a diet high in protein and fat and low in carbohydrates, reducing fluids with meals
    but taking them between meals, and relaxing when eating. The client should eat slowly and regularly
    and rest after meals.
    CN: Health promotion and maintenance; CL: Create

Question 40

40. After surgery for gastric cancer, a client is scheduled to undergo radiation therapy. It will be
    most important for the nurse to include information about which of the following in the client’s
    teaching plan?
41. Nutritional intake.
42. Management of alopecia.3. Exercise and activity levels.
43. Access to community resources.

Answer 40

40. 1. Clients who have had gastric surgery are prone to postoperative complications, such as
       dumping syndrome and postprandial hypoglycemia, which can affect nutritional intake. Vitamin
       absorption can also be an issue, depending on the extent of the gastric surgery. Radiation therapy to
       the upper gastrointestinal area also can affect nutritional intake by causing anorexia, nausea, and
       esophagitis. The client would not be expected to develop alopecia. Exercise and activity levels as
       well as access to community resources are important teaching areas, but nutritional intake is a priority
       need.
       CN: Reduction of risk potential; CL: Synthesize

Question 41

41. One month following a subtotal gastrectomy for cancer, the nurse is evaluating the nursing
    care goal related to nutrition. Which of the following indicates that the client has attained the goal?
    The client has:
42. Regained weight loss.
43. Resumed normal dietary intake of three meals a day.
44. Controlled nausea and vomiting through regular use of antiemetics.
45. Achieved optimal nutritional status through oral or parenteral feedings.

Answer 41

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

Question 42

The Client with Gastroesophageal Reflux Disease
42. Which of the following instructions should the nurse include in the teaching plan for a client
who is experiencing gastroesophageal reflux disease (GERD)?
1. Limit caffeine intake to two cups of coffee per day.
2. Do not lie down for 2 hours after eating.
3. Follow a low-protein diet.
4. Take medications with milk to decrease irritation.

Answer 42

The Client with Gastroesophageal Reflux Disease
42. 2. The nurse should instruct the client to not lie down for about 2 hours after eating to prevent
reflux. Caffeinated beverages decrease pressure in the lower esophageal sphincter and milk increases
gastric acid secretion, so these beverages should be avoided. The client is encouraged to follow a
high-protein, low-fat diet, and avoid foods that are irritating.
CN: Reduction of risk potential; CL: Synthesize

Question 43

43. The client is scheduled to have an upper gastrointestinal tract series of x-rays. Following the
    x-rays, the nurse should instruct the client to:
44. Take a laxative.
45. Follow a clear liquid diet.
46. Administer an enema.
47. Take an antiemetic.

Answer 43

43. 1. The client should take a laxative after an upper gastrointestinal series to stimulate a bowel
       movement. This examination involves the administration of barium, which must be promptly
       eliminated from the body because it may harden and cause an obstruction. A clear liquid diet would
       have no effect on stimulating removal of the barium. The client should not have nausea and an
       antiemetic would not be necessary; additionally, the antiemetic will decrease peristalsis and increase
       the likelihood of eliminating the barium. An enema would be ineffective because the barium is too
       high in the gastrointestinal tract.
       CN: Reduction of risk potential; CL: Synthesize

Question 44

44. A client who has been diagnosed with gastroesophageal reflux disease (GERD) has
    heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the
    following items from the diet?
45. Lean beef.
46. Air-popped popcorn.
47. Hot chocolate.
48. Raw vegetables.

Answer 44

44. 3. With GERD, eating substances that decrease lower esophageal sphincter pressure causes
       heartburn. A decrease in the lower esophageal sphincter pressure allows gastric contents to reflux
       into the lower end of the esophagus. Foods that can cause a decrease in esophageal sphincter pressure
       include fatty foods, chocolate, caffeinated beverages, peppermint, and alcohol. A diet high in protein
       and low in fat is recommended for clients with GERD. Lean beef, popcorn, and raw vegetables
       would be acceptable.
       CN: Physiological adaptation; CL: Synthesize

Question 45

45. The client with gastroesophageal reflux disease (GERD) has a chronic cough. This symptom
    may be indicative of which of the following ?
46. Development of laryngeal cancer.
47. Irritation of the esophagus.
48. Esophageal scar tissue formation.
49. Aspiration of gastric contents.

Answer 45

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

Question 46

46. Bethanechol has been prescribed for a client with gastroesophageal reflux disease (GERD).
    The nurse should assess the client for which of the following adverse effects?
47. Constipation.
48. Urinary urgency.
49. Hypertension.
50. Dry oral mucosa.

Answer 46

46. 2. Bethanechol, a cholinergic drug, may be used in GERD to increase lower esophageal
       sphincter pressure and facilitate gastric emptying. Cholinergic adverse effects may include urinary
       urgency, diarrhea, abdominal cramping, hypotension, and increased salivation. To avoid these
       adverse effects, the client should be closely monitored to establish the minimum effective dose.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 47

47. The client attends two sessions with the dietitian to learn about diet modifications to
    minimize gastroesophageal reflux. The teaching would be considered successful if the client
    decreases the intake of which of the following foods?
48. Fats.
49. High-sodium foods.
50. Carbohydrates.
51. High-calcium foods.

Answer 47

47. 1. Fats are associated with decreased esophageal sphincter tone, which increases reflux.
       Obesity contributes to the development of hiatal hernia, and a low-fat diet might also aid in weightloss. Carbohydrates and foods high in sodium or calcium do not affect gastroesophageal reflux.
       CN: Basic care and comfort; CL: Evaluate

Question 48

48. Which of the following dietary measures would be useful in preventing esophageal reflux?1. Eating small, frequent meals.
49. Increasing fluid intake.
50. Avoiding air swallowing with meals.
51. Adding a bedtime snack to the dietary plan.

Answer 48

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

Question 49

49. The nurse is obtaining a health history from a client who has a sliding hiatal hernia associated
    with reflux. The nurse should ask the client about the presence of which of the following symptoms?
50. Heartburn.
51. Jaundice.
52. Anorexia.
53. Stomatitis.

Answer 49

49. 1. Heartburn, the most common symptom of a sliding hiatal hernia, results from reflux of
       gastric secretions into the esophagus. Regurgitation of gastric contents and dysphagia are other
       common symptoms. Jaundice, which results from a high concentration of bilirubin in the blood, is not
       associated with hiatal hernia. Anorexia is not a typical symptom of hiatal hernia. Stomatitis is
       inflammation of the mouth.
       CN: Physiological adaptation; CL: Analyze

Question 50

50. Which of the following factors would most likely contribute to the development of a client’s
    hiatal hernia?
51. Having a sedentary desk job.
52. Being 5 feet, 3 inches tall (160 cm) and weighing 190 lb (86.2 kg).
53. Using laxatives frequently.
54. Being 40 years old.

Answer 50

50. 2. Any factor that increases intra-abdominal pressure, such as obesity, can contribute to the
       development of hiatal hernia. Other factors include abdominal straining, frequent heavy lifting, and
       pregnancy. Hiatal hernia is also associated with older age and occurs in women more frequently than
       in men. Having a sedentary desk job, using laxatives frequently, or being 40 years old is not likely to
       be a contributing factor in development of a hiatal hernia.
       CN: Reduction of risk potential; CL: Analyze

Question 51

51. Which of the following nursing interventions would most likely promote self-care behaviors
    in the client with a hiatal hernia?
52. Introduce the client to other people who are successfully managing their care.
53. Include the client’s daughter in the teaching so that she can help implement the plan.
54. Ask the client to identify other situations in which the client changed health care habits.
55. Provide reassurance that the client will be able to implement all aspects of the plan
    successfully.

Answer 51

51. 3. Self-responsibility is the key to individual health maintenance. Using examples of situations
       in which the client has demonstrated self-responsibility can be reinforcing and supporting. The client
       has ultimate responsibility for personal health habits. Meeting other people who are managing their
       care and involving family members can be helpful, but individual motivation is more important.
       Reassurance can be helpful but is less important than individualization of care.
       CN: Basic care and comfort; CL: Synthesize

Question 52

52. The client has been taking magnesium hydroxide (milk of magnesia) to control hiatal hernia
    symptoms. The nurse should assess the client for which of the following conditions most commonly
    associated with the ongoing use of magnesium-based antacids?
53. Anorexia.
54. Weight gain.
55. Diarrhea.
56. Constipation.

Answer 52

52. 3. The magnesium salts in magnesium hydroxide are related to those found in laxatives and
       may cause diarrhea. Aluminum salt products can cause constipation. Many clients find that a
       combination product is required to maintain normal bowel elimination. The use of magnesium
       hydroxide does not cause anorexia or weight gain.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 53

53. Which of the following lifestyle modifications should the nurse encourage the client with a
    hiatal hernia to include in activities of daily living?
54. Daily aerobic exercise.
55. Eliminating smoking and alcohol use.
56. Balancing activity and rest.
57. Avoiding high-stress situations.

Answer 53

53. 2. Smoking and alcohol use both reduce esophageal sphincter tone and can result in reflux.
       They therefore should be avoided by clients with hiatal hernia. Daily aerobic exercise, balancing
       activity and rest, and avoiding high-stress situations may increase the client’s general health and well-
       being, but they are not directly associated with hiatal hernia.
       CN: Health promotion and maintenance; CL: Synthesize

Question 54

54. In developing a teaching plan for the client with a hiatal hernia, the nurse’s assessment of
    which work-related factors would be most useful?
55. Number and length of breaks.
56. Body mechanics used in lifting.
57. Temperature in the work area.
58. Cleaning solvents used.

Answer 54

54. 2. Bending, especially after eating, can cause gastroesophageal reflux. Lifting heavy objects
       increases intra-abdominal pressure. Assessing the client’s lifting techniques enables the nurse to
       evaluate the client’s knowledge of factors contributing to hiatal hernia and how to prevent
       complications. Number and length of breaks, temperature in the work area, and cleaning solvents usedare not directly related to treatment of hiatal hernia.
       CN: Basic care and comfort; CL: Create

Question 55

55. The nurse instructs the client on health maintenance activities to help control symptoms from
    a hiatal hernia. Which of the following statements would indicate that the client has understood the
    instructions?
56. “I’ll avoid lying down after a meal.”
57. “I can still enjoy my potato chips and cola at bedtime.”
58. “I wish I didn’t have to give up swimming.”
59. “If I wear a girdle, I’ll have more support for my stomach.”

Answer 55

55. 1. A client with a hiatal hernia should avoid the recumbent position immediately after meals to
       minimize gastric reflux. Bedtime snacks, as well as high-fat foods and carbonated beverages, should
       be avoided. Excessive vigorous exercise also should be avoided, especially after meals, but there is
       no reason why the client must give up swimming. Wearing tight, constrictive clothing such as a girdle
       can increase intra-abdominal pressure and thus lead to reflux of gastric juices.
       CN: Basic care and comfort; CL: Evaluate

Question 56

56. The physician prescribes metoclopramide hydrochloride for the client with hiatal hernia.
    This drug is used in hiatal hernia therapy to accomplish which of the following objectives?
57. Increase tone of the esophageal sphincter.
58. Neutralize gastric secretions.
59. Delay gastric emptying.
60. Reduce secretion of digestive juices.

Answer 56

56. 1. Metoclopramide hydrochloride increases esophageal sphincter tone and facilitates gastric
       emptying; both actions reduce the incidence of reflux. Other drugs, such as antacids or histamine
       receptor antagonists, may also be prescribed to help control reflux and esophagitis and to decrease or
       neutralize gastric secretions. Reglan is not effective in decreasing or neutralizing gastric secretions.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 57

57. The nurse should instruct the client to avoid which of the following drugs while taking
metoclopramide hydrochloride?
1. Antacids.
2. Antihypertensives.
3. Anticoagulants.
4. Alcohol.

Answer 57

57. 4. Metoclopramide hydrochloride can cause sedation. Alcohol and other central nervous
       system depressants add to this sedation. A client who is taking this drug should be cautioned to avoid
       driving or performing other hazardous activities for a few hours after taking the drug. Clients may
       take antacids, antihypertensives, and anticoagulants while on metoclopramide.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 58

58. A client is taking cimetidine (Tagamet) to treat a hiatal hernia. The nurse should evaluate the
    client to determine that the drug has been effective in preventing which of the following?
59. Esophageal reflux.
60. Dysphagia.
61. Esophagitis.
62. Ulcer formation.

Answer 58

58. 3. Cimetidine (Tagamet) is a histamine receptor antagonist that decreases the quantity of
       gastric secretions. It may be used in hiatal hernia therapy to prevent or treat the esophagitis and
       heartburn associated with reflux. Cimetidine is not used to prevent reflux, dysphagia, or ulcer
       development.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 59

59. The client asks the nurse if surgery is needed to correct a hiatal hernia. Which reply by the
    nurse would be most accurate?
60. “Surgery is usually required, although medical treatment is attempted first.”
61. “Hiatal hernia symptoms can usually be successfully managed with diet modifications,
    medications, and lifestyle changes.”
62. “Surgery is not performed for this type of hernia.”
63. “A minor surgical procedure to reduce the size of the diaphragmatic opening will probably be
    planned.”

Answer 59

59. 2. Most clients can be treated successfully with a combination of diet restrictions,
       medications, weight control, and lifestyle modifications. Surgery to correct a hiatal hernia, which
       commonly produces complications, is performed only when medical therapy fails to control the
       symptoms.
       CN: Reduction of risk potential; CL: Synthesize

Question 60

Managing Care Quality and Safety

60. Which of the following hospitalized clients is at risk to develop parotitis?
61. A 50-year-old client with nausea and vomiting who is on nothing-by-mouth status.
62. A 75-year-old client with diabetes who has ill-fitting dentures.
63. An 80-year-old client who has poor oral hygiene and is dehydrated.
64. A 65-year-old client with lung cancer who has a feeding tube in place.

Answer 60

Managing Care Quality and Safety
60. 3. Parotitis is inflammation of the parotid gland. Although any of the clients listed could
develop parotitis, given the data provided, the one most likely to develop parotitis is the elderly
client who is dehydrated with poor oral hygiene. Any client who experiences poor oral hygiene is at
risk for developing parotitis. To help prevent parotitis, it is essential for the nurse to ensure the client
receives oral hygiene at regular intervals and has an adequate fluid intake.
CN: Reduction of risk potential; CL: Analyze

Question 61

61. The nurse instructs the unlicensed nursing personnel (UAP) on how to provide oral hygiene
    for clients who cannot perform this task for themselves. Which of the following techniques should the
    nurse tell the UAP to incorporate into the client’s daily care?
62. Assess the oral cavity each time mouth care is given and record observations.
63. Use a soft toothbrush to brush the client’s teeth after each meal.
64. Swab the client’s tongue, gums, and lips with a soft foam applicator every 2 hours.
65. Rinse the client’s mouth with mouthwash several times a day.

Answer 61

61. 2. A soft toothbrush should be used to brush the client’s teeth after every meal and more often
       as needed. Mechanical cleaning is necessary to maintain oral health, stimulate gingiva, and remove
       plaque. Assessing the oral cavity and recording observations is the responsibility of the nurse, not the
       nursing assistant. Swabbing with a safe foam applicator does not provide enough friction to clean themouth. Mouthwash can be a drying irritant and is not recommended for frequent use.
       CN: Basic care and comfort; CL: Synthesize

Question 62

62. The nurse is developing standards of care for a client with gastroesophageal reflux disease
    and wants to review current evidence for practice. Which one of the following resources will
    provide the most helpful information?
63. A review in the Cochrane Library.
64. A literature search in a database, such as the Cumulative Index to Nursing and Allied Health
    Literature (CINAHL).
65. An online nursing textbook.
66. The policy and procedure manual at the health care agency.

Answer 62

62. 1. The Cochrane Library provides systematic reviews of health care interventions and will
       provide the best resource for evidence for nursing care. CINAHL offers key word searches to
       published articles in nursing and allied health literature, but not reviews. A nursing textbook has
       information about nursing care, which may include evidence-based practices, but textbooks may not
       have the most up-to-date information. While the policy and procedure manual may be based on
       evidence-based practices, the most current practices will be found in evidence-based reviews of
       literature.
       CN: Management of care; CL: Apply

Question 63

63. The nurse in the intensive care unit is giving a report to the nurse in the post surgical unit
    about a client who had a gastrectomy. The most effective way to assure essential information about
    the client is reported is to:
64. Give the report face to face with both nurses in a quiet room.
65. Audiotape the report for future reference and documentation.
66. Use a printed checklist with information individualized for the client.
67. Document essential transfer information in the client’s electronic health record.

Answer 63

63. 3. Using an individualized printed checklist assures that all key information is reported; the
       checklist can then serve as a record to which nurses can refer later. Giving a verbal report leaves
       room for error in memory; using an audiotape or an electronic health record requires nurses to spend
       unnecessary time retrieving information.
       CN: Safety and infection control; CL: Apply

Question 64

64. A client reports vomiting every hour for the past 8 to 10 hours. The nurse should assess the
    client for risk of which of the following? Select all that apply.
65. Metabolic acidosis.
66. Metabolic alkalosis.
67. Hypokalemia.
68. Hyperkalemia.
69. Hyponatremia.

Answer 64

64. 2, 3. Gastric acid contains a substantial amount of potassium, hydrogen ions, and chloride
    ions. Frequent vomiting can induce an excessive loss of these acids leading to alkalosis. Excessive
    loss of potassium produces hypokalemia. Frequent vomiting does not lead to the condition of too
    much potassium (hyperkalemia) or too little sodium (hyponatremia)
    CN: Reduction of risk potential; CL: Analyze