Unit O-GI/Nutrition Flashcards
1
Q
The nurse is interviewing a client who reports having abdominal cramping, bloating, and
diarrhea after drinking milk or ingesting other dairy products. What health problem does the
client most likely have?
a. Steatorrhea
b. Ulcerative colitis
c. Crohn disease
d. Lactose intolerance
A
ANS: D
The client is demonstrating signs and symptoms of lactose intolerance because they occur
after the client eats or drinks dairy products which contain lactose.
2
Q
The primary health care provider documents that a client has a bruit over the abdominal aorta.
What teaching will the nurse provide for assistive personnel (AP) based on this assessment
finding?
a. “Use warm compresses on the client’s abdomen continuously.”
b. “Avoid washing the client’s abdomen too aggressively.”
c. “Apply ice to the client’s abdomen every 4 hours.”
d. “Massage the client’s abdomen to help reduce pain.”
A
ANS: B
A bruit heard over the abdominal aorta possible indicates stenosis or an aneurysm which
should not be palpated or percussed. Therefore, the AP should wash the client’s abdomen very
gently.
3
Q
A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam
hydrochloride. The client’s respiratory rate is 8 breaths/min. What action by the nurse is
appropriate?
a. Administer naloxone.
b. Call the Rapid Response Team.
c. Provide physical stimulation.
d. Ventilate with a bag-valve-mask.
A
ANS:C
For an EGD, clients are given mild sedation but would still be able to follow commands. For
shallow or slow respirations after the sedation is given, the nurse’s most appropriate action is
to provide a physical stimulation such as a sternal rub and directions to breathe deeply.
Naloxone is not the antidote for midazolam HCl. The Rapid Response Team is not needed at
this point. The client does not need manual ventilation.
4
Q
A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel
cleansing regimen. What statement by the client indicates a need for further teaching?
a. “It’s a good thing I love orange and cherry gelatin.”
b. “My spouse will be here to drive me home.”
c. “I’ll avoid ibuprofen for several days before the test.”
d. “I’ll buy a case of clear Gatorade before the prep.”
A
ANS: A
The client would be advised to avoid beverages and gelatin that are red, orange, or purple in
color as their residue can appear to be blood. The other statements show an understanding of
the preparation for the procedure.
5
Q
A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report
a spot of bright red blood on the toilet paper today. What response by the nurse is
appropriate?
a. Ask the client to call back if this happens again today.
b. Instruct the client to go to the emergency department.
c. Remind the client that a small amount of bleeding is possible.
d. Tell the client to come to the clinic this afternoon
A
ANS: C
After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse would
remind the client of this and instruct him or her to go to the emergency department for large
amounts of bleeding, severe pain, or dizziness.
6
Q
An older adult has had an instance of drug toxicity and asks why this happens, since the client
has been on this medication for years at the same dose. What response by the nurse is best?
a. “Changes in your liver cause drugs to be metabolized differently.”
b. “Perhaps you don’t need as high a dose of the drug as before.”
c. “Stomach muscles atrophy with age and you digest more slowly.”
d. “Your body probably can’t tolerate as much medication anymore.”
A
ANS:A
Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of
drugs—possibly to toxic levels. The other options do not accurately explain this age-related
change.
7
Q
To promote comfort and the passage of flatus after a colonoscopy, in what position does the nurse place the client? a. Left lateral b. Prone c. Right lateral d. Supine
A
ANS: A
After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in
the left lateral position.
8
Q
A nurse is assessing a client reporting right upper quadrant (RUQ) abdominal pain. What
technique would the nurse use to assess this client’s abdomen?
a. Auscultate after palpating.
b. Avoid any type of palpation.
c. Lightly palpate the RUQ first.
d. Lightly palpate the RUQ last.
A
ANS: D
If pain is present in a certain area of the abdomen, that area would be palpated last to keep the
client from tensing which could possibly affect the rest of the examination. Auscultation of
the abdomen occurs prior to palpation.
9
Q
The nurse knows that a client with prolonged prothrombin time (PT) values (not related to
medication) probably has dysfunction in which organ?
a. Kidneys
b. Liver
c. Spleen
d. Stomach
A
ANS: B
Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis
of clotting proteins. The other organs are not related to this issue.
10
Q
A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something
to drink. What action by the nurse is appropriate?
a. Allow the client cool liquids only.
b. Assess the client’s gag reflex.
c. Remind the client to remain NPO.
d. Tell the client to wait 4 hours.
A
ANS: B
The local anesthetic used during this procedure depresses the client’s gag reflex. After the
procedure, the nurse would ensure that the gag reflex is intact before offering food or fluids.
The client does not need to be restricted to cool beverages only and is not required to wait 4
hours before oral intake is allowed. Telling the client to remain NPO does not inform the
client of when he or she can have fluids, nor does it reflect the client’s readiness for them.
11
Q
The assistive personnel note that a client had a dark stool. What stool test would the nurse obtain for this client? a. Culture and sensitivity b. Parasites and ova c. Occult blood test d. Total fat content
A
ANS: C
Dark stools are typical in clients who have lower GI bleeding. Therefore, an fecal occult blood
test would be the most appropriate test as a follow-up.
12
Q
The nurse is aware of the most recent American Cancer Society Screening Guidelines for
colon cancer, which include which accepted testing modalities for people over the age of 50?
(Select all that apply.)
a. Colonoscopy every 10 years
b. Endoscopy every 5 years
c. Computed tomography (CT) colonography every 5 years
d. Double-contrast barium enema every 10 years
e. Flexible sigmoidoscopy every 5 years
A
ANS: A, C, E
The options for colon cancer screening for people over the age of 50 include colonoscopy
every 10 years and CT colonography, double-contrast barium enema, or flexible
sigmoidoscopy every 5 years.
13
Q
A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse teaches the client and family about the signs of potential complications which include what problems? (Select all that apply.) a. Cholangitis b. Pancreatitis c. Perforation d. Renal lithiasis e. Sepsis
A
ANS: A, B, C, E
Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis,
and bleeding. Kidney stones are not a complication of ERCP.
14
Q
The nurse working with older clients understands age-related changes in the gastrointestinal
system. Which changes does this include? (Select all that apply.)
a. Decreased hydrochloric acid production
b. Diminished sensation that can lead to constipation
c. Fat not digested as well in older adults
d. Increased peristalsis in the large intestine
e. Pancreatic vessels become calcified
A
ANS: A, B, C, E
Several age-related changes occur in the gastrointestinal system. These include decreased
hydrochloric acid production, diminished nerve function that leads to decreased sensation of
the need to pass stool, decreased fat digestion, decreased peristalsis in the large intestine, and
calcification of pancreatic vessels.
15
Q
The nurse working with clients who have gastrointestinal problems knows that which
laboratory values are related to which organ functions or dysfunctions? (Select all that apply.)
a. Alanine aminotransferase: biliary system
b. Ammonia: liver
c. Amylase: liver
d. Lipase: pancreas
e. Urine urobilinogen: stomach
A
ANS: B, D
Alanine aminotransferase and ammonia are related to the liver. Amylase and lipase are related
to the pancreas. Urobilinogen evaluates both hepatic and biliary function.
16
Q
A nurse cares for a client who is recovering from a colonoscopy. Which actions would the
nurse take? (Select all that apply.)
a. Obtain vital signs every 15 to 30 minutes until alert.
b. Assess the client for rectal bleeding and severe pain.
c. Administer prescribed pain medications as needed.
d. Monitor the client’s serum and urine glucose levels.
e. Confirm the client has a ride home and plans to rest.
A
ANS: A, B, E
During the recovery phase after a colonoscopy, the nurse would obtain vital signs
every 15 to 30 minutes until the client is alert, assess for rectal bleeding or severe pain, and
confirm the client has arranged for another person to drive home to get rest. Pain medications
are not necessary after the procedure, and neither is glucose monitoring.
17
Q
The nurse is teaching a client diagnosed with stomatitis about special mouth care. Which
statement by the client indicates a need for further teaching?
a. “I need to take out my dentures until my mouth heals.”
b. “I’ll try to eat soft foods that aren’t spicy and acidic.”
c. “I will use a more firm toothbrush to keep my mouth clean.”
d. “I’ll be sure to rinse my mouth often with warm salt water.”
A
ANS: C
The client who has stomatitis has oral inflammation which causes discomfort. Therefore, all
of these actions help to avoid irritation except for needing to use a soft toothbrush or gauze
rather than a firm one.
18
Q
A client is admitted with a large oral tumor. What assessment by the nurse takes priority?
a. Airway
b. Breathing
c. Circulation
d. Nutrition
A
ANS: A
Airway always takes priority. Airway must be assessed first and any problems managed if
present.
19
Q
The nurse is teaching a client about the use of viscous lidocaine for oral pain. What health
teaching would the nurse include?
a. “Use the drug before every meal to prevent aspiration.”
b. “Increase your intake of citrus foods to help with healing.”
c. “Use the drug only at bedtime because you won’t be eating.”
d. “Be sure to check food temperatures before eating.”
A
ANS: D
Viscous lidocaine has an anesthetic effect in the oral cavity. Therefore, to promote client
safety, the nurse would want to teach the client to check food temperature before eating.
20
Q
A nurse participates in a community screening event for oral cancer. What client is the
highest priority for referral to a primary health care provider?
a. Client who has poor oral hygiene practices.
b. Client who smokes and drinks daily.
c. Client who tans for an upcoming vacation.
d. Client who occasionally uses illicit drugs.
A
ANS: B
Smoking and alcohol exposure create a high risk for this client. Poor oral hygiene is not
related to the etiology of cancer but may cause a tumor to go unnoticed. Tanning is a risk
factor, but short-term exposure does not have the same risk as daily exposure to tobacco and
alcohol.
21
Q
The nurse notes that the primary health care provider documented the presence of mucosal
erythroplasia in a client. What does the nurse understand that this most likely means for this
client?
a. Early sign of oral cancer
b. Fungal mouth infection
c. Inflammation of the gums
d. Obvious oral tumor
A
ANS: A
Mucosal erythroplasia is the earliest sign of oral cancer. It is not a fungal infection,
inflammation of the gums, or an obvious tumor.
22
Q
The nurse is caring for a client diagnosed with oral cancer. What is the nurse’s priority for
client care?
a. Encourage fluids to liquefy the client’s secretions.
b. Place the client on Aspiration Precautions.
c. Remind the client to use an incentive spirometer.
d. Manage the client’s pain and inflammation.
A
ANS: B
The client who has oral cancer often has difficulty swallowing and is at risk for aspiration and
possibly aspiration pneumonia. Therefore, the most important nursing action is to place the
client on precautions to prevent aspiration. The nurse would implement the other actions but
they are not as vital to promote client safety.
23
Q
A client has an open traditional hiatal hernia repair this morning. What is the nurse’s priority for client care at this time? a. Managing surgical pain b. Ambulating the client early c. Preventing respiratory complications d. Managing the nasogastric tube
A
ANS: C
The client who has traditional surgery (rather than minimally invasive surgery) is at risk for
respiratory complications such as atelectasis and pneumonia because he or she has an incision
that may prevent the client from taking deep breaths or using an incentive spirometer.
Therefore, the nurse’s priority is to prevent these potentially life-threatening respiratory
problems.
24
Q
Which of these client assessment findings is typically associated with oral cancer?
a. Dry sticky oral membranes
b. Increased appetite
c. Itchy rash in oral cavity
d. Painless red or raised lesion
A
ANS: D
A painless red or raised lesion often indicates a diagnosis of oral cancer. The client usually
has a decreased appetite and thick secretions. Itchiness is not a common finding associated
with oral cancer.
25
The nurse is caring for a client with sialadenitis. What comfort measures are appropriate for
this client? (Select all that apply.)
a. Applying warm compresses
b. Applying ice to salivary glands
c. Offering fluids every hour
d. Providing lemon-glycerin swabs
e. Reminding the patient to avoid speaking
ANS: A, C
Warm compresses and fluids can help promote comfort for this client. Application of ice or
lemon-glycerin swabs would not be used. Speaking has no effect on this condition.
26
```
A nurse knows that job-related risks for developing oral cancer include which occupations?
(Select all that apply.)
a. Coal miner
b. Electrician
c. Metal worker
d. Plumber
e. Textile worker
```
ANS: A, C, D, E
The occupations of coal mining, metal working, plumbing, and textile work produce exposure
to polycyclic aromatic hydrocarbons (PAHs), which are known carcinogens. Electricians do
not have this risk.
27
```
The nurse is caring for a client who had an open traditional esophagectomy. Which
assessment findings would the nurse report immediately to the primary health care provider?
(Select all that apply.)
a. Nausea
b. Wound dehiscence
c. Fever
d. Tachycardia
e. Moderate pain
f. Fatigue
```
ANS: B, C, D
Wound dehiscence is a serious, potentially life-threatening problem that needs immediate
attention of the primary health care provider, typically the surgeon. Fever and tachycardia
may indicate that the client has a postoperative infection, another serious, potentially
life-threatening complication. Indications of both of these problems need to be documented
and reported by the nurse. Nausea, fatigue, and moderate pain are expected postoperative
assessment findings
28
```
The nurse is caring for a client diagnosed with probable gastroesophageal reflux disease
(GERD). What assessment finding(s) would the nurse expect? (Select all that apply.)
a. Dyspepsia
b. Regurgitation
c. Belching
d. Coughing
e. Chest discomfort
f. Dysphagia
```
ANS: A, B, C, D, E, F
| All of these signs and symptoms are commonly seen in clients who have GERD
29
The nursing is teaching a client diagnosed with gastroesophageal reflux disease (GERD) who
is planning to have an endoscopic radiofrequency (Stretta) procedure. What preprocedure
health teaching would the nurse include? (Select all that apply.)
a. “You will need to be on a liquid diet for the first week after the procedure.”
b. “Avoid taking any NSAIDs like ibuprofen for 10 days before the procedure.”
c. “Contact the primary health care provider after the procedure if you have increased
pain.”
d. “You will need a nasogastric tube for a few days after the procedure.”
e. “You will have a small incision in your stomach area that will have a wound
closure.
ANS: B, C
The client having this procedure does not have an incision and will not require a nasogastric
tube (NGT). The client should avoid an NGT placement for at least a month after the
procedure. A liquid diet is required for only 24 hours after the procedure and then the client
should progress to include soft floods like custard and applesauce.
30
```
The nurse is teaching a client about risk factors for esophageal cancer. Which risk factors
would the nurse include? (Select all that apply.)
a. Alcohol intake
b. Obesity
c. Smoking
d. Lack of fresh fruits and vegetables
e. Untreated GERD
f. Use of NSAIDs
```
ANS: A, B, C, D, E
All of these factors increase the risk of esophageal cancer except for the use of NSAIDs.
Untreated GERD causes damage to esophageal tissue which may develop into Barrett
esophagus, or precancerous cells.
31
The nurse is teaching a client about the risk of uncontrolled or untreated the client’s
gastroesophageal reflux disease (GERD). What complication(s) may occur if the GERD is not
successfully managed? (Select all that apply.)
a. Asthma
b. Laryngitis
c. Dental caries
d. Cardiac disease
e. Cancer
ANS: A, B, C, D, E
| Any of these complications may occur in clients who have uncontrolled or untreated GERD.
32
The nurse is teaching a client who has been treated for acute gastritis. What statement by the
client indicates a need for further teaching?
a. “I need to cut down on drinking martinis every might.”
b. “I should decrease my intake of caffeinated drinks, especially coffee.”
c. “I will only take ibuprofen once in a while when I really need it.”
d. “I can continue smoking cigarettes which is better than chewing tobacco.”
ANS: D
To prevent another episode of acute gastritis, alcohol, caffeinated drinks, and NSAIDs should
be avoided or kept at a minimum. Smoking and all forms of tobacco should also be avoided.
33
The nurse is caring for a client who has frequent gastric pain and dyspepsia. Which procedure
would the nurse expect for the client to make an accurate diagnosis?
a. Esophagogastroduodenoscopy (EGD)
b. Abdominal arteriogram
c. Nuclear medicine scan
d. Magnetic resonance imaging (MRI
ANS: A
The gold standard for diagnosing disorders of the stomach is an EGD which allows direct
visualization by the endoscopist into the esophagus, stomach, and duodenum.
34
```
The nurse is caring for a client who has been diagnosed with peptic ulcer disease. For which
complication would the nurse monitor?
a. Large bowel obstruction
b. Dyspepsia
c. Upper gastrointestinal (GI) bleeding
d. Gastric cancer
```
ANS: C
Peptic ulcer disease (PUD) can cause gastric mucosal damage or perforation, which causes
upper GI bleeding. Dyspepsia is a symptom of PUD, gastritis, and gastric cancer. PUD affects
the stomach and/or duodenum, not the colon.
35
A client who had a partial gastrectomy 3 days ago begins to experience vertigo, sweating, and
tachycardia about 30 minutes after eating breakfast. What postoperative complication would
the nurse suspect?
a. Pyloric obstruction
b. Dumping syndrome
c. Delayed gastric emptying
d. Pernicious anemia
ANS: B
Dumping syndrome causes autonomic symptoms as food quickly leaves the stomach due to its
decreased size after surgery.
36
A client with peptic ulcer disease is in the emergency department and reports gastric pain that
has gotten much worse over the last 24 hours. The client’s blood pressure when lying down is
112/68 mm Hg and when standing is 98/52 mm Hg. What action by the nurse is most
appropriate?
a. Administer a proton pump inhibitor (PPI).
b. Call the Rapid Response Team.
c. Start a large-bore IV with normal saline.
d. Tell the patient to remain lying down.
ANS: C
This client has orthostatic changes to the blood pressure, indicating fluid volume loss. The
nurse would start a large-bore IV with isotonic solution. PPIs are not a treatment for an ulcer.
The Rapid Response Team is not needed at this point. The client should be put on safety
precautions, which includes staying in bed, but this is not the most appropriate action at this
time.
37
During an interview, the client tells the nurse that the client has a duodenal ulcer. Which
assessment finding would the nurse expect?
a. Hematemesis
b. Pain when eating
c. Melena
d. Weight loss
ANS: C
All of the other assessment findings are more commonly seen in clients who have gastric
ulcers rather than duodenal ulcers.
38
A client who has peptic ulcer disease is prescribed quadruple drug therapy for Helicobacter
pylori infection. What health teaching related to bismuth would the nurse include?
a. “Report stool changes to your primary health care provider immediately.”
b. “Do not take aspirin or aspirin products of any kind while on bismuth.”
c. “Take bismuth about 30 minutes before each meal and at bedtime.”
d. “Be aware that bismuth can cause frequent vomiting and diarrhea.”
ANS: B
Bismuth is a salicylate drug and causes stool discoloration but not vomiting and diarrhea. It
does not have to be taken at a specific time relative to meals. Clients taking bismuth should
not take other salicylates, such as aspirin or aspirin-containing products.
39
```
The nurse caring for clients with gastrointestinal disorders would recall that omeprazole is a
drug in which classification?
a. Gastric acid inhibitor
b. Histamine receptor blocker
c. Mucosal barrier fortifier
d. Proton pump inhibitor
```
ANS: D
| Omeprazole is a proton pump inhibitor.
40
The nurse is caring for a client experiencing upper gastrointestinal (GI) bleeding. What is the
priority action for the client’s care?
a. Maintain airway, breathing, and circulation.
b. Monitor vital signs, including orthostatic blood pressures.
c. Draw blood for hemoglobin and hematocrit immediately.
d. Insert a nasogastric (NG) tube and connect to intermittent suction.
ANS: A
The priority action for any client experiencing deterioration or an emergent situation is
monitor and maintain airway, breathing, and circulation (ABCs). Taking orthostatic blood
pressures would not be appropriate, but the nurse would monitor vital signs carefully and
draw blood for hemoglobin and hematocrit. An NG tube would also need to be inserted and
connected to gastric suction to rest the GI tract. However, none of these actions take priority
over maintaining ABCs.
41
A client has a nasogastric (NG) tube as a result of an upper gastrointestinal (GI) hemorrhage.
What comfort measure would the nurse remind assistive personnel (AP) to provide?
a. Lavaging the tube with ice water
b. Performing frequent oral care
c. Re-positioning the tube every 4 hours
d. Taking and recording vital signs
ANS: B
Clients with NG tubes need frequent oral care both for comfort and to prevent infection.
Lavaging the tube is done by the nurse. Repositioning the tube, if needed, is also done by the
nurse. The can take vital signs, but this is not a comfort measure.
42
A client has a recurrence of gastric cancer and is crying. What response by the nurse is most
appropriate?
a. “Do you have family or friends for support?”
b. “Would you tell me what you are feeling now.”
c. “Well, we knew this would probably happen.”
d. “Would you like me to refer you to hospice
ANS: B
The nurse assesses the client’s emotional state with open-ended questions and statements and
shows a willingness to listen to the client’s concerns. Asking about support people is very
limited in nature, and “yes-or-no” questions are not therapeutic. Stating that this was expected
dismisses the client’s concerns. The client may or may not be ready to hear about hospice, and
this is another limited, yes-or-no question.
43
```
A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would
be appropriate?
a. Arrange a dietary consult.
b. Increase fluid intake.
c. Limit the client’s foods.
d. Make the client NPO.
```
ANS: A
The client with dumping syndrome after a gastrectomy has multiple dietary needs. A referral
to the registered dietitian nutritionist will be extremely helpful. Food and fluid intake is
complicated and needs planning. The client should not be NPO.
44
The nurse recalls that the risk factors for acute gastritis include which of the following?
(Select all that apply.)
a. Alcohol
b. Caffeine
c. Corticosteroids
d. Fruit juice
e. Nonsteroidal anti-inflammatory drugs (NSAIDs)
ANS: A, B, C, E
Risk factors for acute gastritis include alcohol, caffeine, corticosteroids, and chronic NSAID
use. Fruit juice is not a risk factor, although in some people it does cause distress.
45
```
The nurse is caring for a client with a long history of peptic ulcer disease. What assessment
findings would the nurse anticipate if the client experiences upper gastrointestinal (GI)
bleeding? (Select all that apply.)
a. Decreased heart rate
b. Decreased blood pressure
c. Bounding radial pulse
d. Dizziness
e. Hematemesis
f. Decreased urinary output
```
ANS: B, D, E, F
The client who has upper GI bleeding would likely have vomiting that contains blood
(hematemesis), and would have signs and symptoms of dehydration such as a decreased blood
pressure, dizziness, and/or decreased urinary output. The heart rate increases rather than
decreases and the pulse is weak rather than bounding in clients who are dehydrated
46
Which of the following is (are) (a) risk factor(s) for gastric cancer? (Select all that apply.)
a. Achlorhydria
b. Chronic atrophic gastritis
c. H. pylori infection
d. Iron deficiency anemia
e. Pernicious anemia
ANS: A, B, C, E
Achlorhydria, chronic atrophic gastritis, H. pylori infection, and pernicious anemia are all risk
factors for developing gastric cancer. Iron deficiency anemia is not a risk factor.
47
A client has dumping syndrome. What menu selections indicate the client understands the
correct diet to manage this condition? (Select all that apply.)
a. Apricots
b. Coffee cake
c. Milk shake
d. Potato soup
e. Steamed broccoli
ANS:A,D
Canned apricots and potato soup are appropriate selections as they are part of a high-protein,
high-fat, and low- to moderate-carbohydrate diet. Coffee cake and other sweets must be
avoided. Milk products and sweet drinks such as shakes must be avoided. Gas-forming foods
such as broccoli must also be avoided.
48
The nurse assesses a client who has possible gastritis. Which assessment finding(s) indicate(s)
that the client has chronic gastritis? (Select all that apply.)
a. Anorexia
b. Dyspepsia
c. Intolerance of fatty foods
d. Pernicious anemia
e. Nausea and vomiting
ANS: C, D
Intolerance of fatty or spicy foods and pernicious anemia are signs of chronic gastritis.
Anorexia and nausea/vomiting can be seen in both conditions. Dyspepsia is seen in acute
gastritis.
49
What action(s) by the nurse is (are) appropriate to promote nutrition in a client who had a
partial gastrectomy? (Select all that apply.)
a. Administer vitamin B12 injections.
b. Ask the primary health care provider about folic acid replacement.
c. Educate the client on enteral feedings.
d. Obtain consent for total parenteral nutrition.
e. Provide iron supplements for the client.
ANS: A, B, E
After a partial or total gastrectomy, clients are at high risk for anemia due to vitamin B12
deficiency, folic acid deficiency, or iron deficiency. The nurse would provide supplements for
all these nutrients. The client does not need enteral feeding or total parenteral nutrition.
50
A nurse is preparing to administer pantoprazole intravenously to prevent stress ulcers during
surgery. What action(s) by the nurse is (are) most appropriate? (Select all that apply.)
a. Administer the drug through a separate IV line.
b. Infuse pantoprazole using an IV pump.
c. Keep the drug in its original brown container.
d. Take vital signs frequently during infusion.
e. Use an in-line IV filter when infusing.
ANS: A, B, E
When infusing pantoprazole, use a separate IV line, a pump, and an in-line filter. A brown
wrapper and frequent vital signs are not needed.
51
After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client’s
understanding. Which menu selection indicates that the client correctly understands the
dietary teaching?
a. Ham sandwich on white bread, cup of applesauce, carbonated beverage
b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice
c. Grilled cheese sandwich, small banana, cup of hot tea with lemon
d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk
ANS: B
Patients with IBS are advised to eat a high-fiber diet. Chicken with brown rice, broccoli, and
apple juice has the highest fiber content. Clients should avoid alcohol, caffeine, and other
gastric irritants.
52
A nurse assesses a client who is prescribed alosetron. Which assessment question would the
nurse ask this client before starting the drug?
a. “Have you been experiencing any constipation?”
b. “Are you eating a diet high in fiber and fluids?”
c. “Do you have a history of high blood pressure?”
d. “What vitamins and supplements are you taking?”
ANS: A
Ischemic colitis is a life-threatening complication of alosetron. The nurse would assess the
client for constipation because it places the client at risk for this complication. The other
questions do not identify the risk for complications related to alosetron.
53
The nurse is caring for a client who is diagnosed with a complete small bowel obstruction. For
what priority problem is this client most likely at risk?
a. Abdominal distention
b. Nausea
c. Electrolyte imbalance
d. Obstipation
ANS: C
The client who has a small bowel obstruction is at the highest risk for fluid and electrolyte
imbalances, especially dehydration and hypokalemia due to profuse vomiting. Nausea,
abdominal distention, and obstipation are also usually present, but these problems are not as
life threatening as the imbalances in electrolytes.
54
A nurse assesses clients at a community health center. Which client is at highest risk for
developing colorectal cancer?
a. A 37-year-old who drinks eight cups of coffee daily.
b. A 44-year-old with irritable bowel syndrome (IBS).
c. A 60-year-old lawyer who works 65 hours per week.
d. A 72-year-old who eats fast food frequently.
ANS: D
Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing
age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer.
Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer
55
A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and
notes the presence of visible peristaltic waves. Which action would the nurse take?
a. Ask if the client is experiencing pain in the right shoulder.
b. Perform a rectal examination and assess for polyps.
c. Recommend that the client have computed tomography.
d. Administer a laxative to increase bowel movement activity.
ANS: C
The presence of visible peristaltic waves, accompanied by high-pitched or high-pitched bowel
sounds, is indicative of bowel obstruction caused by the tumor. The nurse would contact the
primary health care provider with these results and recommend a computed tomography scan
for further diagnostic testing. This assessment finding is not associated with right shoulder
pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The
nurse generalist is not qualified to complete a rectal examination for polyps, and laxatives
would not help this client.
56
The nurse is caring for a client who has a postoperative paralytic ileus following abdominal
surgery. What drug is appropriate to manage this nonmechanical bowel obstruction?
a. Alosetron
b. Alvimopan
c. Amitiptyline
d. Amlodipine
ANS: B
Alvimopan is the appropriate drug to promote peristalsis for clients who have a paralytic ileus.
The other drugs do not affect intestinal activity.
57
A nurse cares for a client with colorectal cancer who has a new colostomy. The client states,
“I think it would be helpful to talk with someone who has had a similar experience.” How
would the nurse respond?
a. “I have a good friend with a colostomy who would be willing to talk with you.”
b. “The ostomy nurse will be able to answer all of your questions.”
c. “I will make a referral to the United Ostomy Associations of America.”
d. “You’ll find that most people with colostomies don’t want to talk about them.”
ANS: C
Nurses need to become familiar with community-based resources to better assist clients. The
local chapter of the United Ostomy Associations of America has resources for clients and
their families, including ostomates (specially trained visitors who also have ostomies). The
nurse would not suggest that the client speak with a personal contact of the nurse. Although
the ostomy nurse is an expert in ostomy care, talking with him or her is not the same as
talking with someone who actually has had a colostomy. The nurse would not brush aside the
client’s request by saying that most people with colostomies do not want to talk about them.
Many people are willing to share their ostomy experience in the hope of helping others.
58
A nurse cares for a client who states, “My husband is repulsed by my colostomy and refuses
to be intimate with me.” How would the nurse respond?
a. “Let’s talk to the ostomy nurse to help you and your husband work through this.”
b. “You could try to wear longer lingerie that will better hide the ostomy appliance.”
c. “You should empty the pouch first so it will be less noticeable for your husband.”
d. “If you are not careful, you can hurt the stoma if you engage in sexual activity.”
ANS: A
The nurse would collaborate with the ostomy nurse to help the client and her husband work
through intimacy issues. The nurse would not minimize the client’s concern about her
husband with ways to hide the ostomy. The client will not hurt the stoma by engaging in
sexual activity.
59
The nurse is caring for a client with a large bowel obstruction due to fecal impaction. What
position would be appropriate for the client while in bed?
a. Prone
b. Supine
c. Recumbent
d. Semi-Fowler
ANS: D
Having the client in a semi-sitting position helps to decrease the pressure caused by
abdominal distention and promotes thoracic expansion to facilitate breathing.
60
A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago.
The client states, “The stool in my pouch is still liquid.” How would the nurse respond?
a. “The stool will always be liquid with this type of colostomy.”
b. “Eating additional fiber will bulk up your stool and decrease diarrhea.”
c. “Your stool will become firmer over the next couple of weeks.”
d. “This is abnormal. I will contact your primary health care provider.”
ANS: A
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. This finding is not abnormal. 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.
61
A nurse teaches a client who is at risk for colorectal cancer. Which dietary recommendation
would the nurse teach the client?
a. “Eat low-fiber and low-residual foods.”
b. “White rice and bread are easier to digest.”
c. “Add vegetables such as broccoli and cauliflower to your diet.”
d. “Foods high in animal fat help to protect the intestinal mucosa.”
ANS: C
The client would be taught to modify his or her diet to decrease animal fat and refined
carbohydrates. The client should also increase high-fiber foods and Brassica vegetables,
including broccoli and cauliflower, which help to protect the intestinal mucosa from colon
cancer.
62
A nurse cares for a client who has a new colostomy. Which action would the nurse take?
a. Empty the pouch frequently to remove excess gas collection.
b. Change the ostomy pouch and barrier every morning.
c. Allow the pouch to completely fill with stool prior to emptying it.
d. Use surgical tape to secure the pouch and prevent leakage.
ANS: A
The nurse would empty the new ostomy pouch frequently because of excess gas collection,
and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not
need to be changed every morning. Ostomy barriers would be used to secure and seal the
ostomy appliance; surgical tape would not be used.
63
A nurse cares for a client who has a family history of colorectal cancer. The client states, “My
father and my brother had colon cancer. What is the chance that I will get cancer?” How
would the nurse respond?
a. “If you eat a low-fat and low-fiber diet, your chances decrease significantly.”
b. “You are safe. This is an autosomal dominant disorder that skips generations.”
c. “Preemptive surgery and chemotherapy will remove cancer cells and prevent
cancer.”
d. “You should have a colonoscopy more frequently to identify abnormal polyps
early.”
ANS: D
The nurse would encourage the patient to have frequent colonoscopies to identify abnormal
polyps and cancerous cells early. The abnormal gene associated with colon cancer is an
autosomal dominant gene mutation that does not skip a generation and places the client at
high risk for cancer. Changing the client’s diet to more high-fiber (not low-fiber) and
preemptive chemotherapy may decrease the client’s risk of colon cancer but will not prevent
it.
64
A client is preparing to have a fecal occult blood test (FOBT). What health teaching would the
nurse include prior to the test?
a. “This test will determine whether you have colorectal cancer.”
b. “You need to avoid red meat and NSAIDs for 48 hours before the test.”
c. “You don’t need to have this test because you can have a virtual colonoscopy.”
d. “This test can determine your genetic risk for developing colorectal cancer.”
ANS: B
The FOBT is a screening test that is sometimes used to assess for microscopic lower GI
bleeding. To help prevent false positive results, the client needs to avoid red meat, Vitamin C,
and NSAIDs. The test is not diagnostic nor does it determine a client’s genetic risk for
colorectal cancer.
65
The nurse is caring for a client who is planning to have a laparoscopic colon resection for
colorectal cancer tomorrow. Which statement by the client indicates a need for further
teaching?
a. “I should have less pain after this surgery compared to having a large incision.”
b. “I will probably be in the hospital for 3 to 4 days after surgery.”
c. “I will be able to walk around a little on the same day as the surgery.”
d. “I will be able to return to work in a week or two depending on how I do.”
ANS:B
All of these statements are correct about having minimally invasive laparoscopic surgery
except that the hospital stay will likely be only 1 or 2 days
66
The nurse is caring for a client who has been prescribed lubiprostone for irritable bowel
syndrome (IBS-C). What health teaching will the nurse include about taking this drug?
a. “This drug will make you very dry because it will decrease your diarrhea.”
b. “Be sure to take this drug with food and water to help manage constipation.”
c. “Avoid people who have infection as this drug will suppress your immune
system.”
d. “Include high-fiber foods in your diet to help produce more solid stools.”
ANS: B
Lubiprostone is an oral laxative approved for women who have IBS with constipation
(IBS-C). Water and food will also help to improve constipation. The drug is not used for
clients who have diarrhea and does not affect the immune system. Although high-fiber foods
are important for clients who have IBS, this client does not need fiber to help make stool more
solid. Instead the fiber will help prevent constipation.
67
```
A client is admitted with a diagnosis of possible strangulated inguinal hernia. For which
complication would the nurse monitor?
a. Paralytic ileus
b. Bowel volvulus
c. Sepsis
d. Colitis
```
ANS: C
The client who has a strangulated inguinal hernia would likely develop bowel necrosis which
can lead to sepsis. The nurse would observe for early signs and symptoms of sepsis such as
fever, tachypnea, and tachycardia. If the client’s condition is not promptly managed, bowel
perforation, septic shock, and death can result.
68
```
The nurse is teaching a client how to avoid the formation of hemorrhoids. What lifestyle
change would the nurse include?
a. Avoiding alcohol
b. Quitting smoking
c. Decreasing fluid intake
d. Increasing dietary fiber
```
ANS:C
The major cause of hemorrhoid formation is constipation. Therefore, the nurse teaches the
client ways to prevent constipation, which include increasing dietary fiber, increasing exercise
and fluid intake, and avoiding straining when have a stool.
69
```
The nurse is caring for a client with probable colorectal cancer (CRC). What assessment
findings would the nurse expect? (Select all that apply.)
a. Weight gain
b. Rectal bleeding
c. Anemia
d. Change in stool shape
e. Electrolyte imbalances
f. Abdominal discomfort
```
ANS: B, C, D, F
The client who has CRC usually experiences unintentional weight loss and rectal bleeding,
either gross or occult. As a result of bleeding, the client has anemia and fatigue. Electrolyte
imbalances are not common, but the client may note that the shape or consistency of stool has
changed.
70
After teaching a client who is recovering from a colon resection to treat early-stage colorectal
cancer (CRC), the nurse assesses the client’s understanding. Which statements by the client
indicate understanding of the teaching? (Select all that apply.)
a. “I must change the ostomy appliance daily and as needed.”
b. “I will use warm water and a soft washcloth to clean around the stoma.”
c. “I might start bicycling and swimming again once my incision has healed.”
d. “I will make sure that I make lifestyle changes to prevent constipation.”
e. “I will be sure to have the recommended colonoscopies.”
ANS: C, D, E
The client has had a colon resection for early CRC and there is no indication that the client
also had a colostomy. Follow up with recommended colonoscopies are essential to monitor
for CRC recurrence. Avoiding constipation will help improve intestinal motility which helps
to decrease the risk for CRC recurrence. Exercise and other activities do not need to be
restricted after the client has healed.
71
A nurse assesses a client with irritable bowel syndrome (IBS). Which questions would the
nurse include in this client’s assessment? (Select all that apply.)
a. “Which food types cause an exacerbation of symptoms?”
b. “Where is your pain or discomfort and what does it feel like?”
c. “Have you lost a significant amount of weight lately?”
d. “Are your stools soft, watery, and black?”
e. “Do you often experience nausea and vomiting”
ANS: A, B
The nurse would ask the client about factors that may cause exacerbations of symptoms,
including food, stress, and anxiety. The nurse would also assess the location, intensity, and
quality of the patient’s pain or discomfort. Clients who have IBS do not usually lose weight,
have nausea and vomiting, or have stools that are black.
72
A nurse is caring for a client who has been diagnosed with a small bowel obstruction. Which
assessment findings would the nurse correlate with this diagnosis? (Select all that apply.)
a. Serum potassium of 2.8 mEq/L (2.8 mmol/L)
b. Loss of 15 lb (6.8 kg) without dieting
c. Abdominal pain in upper quadrants
d. Low-pitched bowel sounds
e. Serum sodium of 121 mEq/L (121 mmol/L)
ANS: A, C, E
Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is
hypokalemic (normal range is 3.5 to 5.0 mEq/L [3.5 to 5.0 mmol/L]) and hyponatremic
(normal range is 136 to 145 mEq/L [136 to 145 mmol/L]). Abdominal pain across the upper
quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting
followed by bowel obstruction leads to the probable development of colon cancer.
High-pitched sounds may be noted with small bowel obstructions.
73
The nurse is caring for a client who has a nasogastric tube (NGT). Which actions would the
nurse take for client care? (Select all that apply.)
a. Assess for proper placement of the tube every 4 hours or per agency policy.
b. Flush the tube with water every hour to ensure patency.
c. Secure the NG tube to the client’s chin.
d. Disconnect suction when auscultating bowel peristalsis.
e. Monitor the client’s skin around the tube site for irritation.
ANS: A, D, E
The nurse would frequently assess for NGT placement, patency, and output (drainage) every 4
hours or per agency policy. The nurse would also monitor the skin around the tube for
irritation and secure the tube to the client’s nose. When auscultating bowel sounds for
peristalsis, the nurse would disconnect suction. NGT irrigation may or may not be prescribed.
If it is prescribed, hourly irrigation is not appropriate.
74
The nurse is caring for a client who has perineal surgical wound. Which actions would the
nurse take to promote comfort and wound healing? (Select all that apply.)
a. Assist the client into a side-lying position.
b. Use a rubber donut device when sitting up.
c. Apply warm compresses three to four times a day.
d. Instruct the client to wear boxer shorts.
e. Place an absorbent dressing over the wound.
ANS: A, C, E
The nurse would place an absorbent pad over the wound and apply warm compresses to the
wound area. The nurse would also instruct the male client to wear jockey-type shorts for
support rather than boxers, assume a side-lying position in bed, avoid sitting for long periods,
and use foam pads or soft pillows whenever in a sitting position. The patient should avoid the
use of air rings or rubber donut devices.
75
```
The nurse assists the wound care/ostomy nurse assess a client prior to ostomy surgery. Which
assessments would the nurse complete before marking the placement for the ostomy? (Select
all that apply.)
a. Contour of the abdomen when standing
b. Location of the client’s belt line
c. Contour of the abdomen when lying
d. Location of abdominal muscles
e. Contour of the abdomen when sitting
```
ANS: A, B, C, E
Before marking the placement for the ostomy, the nurse would consider the contour of the
abdomen in lying, sitting, and standing positions, the location of the belt line and possible
location in the rectus muscle. The location of abdominal muscles is not considered.
76
The nurse is caring for a client who just had a minimally invasive inguinal hernia repair.
Which nursing actions would the nurse implement? (Select all that apply.)
a. Apply ice to the surgical area for the first 24 hours after surgery.
b. Encourage ambulation with assistance within the first few hours after surgery.
c. Encourage deep breathing after surgery but teach the client to avoid coughing.
d. Assess vital signs frequently for the first few hours after surgery.
e. Teach the client to rest for several days after surgery when at home.
f. Teach the client not to lift more than 10 lb (4.5 kg) until allowed by the surgeon.
ANS: A, B, C, D, E, F
All of these nursing actions are appropriate for the client having MIS for inguinal hernia
repair
77
The nurse is teaching a client who had a descending colostomy 2 days ago about the ostomy
stoma. Which changes in the stoma would the nurse teach the client to report to the primary
health care provider? (Select all that apply.)
a. Stool consistency is similar to paste.
b. Stoma becomes dark and dull.
c. Skin around the stoma becomes excoriated.
d. Skin around stoma becomes protruded.
e. Stoma becomes retracted into the abdomen.
ANS: B, C, D, E
A colostomy placed in the descending colon would be expect to have a paste-like stool
consistency. However, if the stoma becomes retracted or discolored, the client should report
those changes to the primary health care provider. Skin around the stoma that becomes
protruded would suggest the formation of a peristomal hernia, and skin excoriation needs
appropriate management. Therefore, both of those skin changes would need to be reported to
the primary health care provider.
78
The nurse assesses a client who has appendicitis. Which assessment finding would the nurse
expect?
a. Severe, steady right lower quadrant pain
b. Abdominal pain associated with nausea and vomiting
c. Marked peristalsis and hyperactive bowel sounds
d. Abdominal pain that increases with knee flexion
ANS: A
Right lower quadrant pain, specifically at McBurney’s point, is characteristic of appendicitis.
Usually if nausea and vomiting begin first, the client has gastroenteritis. Marked peristalsis
and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to
appendicitis decreases with knee flexion.
79
The nurse reviews the laboratory results for a client who has possible appendicitis. Which
laboratory test finding would the nurse expect?
a. Decreased potassium level
b. Increased sodium level
c. Elevated leukocyte count
d. Decreased thrombocyte count
ANS: C
Appendicitis is an acute inflammatory disorder that frequently results in elevation of
leukocytes (white blood cells). Serum electrolytes are not affected because the client does not
usually have diarrhea. Thrombocyte (platelet) count is unrelated to this GI disorder.
80
The nurse teaches a client who has viral gastroenteritis. Which dietary instruction would the
nurse include in the health teaching?
a. “Drink plenty of fluids to prevent dehydration.”
b. “You should only drink 1 L of fluids daily.”
c. “Increase your protein intake by drinking more milk.”
d. “Sips of cola or tea may help to relieve your nausea.”
ANS: A
The client should drink plenty of fluids to prevent dehydration. Milk products may not be
tolerated. Caffeinated beverages increase intestinal motility and should be avoided.
81
```
The nurse assesses a client with gastroenteritis. What risk factor would the nurse consider as
the most likely cause of this disorder?
a. Consuming too much fruit
b. Consuming fried or pickled foods
c. Consuming dairy products
d. Consuming raw seafood
```
ANS: D
Raw seafood is often contaminated and unless cooked can would most likely cause
gastroenteritis. Any of the other food can also become contaminated if not stored properly or
contaminated by workers/cooks who contaminate these foods.
82
The nurse assesses a client who is hospitalized with an exacerbation of Crohn disease. Which
assessment finding would the nurse expect?
a. Positive Murphy sign with rebound tenderness to palpitation
b. Dull, hypoactive bowel sounds in the lower abdominal quadrants
c. High-pitched, rushing bowel sounds in the right lower quadrant
d. Reports of abdominal cramping that is worse at night
ANS: C
The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in
Crohn disease. A positive Murphy sign is indicative of gallbladder disease, and rebound
tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and
hypoactive bowel sounds is not commonly found with Crohn disease. Nightly worsening of
abdominal cramping is not consistent with Crohn disease.
83
After teaching a patient with diverticular disease, a nurse assesses the client’s understanding.
Which menu selection indicates the client correctly understood the teaching?
a. Roasted chicken with rice pilaf and a cup of coffee with cream
b. Spaghetti with meat sauce, a fresh fruit cup, and hot tea
c. Garden salad with a cup of bean soup and a glass of low-fat milk
d. Baked fish with steamed carrots and a glass of apple juice
ANS: D
Clients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice
pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup [240
mL] of bean soup) would be avoided with a low-residue diet. Canned or cooked vegetables
are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet
84
A nurse cares for a young client with a new ileostomy. The client states, “I cannot go to prom
with an ostomy.” How would the nurse respond?
a. “Sure you can. Purchase a prom dress one size larger to hide the ostomy
appliance.”
b. “The pouch won’t be as noticeable if you avoid broccoli and carbonated drinks
prior to the prom.”
c. “Let’s talk to the ostomy nurse about options for ostomy supplies and dress
styles.”
d. “You can remove the pouch from your ostomy appliance when you are at the prom
so that it is less noticeable.”
ANS: C
The ostomy nurse is a valuable resource for patients, providing suggestions for supplies and
methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy
appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client.
Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not
feasible
85
The nurse teaches a client about how to prevent transmission of gastroenteritis. Which
statement by the nurse indicates a need for further teaching?
a. “I won’t let anyone use my dishes or glasses.”
b. “I’ll wash my hands with antibacterial soap.”
c. “I’ll keep my bathroom extra clean.”
d. “I’ll cook all the meals for my family
ANS: D
All of these statements are correct except for that the client should not prepare meals for
others to help prevent transmission of gastroenteritis.
86
After teaching a client who is prescribed adalimumab for severe ulcerative colitis (UC), the
nurse assesses the client’s understanding. Which statement made by the client indicates a
need for further teaching?
a. “I will avoid large crowds and people who are sick.”
b. “I will take this medication with my breakfast each morning.”
c. “Nausea and vomiting are common side effects of this drug.”
d. “I should wash my hands after I play with my dog.”
ANS: B
Adalimumab is an immune modulator that is 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.
87
The nurse is caring for a client who is prescribed sulfasalazine. Which question would the
nurse ask the client before starting this drug?
a. “Are you taking Vitamin C or B?
b. “Do you have any allergy to sulfa drugs?”
c. “Can you swallow pills pretty easily?”
d. “Do you have insurance to cover this drug?”
ANS: B
Sulfasalazine is a sulfa drug given for clients who have ulcerative colitis. However, it should
not be given to those who have an allergy to sulfa and sulfa drugs to prevent a hypersensitivity
reaction.
88
```
A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment
would the nurse complete first?
a. Inspection of oral mucosa
b. Recent dietary intake
c. Heart rate and rhythm
d. Percussion of abdomen
```
ANS: C
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 would have her or his electrolyte levels monitored, and
electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and
abdominal percussion are important parts of physical assessment but are lower priority for this
patient than heart rate and rhythm.
89
A nurse reviews the electronic health record of a client who has Crohn disease and a draining
fistula. Which documentation would alert the nurse to urgently contact the primary health care
provider for additional prescriptions?
a. Serum potassium of 2.6 mEq/L (2.6 mmol/L)
b. Client ate 20% of breakfast meal
c. White blood cell count of 8200/mm3 (8.2 109/L)
d. Client’s weight decreased by 3 lb (1.4 kg)
ANS: A
Fistulas place the patient with Crohn disease at risk for hypokalemia which can lead to serious
dysrhythmias. This potassium level is low and would 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 level takes priority.
90
A client is preparing to have a laparoscopic restorative proctocolectomy with ileo pouch-anal
anastomosis (RCA-IPAA). Which preoperative health teaching would the nurse include?
a. “You will have to wear an appliance for your permanent ileostomy.”
b. “You should be able to have better bowel continence after healing occurs.”
c. “You will have a large abdominal incision that will require irrigation.”
d. “This procedure can be performed under general or regional anesthesia.”
ANS: B
A RCA-IPAA can improve bowel continence although leakage may still occur for some
clients. The procedure is a 2-step process performed under general anesthesia using a
laparoscope which does not require an abdominal incision or permanent ileostomy.
91
After teaching a client who has diverticulitis, a nurse assesses the client’s understanding.
Which statement made by the client indicates a need for further teaching?
a. “I’ll ride my bike or take a long walk at least three times a week.”
b. “I must try to include at least 25 g of fiber in my diet every day.”
c. “I will take a laxative nightly at bedtime to avoid becoming constipated.”
d. “I should use my legs rather than my back muscles when I lift heavy objects.”
ANS: C
Laxatives are not recommended for patients 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.
92
The nurse plans care for a client with Crohn disease who has a heavily draining fistula. Which
intervention would be the nurse’s priority action?
a. Low-fiber diet
b. Skin protection
c. Antibiotic administration
d. Intravenous glucocorticoids
ANS: B
Protecting the client’s skin is the priority action for a patient who has a heavily draining
fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections
if the skin is not protected. The plan of care for a client who has Crohn disease also includes
adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals,
antibiotic administration, and glucocorticoids.
93
The nurse assesses a patient who is recovering from an ileostomy placement. Which
assessment finding would alert the nurse to immediately contact the primary health care
provider?
a. Pale and bluish stoma
b. Liquid stool
c. Ostomy pouch intact
d. Blood-tinged output
ANS: A
The nurse would assess the stoma for color and contact the primary health care provider if the
stoma is pale, bluish, or dark because these changes indicate possible lack of perfusion. The
nurse would expect the client to have an intact ostomy pouch with dark green liquid stool that
may contain some blood.
94
A nurse cares for a client with a new ileostomy. The client states, “I don’t think my friends
will accept me with this ostomy.” How would the nurse respond?
a. “Your friends will be happy that you are alive.”
b. “Tell me more about your concerns.”
c. “A therapist can help you resolve your concerns.”
d. “With time you will accept your new body.”
ANS: B
Social anxiety and apprehension are common in clients with a new ileostomy. The nurse
would encourage the client to discuss concerns by restating them in an open-ended manner.
The nurse would not minimize the client’s concerns or provide false reassurance.
95
The nurse assesses a client with ulcerative colitis. Which complications are paired correctly
with their physiologic processes? (Select all that apply.)
a. Lower gastrointestinal bleeding—erosion of the bowel wall
b. Abscess formation—localized pockets of infection develop in the ulcerated bowel
lining
c. Toxic megacolon—transmural inflammation resulting in pyuria and fecaluria
d. Nonmechanical bowel obstruction—paralysis of colon resulting from colorectal
cancer
e. Fistula—dilation and colonic ileus caused by paralysis of the colon
ANS: A, B, D
Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of
infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is
paralysis of the colon that results from colorectal cancer. When the inflammation is
transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria.
Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic
megacolon.
96
```
A nurse assesses a patient who has celiac disease. Which signs and symptoms would the nurse
expect? (Select all that apply.)
a. Weight gain
b. Anorexia
c. Constipation
d. Anal fistula
e. Abdominal pain
```
ANS: B, C, E
Signs and symptoms of celiac disease include weight loss, anorexia, constipation, and
abdominal pain. Anal fistulas are not associated with celiac disease.
97
A nurse cares for an older adult who is admitted to the hospital with complications of
diverticulitis. Which actions would the nurse include in the client’s plan of care? (Select all
that apply.)
a. Administer pain medications as prescribed.
b. Palpate the abdomen for distention.
c. Assess for sudden changes in mental status.
d. Provide the client with a high-fiber diet.
e. Evaluate stools for occult blood.
ANS: A, B, C, E
When caring for an older adult who has diverticulitis, the nurse would administer analgesics
as prescribed, palpate the abdomen for distention and tenderness, assess for confusion and
sudden changes in mental status, and check stools for occult or frank bleeding. A
low-fiber/residue diet would be provided when symptoms are present and a high-fiber diet
when inflammation resolves.
98
A nurse prepares to discharge a client who is newly diagnosed with a chronic inflammatory
bowel disease. Which questions would the nurse ask in preparation for discharge? (Select all
that apply.)
a. Does your gym provide yoga classes?
b. When should you contact your provider?
c. What do you plan to eat for dinner?
d. Do you have a scale for daily weights?
e. How many bathrooms are in your home?
ANS: A, B, C, E
A home assessment for a client who has a chronic inflammatory bowel disease would include
identifying adequacy and availability of bathroom facilities, opportunities for rest and
relaxation, and the client’s knowledge of dietary therapy, and when to contact the primary
health care provider. The client does not need to perform daily weights.
99
```
After teaching a patient who has a permanent ileostomy, a nurse assesses the client’s
understanding. Which dietary items chosen for dinner indicate that the client needs further
teaching? (Select all that apply.)
a. Corn
b. String beans
c. Carrots
d. Wheat rice
e. Squash
```
ANS: A, B, D
Clients with an ileostomy should be cautious of high-fiber and high-cellulose foods including
corn, string beans, and rice. Carrots and squash are low-fiber items.
100
A nurse cares for a patient who has a chronic inflammatory bowel disease. Which actions
would the nurse take to prevent skin excoriation? (Select all that apply.)
a. Cleanse the perineum with an antibacterial soap.
b. Use medicated wipes instead of toilet paper.
c. Identify foods that decrease constipation.
d. Apply a thin coat of aloe cream to the perineum.
e. Gently pat the perineum dry after cleansing.
ANS: B, D, E
To prevent skin excoriation from frequent bowel movements associated with inflammatory
bowel disease, the nurse would encourage good skin care with a mild soap and water and
gently patting the area dry after each bowel movement. Using medicated wipes instead of
toilet paper and applying a thin coat of aloe cream are appropriate. The client should identify
and avoid foods that increase diarrhea. Antibacterial soaps are harsh and should not be used.
101
The nurse is caring for a client who is diagnosed with celiac disease and preparing to start
natalizumab. Which health teaching would the nurse include in the teaching? (Select all that
apply. )
a. Need to have drug administered by a primary health care provider.
b. Need to avoid crowds and individuals who have infection.
c. Need to report injection reactions such as redness and swelling.
d. Awareness of a rare but potentially fatal drug complication.
e. Need to report any signs and symptoms of infection immediately
ANS: A, B, D, E
All of these choices are correct except that the drug is given intravenously. Therefore, there is
no need to teach the client to report injection reactions because the client does not
self-administer the medication subcutaneously. Natalizumab can cause progressive multifocal
leukoencephalopathy (PML), but it is a very rare disorder causing cognitive, sensory, and/or
motor changes.
102
```
The nurse is caring for a client with peritonitis. What assessment findings would the nurse
expect? (Select all that apply.)
a. Nausea and vomiting
b. Distended rigid abdomen
c. Abdominal pain
d. Bradycardia
e. Decreased urinary output
f. Fever
```
ANS: A, C, D, E, F
Peritonitis is an acute inflammatory disorder. Therefore, the client would likely have all of
these signs and symptoms but would have tachycardia rather than bradycardia due to
dehydration from fever.
103
A client is scheduled for a hepatobiliary iminodiacetic acid (HIDA) scan. What would the
nurse include in client teaching about this diagnostic test?
a. “You’ll have to drink a contrast medium right before the test.”
b. “You’ll need to do a bowel prep the nursing before the test.”
c. “You’ll be able to drink liquids up until the test begins.”
d. “You’ll have a large camera close to you during the test.”
ANS: D
Clients having a HIDA scan are NPO and receive an injectable nuclear medicine contrast. No
bowel preparation is required. A large camera is close to the client for most of the test which
can be a problem for clients who are claustrophobic.
104
A client has an external percutaneous transhepatic biliary catheter inserted for a biliary
obstruction. What health teaching about catheter care would the nurse provide for the client?
a. “Cap the catheter drain at night to prevent leakage and skin damage.”
b. “Position the drainage bag lower than the catheter insertion site.”
c. “Irrigate the catheter with an ounce of saline every night.”
d. “Pierce a hole in the top of the drainage bag to get rid of odors.”
ANS: B
An external temporary or permanent catheter drains bile by gravity into a bag that collects
bile. Therefore, the drainage bag should be lower that the catheter insertion site. The catheter
should not be capped or irrigated, and no holes should be made in the bag to prevent bile from
having contact with the skin.
105
After teaching a client who has a history of cholelithiasis, the nurse assesses the client’s
understanding. Which menu selection indicates that the client understands the dietary
teaching?
a. Lasagna, tossed salad with Italian dressing, and low-fat milk
b. Grilled cheese sandwich, tomato soup, and coffee with cream
c. Cream of potato soup, Caesar salad with chicken, and a diet cola
d. Roasted chicken breast, baked potato with chives, and orange juice
ANS:D
Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk,
butter, and fried foods. Lasagna, low-fat milk, grilled cheese, cream, and cream of potato soup
all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.
106
```
A client is admitted with acute pancreatitis. What priority problem would the nurse expect
the client to report?
a. Nausea and vomiting
b. Severe boring abdominal pain
c. Jaundice and itching
d. Elevated temperature
```
ANS: B
The client who has acute pancreatitis reports severe boring abdominal pain that is often rated
by clients as a 10+ on a 0-10 pain scale. Nausea, vomiting, and fever may also occur, but that
is not the client’s priority for care.
107
After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse
assesses the client’s understanding. Which statement by the client indicates a need for further
teaching?
a. “The capsules can be opened and the powder sprinkled on applesauce if needed.”
b. “I will wipe my lips carefully after I drink the enzyme preparation.”
c. “The best time to take the enzymes is immediately after I have a meal or a snack.”
d. “I will not mix the enzyme powder with food or liquids that contain protein.”
ANS: C
The enzymes must be taken immediately before eating meals or snacks. If the client cannot
swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce,
mashed fruit, or rice cereal. The client should wipe his or her lips carefully after drinking the
enzyme preparation because the liquid could damage the skin. Protein items will be dissolved
by the enzymes if they are mixed together.
108
A nurse cares for a client with end-stage pancreatic cancer. The client asks, “Why is this
happening to me?” How would the nurse respond?
a. “I don’t know. I wish I had an answer for you, but I don’t.”
b. “It’s important to keep a positive attitude for your family right now.”
c. “Scientists have not determined why cancer develops in certain people.”
d. “I think that this is a trial so you can become a better person because of it.”
ANS: A
The client is not asking the nurse to actually explain why the cancer has occurred. The client
may be expressing his or her feelings of confusion, frustration, distress, and grief related to
this diagnosis. Reminding the client to keep a positive attitude for his or her family does not
address the client’s emotions or current concerns. The nurse would validate that there is no
easy or straightforward answer as to why the client has cancer. Telling a client that cancer is a
trial is untrue and may negatively impact the client–nurse relationship.
109
```
A client had an open traditional Whipple procedure this morning. For what priority
complication would the nurse assess?
a. Urinary tract infection
b. Chronic kidney disease
c. Heart failure
d. Fluid and electrolyte imbalances
```
ANS: D
Due to the length and complexity of this type of surgery, the client is at risk for fluid and
electrolyte imbalances. The nurse would assess for signs and symptoms of these imbalances
so they can be managed early to prevent potentially life-threatening complications.
110
```
A nurse assesses a client who has cholecystitis. Which sign or symptom indicates that this
condition is chronic rather than acute?
a. Temperature of 100.1° F (37.8° C)
b. Positive Murphy sign
c. Clay-colored stools
d. Upper abdominal pain after eating
```
ANS: C
Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic
cholecystitis. The other symptoms are seen in clients with either chronic or acute cholecystitis.
111
A nurse assesses a client who is recovering from a Whipple procedure. Which assessment
finding alerts the nurse to immediately contact the primary health care provider?
a. Drainage from a fistula
b. Diminished bowel sounds
c. Pain at the incision site
d. Nasogastric (NG) tube drainage
ANS: A
Complications of a Whipple procedure include secretions that drain from a fistula and
peritonitis. Absent bowel sounds, pain at the incision site, and NG tube drainage are normal
postoperative findings.
112
The nurse is caring for a client who is recovering from an open traditional Whipple surgical
procedure. What action would the nurse take?
a. Clamp the nasogastric tube.
b. Place the patient in semi-Fowler position.
c. Assess vital signs once every shift.
d. Provide oral rehydration.
ANS: B
Postoperative care for a patient recovering from an open Whipple procedure would include
placing the client in a semi-Fowler position to reduce tension on the suture line and
anastomosis sites and promote breathing, setting the nasogastric tube to low continuous
suction to remove free air buildup and pressure, assessing vital signs frequently to assess fluid
and electrolyte complications, and providing intravenous fluids.
113
```
The nurse is caring for a client who has possible acute pancreatitis. What serum laboratory
findings would the nurse expect for this client? (Select all that apply.)
a. Elevated amylase
b. Elevated lipase
c. Elevated glucose
d. Decreased calcium
e. Elevated bilirubin
f. Elevated leukocyte count
```
ANS: A, B, C, D, E, F
All of these choices are correct. Amylase and lipase are pancreatic enzymes that are released
during pancreatic inflammation and injury. Leukocytes also increased due to his inflammatory
response. Pancreatic injury affects the ability of insulin to be released causing increased
glucose levels. Bilirubin is also typically increased due to hepatobiliary obstruction. Calcium
and magnesium levels decrease because fatty acids bind free calcium and magnesium causing
a lowered serum level; these changes occur in the presence of fat necrosis.
114
The nurse plans care for a client who has acute pancreatitis and is prescribed nothing by
mouth (NPO). With which health care team members would the nurse collaborate to provide
appropriate nutrition to this client? (Select all that apply.)
a. Registered dietitian nutritionist
b. Nursing assistant
c. Clinical pharmacist
d. Certified herbalist
e. Primary health care provider
ANS: A, C, E
Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need
enteral or parenteral nutrition. The nurse would collaborate with the registered dietitian
nutritionist, clinical pharmacist, and primary health care provider to plan and implement the
more appropriate nutritional interventions. The nursing assistant and certified herbalist would
not assist with this clinical decision.
115
```
The nurse is caring for a client who was recently diagnosed with pancreatic cancer. What
factors present risks for developing this type of cancer? (Select all that apply.)
a. Diabetes mellitus
b. Cirrhosis
c. Smoking
d. Female gender
e. Family history
f. Older age
```
ANS: A, B, C, E, F
All of these choices are risk factors except that pancreatic cancer occurs most frequently in
men.
116
```
The nurse assesses a client who has chronic pancreatitis. What assessment findings would the
nurse expect for this client? (Select all that apply.)
a. Ascites
b. Weight gain
c. Steatorrhea
d. Jaundice
e. Polydipsia
f. Polyuria
```
ANS: A, C, D, E, F
The client who has chronic pancreatitis has all of these signs and symptoms except he or she
loses weight. Ascites and jaundice result from biliary obstruction; ascites is associated with
portal hypertension. Steatorrhea is fatty stool that occurs because lipase is not available in the
duodenum; because it is released by the disease pancreas into the bloodstream. Polydipsia,
polyuria, and polyphagia result from diabetes mellitus, a common problem seen in clients
whose pancreas is unable to release adequate amounts of insulin.
117
After teaching a client who has chronic pancreatitis and will be discharged with enzyme
replacement therapy, a nurse assesses the client’s understanding. Which statement by the
client indicates a need for further teaching? (Select all that apply.)
a. “I will take the enzymes between meals.”
b. “The enteric-coated preparations cannot be crushed.”
c. “Swallowing the tables without chewing is best.”
d. “I will wipe my lips after taking the enzymes.”
e. “Enzymes should be taken with high-protein foods.”
ANS:A,E
Client teaching related to self-management of enzyme replacement therapy would include
taking the enzymes with meals and snacks but not mixing enzyme preparations with
protein-containing foods. Clients would not crush enteric-coated preparations and should
swallow tablets without chewing to minimize oral irritation and allow the drug to be released
slowly. Wiping lips after taking enzymes also minimizes skin irritation.
118
The nurse is preparing a client who has chronic pancreatitis about how to prevent
exacerbations of the disease. Which health teaching will the nurse include? (Select all that
apply.)
a. “Avoid alcohol ingestion.”
b. “Be sure and balance rest with activity.”
c. “Avoid caffeinated beverages.”
d. “Avoid green, leafy vegetables.”
e. “Eat small meals and high-calorie snacks.”
ANS: A, B, C, E
Clients who have chronic pancreatitis need to avoid GI stimulants, including alcohol, caffeine,
and nicotine. Food and snacks need to be high-calorie to prevent additional weight loss. Green
vegetables can be consumed if tolerated by the client.
119
The nurse is performing an initial assessment and notes that the client weighs 186.4 lb (84.7
kg). Six months ago, the client weighed 211.8 lb (96.2 kg). What action by the nurse is
appropriate?
a. Ask the client if the weight loss was intentional.
b. Determine if there are food allergies or intolerances.
c. Perform a comprehensive nutritional assessment.
d. Perform a rapid bedside blood glucose test.
ANS: A
This client has had a 12% weight loss. The nurse first determines if the weight loss was
intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food
intolerances are part of this assessment. Depending on risk factors and other findings, a blood
glucose test may be warranted.
120
The nurse assesses a newly admitted client and documents a body mass index (BMI) of 31.2.
What does this value indicate to the nurse?
a. The client has a healthy weight.
b. The client is underweight.
c. The client is obese.
d. The client is overweight.
ANS: C
| A BMI of over 30 indicates that the client is obese.
121
A nurse is reviewing laboratory values for several clients. Which value indicates a need for a
nutritional assessment?
a. Client with an albumin of 3.5 g/dL
b. Client with a cholesterol of 142 mg/dL (3.7 mmol/L)
c. Client with a hemoglobin of 9.8 mg/dL (98 mmol/L)
d. Client with a prealbumin of 28 mg/dL
ANS: B
A cholesterol level below 160 mg/dL (4 mmol/L) is a possible indicator of undernutrition, so
this client would be at highest priority for a nutritional assessment. The albumin and
prealbumin levels are normal. The low hemoglobin could be from several problems, including
dietary deficiencies, hemodilution, and bleeding.
122
A client is receiving bolus feedings through a small-bore nasoduodenal tube. What action by
the nurse is the priority?
a. Auscultate lung sounds after each feeding.
b. Weigh the client daily on the same scale.
c. Check tube placement every 8 hours.
d. Check tube placement before each feeding.
ANS: D
For bolus feedings, the nurse checks placement of the tube per institutional policy prior to
each feeding, which is more often than every 8 hours during the day. Auscultating lung
sounds is also important, but this may indicate a complication that has already occurred.
Weighing the client is important to determine if nutritional goals are being met, but it is not
the priority.
123
A client receiving continuous tube feeding to provide total enteral nutrition begins vomiting.
What action by the nurse is most appropriate?
a. Administer an antiemetic.
b. Check the patient’s gastric residual.
c. Hold the feeding until the vomiting subsides.
d. Reduce the rate of the tube feeding by half.
ANS: C
The nurse would stop the feeding until the vomiting subsides and consult with the registered
dietitian nutritionist or primary health care provider about the rate at which to restart the
feeding. Giving an antiemetic is not appropriate. After vomiting, a gastric residual will not be
accurate. The nurse would not continue to feed the patient while he or she is vomiting.
124
The nurse inserts a small-bore nasoduodenal tube for a client who is undernourished. What
priority nursing action is required prior to starting the continuous tube feeding to confirm
correct tube placement?
a. Assess for carbon dioxide using capnometry.
b. Perform pH testing of gastric fluid.
c. Auscultate over the epigastric area.
d. Request an x-ray before starting the feeding.
ANS: D
The most reliable assessment to determine correct feeding tube placement in to have an x-ray
to visualize where the tip of the tube is located.
125
The nurse is caring for an older client receiving total enteral nutrition via a small-bore
nasoduodenal tube. For what priority complication would the nurse assess?
a. Intermittent diarrhea
b. Cholecystitis
c. Aspiration pneumonia
d. Peptic ulcer disease
ANS: C
Aspiration pneumonia is one of the most common complications in older adults who have
enteral nutrition via a nasoduodenal tube because their gag reflex is often decreased.
Intermittent diarrhea may also occur, but that is not potentially life threatening if the client
does not become dehydrated.
126
The nurse is managing care for a client receiving feeding through a gastrostomy tube
(G-tube). What assessment would the nurse perform?
a. Check the skin around the tube insertion site.
b. Weigh the client every shift with the same scale.
c. Draw blood to assess albumin every shift.
d. Irrigate the tube at least once a day.
ANS: A
The most important assessment would be to observe the skin around the tube for irritation,
redness, and skin breakdown. The skin should be cleaned frequently to keep it free of drainage
and moisture which can lead to excoriation or other type of skin breakdown. For a client who
is undernourished, he or she is usually weighed every day and prealbumin is a more sensitive
indicator of over nutritional health. The G-tube is not routinely irrigated.
127
A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes that the
client’s pulse is 128 beats/min, blood pressure is 98/56 mm Hg, skin is dry, and skin turgor is
poor. What action should the nurse perform next?
a. Assess the 24-hour intake and output.
b. Assess the client’s oral cavity.
c. Prepare to hang a normal saline bolus.
d. Increase the infusion rate of the TPN.
ANS:A
This client has clinical indicators of dehydration, so the nurse calculates the patient’s 24-hour
intake, output, and fluid balance. This information is then reported to the health care provider.
The client’s oral cavity assessment may or may not be consistent with dehydration. The nurse
may need to give the client a fluid bolus, but not as an independent action. The client’s
dehydration is most likely due to fluid shifts from the TPN, so increasing the infusion rate
would make the problem worse, and is not done as an independent action for clients receiving
TPN.
128
A client who had minimally invasive bypass gastric surgery 2 days ago reports new-onset of
severe abdominal pain. What is the nurse’s best action as this time?
a. Listen to the client’s bowel sounds.
b. Call the Rapid Response Team.
c. Take the client’s vital signs.
d. Contact the primary health care provider.
ANS: C
The client may be experiencing either bleeding or anastomosis leak(s). Clients having these
complications have severe abdominal, back, or shoulder pain, tachycardia, and hypotension.
129
```
A client just returned to the surgical unit after an open traditional gastric bypass. What action
by the nurse is the priority?
a. Assess the patient’s pain.
b. Check the surgical incision.
c. Ensure an adequate airway.
d. Program the morphine pump.
```
ANS: C
All actions are appropriate care measures for this patient; however, airway is always the
priority. Bariatric patients tend to have short, thick necks that complicate airway management.
130
A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is
crying and says “I didn’t know it would be this hard to live like this.” What approach by the
nurse is best?
a. Assess the client’s coping and support systems.
b. Inform the client that things will get easier.
c. Re-educate the client on needed dietary changes.
d. Tell the client that lifestyle changes are always hard.
ANS:A
The nurse would assess this patient’s coping styles and support systems to best provide
holistic care. The other options do not address the patient’s distress
131
A client has been prescribed lorcaserin. What health teaching about the drug is appropriate for
the nurse to provide?
a. “Increase the fiber and water in your diet to prevent diarrhea.”
b. “Report any suicidal thoughts to your primary health care provider”
c. “Report dry mouth and decreased sweating.”
d. “Do not take antibiotics or nay other anti-infective drugs.”
ANS: B
Lorcaserin can cause suicidal thoughts which needs to be reported to the client’s primary
health care provider. This drug can also cause dry mouth but not decreased sweating. Loose
stools are most common with orlistat. Increasing fiber and water would help to prevent
constipation, not diarrhea
132
A client is awaiting bariatric surgery in the morning. What action by the nurse is most
important?
a. Answering questions the client has about surgery
b. Beginning venous thromboembolism prophylaxis
c. Informing the client that he or she will be out of bed tomorrow
d. Teaching the client about needed dietary changes
ANS: B
Morbidly obese clients are at high risk of venous thromboembolism and should be started on a
regimen to prevent this from occurring as a priority. Answering questions about the surgery is
done by the surgeon. Teaching is important, but safety comes first.
133
```
Nurses must be alert for increased fluid requirements when a child presents with which
possible concern?
a. Fever
b. Mechanical ventilation
c. Congestive heart failure
d. Increased intracranial pressure (ICP)
```
ANS: A
Fever leads to great insensible fluid loss in young children because of increased body surface
area relative to fluid volume. Respiratory rate influences insensible fluid loss and should be
monitored in the mechanically ventilated child. Congestive heart failure is a case of fluid
overload in children. ICP does not lead to increased fluid requirements in children.
134
Which type of dehydration results from water loss in excess of electrolyte loss?
a. Isotonic dehydration
b. Isosmotic dehydration
c. Hypotonic dehydration
d. Hypertonic dehydration
ANS: D
Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most
dangerous type of dehydration. It is caused by feeding children fluids with high amounts of
solute. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are
present in balanced proportion. Isosmotic dehydration is another term for isotonic
dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water
deficit, leaving the serum hypotonic.
135
An infant is brought to the emergency department with poor skin turgor, sunken fontanel,
lethargy, and tachycardia. This is suggestive of which condition?
a. Overhydration
b. Dehydration
c. Sodium excess
d. Calcium excess
ANS: B
These clinical manifestations indicate dehydration. Symptoms of overhydration are edema and
weight gain. Regardless of extracellular sodium levels, total body sodium is usually depleted
in dehydration. Symptoms of hypocalcemia are a result of neuromuscular irritability and
manifest as jitteriness, tetany, tremors, and muscle twitching.
136
What is a common cause of acute diarrhea?
a. Hirschsprung’s disease
b. Antibiotic therapy
c. Hypothyroidism
d. Meconium ileus
ANS: B
Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may
be associated with antibiotic therapy. Hirschsprung’s disease, hypothyroidism, and meconium
ileus are usually manifested with constipation rather than diarrhea.
137
The viral pathogen that frequently causes acute diarrhea in young children is:
a. Giardia organisms.
b. Shigella organisms.
c. Rotavirus.
d. Salmonella organisms.
ANS: C
Rotavirus is the most frequent viral pathogen that causes diarrhea in young children. Giardia
and Salmonella are bacterial pathogens that cause diarrhea. Shigella is a bacterial pathogen
that is uncommon in the United States
138
A stool specimen from a child with diarrhea shows the presence of neutrophils and red blood
cells. This is most suggestive of which condition?
a. Protein intolerance
b. Parasitic infection
c. Fat malabsorption
d. Bacterial gastroenteritis
ANS: D
Neutrophils and red blood cells in stool indicate bacterial gastroenteritis. Protein intolerance is
suspected in the presence of eosinophils. Parasitic infection is indicated by eosinophils. Fat
malabsorption is indicated by foul-smelling, greasy, bulky stools.
139
A young child is brought to the emergency department with severe dehydration secondary to
acute diarrhea and vomiting. Therapeutic management of this child will begin with which
intervention?
a. Intravenous fluids
b. Oral rehydration solution (ORS)
c. Clear liquids, 1 to 2 ounces at a time
d. Administration of antidiarrheal medication
ANS: A
Intravenous fluids are initiated in children with severe dehydration. ORS is acceptable therapy
if the dehydration is not severe. Diarrhea is not managed by using clear liquids by mouth.
These fluids have a high carbohydrate content, low electrolyte content, and high osmolality.
Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea.
140
Constipation has recently become a problem for a school-age child who is being treated for
seasonal allergies. The nurse should focus the assessment on what possibly related factor?
a. Diet
b. Allergies
c. Antihistamines
d. Emotional factors
ANS: C
Constipation may be associated with drugs such as antihistamines, antacids, diuretics, opioids,
antiepileptics, and iron. Because this is the only known recent change in her habits, the
addition of antihistamines is most likely the etiology of the diarrhea, rather than diet, allergies,
or emotional factors. With a change in bowel habits, the presence and role of any recently
prescribed medications should be assessed.
141
Therapeutic management of most children with Hirschsprung’s disease is primarily:
a. daily enemas.
b. low-fiber diet.
c. permanent colostomy.
d. surgical removal of affected section of bowel.
ANS:D
Most children with Hirschsprung’s disease require surgical rather than medical management.
Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and
restore normal bowel motility and function of the internal anal sphincter. Preoperative
management may include enemas and low-fiber, high-calorie, high-protein diet until the child
is physically ready for surgery. The colostomy that is created in Hirschsprung’s disease is
usually temporary.
142
A 4-month-old infant diagnosed with gastroesophageal reflux disease (GERD) is thriving
without other complications. What should the nurse suggest to minimize reflux?
a. Place in Trendelenburg position after eating.
b. Thicken formula with rice cereal.
c. Give continuous nasogastric tube feedings.
d. Give larger, less frequent feedings.
ANS: B
Giving small frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice
cereal per ounce of formula has been recommended. Milk thickening agents have been shown
to decrease the number of episodes of vomiting and increase the caloric density of the
formula. This may benefit infants who are underweight as a result of GERD. Placing the child
in Trendelenburg position would increase the reflux. Continuous nasogastric feedings are
reserved for infants with severe reflux and failure to thrive. Smaller, more frequent feedings
are recommended in reflux.
143
```
What is the primary purpose of prescribing a histamine receptor antagonist for an infant
diagnosed with gastroesophageal reflux?
a. Prevent reflux
b. Prevent hematemesis.
c. Reduce gastric acid production.
d. Increase gastric acid production.
```
ANS: C
The mechanism of action of histamine receptor antagonists is to reduce the amount of acid
present in gastric contents and may prevent esophagitis. None of the remaining options are
modes of action of histamine receptor antagonists but rather desired effects of medication
therapy.
144
Which clinical manifestation would most suggest acute appendicitis?
a. Rebound tenderness
b. Bright red or dark red rectal bleeding
c. Abdominal pain that is relieved by eating
d. Abdominal pain that is most intense at McBurney point
ANS:D
Pain is the cardinal feature. It is initially generalized and usually periumbilical. The pain
localizes to the right lower quadrant at McBurney point. Rebound tenderness is not a reliable
sign and is extremely painful to the child. Abdominal pain that is relieved by eating and bright
or dark red rectal bleeding are not signs of acute appendicitis.
145
```
When caring for a child with probable appendicitis, the nurse should be alert to recognize
what sign of perforation?
a. Bradycardia
b. Anorexia
c. Sudden relief from pain
d. Decreased abdominal distention
```
ANS: C
Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation.
Tachycardia, not bradycardia, is a manifestation of peritonitis. Anorexia is already a clinical
manifestation of appendicitis. Abdominal distention usually increases in addition to an
increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen).
146
Which statement is most descriptive of Meckel’s diverticulum?
a. It is more common in females than in males.
b. It is acquired during childhood.
c. Intestinal bleeding may be mild or profuse.
d. Medical interventions are usually sufficient to treat the problem.
ANS: C
Blood stools are often a presenting sign of Meckel’s diverticulum. It is associated with
mild-to-profuse intestinal bleeding. It is twice as common in males as in females, and
complications are more frequent in males. Meckel’s diverticulum is the most common
congenital malformation of the gastrointestinal tract and is present in 2% of the general
population. The standard therapy is surgical removal of the diverticulum.
147
What condition is characterized by a chronic inflammatory process that may involve any part
of the gastrointestinal (GI) tract from mouth to anus?
a. Crohn’s disease
b. Ulcerative colitis
c. Meckel’s diverticulum
d. Irritable bowel syndrome
ANS: A
The chronic inflammatory process of Crohn’s disease involves any part of the GI tract from
the mouth to the anus but most often affects the terminal ileum. Ulcerative colitis, Meckel’s
diverticulum, and irritable bowel syndrome do not affect the entire GI tract.
148
What is used to treat moderate-to-severe inflammatory bowel disease?
a. Antacids
b. Antibiotics
c. Corticosteroids
d. Antidiarrheal medications
ANS: C
Corticosteroids such as prednisone and prednisolone are used in short bursts to suppress the
inflammatory response in inflammatory bowel disease. Antacids and antidiarrheals are not
drugs of choice to treat the inflammatory process of inflammatory bowel disease. Antibiotics
may be used as adjunctive therapy to treat complications.
149
Bismuth subsalicylate may be prescribed for a child with a peptic ulcer to effect what result?
a. Eradicate Helicobacter pylori
b. Coat gastric mucosa
c. Treat epigastric pain
d. Reduce gastric acid production
ANS: A
This combination of drug therapy is effective in the treatment and eradication of H. pylori. It
does not bring about any of the results.
150
The best chance of survival for a child with cirrhosis is:
a. liver transplantation.
b. treatment with corticosteroids.
c. treatment with immune globulin.
d. provision of nutritional support.
ANS: A
The only successful treatment for end-stage liver disease and liver failure may be liver
transplantation, which has improved the prognosis for many children with cirrhosis. Liver
transplantation has revolutionized the approach to cirrhosis. Liver failure and cirrhosis are
indications for transplantation. Liver transplantation reflects the failure of other medical and
surgical measures, such as treatment with corticosteroids or immune globulin and nutritional
support, to prevent or treat cirrhosis.
151
The nurse, caring for a neonate with a suspected tracheoesophageal fistula, should include
what intervention into the plan of care?
a. Elevating the head to facilitate secrete drainage.
b. Elevating the head for feedings only.
c. Feeding glucose water only.
d. Avoiding suctioning unless the infant is cyanotic.
ANS: A
When a newborn is suspected of having tracheoesophageal fistula, the most desirable position
is supine with the head elevated on an inclined plane of at least 30 degrees to maintain an
airway and facilitate drainage of secretions. It is imperative that any source of aspiration be
removed at once; oral feedings are withheld. Feeding of fluids should not be given to infants
suspected of having tracheoesophageal fistulas. The oral pharynx should be kept clear of
secretion by oral suctioning. This is to avoid the cyanosis that is usually the result of
laryngospasm caused by overflow of saliva into the larynx.
152
Which type of hernia has an impaired blood supply to the herniated organ?
a. Hiatal hernia
b. Incarcerated hernia
c. Omphalocele
d. Strangulated hernia
ANS: D
A strangulated hernia is one in which the blood supply to the herniated organ is impaired. A
hiatal hernia is the intrusion of an abdominal structure, usually the stomach, through the
esophageal hiatus. An incarcerated hernia is a hernia that cannot be reduced easily.
Omphalocele is the protrusion of intraabdominal viscera into the base of the umbilical cord.
The sac is covered with peritoneum and not skin.
153
What is the most appropriate nursing action when a child with a probable intussusception has
a normal, brown stool?
a. Notify the practitioner
b. Measure abdominal girth
c. Auscultate for bowel sounds
d. Take vital signs, including blood pressure
ANS: A
Passage of a normal brown stool indicates that the intussusception has reduced itself. This is
immediately reported to the practitioner, who may choose to alter the diagnostic/therapeutic
plan of care.
154
An important nursing consideration in the care of a child with celiac disease is to facilitate
which intervention?
a. Refer to a nutritionist for detailed dietary instructions and education.
b. Help the child and family understand that diet restrictions are usually only
temporary.
c. Teach proper hand washing and Standard Precautions to prevent disease
transmission.
d. Suggest ways to cope more effectively with stress to minimize symptoms.
ANS: A
The main consideration is helping the child adhere to dietary management. Considerable time
is spent in explaining to the child and parents the disease process, the specific role of gluten in
aggravating the condition, and those foods that must be restricted. Referral to a nutritionist
would help in this process. The most severe symptoms usually occur in early childhood and
adult life. Dietary avoidance of gluten should be lifelong. Celiac disease is not transmissible
or stress related.
155
What is the major focus of the therapeutic management for a child with lactose intolerance?
a. Compliance with the medication regimen
b. Providing emotional support to family members
c. Teaching dietary modifications
d. Administration of daily normal saline enemas
ANS: C
Simple dietary modifications are effective in the management of lactose intolerance.
Symptoms of lactose intolerance are usually relieved after instituting a lactose-free diet.
Medications are not typically ordered in the management of lactose intolerance. Providing
emotional support to family members is not specific to this medical condition. Diarrhea is a
manifestation of lactose intolerance. Enemas are contraindicated for this alteration in bowel
elimination.
156
```
What food choice by the parent of a 2-year-old child with celiac disease indicates a need for
further teaching?
a. Oatmeal
b. Rice cake
c. Corn muffin
d. Meat patty
```
ANS: A
The child with celiac disease is unable to fully digest gluten, the protein found in wheat,
barley, rye, and oats. Oatmeal contains gluten and is not an appropriate food selection. Rice is
an appropriate choice because it does not contain gluten. Corn is digestible because it does not
contain gluten. Meats do not contain gluten and can be included in the diet of a child with
celiac disease.
157
Which description of a stool is characteristic of intussusception?
a. Ribbon-like stools
b. Hard stools positive for guaiac
c. “Currant jelly” stools
d. Loose, foul-smelling stools
ANS: C
With intussusception, passage of bloody mucus-coated stools occurs. Pressure on the bowel
from obstruction leads to passage of “currant jelly” stools. Ribbon-like stools are
characteristic of Hirschsprung’s disease. Stools will not be hard. Loose, foul-smelling stools
may indicate infectious gastroenteritis.
158
What should the nurse stress in a teaching plan for the mother of an 11-year-old diagnosed
with ulcerative colitis?
a. Preventing the spread of illness to others
b. Nutritional guidance and preventing constipation
c. Teaching daily use of enemas
d. Coping with stress and avoiding triggers
ANS:D
Coping with the stress of chronic illness and the clinical manifestations associated with
ulcerative colitis (diarrhea, pain) are important teaching foci. Avoidance of triggers can help
minimize the impact of the disease and its effect on the child. Ulcerative colitis is not
infectious. Although nutritional guidance is a priority teaching focus, diarrhea is a problem
with ulcerative colitis, not constipation. Daily enemas are not part of the therapeutic plan of
care.
159
```
Careful hand washing before and after contact can prevent the spread of which condition in
day care and school settings?
a. Irritable bowel syndrome
b. Ulcerative colitis
c. Hepatic cirrhosis
d. Hepatitis A
```
ANS: D
Hepatitis A is spread person to person, by the fecal-oral route, and through contaminated food
or water. Good hand washing is critical in preventing its spread. The virus can survive on
contaminated objects for weeks. Irritable bowel syndrome is the result of increased intestinal
motility and is not contagious. Ulcerative colitis and cirrhosis are not infectious.
160
A mother shares with the clinic nurse that she has been giving her 4 year old the antidiarrheal
drug loperamide. What conclusion should the nurse arrive at based on knowledge of this
classification of drugs?
a. Not indicated
b. Indicated because it slows intestinal motility
c. Indicated because it decreases diarrhea
d. Indicated because it decreases fluid and electrolyte losses
ANS: A
Antimotility medications are not recommended for the treatment of acute infectious diarrhea.
These medications have adverse effects and toxicity, such as worsening of the diarrhea
because of slowing of motility and ileus, or a decrease in diarrhea with continuing fluid losses
and dehydration. Antidiarrheal medications are not recommended in infants and small
children.
161
Which vaccine is now recommended for the immunization of all newborns?
a. Hepatitis A vaccine
b. Hepatitis B vaccine
c. Hepatitis C vaccine
d. Hepatitis A, B, and C vaccines
ANS:B
Universal vaccination for hepatitis B is now recommended for all newborns. A vaccine is
available for hepatitis A, but it is not yet universally recommended. No vaccine is currently
available for hepatitis C. Only hepatitis B vaccine is recommended for newborns.
162
```
An infant diagnosed with pyloric stenosis experiences excessive vomiting that can result in
which condition?
a. Hyperchloremia
b. Hypernatremia
c. Metabolic acidosis
d. Metabolic alkalosis
```
ANS: D
Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen
ions. Chloride ions and sodium are lost with vomiting. Metabolic alkalosis, not acidosis, is
likely.
163
Which statements regarding hepatitis B are correct? (Select all that apply.)
a. Hepatitis B cannot exist in a carrier state.
b. Hepatitis B can be prevented by hepatitis B virus vaccine.
c. Hepatitis B can be transferred to an infant of a breastfeeding mother.
d. The onset of hepatitis B is insidious.
e. Immunity to hepatitis B occurs after one attack
ANS: B, C, D, E
The vaccine elicits the formation of an antibody to the hepatitis B surface antigen, which is
protective against hepatitis B. Hepatitis B can be transferred to an infant of a breastfeeding
mother, especially if the mother’s nipples are cracked. The onset of hepatitis B is insidious.
Immunity develops after one exposure to hepatitis B. Hepatitis B can exist in a carrier state
164
Which interventions should a nurse implement when caring for a child with hepatitis? (Select
all that apply.)
a. Provide a well-balanced, low-fat diet.
b. Schedule playtime in the playroom with other children.
c. Teach parents not to administer any over-the-counter medications.
d. Arrange for home schooling because the child will not be able to return to school.
e. Instruct parents on the importance of good hand washing.
ANS: A, C, E
The child with hepatitis should be placed on a well-balanced, low-fat diet. Parents should be
taught to not give over-the-counter medications because of impaired liver function. Hand
hygiene is the most important preventive measure for the spread of hepatitis. The child will be
in contact isolation in the hospital, so playtime with other hospitalized children is not
scheduled. The child will be on contact isolation for a minimum of 1 week after the onset of
jaundice. After that period, the child will be allowed to return to school.
