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Nicole Dela Torre ource: Lippincott Q&A Review for NCLEX-RN, 14th Edition
S he client:
T
Topic:Test 5 - The Adult with Upper Gastrointestinal Tract Health A. has a sore throat.
Problems B. has a temperature of 100°F (37.8°C).
C. appears drowsy following the procedure.
The Adult with Disorders of the Oral Cavity D. has epigastric pain.
E. experiences hematemesis.
. A nurse is caring for a client who has just returned from surgery to
1
treat a fractured mandible. The jaws are wired. What should the nurse 2. A client admitted to the hospital with peptic ulcer disease tells the
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do if the client begins to vomit? nurse about having black, tarry stools. What should the nurse do?
A. Administer an antiemetic as prescribed. A. Encourage the client to increase fluid intake.
B. Cut the wires, and assist the client to expectorate. B. Advise the client to avoid iron-rich foods.
C. Have the client sit up, bend over, and spit into an emesis basin. C. Place the client on contact precautions.
D. Insert a suction tube to clear the vomitus from the oral cavity. D. Report the finding to the health care provider (HCP).
. The nurse is teaching a client with stomatitis about managing oral
2 3. A client with peptic ulcer disease is taking cimetidine. What is the
1
discomfort. Which instruction is most appropriate? expected outcome of this drug?
A. Drink hot tea at frequent intervals. A. Heal the ulcer.
B. Gargle with an antiseptic mouthwash. B. Protect the ulcer surface from acids.
C. Use an electric toothbrush. C. Reduce acid concentration.
D. Eat a soft, bland diet. D. Limit gastric acid secretion.
. A client who has a history of bacterial endocarditis is scheduled to
3 4. A client with a peptic ulcer reports epigastric pain that frequently
1
have oral surgery to remove a tooth. What should the nurse instruct the causes the client to wake up during the night. The nurse should instruct
client to do? the client to take which action(s)? Select all that apply.
A. Gargle with a saline solution before the appointment. A. Obtain adequate rest to reduce stimulation.
B. Rinse the mouth with mouthwash the night before and the day of the B. Eat small, frequent meals throughout the day.
surgery. C. Take all medications on time as prescribed.
C. Contact the health care provider (HCP) to request a sedative. D. Sit up for 1 hour when awakened at night.
D. Be sure the dentist prescribes a prophylactic antibiotic before the E. Stay away from crowded areas.
oral surgery.
5. A client with peptic ulcer disease is taking omeprazole over the
1
. During the assessment of a client’s mouth, the nurse notes the
5 counter to relieve symptoms of stomach pain. The nurse should
absence of saliva. The client reports having pain behind the ear. The instruct the client that long-term use of this drug is a risk for which
client has been nothing-by-mouth (NPO) for several days but now can complication?
have liquids. What should the nurse do next? A. gastric bleeding
A. Request a prescription for an antifungal mouthwash. B. hip fracture
B. Instruct the client to brush the gums as well as the teeth. C. anemia
C. Encourage the client to suck on hard candy. D. dizziness
D. Give the client a hydrogen peroxide–based mouthwash.
6. The nurse is teaching a client with a peptic ulcer about the diet that
1
. The nurse is preparing a community presentation on oral cancer.
6 should be followed after discharge. What types of food should the
Which is a primary risk factor for oral cancer that the nurse should nurse suggest the client include in the diet?
emphasize in the presentation? A. bland foods
A. use of alcohol B. high-protein foods
B. frequent use of mouthwash C. any foods that are tolerated
C. lack of vitamin B12 D. a glass of milk with each meal
D. lack of regular teeth cleaning by a dentist
7. A client is diagnosed with peptic ulcer disease caused by
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. A client has early signs of oral cancer. What should the nurse
7 Helicobacter pylori infection. The client is following a 2-week drug
include in a focused assessment? Select all that apply. regimen that includes clarithromycin along with omeprazole and
A. an infection or inflammation in the mouth amoxicillin. How should the nurse instruct the client to take these
B. lost the sense of taste medications?
C. difficulty swallowing A. Alternate the use of the drugs.
D. significant weight loss B. Take the drugs at different times during the day.
E. changes in the frequency of urination C. Discontinue all drugs if nausea occurs.
F. numbness of the tongue D. Take the drugs for the entire 2-week period.
. Following surgery to set a fractured mandible, the client has swelling
8 8. A client with peptic ulcer disease is admitted to the hospital for a
1
at the surgery site. What is the priority goal of nursing care? gastric resection. The client reports a sudden sharp pain in the
A. Prevent nausea and vomiting. midepigastric area that radiates to the shoulder. What should the nurse
B. Maintain a patent airway. do first?
C. Provide frequent oral hygiene. A. Establish an intravenous (IV) line.
D. Establish a way for the client to communicate. B. Administer pain medication.
C. Notify the surgeon.
he Adult with Peptic Ulcer Disease
T D. Call for a stat electrocardiogram (ECG).
9. A client is admitted to the hospital after vomiting bright red blood and
is diagnosed with a bleeding duodenal ulcer. The client develops a 9. A client is to take one daily dose of ranitidine at home to treat a
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sudden, sharp pain in the midepigastric region along with a rigid, peptic ulcer. Which response from the client indicates that the client
boardlike abdomen. After obtaining the client’s vital signs, what should understands how to take the medication? “I’ll take the drug:
the nurse do next? A. before meals.”
A. Administer pain medication as prescribed. B. with meals.”
B. Raise the head of the bed. C. at bedtime.”
C. Prepare to insert a nasogastric tube. D. when pain occurs.”
D. Notify the health care provider (HCP).
0. A client has been taking aluminum hydroxide 30 mL six times per
2
0. The nurse is obtaining a nursing history from a client with a
1 day at home to treat a peptic ulcer. The client has been unable to have
suspected gastric ulcer. Which sign(s) or symptom(s) should the nurse a bowel movement for 3 days. What should the nurse determine is the
assess? Select all that apply. most likely cause of the client’s constipation?
A. epigastric pain at night A. The client has not been including enough fiber in the diet.
B. relief of epigastric pain after eating B. The client needs to increase daily exercise.
C. vomiting C. The client is experiencing an adverse effect of aluminum hydroxide.
D. weight loss D. The client has developed a gastrointestinal obstruction.
E. melena
he Adult with Cancer of the Stomach
T
1. The nurse is caring for a client who has had a gastroscopy. Which
1 21. The nurse is assessing a client who is being admitted to the
finding(s) indicate that the client is developing a complication hospital with upper gastrointestinal (GI) bleeding. Which finding(s) are
related to the procedure? Select all that apply. significant? Select all that apply.
. dry, flushed skin
A . has resumed their normal dietary intake of three meals a day.
B
B. decreased urine output C. has controlled nausea and vomiting through regular use of
C. tachycardia antiemetics.
D. widening pulse pressure D. has achieved adequate nutritional status through oral or parenteral
E. rapid respirations feedings.
F. thirst
he Adult with Gastroesophageal Reflux Disease
T
2. A client with cancer of the stomach had a total gastrectomy 2 days
2 33. A client is experiencing gastroesophageal reflux. What should the
earlier. Which finding indicates the client is ready to try a liquid diet? nurse teach the client about managing reflux?
The client: A. Limit caffeine intake to two cups of coffee per day.
A. is hungry. B. Do not lie down for 2 hours after eating.
B. took pain medication 2 hours ago. C. Follow a low-protein diet.
C. has frequent bowel sounds. D. Take medications with milk to decrease irritation.
D. has had a bowel movement.
4. The client is scheduled to have an upper gastrointestinal tract
3
3. Within 6 hours following a subtotal gastrectomy, the drainage from
2 series of x-rays. Following the x-rays, what should the nurse instruct
the client’s nasogastric (NG) tube is bright red. What should the nurse the client to do?
do first? A. Take a laxative.
A. Clamp the NG tube. B. Follow a clear liquid diet.
B. Remove the existing NG tube. C. Administer an enema.
C. Irrigate the NG tube with iced saline. D. Take an antiemetic.
D. Chart the finding in the client’s medical record.
5. A client who has been diagnosed with gastroesophageal reflux
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4. Since receiving a diagnosis of stomach cancer, a client has been
2 disease (GERD) has heartburn. To decrease the heartburn, the nurse
having trouble sleeping and is frequently preoccupied with thoughts should instruct the client to eliminate which item from the diet?
about how life will change. The client says, “I wish my life could stay lean beef
the same.” The nurse determines that the client is experiencing which air-popped popcorn
problem? hot chocolate
A. having difficulty coping raw vegetables
B. experiencing a sleep disorder
C. going through a grieving process 6. The client with gastroesophageal reflux disease (GERD) has a
3
D. showing signs of anxiety disorder chronic cough. The nurse should further assess the client for which
other possible problem?
5. A client has had a subtotal gastrectomy and has a nasogastric tube
2 A. development of laryngeal cancer
with intermittent suction. Twenty-four hours after the surgery, the B. irritation of the esophagus
drainage in the client’s nasogastric tube is dark brown. What should C. esophageal scar tissue formation
the nurse do? D. aspiration of gastric contents
A. Reassure the client that this is normal drainage.
B. Irrigate the nasogastric tube. 7. The health care provider (HCP) has prescribed bethanechol for a
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C. Notify the health care provider (HCP). client with gastroesophageal reflux disease (GERD). The nurse should
D. Discontinue the suction. assess the client for which adverse effect?
A. constipation
6. Following a subtotal gastrectomy, a client has a nasogastric (NG)
2 B. urinary urgency
tube connected to low suction. What should the nurse do? C. hypertension
A. Irrigate the tube with 30 mL of sterile water every hour, if needed. D. dry oral mucosa
B. Reposition the tube if it is not draining well.
C. Monitor the client for nausea, vomiting, and abdominal distention. 8. The nurse is developing a care management plan with a client who
3
D. Change to high suction if the drainage is sluggish on low suction. has been diagnosed with gastroesophageal reflux disease (GERD).
What should the nurse instruct the client to do? Select all that apply.
8. The client has just returned to the nursing unit following a
2 A. Avoid a diet high in fatty foods.
gastrectomy. The nurse should place the client in which position? B. Avoid beverages that contain caffeine.
A. prone C. Eat three meals a day, with the largest meal being at dinner in the
B. supine evening.
C. low Fowler D. Avoid all alcoholic beverages.
D. lateral recumbent E. Lie down after consuming each meal for 30 minutes.
F. Use over-the-counter (OTC) antisecretory agents rather than
9. The nurse is teaching a client who had a gastrectomy how to
2 prescriptions.
reduce the risk for dumping syndrome. What should the nurse teach
the client to do? 9. The nurse is obtaining a health history from a client who has a
3
A. Sit upright for 30 minutes after meals. sliding hiatal hernia associated with reflux. The nurse should ask the
B. Drink liquids with meals, avoiding caffeine. client about the presence of which symptom?
C. Avoid milk and other dairy products. A. heartburn
D. Decrease the carbohydrate content of meals. B. jaundice
C. anorexia
0. A client who is recovering from a subtotal gastrectomy experiences
3 D. stomatitis
dumping syndrome and is to eat six small meals a day. The client asks
the nurse, “When will I be able to eat three meals a day again like I 0. The nurse is obtaining a health history for an adult with a possible
4
used to?” Which response by the nurse is most appropriate? hiatal hernia. Which is a risk factor for this client that would most likely
A. “Eating six meals a day is time-consuming, isn’t it?” contribute to the development of a hiatal hernia?
B. “You will have to eat six small meals a day for the rest of your life.” A. having a sedentary desk job
C. “You will be able to tolerate three meals a day before you are B. being 5 feet, 3 inches tall (160 cm) and weighing 190 lb (86.2 kg)
discharged.” C. using laxatives frequently
D. “Most clients can resume their normal meal patterns in about 6 to 12 D. being 40 years old
months.”
1. The nurse is developing a teaching plan with a client who has a
4
1. After a gastric resection for a malignant tumor, a client is scheduled
3 hiatal hernia. What action should the nurse take that would be most
to undergo radiation therapy. What is the most important information helpful in promoting behavior changes for this client?
the nurse should include in the discharge teaching plan? A. Introduce the client to other people who are successfully managing
A. how to maintain adequate nutrition their care.
B. what do for alopecia B. Include the client’s daughter in the teaching so that they can help
C. how to exercise to attain activity goals implement the plan.
D.where to access community resources C. Ask the client to identify other situations in which the client changed
health care habits.
2. One month following a subtotal gastrectomy for cancer, the nurse is
3 D. Provide reassurance that the client will be able to implement all
evaluating the nursing care goal related to improved nutrition. What aspects of the plan successfully.
indicates that the client has attained the goal? The client:
A. has regained weight loss.
2. The client has been taking magnesium hydroxide (milk of
4 very 30 minutes for 2 hours after the procedure. The nurse assigns an
e
magnesia) to control symptoms of a hiatal hernia. The nurse should unlicensed assistive personnel (UAP) to take the vital signs. One hour
assess the client for which condition that is most commonly associated later, the UAP reports the client, who was previously afebrile, has
with the ongoing use of magnesium-based antacids? developed a temperature of 101.8°F (38.8°C). What should the nurse
A. anorexia do next?
B. weight gain A. Promptly assess the client for potential perforation.
C. diarrhea B. Tell the assistant to change thermometers and retake the
D. constipation temperature.
C. Plan to give the client acetaminophen to lower the temperature.
3. The nurse is teaching a client about managing a hiatal hernia.
4 D. Ask the UAP to bathe the client with tepid water.
Which lifestyle modification should the nurse encourage the client with
a hiatal hernia to include in activities of daily living? 2. Which hospitalized client is at risk for developing parotitis?
5
A. engaging in daily aerobic exercise A. a 50-year-old client with nausea and vomiting who is on
B. eliminating smoking and alcohol use nothing-by-mouth status
C. balancing activity and rest B. a 75-year-old client with diabetes who has ill-fitting dentures
D. avoiding high-stress situations C. an 80-year-old client who has poor oral hygiene and is dehydrated
D. a 65-year-old client with lung cancer who has a feeding tube in
4. The nurse is developing a teaching plan for the client with a hiatal
4 place
hernia. Asking the client about which work-related factors would be
most helpful when teaching this client? 3. The nurse instructs the unlicensed assistive personnel (UAP) on
5
A. number and length of breaks how to provide oral hygiene for clients who cannot perform this task for
B. body mechanics used in lifting themselves. Which technique should the nurse ask the UAP to
C. temperature in the work area incorporate into the client’s daily care?
D. cleaning solvents used A. Assess the oral cavity each time mouth care is given and record
observations.
5. The nurse is instructing the client about health maintenance
4 B. Use a soft toothbrush to brush the client’s teeth after each meal.
activities to help control symptoms from a hiatal hernia. Which C. Swab the client’s tongue, gums, and lips with a soft foam applicator
statement would indicate that the client has understood the every 2 hours.
instructions? D. Rinse the client’s mouth with mouthwash several times a day.
A. “I will avoid lying down after a meal.”
B. “I can still enjoy my potato chips and cola at bedtime.” 4. The nurse is developing standards of care for a client with
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C. “I wish I did not have to give up swimming.” gastroesophageal reflux disease and wants to review current evidence
D. “If I wear a girdle, I will have more support for my stomach.” for practice. Which resource will provide the most helpful information?
A. a review in the Cochrane Library
6. The nurse is teaching the client with a hiatal hernia about taking
4 B. a literature search in a database, such as the Cumulative Index to
metoclopramide hydrochloride. Which medication should the client Nursing and Allied Health Literature (CINAHL)
avoid while taking this drug? C. an online nursing textbook
A. antacids D. the policy and procedure manual at the health care agency
B. antihypertensives
C. anticoagulants 5. The nurse in the intensive care unit is giving a hand-off of care
5
D. central nervous system depressants report to the nurse in the postsurgical unit about a client who had a
gastrectomy. What is the most effective way for the nurse to assure
7. A client is taking cimetidine to treat a hiatal hernia. The nurse
4 essential information about the client is reported?
should evaluate the client to determine whether the drug has been A. Give the report face to face with both nurses in a quiet room.
effective in preventing which health problem? B. Audiotape the report for future reference and documentation.
A. esophageal reflux C. Use a checklist with information individualized for the client.
B. dysphagia D. Document essential transfer information in the client’s electronic
C. esophagitis health record.
D. ulcer formation
6. A nurse is delegating activities to unlicensed assistive personnel
5
8. The client asks the nurse if surgery is needed to correct a hiatal
4 (UAP). Which action(s) can be appropriately delegated? Select all that
hernia. Which reply by the nurse would be most accurate? apply.
A. “Surgery is usually required, though medical treatment is attempted A. Assist a client with oral care prior to breakfast.
first.” B. Ask about the location, quality, and radiation of pain.
B. “Hiatal hernia symptoms can usually be successfully managed with C. Observe and document the effect of medication after it is
diet modifications, medications, and lifestyle changes.” administered by the nurse.
C. “Surgery is not performed for this type of hernia.” D. Measure and record intake and output throughout the shift.
D. “A minor surgical procedure to reduce the size of the diaphragmatic E. Determine if the client is oriented to person, place, and time, and
opening will probably be planned.” report findings to the nurse.
F. Change a simple dry dressing on a client’s coccyx while bathing.
anaging Care, Quality, and Safety of Adults with Upper
M
Gastrointestinal Tract Health Problems 7. The nurse is making staffing assignments. Which client can be
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49. A client has returned from surgery during which the jaws were assigned to an unlicensed assistive personnel (UAP)?
wired as treatment for a fractured mandible. The client is in stable A. a client with stomatitis who requires instruction about mouth care
condition. The nurse is instructing the unlicensed assistive personnel before discharge
(UAP) on how to properly position the client. Which instruction about B. a client who is having radiation for cancer of the stomach and is to
positioning would be appropriate for the nurse to give the UAP? have the radiation site bathed with warm water, followed by an
A. Keep the client in a side-lying position with the head slightly application of a moisturizer
elevated. C. a client who had a gastric resection and has a nasogastric tube
B. Do not reposition the client without the assistance of a registered draining bright red blood
nurse (RN). D. a client who had abdominal surgery and requires wet-to-dry
C. The client can assume any position that is comfortable. dressing changes
D. Keep the client’s head elevated on two pillows at all times.
0. The nurse has been assigned to provide care for four clients. In
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what order, from first to last, should the nurse assess these clients? All
options must be used.
A. a client awaiting surgery for a hiatal hernia repair at 1100
B. a client with suspected gastric cancer who is on nothing-by-mouth
(NPO) status for tests
C. a client with peptic ulcer disease experiencing a sudden onset of
acute pain
D. a client who is requesting pain medication 2 days after surgery to
repair a fractured jaw
1. The nurse is caring for a client who has just had an upper
5
gastrointestinal (GI) endoscopy. The client’s vital signs must be taken
answer key nxiety, and the nurse would anticipate that the client will be drowsy
a
.C. Following surgery for a fractured mandible, the client’s jaws will
1 following the procedure.
be wired. The nurse should be prepared to intervene quickly in case 12.D. Black, tarry stools are an important warningsign of bleeding in
the client develops respiratory distress or begins to choke or vomit. If peptic ulcer disease. Digested blood in the stool causes it to be black;
the client begins to vomit, the nurse should assist the client to a sitting the odor of the stool is very offensive. The nurse should instruct the
position and have the client bend over and expectorate the emesis into client to report the incidence of black stools promptly to the HCP.
an emesis basin. Wire cutters or scissors should always be available in Increasing fluids or avoiding iron-rich foods will not change the stool
case the wires need to be cut in a medical emergency, but they are color or consistency if the stools contain digested blood. Until other
only used if the client cannot breathe or is choking. Suction equipment information is available, it is not necessary to initiate contact
should be available to help clear the client’s airway if necessary, but precautions.
this is not the first course of action. The nurse should administer the 13.D. Histamine-2 (H2 ) receptor antagonists, such as cimetidine,
antiemetic if the client reports nausea, but the drug will not be effective reduce gastric acid secretion. Antisecretory drugs, or proton pump
if the client is already vomiting. inhibitors, such as omeprazole, help ulcers heal quickly in 4 to 8
2.D. Clients with stomatitis (inflammation of the mouth) have weeks. Cytoprotective drugs, such as sucralfate, protect the ulcer
significant discomfort, which impacts their ability to eat and drink. They surface against acid, bile, and pepsin. Antacids reduce acid
will be most comfortable eating soft, bland foods and avoiding concentration and help reduce symptoms.
temperature extremes in their food and liquids. Gargling with an 14.A, B, C, D.The nurse should encourage the client to reduce
antiseptic mouthwash will be irritating to the mucosa. Mouth care stimulation that may enhance gastric secretion. The nurse can also
should include gentle brushing with a soft toothbrush and flossing. advise the client to utilize health practices that will prevent recurrences
3.D. Clients who are at risk for developing infective endocarditis due to of ulcer pain, such as avoiding fatigue and eliminating smoking. Eating
cardiac conditions such as a history of bacterial endocarditis must take small, frequent meals helps to prevent gastric distention if not actively
prophylactic antibiotics before any dental procedure that may cause bleeding and decreases distention and release of gastrin. Medications
bleeding. Gargling with saline or using mouthwash is not sufficient to should be administered promptly to maintain optimum levels. After
prevent infection. The client will not need a sedative prior to the awakening during the night, the client should eat a small snack and
surgery. return to bed, keeping the head of the bed elevated for an hour after
5.C. The lack of saliva, pain near the area of theear, and the eating. It is not necessary to stay away from crowded areas.
prolonged NPO status of the client are indications that the client may 15.B. Long-term use of proton pump inhibitors such as omeprazole is
be developing parotitis, or inflammation of the parotid gland. Parotitis a risk factor for fractures, particularly in the hip, spine, and wrist, and
usually develops with dehydration combined with poor oral hygiene or the nurse should instruct the client about this risk, particularly if the
when clients have been NPO for an extended period. Preventive client is taking the drug in high doses. This drug does not contribute to
measures include the use of sugarless hard candy or gum to stimulate gastric bleeding, anemia, or dizziness.
saliva production, adequate hydration, and frequent mouth care. The 16.C. Diet therapy for ulcer disease is a controversial issue. There is
client does not have indications of stomatitis (inflammation of the no scientific evidence that diet therapy promotes healing. Most clients
mouth), which produces excessive salivation and a sore mouth. The are instructed to follow a diet that they can tolerate. There is no need
client does not have indications of oral candidiasis (thrush), which for the client to ingest only a bland or high-protein diet. Milk may be
causes bluish-white mouth lesions, and the nurse does not need to included in the diet, but it is not recommended in excessive amounts.
request a prescription for an antifungal mouthwash. There are no 17.D. The use of the triple-therapy approach to theH. pylori infection
indications that the client has gingivitis, which can be recognized by the has proved effective; therefore, the nurse advises the client to take the
inflamed gingiva and bleeding that occur during toothbrushing, and drugs as prescribed for the duration of the prescription. The nurse
while the client should brush the teeth and gums, increasing salivation instructs the client to avoid alternating the use of the drugs and to take
to prevent parotitis is the priority at this time. all medication at the same time, three times a day unless otherwise
6.A. Chronic and excessive use of alcohol can lead to oral cancer. noted by the health care provider (HCP). Drugs have very few side
Smoking and the use of smokeless tobacco are other significant risk effects; however, the nurse instructs the client to continue taking
factors. Additional risk factors include chronic irritation such as a medications and contact the HCP if adverse effects occur.
broken tooth or ill-fitting dentures, poor dental hygiene, overexposure 18.C. The sharp, sudden midepigastric pain indicates the client may
to the sun (lip cancer), and syphilis. Use of mouthwash, lack of vitamin have a perforated ulcer. The nurse notifies the surgeon and may then
B12, and lack of regular teeth cleaning appointments have not been obtain prescriptions for pain medication and IV fluids. It is not
implicated as primary risk factors for oral cancer necessary to first obtain an ECG because the pain from ulcer
7.A, C, E, F. The nurse is conducting a focused assessment of the perforation is different from that of chest pain that may indicate
client’s mouth and ability to obtain nutrition. Therefore, the nurse coronary artery syndrome (crushing pain radiating to the jaw).
focuses on inspecting the mouth for infection or inflammation, 19.C. Ranitidine blocks the secretion of hydrochloricacid. Clients who
determining if the client has difficulty swallowing, and assuring nutrition take only one daily dose of ranitidine are usually advised to take it at
by noting weight loss. A sign of oral cancer is numbness of the tongue; bedtime to inhibit the nocturnal secretion of acid. Clients who take the
losing a sense of taste is not an early sign of oral cancer. Urinary drug twice a day are advised to take it in the morning and at bedtime. It
output, while important, is not a part of a focused assessment for this is not necessary to take the drug before meals. The client should take
health problem. the drug regularly, not just when pain occurs.
8.B. The priority of care in the immediate postoperative phase is to 20.C. It is most likely that the client is experiencing an adverse effect
maintain a patent airway. The nurse should observe the client carefully of the antacid. Antacids with aluminum salt products, such as
for signs of respiratory distress. If the client becomes nauseated, aluminum hydroxide, form insoluble salts in the body. These precipitate
antiemetics should be administered to decrease the chance of vomiting and accumulate in the intestines, causing constipation. Increasing
with obstruction of the airway and aspiration of vomitus. Providing dietary fiber intake or daily exercise may be a beneficial lifestyle
frequent oral hygiene and an alternative means of communication are change for the client but is not likely to relieve constipation caused by
important aspects of nursing care, but maintaining a patent airway is the aluminum hydroxide. Constipation, in isolation from other
most important. symptoms, is not a sign of a bowel obstruction.
9.D. The client is experiencing a perforation ofthe ulcer, and the nurse 21.B, C, E, F. The client who is experiencing upperGI bleeding is at
should notify the HCP immediately. The body reacts to the perforation risk for developing hypovolemic shock from blood loss. Therefore, the
of an ulcer by immobilizing the area as much as possible. This results signs and symptoms the nurse should expect to find are those related
in boardlike abdominal rigidity, usually with extreme pain. Perforation is to hypovolemia, including decreased urine output, tachycardia, rapid
a medical emergency requiring immediate surgical intervention respirations, and thirst. The client’s skin would be cool and clammy, not
because peritonitis develops quickly after perforation. Administering dry, and flushed. The client would also be likely to develop
pain medication is not the first action, though the nurse should later hypotension, which would lead to a narrowing pulse pressure, not a
institute measures to relieve pain. Elevating the head of the bed will not widening pulse pressure.
minimize the perforation. A nasogastric tube may be used following 22.C. The client can begin eating with a liquid diet when bowel sounds
surgery return, usually in 2 to 3 days. The client may be hungry but cannot
10.C, D, E.Vomiting and weight loss are common with gastric ulcers. have oral fluids or foods until intestinal motility has been established.
The client may also have blood in the stools (melena) from gastric The client may continue to have postoperative pain for several days;
bleeding. Clients with a gastric ulcer are most likely to have a burning because receiving a liquid diet does not depend on the client being
epigastric pain that occurs about 1 hour after eating. Eating frequently pain free, the nurse can continue to offer pain medication. The client
aggravates the pain. Clients with duodenal ulcers are more likely to does not have to experience a bowel movement to receive fluids and
have pain that occurs during the night and is frequently relieved by food
eating. 23.D. NG drainage is expected to be bright red during the first 12
11.B, D, E.Following a gastroscopy, the nurse should monitor the hours after surgery and then darken within 24 hours. The nurse notes
client for complications, which include perforation and the potential for the color of the drainage on the medical record and then monitors the
aspiration. An elevated temperature, epigastric pain, or the vomiting of change of color of the drainage throughout the immediate
blood (hematemesis) are all indications of a possible perforation and postoperative period. To prevent stress on the suture line, NG suction
should be reported promptly. A sore throat is a common occurrence is applied, and patency of the tube is maintained. Removal of the NG
following a gastroscopy. Clients are usually sedated to decrease tube may traumatize the surgical site. The NG tube is irrigated only if
the health care provider prescribes irrigation because there is a danger nd low in fat is recommended for clients with GERD. Lean beef,
a
of injury to the suture line; saline at room temperature is usually popcorn, and raw vegetables would be acceptable.
prescribed. 36.D. Clients with GERD can develop pulmonary symptoms, such as
24.C. The client is going through the grieving processas they adjust to coughing, wheezing, and dyspnea, that are caused by the aspiration of
the diagnosis. There are no indications of inadequate coping as the gastric contents. GERD does not predispose the client to the
client is able to verbalize concerns. The client may be having thoughts development of laryngeal cancer. Irritation of the esophagus and
about their new health status, but there is no indication that the client esophageal scar tissue formation can develop as a result of GERD.
has a sleep disorder or has signs of an anxiety disorder. However, GERD is more likely to cause painful and difficult swallowing.
25.A. About 12 to 24 hours after a subtotal gastrectomy, gastric 37.B. Bethanechol, a cholinergic drug, may be used in GERD to
drainage is normally brown, which indicates digested blood; the nurse increase lower esophageal sphincter pressure and facilitate gastric
can reassure the client that this is a normal color. The nasogastric tube emptying. Cholinergic adverse effects may include urinary urgency,
does not need to be irrigated as it is draining normally. It is not diarrhea, abdominal cramping, hypotension, and increased salivation.
necessary to notify the HCP unless the drainage contains bright red To avoid these adverse effects, the client should be closely monitored
blood. The nurse should continue the suction until the HCP indicates to to establish the minimum effective dose.
discontinue, usually when the drainage has stopped. 38.A,B,D. No specific diet is necessary, but foods that cause reflux
26.C. Nausea, vomiting, or abdominal distention indicates that gas are avoided, including fatty foods (which decrease the rate of gastric
and secretions are accumulating within the gastric pouch due to emptying) and foods that decrease lower esophageal sphincter
impaired peristalsis or edema at the operative site and may indicate pressure such as chocolate, peppermint, coffee, and tea. The client
that the drainage system is not working properly. Saline is used to should also avoid alcohol. The client should not lie down for 3 to 4
irrigate NG tubes. Hypotonic solutions such as water increase hours after eating. Antisecretory agents decrease the secretion of
electrolyte loss. In addition, a health care provider’s (HCP) prescription hydrochloric acid by the stomach; some are available in both OTC and
is needed to irrigate the NG tube because this procedure could disrupt prescription formulations, but the OTC preparations have lower drug
the suture line. After gastric surgery, only the surgeon repositions the dosages compared with prescription drugs. Cimetidine, ranitidine,
NG tube because of the danger of rupturing or dislodging the suture famotidine, and nizatidine are available in both formulations.
line. The amount of suction varies with the type of tube used and is 39.A. Heartburn, the most common symptom of a sliding hiatal hernia,
prescribed by the HCP. High suction may create too much tension on results from reflux of gastric secretions into the esophagus.
the gastric suture line. Regurgitation of gastric contents and dysphagia are other common
28.C. A client who has had abdominal surgery is bestplaced in a low symptoms. Jaundice, which results from a high concentration of
Fowler position postoperatively. This positioning relaxes abdominal bilirubin in the blood, is not associated with hiatal hernia. Anorexia is
muscles and provides for maximum respiratory and cardiovascular not a typical symptom of a hiatal hernia. Stomatitis is inflammation of
function. The prone, supine, or lateral recumbent position would not be the mouth.
tolerated by a client who has had abdominal surgery, nor do those 40.B. Any factor that increases intra-abdominal pressure, such as
positions support respiratory or cardiovascular functioning. obesity, can contribute to the development of a hiatal hernia. Other
29.D. Carbohydrates are restricted, but protein, including meat and factors include abdominal straining, frequent heavy lifting, and
dairy products, is recommended because it is digested more slowly. pregnancy. Hiatal hernia is also associated with older age and occurs
Lying down for 30 minutes after a meal is encouraged to slow the in women more frequently than in men. Having a sedentary desk job,
movement of the food bolus. Fluids are restricted to reduce the bulk of using laxatives frequently, or being 40 years old is not likely to be a
food. There is no need to avoid caffeine. contributing factor in the development of a hiatal hernia.
30.D. The symptoms related to dumping syndrome that occur after a 41.C. Self-responsibility is the key to individual health maintenance.
gastrectomy usually disappear by 6 to 12 months after surgery. Most Using examples of situations in which the client has demonstrated
clients can begin to resume normal meal patterns after signs of the self-responsibility can be reinforcing and supporting. The client has
dumping syndrome have stopped. Acknowledging that eating six meals ultimate responsibility for personal health habits. Meeting other people
a day is time-consuming does not address the client’s question and who are managing their care and involving family members can be
makes an assumption about the client’s concerns. It is not necessarily helpful, but individual motivation is more important. Reassurance can
true that a six-meal-a-day dietary pattern will be required for the rest of be helpful but is less important than individualization of care
the client’s life. Clients will not be able to eat three meals a day before 42.C. The magnesium salts in magnesium hydroxide are related to
hospital discharge those found in laxatives and may cause diarrhea. Aluminum salt
31.A. Clients who have had gastric surgery are prone to products can cause constipation. Many clients find that a combination
postoperative complications, such as dumping syndrome and product is required to maintain normal bowel elimination. The use of
postprandial hypoglycemia, which can affect nutritional intake. Vitamin magnesium hydroxide does not cause anorexia or weight gain.
absorption can also be an issue, depending on the extent of the gastric 43.B. Smoking and alcohol use both reduce esophagealsphincter
surgery. Radiation therapy to the upper gastrointestinal area also can tone and can result in reflux. They therefore should be avoided by
affect nutritional intake by causing anorexia, nausea, and esophagitis. clients with hiatal hernia. Daily aerobic exercise, balancing activity and
The client would not be expected to develop alopecia. Exercise and rest, and avoiding high-stress situations may increase the client’s
activity levels as well as access to community resources are important general health and well-being, but they are not directly associated with
teaching areas, but nutritional intake is a priority need. hiatal hernia.
32.D. An appropriate expected outcome is for the client to achieve 44.B. Bending, especially after eating, can cause gastroesophageal
optimal nutritional status through the use of oral feedings or total reflux. Lifting heavy objects increases intra-abdominal pressure.
parenteral nutrition (TPN). TPN may be used to supplement oral Assessing the client’s lifting techniques enables the nurse to evaluate
intake, or it may be used alone if the client cannot tolerate oral the client’s knowledge of factors contributing to hiatal hernia and how
feedings. The client would not be expected to regain lost weight within to prevent complications. The number and length of breaks, the
1 month after surgery or to tolerate a normal dietary intake of three temperature in the work area, and the cleaning solvents used are not
meals a day. Nausea and vomiting would not be considered an directly related to the treatment of hiatal hernia.
expected outcome of gastric surgery, and regular use of antiemetics 45.A. A client with a hiatal hernia should avoid the recumbent position
would not be anticipated. immediately after meals to minimize gastric reflux. Bedtime snacks, as
33.B. The nurse should instruct the client to not lie down for about 2 well as high-fat foods and carbonated beverages, should be avoided.
hours after eating to prevent reflux. Caffeinated beverages decrease Excessive vigorous exercise also should be avoided, especially after
pressure in the lower esophageal sphincter, and milk increases gastric meals, but there is no reason why the client must give up swimming.
acid secretion, so these beverages should be avoided. The client is Wearing tight, constrictive clothing such as a girdle can increase
encouraged to follow a high-protein, low-fat diet and avoid foods that intra-abdominal pressure and thus lead to reflux of gastric juices.
are irritating. 46.D. Metoclopramide hydrochloride can cause sedation. Alcohol and
34.A. The client should take a laxative after an upper gastrointestinal other central nervous system depressants add to this sedation. A client
series to stimulate a bowel movement. This examination involves the who is taking this drug should be cautioned to avoid driving or
administration of barium, which must be promptly eliminated from the performing other hazardous activities for a few hours after taking the
body because it may harden and cause an obstruction. A clear liquid drug. Clients may take antacids, antihypertensives, and anticoagulants
diet would have no effect on stimulating the removal of the barium. The while on metoclopramide.
client should not have nausea, and an antiemetic would not be 47.C. Cimetidine is a histamine receptor antagonist that decreases the
necessary; additionally, the antiemetic will decrease peristalsis and quantity of gastric secretions. It may be used in hiatal hernia therapy to
increase the likelihood of eliminating the barium. An enema would be prevent or treat the esophagitis and heartburn associated with reflux.
ineffective because the barium is too high in the gastrointestinal tract. Cimetidine is not used to prevent reflux, dysphagia, or ulcer
35.C. With GERD, eating substances that decrease lower esophageal development.
sphincter pressure causes heartburn. A decrease in the lower 48.B. Most clients can be treated successfully with a combination of
esophageal sphincter pressure allows gastric contents to reflux into the diet restrictions, medications, weight control, and lifestyle
lower end of the esophagus. Foods that can cause a decrease in modifications. Surgery to correct a hiatal hernia, which commonly
esophageal sphincter pressure include fatty foods, chocolate, produces complications, is performed only when medical therapy fails
caffeinated beverages, peppermint, and alcohol. A diet high in protein to control the symptoms.
9.A. Immediately after surgery, the client should be placed on the
4
side with the head slightly elevated. This position helps facilitate the
removal of secretions and decreases the likelihood of aspiration should
vomiting occur. An RN does not need to be present to reposition the
client unless the client’s condition warrants the presence of the nurse.
Although it is important to elevate the head, there is no need to keep
the client’s head elevated on two pillows unless that position is
comfortable for the client
50.C,D,B,A. The client with peptic ulcer disease who is experiencing
a sudden onset of acute stomach pain should be assessed first by the
nurse. The sudden onset of stomach pain could be indicative of a
perforated ulcer, which would require immediate medical attention. It is
also important for the nurse to thoroughly assess the nature of the
client’s pain. The client with the fractured jaw is experiencing pain and
should be assessed next. The nurse should then assess the client who
is NPO for tests to ensure NPO status and comfort. Last, the nurse can
assess the client before surgery.
51.A. A sudden spike in temperature following an endoscopic
procedure may indicate perforation of the GI tract. The nurse should
promptly conduct a further assessment of the client, looking for further
indicators of perforation, such as a sudden onset of acute upper
abdominal pain; a rigid, boardlike abdomen; and developing signs of
shock. Telling the assistant to change thermometers is not an
appropriate action and only further delays the appropriate action of
assessing the client. The nurse would not administer acetaminophen
without further assessment of the client or without a health care
provider’s prescription; a suspected perforation would require that the
client be placed on nothing-by-mouth status. Asking the assistant to
bathe the client before any assessment by the nurse is inappropriate.
52.C. Parotitis is inflammation of the parotid gland.Although any of the
clients listed could develop parotitis, given the data provided, the one
most likely to develop parotitis is the older adult client who is
dehydrated with poor oral hygiene. Any client who experiences poor
oral hygiene is at risk for developing parotitis. To help prevent parotitis,
it is essential for the nurse to ensure the client receives oral hygiene at
regular intervals and has an adequate fluid intake.
53.B. A soft toothbrush should be used to brush theclient’s teeth after
every meal and more often as needed. Mechanical cleaning is
necessary to maintain oral health, stimulate gingiva, and remove
plaque. Assessing the oral cavity and recording observations are the
responsibilities of the nurse, not of the UAP. Swabbing with a safe
foam applicator does not provide enough friction to clean the mouth.
Mouthwash can be a drying irritant and is not recommended for
frequent use.
54.A. The Cochrane Library provides systematic reviewsof health
care interventions and will provide the best resource for evidence for
nursing care. The CINAHL offers keyword searches to published
articles in nursing and allied health literature, but not reviews. A
nursing textbook has information about nursing care, which may
include evidence-based practices, but textbooks may not have the
most up-to-date information. While the policy and procedure manual
may be based on evidence-based practices, the most current practices
will be found in evidence-based reviews of literature.
55.C. Using a checklist assures that all key information is reported; the
checklist can then serve as a record to which nurses can refer later.
Giving a verbal report leaves room for error in memory; using an
audiotape or an electronic health record requires nurses to spend
unnecessary time retrieving information.
56.A,D. Although the nurse is still responsiblefor following up to
make sure oral care is completed and accurate intake and output is
ongoing, these are appropriate tasks to delegate to UAP. Evaluating
the level of consciousness (orientation), pain, and the effect of
medications given by the nurse requires nursing judgment and should
not be delegated to UAP. Although UAP often assists clients with
bathing, dressing changes are not delegated to UAP as the wound
should be assessed by a nurse while changing the dressing.
57.B. The care of the client who is having radiation treatments and
who requires skin care at the site that involves bathing and application
of a non medicated moisturizer is within the scope of practice for the
UAP. Discharge planning, assessing drainage, and changing wet-to dry
dressings are nursing care activities that must be performed by a
licensed nurse.
Topic:Test 6 - The Adult with Lower Gastrointestinal Tract Health . The nurse is instructing the client with a new colostomy about
9
Problems protecting the skin around the colostomy. Which skin barrier should the
nurse tell the client is best to apply around the colostomy?
he Adult with Cancer of the Colon
T A. adhesive skin barrier
1. A client refuses to look at or care for their colostomy. Which B. petroleum jelly
statement by the nurse would be most appropriate? C. cornstarch
A. “It’s been 4 days since your surgery, and you’ll soon be discharged. D. antiseptic cream
You have to learn to care for your colostomy before you leave the
hospital.” 0. The nurse is teaching the client who has a colostomy about diet
1
B. “I think we will need to teach your spouse to care for your colostomy management. Which information should the nurse discuss with the
if you are not going to be able to do it.” client?
C. “I understand how you are feeling. It is important for you to feel A. Avoid foods containing roughage.
attractive, and you think having a colostomy changes B. Liquids are best limited to prevent diarrhea.
your attractiveness.” C. Experiment to find what diet works best.
D. “I can see that you are upset. Would you like to share your concerns D. Follow a high-fiber diet.
with me?”
1. The nurse is teaching a client who is recovering from an abdominal
1
. The nurse is conducting a wellness program for adults about cancer.
2 perineal resection with a colostomy about health promotion. What is
The nurse should teach clients about which potential risk factor for the an expected outcome for a client during the first 2 weeks after surgery?
development of colon cancer? A. maintaining a fluid intake of 3000 mL a day
A. chronic constipation B. eliminating fiber from the diet
B. long-term use of laxatives C. limiting physical activity to light exercise
C. history of smoking D. accepting that sexual activity will be diminished
D. history of inflammatory bowel disease
2. A client with colon cancer has developed ascites. The nurse should
1
. A client had a colon resection yesterday. The client’s hemoglobin
3 conduct a focused assessment for which additional sign(s) or
reading was 14.1 g/dL (141 g/L) yesterday, and today it is 7.2 g/dL (72 symptom(s)? Select all that apply.
g/L). The client’s oxygen saturation is 87%. After reviewing the chart A. respiratory distress
(see chart) and notifying the health care provider, the nurse should do B. bleeding
which action first? C. fluid and electrolyte imbalance
Prescriptions: D. weight gain
1000 mL normal saline every 8 hours at 125 gtt/h E. infection
Vital signs every 4 hours
Morphine sulfate 10 mg IV every 4 hours as needed for pain 4. Two days following a colon resection, an older adult client shows
1
Nothing by mouth new-onset confusion. When contacting the health care provider, the
Oxygen 2 to 4 L/min per mask nurse should make which recommendation?
A. Take vital signs every hour. A. “Do you want to request a computed tomography scan to rule out
B. Increase the saline infusion to 150 gtt/h. stroke?”
C. Administer oxygen at 2 L per minute. B. “May we have a prescription for restraining this client?”
D. Determine when pain medication was last administered. C. “Shall I collect and send a urine sample for culture and sensitivity?”
D. “Would you like a stat potassium level done?”
. A client with colon cancer is having a barium enema. The nurse
4
should instruct the client to take which type of medication after the 5. The nurse is caring for a 70-year-old male client after a colectomy.
1
procedure is completed? The client received chemotherapy before surgery and has
A. laxative hypertension and diabetes mellitus. Which factor(s) would put this
B. anticholinergic client at risk for sepsis? Select all that apply.
C. antacid A. age of 70
D. demulcent B. abdominal surgery
C. sex
. A client has a nasogastric tube inserted at the time of an abdominal
5 D. diabetes mellitus
perineal resection with a permanent colostomy for colon cancer. When E. weight
should the nurse tell the client that the tube will most likely be
removed? he Adult with Hemorrhoids
T
A. The client no longer has nausea and vomiting. 16. A 36-year-old female client has been diagnosed with hemorrhoids.
B. Mucus from passes from the rectum. Which factor in the client’s history would most likely be a primary cause
C. Gas and fecal material pass from the colostomy. of the hemorrhoids?
D. There is absence of stomach drainage for 24 hours. A. the client’s age
B. three vaginal births
. A client with colon cancer has an abdominal-perineal resection with
6 C. the client’s job as a schoolteacher
a colostomy. To promote hygiene following surgery, the nurse should D. varicosities in the client’s legs
take which action?
A. Maintain the client in a semi-Fowler’s position. 7. The nurse is teaching a client who has had a hemorrhoidectomy
1
B. Assist the client with warm sitz baths. about postoperative care at home. The nurse should tell the client not
C. Administer 30 mL of milk of magnesia to stimulate peristalsis. to use sitz baths until at least 12 hours postoperatively to avoid causing
D. Remove the ostomy pouch as needed so the stoma can be which complication?
assessed. A. bleeding
B. rectal spasm
. The nurse assesses the client’s stoma during the initial
7 C. urine retention
postoperative period. What observation should the nurse report to the D. constipation
health care provider (HCP) immediately? The stoma:
A. is slightly edematous. 8. The nurse teaches a client who has had rectal surgery the proper
1
B. is dark red to purple. timing for a cleansing sitz bath. What will indicate to the nurse that the
C. oozes a small amount of blood. client has understood when to take the sitz bath? The client will take
D. does not expel stool. the sitz bath:
A. first thing each morning.
. The nurse is changing the client’s colostomy bag and dressing.
8 B. as needed for discomfort.
What observation will indicate to the nurse that the client is ready to C. after a bowel movement.
participate in self-care? The client: D. at bedtime.
A. asks if the health care provider (HCP) will change the dressing
soon. he Adult with Ulcerative Colitis
T
B. asks about the supplies used during the dressing change. 20. The nurse is planning care for a client who is being treated for an
C. inquires about who will change the dressing at home. exacerbation of ulcerative colitis. Which goal is the priority?
D. is upset about the way the night nurse changed the dressing. A. promoting self-care and independence
B. managing diarrhea
C. maintaining adequate nutrition
D. promoting rest and comfort
1. The client with an exacerbation of ulcerative colitis is to be on bed
2
rest with bathroom privileges. What will indicate to the nurse that being 2. The nurse is planning care for a client who had surgery 24 hours
3
on bed rest has had the desired outcome? The client has: ago to create an ileostomy. Which goal has the highest priority?
A. not fallen. A. providing relief from constipation
B. slowed intestinal peristalsis. B. assisting the client with self-care activities
C. slept through the night. C. maintaining fluid and electrolyte balance
D. minimized stress. D. minimizing odor formation
2. A client has had an exacerbation of ulcerative colitis with cramping
2 3. The client asks the nurse, “Is it really possible to lead a normal life
3
and diarrhea persisting longer than 1 week. The nurse should assess with an ileostomy?” Which action by the nurse would be the most
the client for which complication? effective to address this question?
A. heart failure A. Have the client talk with a member of the clergy about these
B. deep vein thrombosis concerns.
C. hypokalemia B. Tell the client to worry about those concerns after surgery.
D. hypocalcemia C. Arrange for a person with an ostomy to visit the client
preoperatively.
3. A client who has ulcerative colitis says to the nurse, “I can’t take
2 D. Notify the health care provider (HCP) of the client’s question.
this anymore; I’m constantly in pain, and I can’t leave my room
because I need to stay by the toilet. I don’t know how to deal with this.” 4. Three weeks after the client has had an ileostomy, the nurse is
3
Based on these comments, what judgment should the nurse make following up with instructions on using a skin barrier around the stoma.
about what the client is experiencing? How will the nurse determine that the client has been applying the skin
A. extreme fatigue barrier correctly?
B. disturbed thought A. There is no odor from the stoma.
C. a sense of isolation B. The client is adequately hydrated.
D. difficulty coping C. There is no skin irritation around the stoma.
D. The client only changes the ostomy pouch once a day.
4. A client newly diagnosed with ulcerative colitis who has been
2
placed on steroids asks the nurse why steroids are prescribed. What 5. The nurse is teaching a client about managing an ileostomy. What
3
should the nurse tell the client? observation should the nurse instruct the client with an ileostomy to
A. “Ulcerative colitis can be cured by the use of steroids.” report immediately?
B. “Steroids are used in severe flare-ups because they can decrease A. passage of liquid stool from the stoma
the incidence of bleeding.” B. occasional presence of undigested food in the effluent
C. “Long-term use of steroids will prolong periods of remission.” C. absence of drainage from the ileostomy for 6 or more hours
D. “The side effects of steroids outweigh their benefits to clients with D. temperature of 99.8°F (37.7°C)
ulcerative colitis.”
6. The nurse finds the client who has had an ileostomy crying. The
3
5. A client who has ulcerative colitis has persistent diarrhea and has
2 client explains to the nurse, “I’m upset because I know I won’t be able
lost 12 lb (5.5 kg) since the exacerbation of the disease. Which to have children now that I have an ileostomy.” Which response by the
approach will be most effective in helping the client meet nutritional nurse is best?
needs and allow healing? A. “Many women with ileostomies decide to adopt. Perhaps you could
A. continuous enteral feedings consider that option?”
B. following a high-calorie, high-protein diet B. “Having an ileostomy doesn’t necessarily mean that you can’t have
C. total parenteral nutrition (TPN) children. Let’s talk about your concerns.”
D. eating six small meals a day C. “I can understand your reasons for being upset. Having children
must be important to you.”
6. A client with ulcerative colitis is to take sulfasalazine. Which
2 D. “I’m sure you will adjust to this situation with time. Try not to be too
instruction(s) should the nurse give the client about taking this upset.”
medication at home? Select all that apply.
A. Drink enough fluids to maintain a urine output of at least 1200 to 7. Which statement about ileostomy care indicates that the client
3
1500 mL a day. understands the discharge instructions?
B. Discontinue therapy if symptoms of acute intolerance develop, and A. “I should be able to resume weight lifting in 2 weeks.”
notify the health care provider (HCP). B. “I can return to work in 2 weeks.”
C. Stop taking the medication if the urine turns orange-yellow. C. “I need to drink at least 3000 mL a day of fluid.”
D. Avoid activities that require alertness. D. “I will need to avoid getting my stoma wet while bathing.”
E. If a dose is missed, skip it and continue with the next dose.
8. A client with a well-managed ileostomy has the sudden onset of
3
8. The nurse is instructing the client with ulcerative colitis about the
2 abdominal cramps, vomiting, and watery discharge from the ileostomy.
best diet to maintain nutrition for tissue healing while avoiding foods What should the nurse tell the client to do?
that will exacerbate ulceration. Which diet would be most appropriate? A. Take an antiemetic.
A. high-calorie, low-protein B. Increase fluid intake to 3 L per day.
B. high-protein, low-residue C. Use 30 mL of milk of magnesia daily.
C. low-fat, high-fiber D. Notify the health care provider (HCP).
D. low-sodium, high-carbohydrate
he Adult with an Intestinal Obstruction
T
he Adult with an Ileostomy
T 39. A nurse is assessing a client who has been admitted with a
29. The nurse is teaching a client how to care for an ileostomy. The diagnosis of an obstruction in the small intestine. The nurse should
client asks the nurse how long to wear the pouch before changing it. assess the client for which sign(s) or symptom(s)? Select all that apply.
What should the nurse tell the client? A. projectile vomiting
A. “The pouch is changed only when it leaks.” B. significant abdominal distention
B. “You can wear the pouch for about 4 to 7 days.” C. copious diarrhea
C. “You should change the pouch every evening before bedtime.” D. rapid onset of dehydration
D. “It depends on your activity level and your diet.” E. increased bowel sounds
0. A client is scheduled for an ileostomy. Which would be most helpful
3 0. A client is admitted with a bowel obstruction. The client has
4
in preparing the client psychologically for the surgery? nausea, vomiting, and crampy abdominal pain. The health care
A. Include family members in preoperative teaching sessions. provider (HCP) has written the following prescriptions: for the client to
B. Encourage the client to ask questions about managing an ileostomy. be up ad lib, have narcotics for pain, have a nasogastric tube inserted
C. Provide a brief, thorough explanation of all preoperative and if needed, and for intravenous (IV) Ringer’s lactate and
postoperative procedures. hyperalimentation fluids. What should the nurse do in order of priority
D. Invite a member of the ostomy association to visit the client. from first to last? All options must be used.
A. Assist with ambulation to promote peristalsis
1. The nurse is preparing a client for an ileostomy. Two weeks before
3 B. Insert a nasogastric tube
the surgery, the nurse should instruct the client to take which action? C. Administer IV Ringer’s lactate
A. Stop taking drugs that will interfere with clotting. D. Start an infusion of hyperalimentation fluids
B. Follow a low-residue diet.
C. Limit fluids to 1000 mL a day. 1. The health care provider (HCP) prescribes intestinal
4
D. Report having a temperature above 99°F (37.2°C). decompression with a Cantor tube for a client with an intestinal
bstruction. What should the nurse evaluate to determine the
o . Keep the client in a supine position for 24 hours after insertion.
C
effectiveness of intestinal decompression? D. E. Cover the insertion site with a moisture-proof dressing.
A. Intestinal fluid and gas have been removed. Limit ambulation to walking to the bathroom.
B. The client has had a bowel movement.
C. The client’s urinary output is adequate. 1. A client is receiving total parenteral nutrition (TPN) therapy. Which
5
D. The client can sit up without pain. finding should the nurse report to the health care provider?
A. glycosuria
2. The client has had a nasoenteric tube inserted. The nurse should
4 B. a 1- to 2-lb (0.45- to 0.9-kg) weight gain
place the client in which position? C. decreased appetite
A. supine D. elevated temperature
B. right side-lying
C. semi-Fowler’s 2. The nurse is assessing a client who is receiving an infusion of total
5
D. upright in a bedside chair parenteral nutrition (TPN). The infusion rate is now faster than
prescribed. After adjusting the infusion rate, the nurse should assess
3. The client with an intestinal obstruction continues to have acute
4 the client for which adverse effect?
pain even though the nasoenteric tube is patent and draining. What A. negative nitrogen balance
should the nurse do first? B. circulatory overload
A. Reassure the client that the nasoenteric tube is functioning. C. hypoglycemia
B. Assess the client for signs of peritonitis. D. hypokalemia
C. Administer an opioid as prescribed.
D. Reposition the client on the left side. he Adult with Diverticular Disease
T
53. The nurse is teaching a client with diverticulosis about dietary
4. Before a client undergoes abdominal surgery for an intestinal
4 management of the disease. Which food(s) should the nurse
obstruction, the nurse monitors the client’s urine output and finds that encourage the client to incorporate into their diet? Select all that apply.
the total output for the past 2 hours was 35 mL. The nurse then A. bran cereal
assesses the client’s total intake and output over the last 24 hours and B. broccoli
notes 2000 mL of intravenous fluid for intake, 500 mL of drainage C. tomato juice
from the nasogastric tube, and 700 mL of urine, for a total output of D. navy beans
1200 mL. How should the nurse interpret these findings? E. cheese
A. decreased renal function
B. the nasogastric tube not draining well 4. A client is having an acute attack of diverticulitis. What should the
5
C. extension of the obstruction nurse do first?
D. inadequate fluid replacement A. Prepare the client for a colonoscopy.
B. Encourage the client to eat a high-fiber diet.
he Adult Receiving Total Parenteral Nutrition
T C. Assess the client for signs of peritonitis.
45. The nurse is changing the subclavian dressing of a client who is D. Encourage the client to drink a glass of water every 2 hours.
receiving total parenteral nutrition. When assessing the catheter
insertion site, the nurse notes the presence of yellow drainage from 5. The nurse is teaching a client about managing diverticulitis. The
5
around the sutures that are anchoring the catheter. What should the nurse should teach the client to integrate which measure into their daily
nurse do first? routine?
A. Clean the insertion site and redress the area. A. using enemas to relieve constipation
B. Document assessment findings in the client’s chart. B. decreasing fluid intake to increase the formed consistency of the
C. Request a prescription to obtain a culture of the drainage. stool
D. Check the client’s temperature. C. eating a high-fiber diet when symptomatic with diverticulitis
D. refraining from straining and lifting activities
6. The health care provider (HCP) has ordered total parenteral
4
nutrition (TPN) for a client who has recently had a small and large 6. The nurse is instructing a client with diverticulosis about
5
bowel resection and who is currently not taking anything by mouth. appropriate self-care activities. Which comment(s) by the client would
What should the nurse do to safely administer the TPN? indicate effective teaching? Select all that apply.
A. Administer the TPN through a nasogastric or gastrostomy tube. A. “With careful attention to my diet, my diverticulosis can be cured.”
B. Handle the TPN using strict aseptic technique. B. “Using a cathartic laxative weekly is okay to control bowel
C. Auscultate for the presence of bowel sounds before administering movements.”
the TPN. C. “I should follow a diet that is high in fiber.”
D. Designate a peripheral intravenous (IV) site for TPN administration. D. “It is important for me to drink at least 2000 mL of fluid every day.”
E. “I should exercise regularly.”
7. Using a sliding scale schedule, the nurse is preparing to administer
4
an evening dose of regular insulin to a client who is receiving total 7. A client with diverticular disease is receiving psyllium hydrophilic
5
parenteral nutrition (TPN). On which information should the nurse base mucilloid. Which response from the client indicates to the nurse that
the dosage? the drug is having the intended effect?
A. glucometer reading of the client’s glucose level obtained A. “I can pass stool without cramping.”
immediately before administering the insulin B. “I have occasional diarrhea.”
B. fasting blood glucose level obtained earlier in the day C. “My stool is firm.”
C. amount of TPN fluid the client has received since the last dose of D. “I don’t expel gas.”
insulin
D. client’s dietary intake for the evening meal and snack 8. A client with diverticulitis has developed peritonitis following
5
diverticular rupture. When assessing the client, the nurse should
8. A nurse is assisting the health care provider (HCP) with the
4 perform which action? Select all that apply.
removal of a central venous access device (CVAD). What should the A. Percuss the abdomen to note tympany.
nurse do to prepare the client? B. Percuss the liver to note lack of dullness.
A. Turn the client to the left side. C. Monitor the vital signs for fever.
B. Have the client exhale slowly and evenly. D. Assess the presence of excessive thirst.
C. Elevate the head of the bed. E. Auscultate bowel sounds to note frequency.
D. Instruct the client to take a deep breath and hold it.
he Adult with Appendicitis
T
9. A client is receiving total parenteral nutrition (TPN) solution. The
4 59. A nurse is providing wound care to a client 1 day after an
nurse should assess a client’s ability to metabolize the TPN solution appendectomy. A drain was inserted into the incisional site during
adequately by monitoring the client for which sign? surgery. What should the nurse do to provide wound care?
A. tachycardia A. Remove the dressing, and leave the incision open to air.
B. hypertension B. Remove the drain if wound drainage is minimal.
C. elevated blood urea nitrogen concentration C. Gently irrigate the drain to remove exudate.
D. hyperglycemia D. Clean the area around the drain, moving away from the drain.
0. A client is receiving total parenteral nutrition (TPN) through a
5 0. An adult with appendicitis has severe abdominal pain. Which action
6
central line. What should the nurse do to prevent complications will be the most effective to assist the client to manage pain before
associated with this infusion? Select all that apply. surgery?
A. Use aseptic technique for dressing changes. A. Place the client in semi-Fowler’s position with the knee gatch raised.
B. Secure all connections of the system. B. Apply moist heat to the abdomen.
. Teach the client to massage the painful area.
C nd is patent. Which prescription should the nurse implement first?
a
D. Provide distraction with music. A. Obtain a stat portable chest x-ray.
B. Administer vancomycin intravenously.
1. The nurse is instructing a client about postoperative care following
6 C. Draw blood cultures.
a laparoscopic appendectomy. What information should the nurse D. Insert an indwelling urinary catheter.
include in the teaching plan? Select all that apply.
A. “Nausea, gas, and diarrhea are normal for several days.” 0. The nurse is taking care of a client with Clostridioides difficile. To
7
B. “You can return to work in 1 to 3 weeks.” prevent the spread of infection, the nurse should take which action(s)?
D. “Follow a low-residue diet until the incision has healed.” Select all that apply.
E. “Take a tub bath to relieve abdominal swelling.” A. Wear a particulate respirator.
F. “You can drive when you are not taking pain medications.” B. Wear sterile gloves when providing care.
C. Cleanse the hands with alcohol-based hand sanitizer.
2. A client who had an open appendectomy for a perforated appendix
6 D. Wash the hands with soap and water.
has an incision secured with adhesive strips. What instruction should E. Wear a protective gown when in the client’s room.
the nurse give the client about caring for the incision?
A. Remove the adhesive strips to cleanse the area. 1. The nurse discovers that a client’s TPN solution was running at an
7
B. Cover the adhesive strips with a dressing to protect the area. incorrect rate and is now 2 hours behind schedule. Which action is
C. Leave the adhesive strips in place until they fall off. most appropriate for the nurse to take to correct the problem?
D. Place plastic wrap over the incision when taking a bath. A. Readjust the solution to infuse the desired amount.
B. Continue the infusion at the current rate, but run the next bottle at
he Adult with an Inguinal Hernia
T an increased rate.
63. A client who has a history of an inguinal hernia is admitted to the C. Double the infusion rate for 2 hours.
hospital with sudden, severe abdominal pain, vomiting, and abdominal D. Notify the health care provider (HCP).
distention. The nurse should assess the client further for which
complication? 2. The nurse is to administer ampicillin 500 mg orally to a client with a
7
A. peritonitis ruptured appendix. The nurse checks the capsule in the client’s
B. incarcerated hernia medication box, which is located inside the client’s room. The dosage
C. strangulated hernia of the medication is not labeled, but the nurse recognizes the color and
D. intestinal perforation shape of the capsule. What should the nurse do next?
A. Administer the medication to maintain blood levels of the drug.
4. The nurse is providing discharge instructions for a client who had
6 B. Ask another registered nurse to verify that the capsule is ampicillin
an inguinal herniorrhaphy. What information should the nurse give the C. Contact the pharmacy to bring a properly labeled medication.
client? D. Notify the unit manager to report the problem.
A. Cough and deep breathe every 2 hours.
B. Apply warm, moist heat to the groin. 3. On the second day following an abdominal-perineal resection, the
7
C. Sneeze with the mouth closed. nurse notes that the wound edges are not approximated and one-half
D. Avoid lifting items weighing more than 5 lb (2.3 kg). of the incision has torn apart. What should the nurse do first?
A. Flush the wound with sterile water.
5. The nurse is assessing a male client who has an inguinal
6 B. Apply an abdominal binder.
herniorrhaphy. The nurse should assess the male client carefully for C. Cover the wound with a sterile dressing moistened with normal
which potential complication? saline.
A. hypostatic pneumonia D. Apply strips of tape.
B. deep vein thrombosis
C. paralytic ileus 4. A client has received numerous different antibiotics and now is
7
D. urine retention experiencing diarrhea. What type of precautions should the nurse
institute?
anaging Care, Quality, and Safety for Adults with Lower
M A. airborne precautions
Gastrointestinal Tract Health Problems B. contact precautions
66. A client has anemia resulting from bleeding from ulcerative colitis C. droplet precautions
and is to receive two units of packed red blood cells (PRBCs). The D. standard precautions
client is receiving an infusion of total parenteral nutrition (TPN). In
preparing to administer the PRBCs, the nurse should take which action 5. The health care provider has prescribed ciprofloxacin for a client
7
to ensure client comfort and safety? who takes warfarin. What should the nurse instruct the client to do?
A. Discontinue the TPN infusion. Select all that apply.
B. Start an intravenous (IV) infusion of normal saline. A. Take the medication with food.
C. Administer PRBCs in the same IV line as the TPN. B. Avoid exposure to sunlight.
D. Wait until the TPN infusion is completed, and use the same IV line C. Eliminate caffeine from the diet.
to infuse the PRBCs. D. Report unusual bleeding.
E. Increase fluid intake to 3000 mL a day.
7. The nurse is assigning clients for the evening shift. Which client(s)
6
would be appropriate for the nurse to assign to a licensed 6. The nurse has completed the discharge process for a client, but the
7
practical/vocational nurse (LPN/VN) to provide client care? Select all client has turned on the nurse call light, and on assessment, the nurse
that apply. The client: notices the client has indigestion, shortness of breath, and is
A. who is receiving total parenteral nutrition (TPN). diaphoretic and anxious. The client’s blood pressure and heart rate are
B. who had an inguinal hernia repair surgery 3 hours ago; vital signs elevated. The nurse notifies the health care provider who tells the
are stable. nurse to discharge the client. The nurse explains the situation again,
C. with an intestinal obstruction who needs a Cantor tube inserted. but the health care provider hangs up. What should the nurse do next?
D. with diverticulitis who needs teaching about take-home medications. A. Contact the discharge coordinator to arrange for home health
E. being treated for an exacerbation of ulcerative colitis who is services.
ambulatory. B. Notify the charge nurse and request a second opinion.
C. Reassure the client that the health care provider is aware of the
8. When the nurse is planning care for a client with ulcerative colitis
6 client’s situation and discharge the client.
who is experiencing an exacerbation of symptoms, which client care D. Notify the risk manager of the client’s status before
measure(s) can the nurse appropriately delegate to an unlicensed discharge.
assistive personnel (UAP)? Select all that apply.
A. assessing the client’s bowel sounds
B. providing skin care following bowel movements
C. evaluating the client’s response to antidiarrheal medications
D. maintaining intake and output records
E. obtaining the client’s weight
9. The nurse is caring for a client 1 day after having a colectomy. The
6
client is lethargic and difficult to arouse; the temperature is 101.5°F
(38.6°C), blood pressure is 92/36 mm Hg (mean arterial pressure
[MAP 55 mm Hg]), and heart rate is 114 bpm, with a percutaneous
oxygen saturation (SpO2) of 88% on oxygen at 2 L per minute per
nasal cannula (previously 94%). A saline lock has been established
nswer key
a 5.A,B,D. Known risk factors for sepsis include age (younger than 1
1
1.D. It is important for the nurse to recognize thatindividuals go year and older than 65 years), chronic illness, and invasive
through a grieving process when adjusting to a colostomy. The nurse procedures. Immunosuppression and malnourishment are also risk
should be accepting and provide the client with opportunities to share factors. There is no correlation between sex or age and risk for sepsis.
concerns and feelings when ready. Lecturing the client about the need Nurses must be aware of risk factors and monitor clients at risk closely
to learn how to care for the colostomy is not productive, nor is for any signs of sepsis.
attempting to shame the client into caring for the colostomy by implying 16.B. Hemorrhoids are associated with prolonged sitting or standing,
the spouse will have to provide the care if the client does not. It is not portal hypertension, chronic constipation, and prolonged increased
possible for the nurse to understand what the client is feeling. intra-abdominal pressure, as associated with pregnancy and the strain
2.D. A history of inflammatory bowel disease is a risk factor for colon of vaginal birth. The client’s job as a schoolteacher does not require
cancer. Other risk factors include age (older than 40 years), history of prolonged sitting or standing. Age and leg varicosities are not related to
familial polyposis, colorectal polyps, and a high-fat or low-fiber diet. the development of hemorrhoids.
3.C. This client has decreased oxygen saturationand also decreased 17.A. Applying heat during the immediate postoperativeperiod may
hemoglobin, which puts the client at great risk for cardiac ischemia. cause hemorrhage at the surgical site. Moist heat may relieve rectal
The nurse should start the oxygen as prescribed. The nurse can take spasms after bowel movements. Urine retention caused by reflex
the vital signs more frequently once the oxygen flow has been started. spasms may also be relieved by moist heat. Increasing fiber and fluid
It is not appropriate to increase the rate of the intravenous infusion, in the diet can help prevent constipation
and it would be necessary to request a prescription to do so. After 18.C. Adequate cleaning of the anal area is difficultbut essential. After
starting the oxygen, the nurse can ask the client about the current pain rectal surgery, sitz baths assist in this process, so the client should
level. take a sitz bath after a bowel movement. Other times are dictated by
4.A. After a barium enema, a laxative is ordinarily prescribed. This is client comfort.
done to promote the elimination of barium. Retained barium 20.B. Diarrhea is the primary symptom in an exacerbation of
predisposes the client to constipation and fecal impaction. ulcerative colitis, and decreasing the frequency of stools is the first goal
Anticholinergic drugs decrease gastrointestinal motility. Antacids of treatment. The other goals are ongoing and will be best achieved by
decrease gastric acid secretion. Demulcents soothe mucous halting the exacerbation. The client may receive antidiarrheal agents,
membranes of the gastrointestinal tract and are used to treat diarrhea. antispasmodic agents, bulk hydrophilic agents, or antiinflammatory
5.C. A sign indicating that a client’s colostomyis open and ready to drugs
function is the passage of feces and flatus. When this occurs, gastric 21.B. Although bed rest does help conserve energyand promote
suction is ordinarily discontinued, and the client is allowed to start comfort, falling is not a risk, and its primary purpose in this case is to
taking fluids and food orally. The absence of bowel sounds would help reduce the hypermotility of the colon. Remaining on bed rest does
indicate that the tube should remain in place because peristalsis has not by itself reduce stress, and if the client is having stress, the nurse
not yet returned. can plan with the client to use strategies that will help the client
6.B. Appropriate nursing interventions after an abdominal-perineal manage the stress.
resection with a colostomy include assisting the client with warm sitz 22.C. Excessive diarrhea causes significant depletion of the body’s
baths three to four times a day to clean the perineal incision. The client stores of sodium and potassium as well as fluid. The client should be
will be more comfortable assuming a side-lying position because of the closely monitored for hypokalemia and hyponatremia. Ulcerative colitis
perineal incision. It would be inappropriate to administer milk of does not place the client at risk for heart failure, deep vein thrombosis,
magnesia to stimulate colostomy activity. Stool passage will begin as or hypocalcemia.
peristalsis returns. It is not necessary or desirable to change the 23.D. It is not uncommon for clients with ulcerative colitis to become
ostomy pouch daily to assess the stoma. The ostomy pouch should be apprehensive and have difficulty coping with the frequency of stools
transparent to allow easy observation of the stoma and drainage. and the presence of abdominal cramping. During these acute
7.B. A dark red to purple stoma indicates inadequateblood supply. exacerbations, clients need emotional support and encouragement to
Mild edema and slight oozing of blood are normal in the early verbalize their feelings about their chronic health concerns and
postoperative period. The colostomy would typically not begin assistance in developing effective coping methods. The client has not
functioning until 2 to 4 days after surgery expressed feelings of fatigue or isolation or demonstrated disturbed
8.B. A client who displays interest in the procedure and asks about thought processes.
supplies used for dressings may be ready to participate in self-care. 24.B. Steroids are effective in the management of the acute
Inquiring about when the HCP will change the dressing does not symptoms of ulcerative colitis. Steroids do not cure ulcerative colitis,
indicate the client’s readiness to change the dressing, nor does asking which is a chronic disease. Long-term use is not effective in prolonging
about who will do the irrigation when the client is at home. the remission and is not advocated. Clients should be assessed
9.A. An adhesive skin barrier is effective for protecting the skin around carefully for side effects related to steroid therapy, but the benefits of
a colostomy to keep the skin healthy and prevent skin irritation from short term steroid therapy usually outweigh the potential adverse
stoma drainage. Petroleum jelly, cornstarch, and antiseptic creams do effects
not protect the skin adequately and may prevent an adequate seal 25.C. Food will be withheld from the client with severe symptoms of
between the skin and the colostomy bag. ulcerative colitis to rest the bowel. To maintain the client’s nutritional
10.C. It is best to adjust the diet of a client witha colostomy in a status, the client will be started on TPN. Enteral feedings or dividing
manner that suits the client rather than trying special diets. Severe the diet into six small meals does not allow the bowel to rest. A
restriction of roughage is not recommended. The client is encouraged high-calorie, high-protein diet will worsen the client’s symptoms.
to drink 2 to 3 L of fluid per day. A high-fiber diet may produce loose 26.A,B,D. Sulfasalazine may cause dizziness, and the nurse should
stools caution the client to avoid driving or other activities that require
11.A. An expected outcome is that the client will maintain a fluid intake alertness until response to medication is known. If symptoms of acute
of 3000 mL a day unless contraindicated. There is no need to eliminate intolerance (cramping, acute abdominal pain, bloody diarrhea, fever,
fiber from the diet; the client can eat whatever foods are desired and headache, rash) occur, the client should discontinue therapy and notify
avoid those that are bothersome. Physical activity does not need to be the HCP immediately. Fluid intake should be sufficient to maintain a
limited to light exercise. The client can resume normal activities as urine output of at least 1200 to 1500 mL daily to prevent crystalluria
tolerated, usually within 6 to 8 weeks. The client’s sexual activity may and stone formation. The nurse can also inform the client that this
be affected, but it does not need to be diminished. medication may cause orange-yellow discoloration of urine and skin,
12.A,C.D. Ascites limits the movement of the diaphragm leading to which is not significant and does not require the client to stop taking
respiratory distress. Fluid shift from the intravascular space precipitates the medication. The nurse should instruct the client to take missed
fluid and electrolyte imbalances. The client may gain weight due to the doses as soon as remembered unless it is 1 hour before the next dose.
fluid gain, but weight loss may result in decreased albumin levels. 28.B. Clients with ulcerative colitis should followa well-balanced
Decreased albumin in the intravascular space results in decreased high-protein, high-calorie, low-residue diet, avoiding such highresidue
oncotic pressure, precipitating movement of fluid out of space. A client foods as whole-wheat grains, nuts, and raw fruits and vegetables.
with ascites is not at increased risk for infection unless a peritoneal tap Clients with ulcerative colitis need more protein for tissue healing and
is done to remove fluid. The risk of bleeding is a result of alterations in should avoid excess roughage. There is no need for clients with
liver enzymes affecting coagulation ulcerative colitis to follow low-sodium diets.
14.C. Sending a urine sample for culture and sensitivity is most 29.B. Unless the pouch leaks, the client can wear the ileostomy pouch
warranted. An older adult often has confusion when experiencing a for about 4 to 7 days. If leakage occurs, it is important to promptly
bladder infection. Although stroke is always a concern, particularly in change the pouch to avoid skin irritation. It is not necessary to change
an older adult, the presenting information most supports a bladder the pouch daily or in the evening. Diet and activity typically do not
infection and perhaps early-onset urosepsis. Restraining the client may affect the schedule for changing the pouch.
be needed at some point in time, but finding the cause of the client’s 30.C. Providing explanations of preoperative and postoperative
new onset of confusion has the greatest priority. Potassium is usually procedures helps the client prepare and understand what to expect. It
related to cardiac rhythm irritability rather than confusion. also provides an opportunity for the client to share concerns. Including
family members in the teaching sessions is beneficial but does not
focus on the client’s psychological preparation. Encouraging the client orrect fluid and electrolyte imbalances (sodium and potassium) with
c
to ask questions about managing the ileostomy may be rushing the Ringer’s lactate to correct the interstitial fluid deficit. Nasogastric
client psychologically into accepting the change in body image and decompression of the gastrointestinal tract to reduce gastric secretions
function. The client may need time to first handle the stress of surgery and nasointestinal tubes may also be used as necessary. Lastly,
and then observe the care of the ileostomy by others before it is hyperalimentation can be used to correct protein deficiency from
appropriate to begin discussing selfmanagement. The nurse should chronic obstruction, paralytic ileus, or infection.
gently explore whether the client is ready to ask questions about 41.A. Intestinal decompression is accomplished with a Cantor, Harris,
management throughout the hospitalization. The client should have the or Miller-Abbott tube. These 6- to 10-foot (180- to 300-cm) tubes are
opportunity to express concerns and to agree to an ostomy association passed into the small intestine to the obstruction. They remove
visitor before an invitation is extended. accumulated fluid and gas, relieving the pressure. The client will not
31.A. The nurse should instruct the client to stop taking drugs that have an adequate bowel movement until the obstruction is removed.
would interfere with clotting, such as aspirin or ibuprofen. The client The pressure from the distended intestine should not obstruct urinary
should follow a high-fiber diet with increased fluids during the 2-week output. Although the client may be able to sit up more easily and the
preoperative period. It is not necessary to limit fluids. The client does pain caused by the intestinal pressure will be less, these are not the
not need to report having a temperature above 99°F (37.2°C) to the primary indicators for successful intestinal decompression.
health care provider (HCP) as this is within normal limits; however, if 42.B. The client is placed in a right side-lying position to facilitate
the temperature is higher, this could indicate an infection, and the client movement of the mercury-weighted tube through the pyloric sphincter.
should notify the HCP. After the tube is in the intestine, the client is turned from side to side or
32.C. A high-priority outcome after ileostomy surgeryis the encouraged to ambulate to facilitate tube movement through the
maintenance of fluid and electrolyte balance. The client will experience intestinal loops. Placing the client in the supine or semiFowler’s
continuous liquid to semiliquid stools. The client should be engaged in position or having the client sitting out of bed in a chair will not facilitate
self-care activities, and minimizing odor formation is important; tube progression.
however, these goals do not take priority over maintaining fluid and 43.B. The client’s pain may be indicative of peritonitis,and the nurse
electrolyte balance. should assess for signs and symptoms, such as a rigid abdomen,
33.C. If the client agrees, having a visit by a person who has elevated temperature, and increasing pain. Reassuring the client is
successfully adjusted to living with an ileostomy would be the most important, but an accurate assessment of the client is essential. A full
helpful measure. This would let the client see that typical activities of assessment should occur before pain relief measures are employed.
daily living can be pursued postoperatively. Someone who has felt Repositioning the client to the left side will not resolve the pain.
some of the same concerns can answer the client’s questions. A visit 44.D. Considering that there is usually 1 L of insensiblefluid loss, this
from the clergy may be helpful to some clients but would not provide client’s output exceeds their intake (intake, 2000 mL; output, 2200 mL),
this client with the information sought. Disregarding the client’s indicating deficient fluid volume. The kidneys are concentrating urine in
concerns is not helpful. Although the HCP should know about the response to low circulating volume, as evidenced by a urine output of
client’s concerns, this in itself will not reassure the client about life after less than 30 mL an hour. This indicates that increased fluid
an ileostomy. replacement is needed. Decreased urine output can be a sign of
34.C. Because of high concentrations of digestiveenzymes, ileostomy decreased renal function, but the data provided suggest that the client
effluent is irritating to the skin and can cause excoriation and is dehydrated. Pain does not affect urine output. There are no data to
ulceration. Some form of protection must be used to keep the effluent suggest that the obstruction has worsened
from contacting the skin. A skin barrier does not decrease odor 45.C. The nurse should first obtain a prescription to obtain a culture
formation; odor is controlled by diet. The barrier does not affect the specimen. The presence of drainage is a potential indication of an
client’s hydration status, and the nurse can encourage the client to infection, and the catheter may need to be removed. A culture
have an adequate daily intake of fluids. Pouches are usually worn for 4 specimen should be obtained and sent for analysis so that treatment
to 7 days before being changed can be promptly initiated. Since removing the catheter will be required
35.C. Any sudden decrease in drainage or onset ofsevere abdominal in the presence of an infection, the nurse would not clean and redress
pain should be reported to the health care provider immediately the area. Although the body temperature may increase, indicating an
because it could mean that an obstruction has developed. The infection, a culture needs to be obtained to identify the causative
ileostomy drains liquid stool at frequent intervals throughout the day. organism. After the culture report is obtained, the nurse should notify
Undigested food may be present at times. A temperature of 99.8°F the health care provider and document all assessments and client care
(37.7°C) is not necessarily abnormal or a cause for concern. activities in the client’s record.
36.B. The fact that the client has an ileostomy does not necessarily 46.B. TPN is a hypertonic, high-calorie, high-protein IV fluid that
mean that they cannot get pregnant and give birth. It may be should be provided for clients who do not have functional
recommended, however, that the number of pregnancies be limited. gastrointestinal tract motility to better meet the metabolic needs of the
Women of an age to give birth should be encouraged to discuss their client and to support optimal nutrition and healing. TPN is prescribed
concerns with their health care provider. Discussing their concerns once daily, based on the client’s current electrolyte and fluid balance,
about sexual functioning and pregnancy will help decrease fears and and must be handled with strict aseptic technique (due to the high
anxiety. Empathizing or telling the client that they can adopt does not glucose content, it is a perfect medium for bacterial growth). Also,
address their concerns. The client’s current fears may be based on because of the high tonicity, TPN must be administered through a
erroneous understanding. Telling the client that they will adjust to the central venous access, not a peripheral IV line. There is no specific
situation ignores their concerns. need to auscultate for bowel sounds to determine whether TPN can
37.C. To maintain an adequate fluid balance, the client needs to drink safely be administered.
at least 3000 mL a day. Heavy lifting should be avoided; the health 47.A. When using a sliding scale insulin schedule,the nurse obtains a
care provider will indicate when the client can participate in sports glucometer reading of the client’s blood glucose level immediately
again. The client will not resume working as soon as 2 weeks after before giving the insulin and bases the dosage on those findings. The
surgery. Water does not harm the stoma, so the client does not have to fasting blood glucose level obtained earlier in the day is not relevant to
worry about getting it wet. an evening sliding scale insulin dosage. The nurse cannot calculate
38.D. The sudden onset of abdominal cramps, vomiting, and watery insulin dosage by assessing the amount of TPN intake or dietary
discharge with no stool from an ileostomy are likely indications of an intake.
obstruction. It is imperative that the HCP examine the client 48.D. The client should be asked to perform the Valsalvamaneuver
immediately. Although the client is vomiting, the client should not take (take a deep breath and hold it) during the insertion and removal of a
an antiemetic until the HCP has examined the client. If an obstruction CVAD. This increases central venous pressure during the procedure
is present, ingesting fluids or taking milk of magnesia will increase the and prevents air embolism. Trendelenburg is the preferred position for
severity of symptoms. Oral intake is avoided when a bowel obstruction CVAD insertion and removal. If not possible, a supine position is
is suspected. sufficient for CVAD removal. The client should hold their breath, not
39.A,D,E. Signs and symptoms of intestinal obstructionsin the small exhale
intestine may include projectile vomiting and rapidly developing 49.D. During TPN administration, the client should be monitored
dehydration and electrolyte imbalances. The client will also have regularly for hyperglycemia. The client may require small amounts of
increased bowel sounds that are usually high pitched and tinkling. The insulin to improve glucose metabolism. The client should also be
client would not normally have diarrhea and would have minimal observed for signs and symptoms of hypoglycemia, which may occur if
abdominal distention. Pain is intermittent and relieved by vomiting. the body overproduces insulin in response to a high glucose intake or if
Intestinal obstructions in the large intestine usually evolve slowly and too much insulin is administered to help improve glucose metabolism.
produce persistent pain, and vomiting is less common. Clients with a Tachycardia or hypertension is not indicative of the client’s ability to
large intestine obstruction may develop obstipation and significant metabolize the solution. An elevated blood urea nitrogen concentration
abdominal distention. is indicative of renal status and fluid balance.
40.A,C,B,D. The nurse should first help the client ambulate to try to 50.A,B,D. Complications associated with the administrationof TPN
induce peristalsis; this may be effective and require the least amount of through a central line include infection and air embolism. To prevent
invasive procedures. Next, the nurse should initiate IV fluid therapy to these complications, strict aseptic technique is used for all dressing
hanges, the insertion site is covered with an air-occlusive dressing,
c 2.C. The adhesive strips should stay in place until they fall off. The
6
and all connections of the system must be secure. Ambulation and client should not remove them to cleanse the area. It is not necessary
activities of daily living are encouraged and not limited during the to place an additional dressing over the adhesive strips. The client
administration of TPN, and the client does not need to remain in a should not take a tub bath until the incision has healed.
prone position immediately after the insertion of the central line. 63.C. The symptoms are indicative of a strangulatedhernia. In a
51.D. An elevated temperature can be an indication of an infection at strangulated hernia, the hernia cannot be reduced back into the
the insertion site or in the catheter. Vital signs should be taken every 2 abdominal cavity. The intestinal lumen and the blood supply to the
to 4 hours after initiation of TPN therapy to detect early signs of intestine are obstructed, causing an acute intestinal obstruction.
complications. Glycosuria is to be expected during the first few days of Without immediate intervention, necrosis and gangrene may develop.
therapy until the pancreas adjusts by secreting more insulin. A gradual Surgery is required to release the strangulation. Although many of
weight gain is to be expected as the client’s nutritional status improves. these signs and symptoms are present with peritonitis or perforated
Some clients experience a decreased appetite during TPN therapy. bowel, abdominal rigidity, a cardinal sign of peritonitis and perforated
52.B. A too rapid infusion of TPN solution can leadto circulatory bowel, is not mentioned. Therefore, the nurse would not immediately
overload. The client should be assessed carefully for indications of suspect these conditions. An incarcerated hernia is a hernia that is
excess fluid volume. A negative nitrogen balance occurs in nutritionally irreducible but has not necessarily resulted in an obstruction
depleted individuals, not when TPN fluids are administered in excess. 64.D. The client is instructed to avoid lifting items heavier than 5 lb
When TPN is administered too rapidly, the client is at risk for receiving (2.3 kg) for 4 to 6 weeks after hernia repair. The client continues to
an excess of dextrose and electrolytes. Therefore, the client is at risk take deep breaths and expand the lungs but is instructed to avoid
for hyperglycemia and hyperkalemia coughing. Ice, rather than heat, is used to reduce scrotal swelling. The
53.A,B,D. Clients with diverticulosis are encouraged to follow a client is instructed to sneeze with the mouth open to avoid sudden
high-fiber diet. Bran, broccoli, and navy beans are foods high in fiber. stress on the sutures.
Tomato juice and cheese are low-residue foods. 65.D. The most common complication after an inguinalhernia repair is
54.C. The nurse should first assess the client forsigns of peritonitis. the inability to void, especially in male clients. The nurse should
Complications of diverticulitis include perforation with peritonitis, evaluate the client carefully for urine retention. Hypostatic pneumonia,
abscess, and fistula formation; bowel obstruction; ureteral obstruction; deep vein thrombosis, and paralytic ileus are potential postoperative
and bleeding. A computed tomography scan with oral contrast is the problems with any surgical client but are not as likely to occur after an
test of choice for diverticulitis. A client with acute diverticulitis does not inguinal hernia repair as is urine retention.
receive a barium enema or colonoscopy because of the possibility of 66.B. The nurse administers the PRBCs using a separateinfusion line
peritonitis and perforation. With acute diverticulitis, the goal of and appropriate tubing, with normal saline as the priming solution. It is
treatment is to allow the colon to rest and inflammation to subside. The not necessary to discontinue the TPN infusion or wait until the TPN
client is kept on nothing-by-mouth (NPO) status; parenteral fluid infusion is completed.
therapy is provided. 67.B,E. The nurse should consider client needs and scope of
55.D. Clients with diverticular disease should refrain from any practice when assigning staff to provide care. The client who is
activities, such as lifting, straining, or coughing, that increase intra recovering from inguinal hernia repair surgery and the client who is
abdominal pressure and may precipitate an attack. Enemas are experiencing an exacerbation of ulcerative colitis are appropriate
contraindicated because they increase intestinal pressure. Fluid intake clients to assign to an LPN/VN as the care they require falls within the
should be increased, rather than decreased, to promote soft, formed scope of practice for an LPN or a VN. It is not within the scope of
stools. A low-fiber diet is used when inflammation is present. practice for the LPN/VN to administer TPN, insert nasoenteric tubes, or
56.C,D,E. Clients who have diverticulosis shouldbe instructed to provide client teaching related to medications.
maintain a diet high in fiber and, unless contraindicated, should 68.B,D,E. The nurse can delegate the followingbasic care activities
increase their fluid intake to a minimum of 2000 mL/day. Participating to the UAP: providing skin care following bowel movements,
in a regular exercise program is also strongly encouraged. maintaining intake and output records, and obtaining the client’s
Diverticulosis can be controlled with treatment but cannot be cured. weight. Assessing the client’s bowel sounds and evaluating the client’s
Clients should be instructed to avoid the regular use of cathartic response to medication are registered nurse (RN) activities that cannot
laxatives. Bulk laxatives and stool softeners may be helpful to maintain be delegated.
regularity and decrease straining. 69.C. This client has signs and symptoms of severesepsis. Blood
57.A. Diverticular disease is treated with a high-fiber diet and bulk cultures should be drawn before administering the antibiotic
laxatives such as psyllium hydrophilic mucilloid. Fiber decreases the (vancomycin), and the antibiotics should be administered within the
intraluminal pressure and makes it easier for stool to pass through the first 45 minutes after recognition of these signs to try to prevent septic
colon. Bulk laxatives do not manage diarrhea or relieve gas formation. shock. Obtaining a chest x-ray and inserting a urinary catheter to
The stool should remain soft and easy to expel. accurately measure intake and output are also important actions, but
58.A,B,C,E. Percussion will show resonance and tympany, they are not the first priority for this client.
indicating paralytic ileus. Lack of liver dullness may indicate free air in 70.D,E. C. difficile is an organism that has developed very resistant
the abdomen. The client with peritonitis will have fever, tachypnea, and and highly morbid strains. Universal precautions, most importantly
tachycardia. The abdomen becomes rigid with rebound tenderness, handwashing, wearing personal protective gear, and modest use of
and there will be absent bowel sounds. The client will not demonstrate antibiotics, are critical actions for stopping the spread. C. difficile is not
excessive thirst but may have anorexia, nausea, and vomiting as spread via the respiratory tract; therefore, a mask is not needed.
peristalsis decreases. Alcohol-based hand sanitizers do not kill the spores of C. difficile; soap
59.D. The nurse should gently clean the area aroundthe drain by and water must be used. Sterile gloves are not needed to provide care;
moving in a circular motion away from the drain. Doing so prevents the clean gloves may be worn.
introduction of microorganisms to the wound and drain site. The 71.D. When TPN fluids are infused too rapidly ortoo slowly, the HCP
incision cannot be left open to air as long as the drain is intact. The should be notified. TPN solutions must be carefully and accurately
nurse should note the amount and character of wound drainage, but infused. Rate adjustments should not be made without a written
the surgeon will determine when the drain should be removed. Surgical prescription from the HCP. Significant alterations in rate (10% increase
wound drains are not irrigated. or decrease) can result in fluctuations of blood glucose levels.
60.A. Appendicitis typically begins with periumbilicalpain, followed by Speeding up the solution can result in too much glucose entering the
anorexia, nausea, and vomiting. The pain is persistent and continuous, system.
eventually shifting to the right lower quadrant and localizing at 72.C. The nurse should contact the pharmacy directlyand request
McBurney’s point (located halfway between the umbilicus and the right that a properly labeled medication be provided. The nurse should not
iliac crest). To relieve pain before surgery, the nurse assists the client administer any drug that is not properly labeled, even if the nurse or
into a comfortable position with the knees drawn to the chest and the another nurse recognizes the medication. It is not necessary to notify
head of the bed slightly elevated. The nurse may also administer the unit manager at this point because the client needs to receive the
analgesics and ice packs if prescribed; heat is avoided as heat may antibiotic as soon as possible.
precipitate rupture of the appendix. The abdomen is not palpated or 73.C. When dehiscence occurs, the nurse should immediately cover
massaged more than necessary to avoid increasing the pain. the wound with a sterile dressing moistened with normal saline. If the
Distraction with music may be helpful, but positioning, using ice packs, dehiscence is extensive, the incision must be resutured in surgery.
and analgesics are most effective Later, after the sutures are removed, additional support may be
61.A,B,E. The nurse should instruct the clientthat nausea, provided to the incision by applying strips of tape as directed by
abdominal distention from gas, and diarrhea are normal following an institutional policy or by the surgeon. An abdominal binder may also be
appendectomy. The client will be able to return to work and usual utilized for additional support
activities in 1 to 3 weeks. The client does not need to follow a 74.B. The nurse should initiate contact precautions to prevent
lowresidue diet but may prefer a bland diet if the client has nausea or bloodborne infection through percutaneous injury. Extreme care is
an upset stomach. The client can drive if not taking pain medication. essential when needles, scalpels, and other sharp objects are handled.
The client should not take a tub bath until the incision has healed. Airborne precautions are required for clients with presumed or proven
pulmonary tuberculosis, chickenpox, or other airborne pathogens.
ontact precautions are used for organisms that are spread by
C
skin-to-skin contact, such as antibiotic-resistant organisms or
Clostridioides difficile. Droplet precautions are used for organisms such
as influenza or Neisseria meningitidis that can be transmitted by close
respiratory or mucous membrane contact with respiratory secretions.
Standard precautions include handwashing and the use of a mask and
gown.
75.B,D. A black box warning for ciprofloxacin isthat ciprofloxacin
may increase the anticoagulant effects of warfarin. The nurse should
instruct the client to report increased bleeding and to monitor the
prothrombin time and the international normalized ratio closely. The
client can take the drug with or without food. Although there is a
drug-food interaction and taking ciprofloxacin may increase the
stimulatory effect of caffeine, the client does not need to eliminate
caffeine but should report signs of stimulant effect. Ciprofloxacin may
cause photosensitivity reactions; the nurse must advise the client to
avoid excessive sunlight or artificial ultraviolet light during therapy.
Clients must be advised not to crush, split, or chew the
extended-release tablets.
76.B. A reasonable and prudent nurse would act as the client’s
advocate and question a prescription that places a client at risk.
Consulting the charge nurse to assess the client, shifts responsibility to
the next in command with higher authority and will validate the nurse’s
assessment. The client should not be discharged until the client is
stable. Although the client may require home health services, the client
is not ready for discharge at this time. It is not appropriate to notify the
risk manager at this time, and if necessary, that would be the role of
the charge nurse or nurse manager.
Topic:Test 7 - The Adult with Pancreatic and Biliary Tract Disorders D. roast beef sandwich with lettuce and tomato
he Adult with Cholecystitis
T . A client with cholecystitis has severe pain unrelieved by ibuprofen.
9
1. A client has undergone a laparoscopic cholecystectomy. Which The client feels nauseated. The nurse obtains the following vital signs:
instruction should the nurse include in the discharge teaching? temperature 101.1°F (38.4°C); pulse 114 bpm; respirations 22
A. Empty the bile bag daily. breaths/min; and blood pressure 142/90 mm Hg. Using the SBAR
B. Breathe deeply into a paper bag when nauseated. (Situation-Background-Assessment-Recommendation) technique for
C. Keep adhesive dressings in place for 6 weeks. communication, what should the nurse recommend to the health care
D. Report bile-colored drainage from any incision. provider for this client?
A. a medication for severe pain
. A client with acute cholecystitis has severe pain. Which prescription
2 B. a medication for increased temperature
will be most effective in relieving the pain? C. a medication for elevated blood pressure
A. infusing normal saline solution at 100 mL per hour D. a medication for feelings of nausea
B. administering morphine sulfate 10 mg intramuscularly every 3 to 4
hours 1. A client undergoes a laparoscopic cholecystectomy. Which
1
C. receiving nothing by mouth (NPO) instruction should the nurse give the client about a diet immediately
D. having a nasogastric tube connected to low intermittent suction after surgery?
A. “You can’t eat or drink anything for 24 hours.”
. A client’s stools are light gray in color. What additional information
3 B. “You may resume your normal diet the day after your surgery.”
should the nurse obtain from the client? Select all that apply. C. “Start with liquids and see how you feel.”
A. intolerance to fatty foods D. “You can progress from a liquid to a bland diet as tolerated.”
B. fever
C. jaundice 2. The nurse is preparing a client for discharge. The client had a
1
D. respiratory distress laparoscopic cholecystectomy and has sutures covered by a dressing.
E. pain at McBurney’s point Which instruction should the nurse give this client?
F. bleeding ulcer A. “Avoid showering for 1 week after surgery.”
B. “You can return to work within 1 week.”
. A client has an open cholecystectomy with bile duct exploration.
4 C. “Leave the dressing in place until seeing the surgeon at the
Following surgery, the client has a T-tube. What should the nurse do postoperative visit.”
to determine the effectiveness of the T-tube? D. “Use acetaminophen to control any fever.”
A. Irrigate the tube with 20 mL of normal saline every 4 hours.
B. Unclamp the T-tube, and empty the contents every day. 3. A client who has had a laparoscopic cholecystectomy has adhesive
1
C. Assess the color and amount of drainage every shift. strips over the puncture sites. When preparing the client for discharge,
D. Monitor the incision sites for bile drainage. which client statement(s) would indicate that the teaching has been
successful? Select all that apply.
. At 0800, the nurse reviews the amount of T-tube drainage for a client
5 A. “I can resume my normal diet when I feel ok.”
who underwent an open cholecystectomy yesterday. After reviewing B. “I need to avoid driving for about 4 weeks.”
the output record (see chart), the nurse should perform which action C. “I may experience some pain in my right shoulder.”
next? Output Record D. “I should spend 2 to 3 days in bed before resuming activity.”
E. “I can take a shower 2 days later.”
Time T-Tube
4. Following an emergency cholecystectomy, the client has a
1
1200 50mL JacksonPratt drain with closed suction. After 4 hours, the drainage unit
is full. What should the nurse do?
1600 60mL
A. Notify the surgeon.
B. Remove the drain and suction unit.
2000 60mL
C. Check the dressing for bleeding.
0000 70mL D. Empty the drainage unit.
0400 70mL he Adult with Pancreatitis
T
15. The nurse is obtaining a health history for a client with pancreatitis.
0800 10mL
The does not drink alcohol because of religious convictions and
becomes upset when the nurse asks about alcohol intake. What should
. Report the 24-hour drainage amount at 1200.
A the nurse tell the client about why this is an important
B. Clamp the T-tube. question?
C. Evaluate the tube for patency. A. “There is a strong link between alcohol use and acute pancreatitis.”
D. Irrigate the T-tube. B. “Alcohol intake can interfere with the tests used to diagnose
pancreatitis.”
. A client who had a cholecystectomy has a T-tube for drainage. The
6 C. “Alcoholism is a major health problem, and all clients are questioned
nurse measures the amount of bile drainage from the T-tube at the end about alcohol intake.”
of each shift. How should the nurse record the drainage? D. “The health care provider (HCP) must obtain the pertinent facts,
A. adding it to the client’s urine output regardless of religious beliefs.”
B. charting it separately on the output record
C. adding it to the amount of wound drainage 6. A client with acute pancreatitis has a blood pressure of 88/40 mm
1
D. subtracting it from the total intake for each day Hg, a heart rate of 128 bpm, respirations of 28 breaths/min, and Grey
Turner sign. What prescription should the nurse implement first?
. The nurse is caring for a client who had an open cholecystectomy 24
7 A. Initiate an intake/output record.
hours ago. The client’s vital signs have been stable over the last 24 B. Place an intravenous (IV) line.
hours, with the most recent being temperature 98.6°F (37°C), blood C. Position the client on the left side.
pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16 breaths/min, D. Insert a nasogastric tube.
and heart rate (HR) 78 bpm, but these signs are now changing. Which
set of vital signs indicates that the nurse should contact the 7. When the nurse is providing care for a client hospitalized with acute
1
health care provider (HCP)? pancreatitis who has severe abdominal pain, which nursing
A. temperature 101.8°F (38.8°C); BP 140/ 86 mm Hg; HR 94 bpm; RR intervention(s) would be most appropriate for this client? Select all that
24 breaths/min apply.
B. temperature 100.7°F (38.2°C); BP 118/ 68 mm Hg; HR 84 bpm; RR A. Place the client in a side-lying position.
20 breaths/min B. Administer morphine sulfate for pain as needed.
C. temperature 99.5°F (37.5°C); BP 126/80 mm Hg; HR 58 bpm; RR C. Maintain the client on a high-calorie, high-protein diet.
16 breaths/min D. Monitor the client’s respiratory status.
D. temperature 97.5°F (36.4°C); BP 98/64 mm Hg; HR 98 bpm; RR 18 E. Obtain daily weights.
breaths/min
8. The nurse notes that a client with acute pancreatitis occasionally
1
. After a cholecystectomy, the client is to follow a low-fat diet. Which
8 experiences muscle twitching and jerking. How should the nurse
food would be most appropriate to include in a low-fat diet? interpret the significance of these symptoms? The client:
A. cheese omelet with onions A. may be developing hypocalcemia.
B. peanut butter on wheat toast B. is experiencing a reaction to meperidine.
C. ham salad sandwich made with mayonnaise C. has a nutritional imbalance.
D. needs a muscle relaxant to promote rest. 8. The nurse is caring for a client recently diagnosed with hepatitis C.
2
In reviewing the client’s history, what information will be most helpful as
9. A client is receiving propantheline bromide for the management of
1 the nurse develops a teaching plan? The client:
acute pancreatitis. Which finding would indicate that the nurse should A. has a history of exercise-induced asthma.
discuss withholding the medication with the health care B. is a scientist and is frequently exposed to multiple chemicals.
provider? C. traveled to Central America recently and ate uncooked vegetables.
A. absent bowel sounds D. has a known history of sexually transmitted disease.
B. increased urine output
C. diarrhea 9. The nurse is developing a teaching plan for a client with viral
2
D. decreased heart rate hepatitis. What information should the nurse include in the plan?
A. Obtain adequate bed rest.
0. The health care provider has prescribed pancreatic enzyme
2 B. Increase fluid intake.
replacements for a client with chronic pancreatitis. When should the C. Take antibiotic therapy as prescribed.
nurse tell the client about how to take them to obtain the most D. Drink 8 oz (240 mL) of an electrolyte solution every day.
therapeutic effect?
A. three times daily between meals 0. The nurse is planning care for a client with hepatitis A. Information
3
B. with each meal and snack from which laboratory report will be helpful in planning care?
C. in the morning and at bedtime A. prolonged prothrombin time
D. every 4 hours, at specified times B. decreased blood glucose level
C. elevated serum potassium level
1. A client has chronic pancreatitis. What should the nurse teach the
2 D. decreased serum calcium level
client to do to monitor the effectiveness of pancreatic enzyme
replacement? 1. The nurse develops a teaching plan for the client about how to
3
A. Record daily fluid intake. prevent the transmission of hepatitis A. Which discharge instruction is
B. Perform glucose fingerstick tests twice a day. appropriate for the client?
C. Observe stools for steatorrhea. A. Spray the house to eliminate infected insects.
D. Test urine for ketones. B. Tell family members to try to stay away from the client.
C. Ask family members to wash their hands frequently.
he Adult with Viral Hepatitis
T D. Disinfect all clothing and eating utensils.
22. The nurse is assessing a client with chronic hepatitis B who is
receiving lamivudine. What information about the client is most 2. The client with hepatitis A is experiencing fatigue, weakness, and a
3
important to communicate to the health care provider? general feeling of malaise. The client tires rapidly during morning care.
A. a 6.6-lb (3-kg) weight gain over 2 days What is the most appropriate goal for this client?
B. intermittent nausea A. Increase mobility.
C. a temperature of 99°F (37.2°C) orally B. Learn new self-care skills.
D. constant fatigue C. Adapt to new levels of energy.
D. Gradually increase activity tolerance.
3. The nurse is assessing a client with hepatitis A and notices that the
2
aspartate transaminase (AST) and alanine transaminase (ALT) lab 3. The health care provider has prescribed interferon alfa-2b to treat a
3
values have increased. Which statement by the client indicates the client with chronic hepatitis B. The nurse should assess the client for
need for further instruction by the nurse? which common adverse effect?
A. “I require increased periods of rest.” A. retinopathy
B. “I follow a low-fat, high-carbohydrate diet.” B. constipation
C. “I eat dry toast to relieve my nausea.” C. flulike symptoms
D. “I take acetaminophen for arthritis pain.” D. hypoglycemia
4. A client plans to travel to a country where hepatitis B is common.
2 4. The nurse is preparing a community education program about
3
What should the nurse advise the client about the most effective way preventing hepatitis B infection. Which information should be
to prevent the disease? incorporated into the teaching plan?
A. Drink purified water. A. Hepatitis B is relatively uncommon among college students.
B. Avoid crowded, enclosed spaces. B. Frequent ingestion of alcohol can predispose an individual to the
C. Complete the vaccination series. development of hepatitis B.
D. Observe safe sex practices. C. Good personal hygiene habits are most effective at preventing the
spread of hepatitis B.
5. The nurse is assessing a client who is in the icteric phase of
2 D. The use of a condom is advised for sexual intercourse.
hepatitis A. Which is an expected finding?
A. tarry stools 5. The nurse is establishing goals for the client with hepatitis A. Which
3
B. yellowed sclerae goal is appropriate?
C. shortness of breath A. Demonstrate a decrease in fluid retention related to ascites.
D. light, frothy urine B. Verbalize the importance of reporting bleeding gums or bloody
stools.
6. The nurse is teaching an adult with intravenous substance use
2 C. Limit the use of alcohol to two to three drinks per week.
disorder about measures to avoid acquiring hepatitis A. What D. Restrict activity to within the home to prevent disease transmission.
information should the nurse include in the instruction? Select all that
apply. he Adult with Cirrhosis
T
A. observing proper handwashing technique 36. A client had a liver biopsy 1 hour ago. What should the nurse do
B. following safe syringe disposal procedures first?
C. obtaining a vaccination A. Auscultate lung sounds.
D. wearing a mask when in crowds B. Check for fever.
E. using caution when eating fresh fruits and vegetables C. Obtain a complete blood count (CBC).
D. Apply packing to the biopsy site.
7. A client with chronic hepatitis C is experiencing nausea, anorexia,
2
and fatigue. During the health history, the client states that they are 7. The nurse is assessing a client for ascites. Where does the nurse
3
homosexual, drink one to two glasses of wine with dinner, take St. place the hands to percuss for the presence of fluid?
John’s wort for a “bit of depression,” and take acetaminophen for ANSWER:The nurse places the client in a supine position and
frequent headaches. What action(s) should the nurse take? Select all percusses from the midline laterally and listens for a change from
that apply. tympany from bowel gas to dullness, which indicates the presence of
A. Instruct the client that the wine with meals can be beneficial for fluid.
cardiovascular health.
B. Instruct the client to ask the health care provider (HCP) about taking 8. A client with cirrhosis is receiving lactulose. The nurse notes the
3
any other medications as they may interact with medications the client client is more confused and has asterixis. What should the nurse do
is currently taking. next?
C. Instruct the client to increase the protein in their diet and eat less A. Assess for gastrointestinal (GI) bleeding.
frequently. B. Withhold the lactulose.
D. Advise the client of the need for additional testing for HIV. C. Increase protein in the diet.
E. Encourage the client to obtain sufficient rest. D. Monitor serum bilirubin levels.
9. The nurse is assessing a client with cirrhosis who has developed
3 e used.
b
hepatic encephalopathy. The nurse should notify the health care A. Affirm airway obstruction by the tube
provider of a decrease in which serum lab value that is a potential B. Remove the tube
precipitating factor for hepatic encephalopathy? C. Deflate the tube by cutting with bedside scissors
A. aldosterone D. Apply oxygen via face mask
B. creatinine
C. potassium 9. The nurse monitors a client with cirrhosis for the development of
4
D. protein hepatic encephalopathy. Which is an indication that hepatic
encephalopathy is developing?
0. A client has advanced cirrhosis of the liver. The client’s spouse
4 A. decreased mental status
asks the nurse why the client’s abdomen is swollen, making it very B. elevated blood pressure
difficult to fasten their pants. How should the nurse respond to C. decreased urine output
provide the most accurate explanation of the disease process? D. labored respirations
A. “They must have been eating too many foods with salt in them. Salt
pulls water with it.” 0. A client’s serum ammonia level is elevated, and the health care
5
B. “The swelling in the ankles must have moved up closer to their heart provider prescribes 30 mL of lactulose. The nurse should assess the
so the fluid circulates better.” client for which expected effect of this drug?
C. “The client must have forgotten to take their daily water pill.” A. increased urine output
D. “Blood is not able to flow readily through the liver now, and the liver B. improved level of consciousness
cannot make protein to keep fluid inside the blood vessels.” C. increased bowel movements
D. absence of nausea and vomiting
1. A nurse is developing a care plan for a client with hepatic
4
encephalopathy. Which would be the goal(s) for the care for this client? 1. A client is to be discharged with a prescription for lactulose. The
5
Select all that apply. nurse teaches the client how to administer this medication. Which
A. Prevent constipation. statement would indicate that the client has understood the
B. Administer lactulose to reduce blood ammonia levels. information? “I will:
C. Monitor coordination while walking. A. take it with an antacid.”
D. Check the pupil reaction. B. mix it with apple juice.”
E. Provide food and fluids high in carbohydrates. C. take it with a laxative.”
F. Encourage physical activity. D. mix the crushed tablets in some gelatin.”
2. A client with cirrhosis begins to develop ascites. The health care
4 2. The nurse is providing discharge instructions for a client with
5
provider prescribes spironolactone to treat the ascites. The nurse cirrhosis. Which statement best indicates that the client has understood
should monitor the client closely for which drug-related adverse effect? the teaching?
A. constipation A. “I should eat a high-protein, high-carbohydrate diet to provide
B. hyperkalemia energy.”
C. irregular pulse B. “It is safer for me to take acetaminophen for pain instead of aspirin.”
D. dysuria C. “I should avoid constipation to decrease chances of bleeding.”
D. “If I get enough rest and follow my diet, it’s possible for my cirrhosis
3. A client with jaundice has pruritus and areas of irritation from
4 to be cured.”
scratching. What measure(s) can the nurse suggest the client use to
prevent skin breakdown? Select all that apply. 3. The nurse is preparing a client for a paracentesis. What should the
5
A. Avoid lotions containing calamine. nurse do?
B. Add baking soda to the water in a tub bath. A. Have the client void immediately before the procedure.
C. Keep nails short and clean. B. Place the client in a side-lying position.
D. Rub the skin when it itches with knuckles instead of nails. C. Initiate an intravenous (IV) line to administer sedatives.
E. Massage skin with alcohol. D. Place the client on nothing-by-mouth (NPO) status 6 hours before
F. Increase sodium intake in the diet. the procedure.
4. The nurse is developing a health promotion plan with a client with
4 4. A client with ascites and peripheral edema is at risk for impaired
5
cirrhosis. Which activity should the nurse suggest the client add to skin integrity. To prevent skin breakdown, the nurse should perform
the daily routine at home? which action?
A. Supplement the diet with daily multivitamins. A. Institute range-of-motion (ROM) exercises every 4 hours.
B. Abstain from drinking alcohol. B. Massage the abdomen once a shift.
C. Take a sleeping pill at bedtime. C. Use an alternating air pressure mattress.
D. Limit contact with other people whenever possible. D. Elevate the lower extremities.
5. The nurse is reviewing the chart information for a client with
4 anaging Care, Quality, and Safety of Adults with Biliary Tract
M
increased ascites. The data include: temperature 98.9°F (37.2°C); Disorders
heart rate 118 bpm; shallow respirations 26 breaths/min; blood 55. A client is admitted to the hospital with a diagnosis of hepatitis A.
pressure 128/76 mm Hg; and percutaneous oxygen saturation (SpO2) Which precautions should the health care team observe when caring
89% on room air. What should the nurse do first? for this client?
A. Assess heart sounds. A. gowning when entering a client’s room
B. Obtain a prescription for blood cultures. B. wearing a mask when providing care
C. Prepare for a paracentesis. C. assigning the client to a private room
D. Raise the head of the bed. D. wearing gloves when giving direct care
6. The nurse is caring for a client with esophageal varices. The nurse
4 6. The nurse has made rounds on a team of clients. The nurse should
5
should discuss which laboratory report finding with the health care discuss which client with the health care provider (HCP)?
provider (HCP)? A. a client with cirrhosis who is depressed and has refused to eat for
A. normal serum albumin the past 2 days
B. decreased ammonia a client with stable vital signs who has been receiving
C. slightly decreased levels of calcium B. intravenous (IV) ciprofloxacin following a cholecystectomy for 1 day
D. elevated prothrombin time (PT)/international normalized ratio (INR) and has developed a rash on the chest and arms
C. a client with pancreatitis whose family requests to speak with the
7. A client with cirrhosis who has ascites receives 100 mL of 25%
4 HCP regarding the treatment plan
serum albumin intravenously. Which finding would indicate that the D. a client with hepatitis whose pulse was 84 bpm and regular and is
albumin is having its desired effect? now 118 bpm and irregular
A. reduced ascites
B. increased serum albumin level 7. The nurse’s assignment consists of four clients. From highest to
5
C. decreased anorexia lowest priority, in which order should the nurse assess the clients
D. increased ease of breathing after receiving the morning report? All options must be used.
A. the client with cirrhosis who became confused and disoriented
8. The nurse is assessing a client with a Sengstaken-Blakemore tube.
4 during the night
The oxygen saturation on pulse oximetry has dropped from 97% to B. the client who is 1-day postoperative following a cholecystectomy
91%, and the respiratory rate has changed from 24 to 40 breaths/min. and has a T-tube inserted
What should the nurse do in order from first to last? All options must C. the client with acute pancreatitis who is requesting pain medication
. the client with hepatitis B who has questions about discharge
D 1.C. Immediately after surgery, the client can drink liquids. A light or
1
instructions regular diet can be resumed when the client can tolerate the liquids.
There is no need for the client to remain on nothing-by-mouth status
8. A client with hepatitis C has been admitted to the hospital. The
5 after surgery because peristaltic bowel activity should not be affected.
nurse should institute which measure to prevent transmission of the The client will probably not be able to tolerate a full meal comfortably
hepatitis C virus to health care personnel? the day after surgery. There is no need for the client to stay on a bland
A. administering hepatitis C vaccine to all health care personnel diet after a laparoscopic cholecystectomy. The client should, however,
B. decreasing contact with blood and blood-contaminated fluids avoid excessive fats.
C. wearing gloves when emptying the bedpan 12.C. After a laparoscopic cholecystectomy when there are sutures
D. wearing a gown and mask when providing direct care covered by a dressing, the client should not remove dressings from the
puncture sites but should wait until visiting the surgeon. The client may
9. The nurse is taking care of a client who has an IV infusion pump.
5 shower 48 hours after surgery. A client can return to work within 1
The pump alarm rings. What should the nurse do in order from first to week, but only if approved by the surgeon and no strenuous activity is
last? All options must be used. involved. The client should report any fever, which could be an
A. Silence the pump alarm indication of a complication.
B. Determine if the infusion pump is plugged into an electrical outlet 13.A,C,E. Following a laparoscopic cholecystectomy,the client can
C. Assess the client’s site for infiltration of inflammation resume a normal diet as tolerated. The client may experience right
D. Assess the tubing for hindrances to flow of solution shoulder pain from the gas that was used to inflate the abdomen
during surgery. The client can take a shower 48 hours after the
surgery. The adhesive strips will fall off in about 10 days. The client can
resume driving within 3 to 4 days following surgery as long as the client
answer key is not taking pain medication. There is no need for the client to
maintain bed rest in the days following surgery. Light exercise such as
.D. There should be no bile-colored drainage comingfrom any of the
1 walking can be resumed immediately.
incisions postoperatively. A laparoscopic cholecystectomy does not 14.D. Portable suction units should be emptied anddrained every shift
involve a bile bag. Breathing deeply into a paper bag will prevent a or when full. It is normal for the unit to fill within the first hours after
person from passing out due to hyperventilation; it does not alleviate surgery; the nurse does not need to contact the surgeon. There should
nausea. If the adhesive dressings have not already fallen off, they are not be bleeding on the dressing if the drainage system is emptied when
removed by the surgeon in 7 to 10 days, not 6 weeks full. The drain should not be removed until prescribed by the health
2.B. The client is in severe pain, and the nurse should administer the care provider.
morphine to relieve the pain. The client will receive intravenous fluids 15.A. Alcoholism is a major cause of acute pancreatitis in the United
to maintain fluid and electrolyte balance, but that will not relieve the States and Canada. Because some clients are reluctant to discuss
pain. The client may be NPO and have a nasogastric tube to promote alcohol use, staff may inquire about it in several ways. Generally,
gastric decompression to prevent further gallbladder stimulation, but alcohol intake does not interfere with the tests used to diagnose
these are not sufficient to manage the pain. pancreatitis. Recent ingestion of large amounts of alcohol, however,
3.A,B,C. Bile is created in the liver, stored in the gallbladder, and may cause an increased serum amylase level. Large amounts of ethyl
released into the duodenum, giving stool its brown color. A bile duct and methyl alcohol may produce an elevated urinary amylase
obstruction can cause pale-colored stools. Other symptoms associated concentration. All clients are asked about alcohol and drug use on
with cholelithiasis are right upper quadrant tenderness, fever from hospital admission, but this information is especially pertinent for
inflammation or infection, jaundice from elevated serum bilirubin levels, clients with pancreatitis. HCPs do need to seek facts, but this can be
and nausea or right upper quadrant pain after a fatty meal. Pain at done while respecting the client’s religious beliefs. Respecting religious
McBurney’s point lies between the umbilicus and the right iliac crest beliefs is important in providing holistic client care.
and is associated with appendicitis. A bleeding ulcer produces black, 16.B. Grey Turner sign is a bluish discolorationin the flank area
tarry stools. Respiratory distress is not a symptom of cholelithiasis. caused by retroperitoneal bleeding. The vital signs are showing
4.C. A T-tube is inserted in the common bile duct to maintain patency hemodynamic instability. IV access should be obtained to provide
when there is a likelihood of edema. The tube remains in place until immediate volume replacement. The urine output will provide
edema from the duct exploration subsides. The bile color should be information on the fluid status. A nasogastric tube is indicated for
gold to dark green, and the amount of drainage should be closely clients with uncontrolled nausea and vomiting or gastric distension.
monitored to ensure tube patency. Irrigation is not routinely done Repositioning the client may be considered for pain management once
unless it was prescribed using a smaller volume of fluid. The T-tube is the client’s vital signs are stable.
not clamped in the early postoperative period to allow for continuous 17.A,B,D,E. The client with acute pancreatitis usually experiences
drainage. An open cholecystectomy has one right subcostal incision, severe abdominal pain. The client will likely receive an opioid such as
whereas a laparoscopic cholecystectomy has multiple small incisions. morphine to treat the pain. Placing the client in a side-lying position
5.C. The T-tube should drain approximately 300 to500 mL in the first relieves the tension on the abdominal area and promotes comfort. A
24 hours, and after 3 to 4 days, the amount should decrease to less semi-Fowler position is also appropriate. The nurse should also
than 200 mL in 24 hours. With the sudden decrease in drainage at monitor the client’s respiratory status because clients with pancreatitis
0800, the nurse should immediately assess the tube for obstruction of are prone to develop respiratory complications. Daily weights are
flow that can be caused by kinks in the tube or the client lying on the obtained to monitor the client’s nutritional and fluid volume status.
tube. Clients with drainage color must also be assessed for signs of During the acute phase of the illness, when the client is experiencing
bleeding. The tube should not be irrigated or clamped without a pain, the pancreas is rested by withholding food and drink. When the
prescription. diet is reintroduced, it is a high-carbohydrate, low-fat, bland diet.
6.B. T-tube bile drainage is recorded separately on the output record. 18.A. Hypocalcemia develops in severe cases of acute pancreatitis.
Adding the T-tube drainage to the urine output or wound drainage The exact cause is unknown. Signs and symptoms of hypocalcemia
makes it difficult to accurately determine the amounts of bile, urine, or include jerking and muscle twitching, numbness of fingers and lips, and
drainage. The client’s total intake will be incorrect if drainage is irritability. Meperidine may cause tremors or seizures as an adverse
subtracted from it. effect, but not muscle twitching. Muscle twitching is not caused by a
7.A. This client is exhibiting signs of sepsis, andthe nurse should nutritional deficit, nor does it indicate that the client needs a muscle
notify the HCP. The client has three signs indicating sepsis: relaxant.
temperature higher than 101.0°F (38.3°C) (or lower than 96.8°F 19.A. Propantheline is an anticholinergic, antispasmodic medication
[36°C]), HR greater than 90 bpm, and RR greater than 20 breaths/min. that decreases vagal stimulation and pancreatic secretions. It is
At least two of these variables are required to diagnose sepsis. contraindicated in paralytic ileus; therefore, the nurse should be
8.D. Lean meats, such as beef, lamb, veal, and well-trimmed lean concerned with the absent bowel sounds. Side effects are urinary
ham and pork, are low in fat. Rice, pasta, and vegetables are low in fat retention, constipation, and tachycardia.
when not served with butter, cream, or sauces. Fruits are low in fat. 20.B. In chronic pancreatitis, destruction of pancreatictissue requires
The amount of fat allowed in a client’s diet after a cholecystectomy will pancreatic enzyme replacement. Pancreatic enzymes are prescribed to
depend on the client’s ability to tolerate fat. Typically, the client does facilitate the digestion of proteins and fats and should be taken in
not require a special diet but is encouraged to avoid excessive fat conjunction with every meal and snack. Specified hours or limited
intake. A cheese omelet and peanut butter have high fat content. Ham times for administration are ineffective because the enzymes must be
salad is high in fat from the fat in a mayonnaise-based salad dressing. taken in conjunction with food ingestion.
9.A. The client has severe pain, and the nurse should contact the 21.C. If the dosage and administration of pancreatic enzymes are
health care provider for pain medication. An opioid such as morphine is adequate, the client’s stool will be relatively normal. Any increase in
usually prescribed intravenously to manage severe pain. Elevation of odor or fat content would indicate the need for dosage adjustment.
the heart rate and blood pressure is likely due to the pain. The pain Stable body weight would be another indirect indicator. Fluid intake
medication may also relieve the nausea. does not affect enzyme replacement therapy. If diabetes has
developed, the client will need to monitor glucose levels. However,
lucose and ketone levels are not affected by pancreatic enzyme
g ay be prescribed to treat the symptoms. The drug may also cause
m
therapy and would not indicate the effectiveness of the therapy. hematologic changes; therefore, laboratory tests such as a complete
22.A. The fluid weight gain is of concern since thedrug should be blood count and differential should be conducted monthly during drug
used with caution with impaired renal function. Dosage adjustment may therapy. Blood glucose laboratory values should be monitored for the
be needed with renal insufficiency since the drug is excreted in the development of hyperglycemia.
urine. Nausea, minor temperature elevation, and fatigue are symptoms 34.D. Hepatitis B is spread through exposure to bloodor blood
that should be monitored, but they are associated with hepatitis products and through high-risk sexual activity. Hepatitis B is considered
23.D. Acetaminophen is toxic to the liver and should be avoided in a to be a sexually transmitted disease. High-risk sexual activities include
client with liver dysfunction. Increased periods of rest allow for liver sex with multiple partners, unprotected sex with an infected individual,
regeneration. A low-fat, high-carbohydrate diet and dry toast to relieve male homosexual activity, and sexual activity with intravenous drug
nausea are appropriate. users. College students are at high risk for the development of hepatitis
24.C. The hepatitis B vaccine is the most effective way to prevent B and are encouraged to be immunized. Alcohol intake by itself does
infection. The client must complete a series of three or four injections not predispose an individual to hepatitis B, but it can lead to high-risk
over a period of time for the vaccine to be effective. Hepatitis B is behaviors such as unprotected sex. Good personal hygiene alone will
considered a sexually transmitted disease, and the client also should not prevent the transmission of hepatitis B.
observe safe sex practices, but being vaccinated is most effective. 35.B. The client should be able to verbalize theimportance of
Poor sanitary conditions contribute to the spread of hepatitis A and E, reporting any bleeding tendencies that could be the result of a
but the client should also avoid drinking liquids that are not bottled. It is prolonged prothrombin time. Ascites is not typically a clinical
not necessary to avoid crowds or closed-in areas. manifestation of hepatitis; it is associated with cirrhosis. Alcohol use
25.B. Liver inflammation and obstruction block the normal flow of bile. should be eliminated for at least 1 year after the diagnosis of hepatitis
Excess bilirubin turns the skin and sclerae yellow and the urine dark to allow the liver time to fully recover. There is no need for a client to be
and frothy. Profound anorexia is also common. Tarry stools are restricted to the home because hepatitis is not spread through casual
indicative of gastrointestinal bleeding and would not be expected in contact between individuals.
hepatitis. Light- or clay-colored stools may occur in hepatitis owing to 36.A. Because the biopsy needle insertion site isclose to the lung,
bile duct obstruction. Shortness of breath would be unexpected. there is a risk for lung puncture and pneumothorax; therefore,
26.A,B,C,E. The client is at risk for having hepatitisC because of immediately after the procedure, the nurse should determine
intravenous drug use. The main route of transmission for hepatitis A is diminished or absent lung sounds in the right lung. Although fever
the oral-fecal route; the disease can be prevented by good indicates infection, a rise in temperature is not seen immediately. A
handwashing. The client should receive a vaccine for hepatitis A. The CBC is warranted if the vital signs and client symptoms indicate
vaccine is administered in 2 doses 6 months apart. Percutaneous potential hemorrhage. The needle insertion site is covered with a
transmission is more common with hepatitis B, C, and D, but the client pressure dressing; there is no need for a dressing requiring packing.
should follow safe needle and syringe precautions. Hepatitis A is not 38.A. Clients with cirrhosis can develop hepaticencephalopathy
transmitted by droplet infection; the client does not need to wear a caused by increased ammonia levels. Asterixis, a flapping tremor, is a
mask. characteristic symptom of increased ammonia levels. Bacterial action
27.B,D,E. Clients with chronic hepatitis C should abstain from on increased protein in the bowel will increase ammonia levels and
alcohol as it can speed cirrhosis and end-stage liver disease. Clients cause the encephalopathy to worsen. GI bleeding and protein
should also check with their HCPs before taking any nonprescription or consumed in the diet increase protein in the intestine and can elevate
prescription medications or herbal supplements. It is also important ammonia levels. Lactulose is given to reduce ammonia formation in the
that clients who are infected with HCV be tested for HIV, as clients who intestine and should not be held since neurologic symptoms are
have both HIV and HCV have a more rapid progression of liver disease worsening. Bilirubin is associated with jaundice
than do those who have HCV alone. Clients with HCV and nausea 39.C. Hypokalemia is a precipitating factor in hepatic encephalopathy.
should be instructed to eat four to five times a day to help reduce A decrease in creatinine results from muscle atrophy; an increase in
anorexia and nausea. The client should obtain sufficient rest to creatinine would indicate renal insufficiency. With liver dysfunction,
manage the fatigue increased aldosterone levels are seen. A decrease in serum protein
28.D. Although primarily bloodborne, unprotected sex with multiple will decrease colloid osmotic pressure and promote edema.
partners and a history of sexually transmitted disease are risk factors 40.D. Portal hypertension and hypoalbuminemia asa result of
for transmission of the hepatitis C virus. Other risk factors include cirrhosis cause a fluid shift into the peritoneal space causing ascites. In
blood transfusions, past treatment with chronic hemodialysis, being a a cardiac or kidney problem, not cirrhosis, sodium can promote edema
child born to a birth mother infected with hepatitis C virus, past or formation and subsequent decreased urine output. Edema does not
current intravenous drug use disorder, or needlestick injuries to health migrate upward toward the heart to enhance its circulation. Although
care workers. It is important for the nurse to be aware of the client’s diuretics promote the excretion of excess fluid, occasionally forgetting
history to help determine the client’s level of understanding of the or omitting a dose will not yield the ascites found in cirrhosis of the
disease, promote a healthy lifestyle, and discuss the role of viral liver.
transmission of the disease 41.A,B,C,D,E. Constipation leads to increasedammonia
29.A. Treatment of hepatitis consists primarily ofbed rest with production. Lactulose is a hyperosmotic laxative that reduces blood
bathroom privileges. Bed rest is maintained during the acute phase to ammonia by acidifying the colon contents, which retards the diffusion
reduce metabolic demands on the liver, thus increasing its blood of nonionic ammonia from the colon to the blood while promoting its
supply and promoting liver cell regeneration. When activity is gradually migration from the blood to the colon. Hepatic encephalopathy is
resumed, the client should be taught to rest before becoming overly considered a toxic or metabolic condition that causes cerebral edema;
tired. Although adequate fluid intake is important, it is not necessary to it affects a person’s coordination and pupil reaction to light and
force fluids to treat hepatitis. Antibiotics are not used to treat hepatitis. accommodation. Food and fluids high in carbohydrates should be
Electrolyte imbalances are not typical of hepatitis given because the liver is not synthesizing and storing glucose.
30.A. The prothrombin time may be prolonged becauseof decreased Because exercise produces ammonia as a byproduct of metabolism,
absorption of vitamin K and decreased production of prothrombin by physical activity should be limited, not encouraged.
the liver. The client should be assessed carefully for bleeding 42.B. Spironolactone is a potassium-sparing diuretic;therefore, clients
tendencies. Blood glucose, serum potassium, and serum calcium should be monitored closely for hyperkalemia. Other common adverse
levels are not affected by hepatitis. effects include abdominal cramping, diarrhea, dizziness, headache,
31.C. The hepatitis A virus is transmitted via the fecal-oral route. It and rash. Constipation and dysuria are not common adverse effects of
spreads through contaminated hands, water, and food, especially spironolactone. An irregular pulse is not an adverse effect of
shellfish growing in contaminated water. Certain animal handlers are at spironolactone but could develop if serum potassium levels are not
risk for hepatitis A, particularly those handling primates. Frequent closely monitored
handwashing is probably the single most important preventive action. 43.B,C,D. Baking soda baths can decrease pruritus. Keeping nails
Insects do not transmit hepatitis A. Family members do not need to short and rubbing the area with knuckles can decrease breakdown
stay away from the client with hepatitis. It is not necessary to disinfect when scratching. Calamine lotions help relieve itching. Alcohol will
food and clothing. increase skin dryness. Sodium in the diet will increase edema and
32.D. The most appropriate goal for this client with hepatitis is to weaken skin integrity.
increase activity gradually as tolerated. Periods of alternating rest and 44.B. General health promotion measures include maintaining good
activity should be included in the plan of care. There is no evidence nutrition, avoiding infection, and abstaining from alcohol. It is not
that the client is physically immobile, is unable to provide self-care, or necessary to take multivitamins if the client is obtaining adequate
needs to adapt to new energy levels. nutrition. Rest and sleep are essential, but an impaired liver may not be
33.C. Interferon alfa-2b most commonly causes flulike adverse able to detoxify sedatives and barbiturates. Such drugs must be used
effects, such as myalgia, arthralgia, headache, nausea, fever, and cautiously, if at all, by clients with cirrhosis. The client does not need to
fatigue. Retinopathy is a potential adverse effect, but not a common limit contact with others but should exercise caution to stay away from
one. Diarrhea may develop as an adverse effect. Clients are advised to ill people
administer the drug at bedtime and get adequate rest. Medications
5.D. Elevating the head of the bed will allow for increased lung
4 r esponsible to facilitate discussion between the client, the client’s
expansion by decreasing the ascites pressing on the diaphragm. The family, and the HCP, but only after all of the immediate physical and
client requires reassessment. A paracentesis is reserved for psychological needs of all clients have been met.
symptomatic clients with ascites with impaired respiration or abdominal 57.A,C,B,D. The nurse should first assess the client with cirrhosis
pain not responding to other measures such as sodium restriction and to ensure the client’s safety and assess the client for the onset of
diuretics. There is no indication for blood cultures. Heart sounds are hepatic encephalopathy. The nurse should then assess the client with
assessed with a routine physical assessment acute pancreatitis who is requesting pain medication and administer
46.D. The client with esophageal varices is at even higher risk for the needed medication. The nurse should next assess the client who
bleeding with an elevated PT/INR. The nurse and HCP collaborate to underwent a cholecystectomy and is 1 day postoperative to make sure
prevent bleeding. The other laboratory findings are not as that the T-tube is draining and that the client is performing
lifethreatening. A decreased serum albumin can cause fluid to move postoperative breathing exercises. This client’s safety is not at risk, and
into the interstitial tissues. Increased ammonia levels are toxic to the the client is not reporting having pain. The nurse can speak last with
brain. Calcium loss is more common with pancreatitis. the client with hepatitis B who has questions about discharge
47.A. Normal serum albumin is administered to reduce ascites. instructions because this client’s issues are not urgent.
Hypoalbuminemia, a mechanism underlying ascites formation, results 58.B. Hepatitis C is usually transmitted through blood exposure or
in decreased colloid osmotic pressure. Administering serum albumin needlesticks. A hepatitis C vaccine is currently under development, but
increases the plasma colloid osmotic pressure, which causes fluid to it is not available for use. The first line of defense against hepatitis B is
flow from the tissue space into the plasma. Increased urine output is the hepatitis B vaccine. Hepatitis C is not transmitted through feces or
the best indication that the albumin is having the desired effect. An urine. Wearing a gown and mask will not prevent transmission of the
increased serum albumin level and increased ease of breathing may hepatitis C virus if the caregiver comes in contact with infected blood or
indirectly imply that the administration of albumin is effective in needles.
relieving the ascites. However, it is not as direct an indicator as 59.A,C,D,B. Silencing the alarm will eliminate a stressor for the
increased urine output and reduced ascites. Anorexia is not affected by client and allow the nurse to focus on the task at hand. The nurse
the administration of albumin. should then assess the access site to note if the needle is inserted in
48.A,C,B,D. The nurse should first assess theclient to determine if the vein or if there is tissue trauma, infiltration, or inflammation. Next,
the tube is obstructing the airway; assessment is done by assessing the nurse should check for kinks in the tubing. Finally, the nurse can
airflow. Once the obstruction is established, the tube should be plug the pump into the wall to allow the battery to become recharged.
deflated and then quickly removed. A set of scissors should always be
at the bedside to allow for emergency deflation of the balloon. Oxygen
via face mask should then be applied once the tube is removed.
49.A. The client should be monitored closely for changes in mental
status. Ammonia has a toxic effect on central nervous system tissue
and produces an altered level of consciousness, marked by
drowsiness and irritability. If this process is unchecked, the client may
lapse into a coma. Increasing ammonia levels are not detected by
changes in blood pressure, urine output, or respirations.
50.C. Lactulose increases intestinal motility, thereby trapping and
expelling ammonia in the feces. An increase in the number of bowel
movements is expected.. Lactulose does not affect urine output. Any
improvements in mental status would be the result of increased
ammonia elimination, not a direct effect of the drug. Nausea and
vomiting are not expected effects of lactulose.
51.B. The taste of lactulose is a problem for someclients. Mixing it
with fruit juice, water, or milk can make it more palatable. Lactulose
should not be given with antacids, which may inhibit its action.
Lactulose should not be taken with a laxative because increased
stooling is an adverse effect of the drug and would be potentiated by
using a laxative. Lactulose comes in the form of syrup for oral or rectal
administration
52.C. Clients with cirrhosis should be instructedto avoid constipation
and straining at stool to prevent hemorrhage. The client with cirrhosis
has bleeding tendencies because of the liver’s inability to produce
clotting factors. A low-protein and high-carbohydrate diet is
recommended. Clients with cirrhosis should not take acetaminophen,
which is potentially hepatotoxic. Aspirin also should be avoided if
esophageal varices are present. Cirrhosis is a chronic disease
53.A. Immediately before a paracentesis, the clientshould empty the
bladder to prevent perforation. The client will be placed in a high
Fowler position or seated on the side of the bed for the procedure. IV
sedatives are not usually administered. The client does not need to be
NPO.
54.C. Edematous tissue is easily traumatized and must receive
meticulous care. An alternating air pressure mattress will help
decrease pressure on the edematous tissue. ROM exercises are
important to maintain joint function, but they do not necessarily prevent
skin breakdown. When abdominal skin is stretched taut due to ascites,
it must be cleaned very carefully. The abdomen should not be
massaged. Elevation of the lower extremities promotes venous return
and decreases swelling.
55.D. Contact precautions are recommended for clientswith hepatitis
A. This includes wearing gloves for direct care. A gown is not required
unless substantial contact with the client is anticipated. It is not
necessary to wear a mask. The client does not need a private room
unless incontinent of stool.
56.D. A change in a client’s baseline vital signs should be brought to
the HCP’s attention immediately. In this case, the client’s heart rate has
increased, and the rhythm appears to have changed; the HCP may
prescribe an electrocardiogram to determine if treatment is necessary.
The nurse should also have a complete set of current vital signs as
well as a physical assessment before providing the HCP information
using the SBAR (Situation-Background-AssessmentRecommendation)
format. The nutritional as well as psychological needs of a client must
be addressed, but they are not the first priority. A rash that develops
after a new antibiotic is started must be brought to the HCP’s attention;
however, this client is stable and is not the first priority. The nurse is
Ignatavicius Medical-Surgical Nursing, 10th Edition Test Bank . “Having this new diagnosis must be very hard for you.”
c
d. “It is important that you be realistic about your prognosis.”
hapter 41: Upper Gastrointestinal Problems Lewis: Medical-Surgical
C
Nursing, 10th Edition 2. Which information will the nurse include for a patient with newly
1
diagnosed gastroesophageal reflux disease (GERD)?
. A 53-yr-old male patient with deep partial-thickness burns from a
1 a. “Peppermint tea may reduce your symptoms.”
chemical spill in the workplace experiences severe pain followed by b. “Keep the head of your bed elevated on blocks.”
nausea during dressing changes. Which action will be most useful in c. “You should avoid eating between meals to reduce acid secretion.”
decreasing the patient’s nausea? d. “Vigorous physical activities may increase the incidence of reflux.”
a. Keep the patient NPO for 2 hours before dressing changes.
b. Give the ordered prochlorperazine before dressing changes. 3. Which nursing action should be included in the postoperative plan
1
c. Administer the prescribed morphine sulfate before dressing of care for a patient after a laparoscopic esophagectomy?
changes. a. Reposition the NG tube if drainage stops.
d. Avoid performing dressing changes close to the patient’s mealtimes. b. Elevate the head of the bed to at least 30 degrees.
c. Start oral fluids when the patient has active bowel sounds.
. Which item should the nurse offer to the patient who is to restart oral
2 d. Notify the doctor for any bloody nasogastric (NG) drainage.
intake after being NPO
due to nausea and vomiting? 4. When a patient is diagnosed with achalasia, the nurse will teach
1
a. Glass of orange juice c. Cup of coffee with cream the patient that
b. Dish of lemon gelatin d. Bowl of hot chicken broth a. lying down after meals is recommended.
b. a liquid or blenderized diet will be necessary.
. A 38-year old woman receiving chemotherapy for breast cancer
3 c. drinking fluids with meals should be avoided.
develops a Candida albicans oral infection. The nurse will anticipate d. treatment may include endoscopic procedures.
the need for
a. hydrogen peroxide rinses. 5. A patient vomiting blood-streaked fluid is admitted to the hospital
1
b. the use of antiviral agents. with acute gastritis. To determine possible risk factors for gastritis, the
c. administration of nystatin tablets. nurse will ask the patient about
d. referral to a dentist for professional tooth cleaning. a. the amount of saturated fat in the diet.
b. a family history of gastric or colon cancer.
. Which finding in the mouth of a patient who uses smokeless tobacco
4 c. a history of a large recent weight gain or loss.
is suggestive of oral cancer? d. use of nonsteroidal antiinflammatory drugs (NSAIDs).
a. Bleeding during tooth brushing
b. Painful blisters at the lip border 6. The nurse determines that teaching regarding cobalamin injections
1
c. Red, velvety patches on the buccal mucosa has been effective when the patient with chronic atrophic gastritis
d. White, curdlike plaques on the posterior tongue states
a. “The cobalamin injections will prevent gastric inflammation.”
. Which information will the nurse include when teaching adults to
5 b. “The cobalamin injections will prevent me from becoming anemic.”
decrease the risk for cancers of the tongue and buccal mucosa? c. “These injections will increase the hydrochloric acid in my stomach.”
a. Avoid use of cigarettes and smokeless tobacco. d. “These injections will decrease my risk for developing stomach
b. Use sunscreen when outside even on cloudy days. cancer.”
c. Complete antibiotic courses used to treat throat infections.
d. Use antivirals to treat herpes simplex virus (HSV) infections. 7. A patient has peptic ulcer disease that has been associated with
1
Helicobacter pylori. About which medications will the nurse plan to
. A patient who has gastroesophageal reflux disease (GERD) is
6 teach the patient?
experiencing increasing discomfort. Which patient statement to the a. Sucralfate (Carafate), nystatin, and bismuth (Pepto-Bismol)
nurse indicates that additional teaching about GERD is needed? b. Metoclopramide (Reglan), bethanechol (Urecholine), and
a. “I take antacids between meals and at bedtime each night.” promethazine
b. “I sleep with the head of the bed elevated on 4-inch blocks.” c. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole
c. “I eat small meals during the day and have a bedtime snack.” (Prilosec)
d. “I quit smoking several years ago, but I still chew a lot of gum.” d. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and
pantoprazole
(Protonix)
. A 68-yr-old male patient with a stroke is unconscious and
7
unresponsive to stimuli. After 8. Which action should the nurse in the emergency department
1
learning that the patient has a history of gastroesophageal reflux anticipate for a young adult patient who has had several episodes of
disease (GERD), the nurse bloody diarrhea?
will plan to do frequent assessments of the patient’s a. Obtain a stool specimen for culture.
a. apical pulse. c. breath sounds. b. Administer antidiarrheal medication.
b. bowel sounds. d. abdominal girth. c. Provide teaching about antibiotic therapy.
d. Teach the adverse effects of acetaminophen (Tylenol).
. The nurse explaining esomeprazole (Nexium) to a patient with
8
recurring heartburn describes that the medication 9. The nurse will anticipate preparing an older patient who is vomiting
1
a. reduces gastroesophageal reflux by increasing the rate of gastric “coffee-ground” emesis for
emptying. a. endoscopy. c. barium studies.
b. neutralizes stomach acid and provides relief of symptoms in a few b. Angiography. d. gastric analysis.
minutes.
c. coats and protects the lining of the stomach and esophagus from 0. An adult with Escherichia coli O157:H7 food poisoning is admitted
2
gastric acid. to the hospital with bloody diarrhea and dehydration. Which prescribed
d. treats gastroesophageal reflux disease by decreasing stomach acid action will the nurse question?
production. a. Infuse lactated Ringer’s solution at 250 mL/hr.
b. Monitor blood urea nitrogen and creatinine daily.
. Which patient choice for a snack 3 hours before bedtime indicates
9 c. Administer loperamide (Imodium) after each stool.
that the nurse’s teaching about gastroesophageal reflux disease d. Provide a clear liquid diet and progress diet as tolerated.
(GERD) has been effective?
a. Chocolate pudding c. Cherry gelatin with fruit 1. Which information will the nurse include when teaching a patient
2
b. Glass of low-fat milk d. Peanut butter and jelly sandwich with peptic ulcer disease about the effect of ranitidine (Zantac)?
a. “Ranitidine absorbs the excess gastric acid.”
0. The nurse will anticipate teaching a patient experiencing frequent
1 b. “Ranitidine decreases gastric acid secretion.”
heartburn about c. “Ranitidine constricts the blood vessels near the ulcer.”
a. a barium swallow. c. endoscopy procedures. d. “Ranitidine covers the ulcer with a protective material.”
b. radionuclide tests. d. proton pump inhibitors.
2. A young adult patient is hospitalized with massive abdominal
2
1. A 58-yr-old woman who was recently diagnosed with esophageal
1 trauma from a motor vehicle
cancer tells the nurse, “I do not feel ready to die yet.” Which response crash. The patient asks the nurse about the purpose of receiving
by the nurse is most appropriate? famotidine (Pepcid). The
a. “You may have quite a few years still left to live.” nurse will explain that the medication will
b. “Thinking about dying will only make you feel worse.” a. decrease nausea and vomiting.
. inhibit development of stress ulcers.
b 3. The nurse is assessing a patient who had a total gastrectomy 8
3
c. lower the risk for H. pylori infection. hours ago. What information is most important to report to the health
d. prevent aspiration of gastric contents. care provider?
a. Hemoglobin (Hgb) 10.8 g/dL
3. An older patient with a bleeding duodenal ulcer has a nasogastric
2 b. Temperature 102.1°F (38.9°C)
(NG) tube in place. The health care provider prescribes 30 mL of c. Absent bowel sounds in all quadrants
aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled d. Scant nasogastric (NG) tube drainage
through the tube every hour. To evaluate the effectiveness of this
treatment, the nurse 4. A 58-yr-old patient has just been admitted to the emergency
3
a. monitors arterial blood gas values daily. department with nausea and vomiting. Which information requires the
b. periodically aspirates and tests gastric pH. most rapid intervention by the nurse?
c. checks each stool for the presence of occult blood. a. The patient has been vomiting for 4 days.
d. measures the volume of residual stomach contents. b. The patient takes antacids 8 to 10 times a day.
c. The patient is lethargic and difficult to arouse.
4. A patient admitted with a peptic ulcer has a nasogastric (NG) tube
2 d. The patient has had a small intestinal resection.
in place. When the patient develops sudden, severe upper abdominal
pain, diaphoresis, and a firm abdomen, which action should the nurse 5. A young adult been admitted to the emergency department with
3
take? nausea and vomiting. Which action could the RN delegate to
a. Irrigate the NG tube. c. Give the ordered antacid. unlicensed assistive personnel (UAP)?
b. Check the vital signs. d. Elevate the foot of the bed. a. Auscultate the bowel sounds. c. Assist the patient with oral care.
b. Assess for signs of dehydration.
5. A patient who underwent a gastroduodenostomy (Billroth I) 12
2 d. Ask the patient about the nausea.
hours ago complains of increasing abdominal pain. The patient has no
bowel sounds and 200 mL of bright red nasogastric (NG) drainage in 6. A 49-yr-old man has been admitted with hypotension and
3
the past hour. The highest priority action by the nurse is to dehydration after 3 days of nausea and vomiting. Which prescribed
a. contact the surgeon. action will the nurse implement first?
b. irrigate the NG tube. a. Insert a nasogastric (NG) tube.
c. monitor the NG drainage. b. Infuse normal saline at 250 mL/hr.
d. administer the prescribed morphine. c. Administer IV ondansetron (Zofran).
d. Provide oral care with moistened swabs.
6. Which patient statement indicates that the nurse’s postoperative
2
teaching after a gastroduodenostomy has been effective? 7. Which patient should the nurse assess first after receiving
3
a. “I will drink more liquids with my meals.” change-of-shift report?
b. “I should choose high carbohydrate foods.” a. A patient with nausea who has a dose of metoclopramide (Reglan)
c. “Vitamin supplements may prevent anemia.” due
d. “Persistent heartburn is common after surgery.” b. A patient who is crying after receiving a diagnosis of esophageal
cancer
7. At his first postoperative checkup appointment after a
2 c. A patient with esophageal varices who has a blood pressure of
gastrojejunostomy (Billroth II), a patient reports that dizziness, 92/58 mm Hg
weakness, and palpitations occur about 20 minutes after each meal. d. A patient admitted yesterday with gastrointestinal (GI) bleeding who
The nurse will teach the patient to has melena
a. increase the amount of fluid with meals.
b. eat foods that are higher in carbohydrates. 8. A patient returned from a laparoscopic Nissen fundoplication for
3
c. lie down for about 30 minutes after eating. hiatal hernia 4 hours ago. Which assessment finding is most important
d. drink sugared fluids or eat candy after meals. for the nurse to address immediately?
a. The patient is experiencing intermittent waves of nausea.
8. A patient who requires daily use of a nonsteroidal antiinflammatory
2 b. The patient has no breath sounds in the left anterior chest.
drug (NSAID) for the management of severe rheumatoid arthritis has c. The patient complains of 7/10 (0 to 10 scale) abdominal pain.
recently developed melena. The nurse will d. The patient has hypoactive bowel sounds in all four quadrants.
anticipate teaching the patient about
a. substitution of acetaminophen (Tylenol) for the NSAID. 9. Which assessment should the nurse perform first for a patient who
3
b. use of enteric-coated NSAIDs to reduce gastric irritation. just vomited bright red blood?
c. reasons for using corticosteroids to treat the rheumatoid arthritis. a. Measuring the quantity of emesis
d. misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa. b. Palpating the abdomen for distention
c. Auscultating the chest for breath sounds
9. The health care provider prescribes antacids and sucralfate
2 d. Taking the blood pressure (BP) and pulse
(Carafate) for treatment of a patient’s peptic ulcer. The nurse will teach
the patient to take 0. Which prescribed action will the nurse implement first for a patient
4
a. sucralfate at bedtime and antacids before each meal. who has vomited 1100 mL of blood?
b. sucralfate and antacids together 30 minutes before meals. a. Give an IV H2 receptor antagonist.
c. antacids 30 minutes before each dose of sucralfate is taken. b. Draw blood for typing and crossmatching.
d. antacids after meals and sucralfate 30 minutes before meals c. Administer 1 L of lactated Ringer’s solution.
d. Insert a nasogastric (NG) tube and connect to suction.
0. Which information about dietary management should the nurse
3
include when teaching a patient with peptic ulcer disease (PUD)? 1. The nurse is administering IV fluid boluses and nasogastric
4
a. “You will need to remain on a bland diet.” irrigation to a patient with acute gastrointestinal (GI) bleeding. Which
b. “Avoid foods that cause pain after you eat them.” assessment finding is most important for the nurse to communicate to
c. “High-protein foods are least likely to cause you pain.” the health care provider?
d. “You should avoid eating any raw fruits and vegetables.” a. The bowel sounds are hyperactive in all four quadrants.
b. The patient’s lungs have crackles audible to the midchest.
1. A 73-yr-old patient is diagnosed with stomach cancer after an
3 c. The nasogastric (NG) suction is returning coffee-ground material.
unintended 20-lb weight loss. Which nursing action will be included in d. The patient’s blood pressure (BP) has increased to 142/84 mm Hg.
the plan of care?
a. Refer the patient for hospice services. 2. After the nurse has completed teaching a patient with newly
4
b. Infuse IV fluids through a central line. diagnosed eosinophilic esophagitis about the management of the
c. Teach the patient about antiemetic therapy. disease, which patient action indicates that the teaching has been
d. Offer supplemental feedings between meals. effective?
a. Patient orders nonfat milk for each meal.
2. A 26-yr-old patient with a family history of stomach cancer asks the
3 b. Patient uses the prescribed corticosteroid inhaler.
nurse about ways to decrease the risk for developing stomach cancer. c. Patient schedules an appointment for allergy testing.
The nurse will teach the patient to avoid d. Patient takes ibuprofen (Advil) to control throat pain.
a. emotionally stressful situations.
b. smoked foods such as ham and bacon. 3. An 80-yr-old patient who is hospitalized with peptic ulcer disease
4
c. foods that cause distention or bloating. develops new-onset auditory hallucinations. Which prescribed
d. chronic use of H2 blocking medications. medication will the nurse discuss with the health care provider before
administration?
a. Sucralfate (Carafate) c. Omeprazole (Prilosec)
b. Aluminum hydroxide d. Metoclopramide (Reglan) that the nurse is not open to discussing the patient’s fears of dying.
The response beginning, “It is important that you be realistic”
4. The nurse and a licensed practical/vocational nurse (LPN/LVN) are
4 discourages the patient from feeling hopeful, which is important to
working together to care for a patient who had an esophagectomy 2 patients with any life-threatening diagnosis.
days ago. Which action by the LPN/LVN requires that the nurse 12. ANS: B Elevating the head of the bed will reduce the incidence of
intervene? reflux while the patient is sleeping. Peppermint will decrease lower
a. The LPN/LVN uses soft swabs to provide oral care. esophageal sphincter (LES) pressure and increase the chance for
b. The LPN/LVN positions the head of the bed in the flat position. reflux. Small, frequent meals are recommended to avoid abdominal
c. The LPN/LVN includes the enteral feeding volume when calculating distention. There is no need to make changes in physical activities
intake. because of GERD.
d. The LPN/LVN encourages the patient to use pain medications 13. ANS: B Elevation of the head of the bed decreases the risk for
before coughing. reflux and aspiration of gastric secretions. The NG tube should not be
repositioned without consulting with the health care provider. Bloody
5. After change-of-shift report, which patient should the nurse assess
4 NG drainage is expected for the first 8 to 12 hours. A swallowing study
first? is needed before oral fluids are started.
a. A 42-yr-old patient who has acute gastritis and ongoing epigastric 14. ANS: D Endoscopic and laparoscopic procedures are the most
pain effective therapy for improving symptoms caused by achalasia.
b. A 70-yr-old patient with a hiatal hernia who experiences frequent Keeping the head elevated after eating will improve esophageal
heartburn emptying. A semisoft diet is recommended to improve esophageal
c. A 60-yr-old patient with nausea and vomiting who has dry mucosa emptying. Patients are advised to drink fluid with meals.
and lethargy 15. ANS: D Use of an NSAID is associated with damage to the gastric
d. 53-yr-old patient who has dumping syndrome after a recent partial mucosa, which can result in acute gastritis. Family history, recent
gastrectomy weight gain or loss, and fatty foods are not risk factors for acute
gastritis.
16. ANS: B Cobalamin supplementation prevents the development of
pernicious anemia. Chronic gastritis may cause achlorhydria, but
cobalamin does not correct this. The loss of intrinsic factor secretion
answer key with chronic gastritis is permanent, and the patient will need lifelong
supplementation with cobalamin. The incidence of stomach cancer is
. ANS: C Because the patient’s nausea is associated with severe
1 higher in patients with chronic gastritis, but cobalamin does not reduce
pain, it is likely that it is precipitated by stress and pain. The best the risk for stomach cancer.
treatment will be to provide adequate pain medication before dressing 17. ANS: C The drugs used in triple drug therapy include a proton
changes. The nurse should avoid doing painful procedures close to pump inhibitor such as omeprazole and the antibiotics amoxicillin and
mealtimes, but nausea or vomiting that occur at other times also clarithromycin. The other combinations listed are not included in the
should be addressed. Keeping the patient NPO does not address the protocol for H. pylori infection.
reason for the nausea and vomiting and will have an adverse effect on 18. ANS: A Patients with bloody diarrhea should have a stool culture
the patient’s nutrition. Administration of antiemetics is not the best for Escherichia coli O157:H7. Antidiarrheal medications are usually
choice for a patient with nausea caused by pain. However, an avoided for possible infectious diarrhea to avoid prolonging the
antiemetic may be added later if the nausea persists despite pain infection. Antibiotic therapy in the treatment of infectious diarrhea is
management. controversial because it may precipitate kidney complications.
2. ANS: B Clear cool liquids are usually the first foods started after a Acetaminophen does not cause bloody diarrhea.
patient has been nauseated. Acidic foods such as orange juice, very 19. ANS: A Endoscopy is the primary tool for visualization and
hot foods, and coffee are poorly tolerated when patients have been diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used
nauseated. only when endoscopy cannot be done because it is more invasive and
3. ANS: C Candida albicans infections are treated with an antifungal has more possible complications. Barium studies are helpful in
such as nystatin. Peroxide rinses would be painful. Oral saltwater determining the presence of gastric lesions, but not whether the lesions
rinses may be used but will not cure the infection. Antiviral agents are are actively bleeding. Gastric analysis testing may help with
used for viral infections such as herpes simplex. Referral to a dentist is determining the cause of gastric irritation, but it is not used for acute GI
indicated for gingivitis but not for Candida infection. bleeding.
4. ANS: C A red, velvety patch suggests erythroplasia, which has a 20. ANS: C Use of antidiarrheal agents is avoided with this type of food
high incidence (>50%) of progression to squamous cell carcinoma. The poisoning. The other orders are appropriate.
other lesions are suggestive of acute processes (e.g., gingivitis, oral 21. ANS: B Ranitidine is a histamine-2 (H2) receptor blocker that
candidiasis, herpes simplex). decreases the secretion of gastric acid. The response beginning,
5. ANS: A Tobacco use greatly increases the risk for oral cancer. Acute “Ranitidine constricts the blood vessels” describes the effect of
throat infections do not increase the risk for oral cancer, although vasopressin. The response “Ranitidine absorbs the gastric acid”
chronic irritation of the oral mucosa does increase risk. Sun exposure describes the effect of antacids. The response beginning “Ranitidine
does not increase the risk for cancers of the buccal mucosa. Human covers the ulcer” describes the action of sucralfate (Carafate).
papillomavirus (HPV) infection is associated with an increased risk, but 22. ANS: B Famotidine is administered to prevent the development of
HSV infection is not a risk factor for oral cancer physiologic stress ulcers, which are associated with a major
6. ANS: C GERD is exacerbated by eating late at night, and the nurse physiologic insult such as massive trauma. Famotidine does not
should plan to teach the patient to avoid eating at bedtime. The other decrease nausea or vomiting, prevent aspiration, or prevent
patient actions are appropriate to control symptoms of GERD. Helicobacter pylori infection.
7. ANS: C Because GERD may cause aspiration, the unconscious 23. ANS: B The purpose for antacids is to increase gastric pH.
patient is at risk for developing aspiration pneumonia. Bowel sounds, Checking gastric pH is the most direct way of evaluating the
abdominal girth, and apical pulse will not be affected by the patient’s effectiveness of the medication. Arterial blood gases may change
stroke or GERD and do not require more frequent monitoring than the slightly, but this does not directly reflect the effect of antacids on gastric
routine. pH. Because the patient has upper gastrointestinal bleeding, occult
8. ANS: D The proton pump inhibitors decrease the rate of gastric acid blood in the stools will appear even after the acute bleeding has
secretion. Promotility drugs such as metoclopramide (Reglan) increase stopped. The amount of residual stomach contents is not a reflection of
the rate of gastric emptying. Cryoprotective medications such as resolution of bleeding or of gastric pH.
sucralfate (Carafate) protect the stomach. Antacids neutralize stomach 24. ANS: B The patient’s symptoms suggest acute perforation, and the
acid and work rapidly. nurse should assess for signs of hypovolemic shock. Irrigation of the
9. ANS: C Gelatin and fruit are low fat and will not decrease lower NG tube, administration of antacids, or both would be contraindicated
esophageal sphincter (LES) pressure. Foods such as chocolate are because any material in the stomach will increase the spillage into the
avoided because they lower LES pressure. Milk products increase peritoneal cavity. Elevating the foot of the bed may increase abdominal
gastric acid secretion. High-fat foods such as peanut butter decrease pressure and discomfort, as well as making it more difficult for the
both gastric emptying and LES pressure. patient to breathe.
10. ANS: D Because diagnostic testing for heartburn that is probably 25. ANS: A Increased pain and 200 mL of bright red NG drainage 12
caused by gastroesophageal reflux disease (GERD) is expensive and hours after surgery indicate possible postoperative hemorrhage, and
uncomfortable, proton pump inhibitors are frequently used for a short immediate actions such as blood transfusion or return to surgery are
period as the first step in the diagnosis of GERD. The other tests may needed (or both). Because the NG is draining, there is no indication
be used but are not usually the first step in diagnosis. that irrigation is needed. Continuing to monitor the NG drainage is not
11. ANS: C This response is open ended and will encourage the an adequate response. The patient may need morphine, but this is not
patient to further discuss feelings of anxiety or sadness about the the highest priority action.
diagnosis. Patients with esophageal cancer have a low survival rate, so 26. ANS: C Cobalamin deficiency may occur after partial gastrectomy,
the response “You may have quite a few years still left to live” is and the patient may need to receive cobalamin via injections or nasal
misleading. The response beginning, “Thinking about dying” indicates spray. Although peptic ulcer disease may recur, persistent heartburn is
ot expected after surgery, and the patient should call the health care
n 3.ANS: D Metoclopramide can cause central nervous system side
4
provider if this occurs. Ingestion of liquids with meals is avoided to effects ranging from anxiety to hallucinations. Hallucinations are not a
prevent dumping syndrome. Foods that have moderate fat and low side effect of proton pump inhibitors, mucosal protectants, or antacids.
carbohydrate should be chosen to prevent dumping syndrome. 44.ANS: B The patient’s bed should be in Fowler’s position to prevent
27. ANS: C The patient is experiencing symptoms of dumping reflux and aspiration of gastric contents. The other actions by the
syndrome, which may be reduced by lying down after eating. LPN/LVN are appropriate.
Increasing fluid intake and choosing high carbohydrate foods will 45.ANS: C This patient is at high risk for problems such as aspiration,
increase the risk for dumping syndrome. Having a sweet drink or hard dehydration, and fluid and electrolyte disturbances. The other patients
candy will correct the hypoglycemia that is associated with dumping will also need to be assessed, but the information about them indicates
syndrome but will not prevent dumping syndrome. symptoms that are typical for their diagnoses and are not life
28.ANS: D Misoprostol, a prostaglandin analog, reduces acid secretion threatening.
and the incidence of upper GI bleeding associated with NSAID use.
Enteric coating of NSAIDs does not reduce the risk for GI bleeding.
Corticosteroids increase the risk for ulcer development and will not be
substituted for NSAIDs for this patient. Acetaminophen will not be
effective in treating rheumatoid arthritis.
29.ANS: D Sucralfate is most effective when the pH is low and should
not be given with or soon after antacids. Antacids are most effective
when taken after eating. Administration of sucralfate 30 minutes before
eating and antacids just after eating will ensure that both drugs can be
most effective. The other regimens will decrease the effectiveness of
the medications.
30. ANS: B The best information is that each individual should choose
foods that are not associated with postprandial discomfort. Raw fruits
and vegetables may irritate the gastric mucosa, but chewing well
seems to decrease this problem and some patients may tolerate these
foods well. High-protein foods help neutralize acid, but they also
stimulate hydrochloric (HCl) acid secretion and may increase
discomfort for some patients. Bland diets may be recommended during
an acute exacerbation of PUD, but there is little scientific evidence to
support their use.
31. ANS: D The patient data indicate a poor nutritional state and
improvement in nutrition will be helpful in improving the response to
therapies such as surgery, chemotherapy, or radiation. Nausea and
vomiting are not common clinical manifestations of stomach cancer.
There is no indication that the patient requires hospice or IV fluid
infusions.
32. ANS: B Smoked foods such as bacon, ham, and smoked sausage
increase the risk for stomach cancer. Stressful situations, abdominal
distention, and use of H2 blockers are not associated with an
increased incidence of stomach cancer.
33. ANS: B An elevation in temperature may indicate leakage at the
anastomosis, which may require return to surgery or keeping the
patient NPO. The other findings are expected in the immediate
postoperative period for patients who have this surgery and do not
require any urgent action.
34. ANS: C A lethargic patient is at risk for aspiration, and the nurse
will need to position the patient to decrease aspiration risk. The other
information is also important to collect, but it does not require as quick
action as the risk for aspiration.
35.ANS: C Oral care is included in UAP education and scope of
practice. The other actions are all assessments that require more
education and a higher scope of nursing practice.
36.ANS: B Because the patient has severe dehydration, rehydration
with IV fluids is the priority. The other orders should be accomplished
after the IV fluids are initiated.
37. ANS: C The patient’s history and blood pressure indicate possible
hemodynamic instability caused by GI bleeding. The data about the
other patients do not indicate acutely life-threatening complications.
38.ANS: B Decreased breath sounds on one side may indicate a
pneumothorax, which requires rapid diagnosis and treatment. The
nausea and abdominal pain should also be addressed, but they are not
as high priority as the patient’s respiratory status. The patient’s
decreased bowel sounds are expected after surgery and require
ongoing monitoring but no other action.
39.ANS: D The nurse is concerned about blood loss and possible
hypovolemic shock in a patient with acute gastrointestinal bleeding. BP
and pulse are the best indicators of these complications. The other
information is important to obtain, but BP and pulse rate are the best
indicators for assessing intravascular volume.
40.ANS: C Because the patient has vomited a large amount of blood,
correction of hypovolemia and prevention of hypovolemic shock are the
priorities. The other actions also are important to implement quickly,
but are not the highest priorities.
41.ANS: B The patient’s lung sounds indicate that pulmonary edema
may be developing as a result of the rapid infusion of IV fluid and that
the fluid infusion rate should be slowed. The return of coffee-ground
material in an NG tube is expected for a patient with upper GI bleeding.
The BP is slightly elevated but would not be an indication to contact the
health care provider immediately. Hyperactive bowel sounds are
common when a patient has GI bleeding.
42.ANS: C Eosinophilic esophagitis is frequently associated with
environmental allergens, so allergy testing is used to determine
possible triggers. Corticosteroid therapy may be prescribed, but the
medication will be swallowed, not inhaled. Milk is a frequent trigger for
attacks. NSAIDs are not used for eosinophilic esophagitis.
hapter 42: Lower Gastrointestinal Problems Lewis: Medical-Surgical
C
Nursing, 10th Edition 1. Which patient statement indicates that the nurse’s teaching about
1
sulfasalazine (Azulfidine) for ulcerative colitis has been effective?
. Which action will the nurse include in the plan of care for a patient
1 a. “The medication will be tapered if I need surgery.”
who is being admitted with Clostridium difficile? b. “I will need to use a sunscreen when I am outdoors.”
a. Teach the patient about proper food storage. c. “I will need to avoid contact with people who are sick.”
b. Order a diet without dairy products for the patient. d. “The medication prevents the infections that cause diarrhea.”
c. Place the patient in a private room on contact isolation.
d. Teach the patient about why antibiotics will not be used. 2. A 22-yr-old female patient with an exacerbation of ulcerative colitis
1
is having 15 to 20 stools daily and has excoriated perianal skin. Which
. A 74-yr-old male patient tells the nurse that growing old causes
2 patient behavior indicates that teaching regarding maintenance of skin
constipation so he has been using a suppository for constipation every integrity has been effective?
morning. Which action should the nurse take first? a. The patient uses incontinence briefs to contain loose stools.
a. Encourage the patient to increase oral fluid intake. b. The patient uses witch hazel compresses to soothe irritation.
b. Question the patient about risk factors for constipation. c. The patient asks for antidiarrheal medication after each stool.
c. Suggest that the patient increase intake of high-fiber foods. d. The patient cleans the perianal area with soap after each stool.
d. Teach the patient that a daily bowel movement is unnecessary.
3. Which diet choice by the patient with an acute exacerbation of
1
. A patient who has chronic constipation asks the nurse about the use
3 inflammatory bowel disease (IBD) indicates a need for more teaching?
of psyllium (Metamucil). Which information will the nurse include in the a. Scrambled eggs c. Oatmeal with cream
response? b. White toast and jam d. Pancakes with syrup
a. Absorption of fat-soluble vitamins may be reduced by
fiber-containing laxatives. 4. After a total proctocolectomy and permanent ileostomy, the patient
1
b. Dietary sources of fiber should be eliminated to prevent excessive tells the nurse, “I cannot manage all these changes. I don’t want to look
gas formation. at the stoma.” What is the best action by the nurse?
c. Use of this type of laxative to prevent constipation does not cause a. Reassure the patient that ileostomy care will become easier.
adverse effects. b. Ask the patient about the concerns with stoma management.
d. Large amounts of fluid should be taken to prevent impaction or c. Postpone any teaching until the patient adjusts to the ileostomy.
bowel obstruction. d. Develop a detailed written list of ostomy care tasks for the patient.
. A 26-yr-old woman is being evaluated for vomiting and abdominal
4 5. A patient has a new diagnosis of Crohn’s disease after having
1
pain. Which question from the nurse will be most useful in determining frequent diarrhea and a weight loss of 10 lb (4.5 kg) over 2 months.
the cause of the patient’s symptoms? The nurse will plan to teach about
a. “What type of foods do you eat?” a. medication use . c. enteral nutrition.
b. “Is it possible that you are pregnant?” b. fluid restriction. d. activity restrictions
c. “Can you tell me more about the pain?”
d. “What is your usual elimination pattern?” 6. A young woman who has Crohn’s disease develops a fever and
1
symptoms of a urinary tract infection (UTI) with tan, fecal-smelling
. A patient complains of gas pains and abdominal distention 2 days
5 urine. What information will the nurse add to a general teaching plan
after a small bowel resection. Which nursing action should the nurse about UTIs in order to individualize the teaching for this patient?
take? a. Bacteria in the perianal area can enter the urethra.
a. Encourage the patient to ambulate. b. Fistulas can form between the bowel and bladder.
b. Instill a mineral oil retention enema. c. Drink adequate fluids to maintain normal hydration.
c. Administer the prescribed IV morphine sulfate. d. Empty the bladder before and after sexual intercourse.
d. Offer the prescribed promethazine (Phenergan).
7. A patient with diverticulosis has a large bowel obstruction. The
1
. A 58-yr-old patient with blunt abdominal trauma from a motor vehicle
6 nurse will monitor for
crash undergoes peritoneal lavage. If the lavage returns brown fecal a. referred back pain. c. projectile vomiting.
drainage, which action will the nurse plan to take next? b. metabolic alkalosis. d. abdominal distention.
a. Auscultate the bowel sounds.
b. Prepare the patient for surgery. 8. The nurse preparing for the annual physical exam of a 50-yr-old
1
c. Check the patient’s oral temperature. man will plan to teach the patient about
d. Obtain information about the accident. a. endoscopy.
b. colonoscopy.
. A young adult patient is admitted to the hospital for evaluation of
7 c. computerized tomography screening.
right lower quadrant abdominal pain with nausea and vomiting. Which d. carcinoembryonic antigen (CEA) testing.
action should the nurse take?
a. Assist the patient to cough and deep breathe. 9. The nurse is providing preoperative teaching for a patient
1
b. Palpate the abdomen for rebound tenderness. scheduled for an abdominal-perineal resection. Which information will
c. Suggest the patient lie on the side, flexing the right leg. the nurse include?
d. Encourage the patient to sip clear, noncarbonated liquids. a. The patient will begin sitting in a chair at the bedside on the first
postoperative day.
. Which nursing action will be included in the plan of care for a
8 b. IV antibiotics will be started at least 24 hours before surgery to
25-yr-old male patient with a new diagnosis of irritable bowel syndrome reduce the bowel bacteria.
(IBS)? c. An additional surgery in 8 to 12 weeks will be used to create an
a. Encourage the patient to express concerns and ask questions about ileal-anal reservoir.
IBS. d. The site where the stoma will be located will be marked on the
b. Suggest that the patient increase the intake of milk and other dairy abdomen preoperatively
products.
c. Teach the patient to avoid using nonsteroidal antiinflammatory drugs 0. A patient preparing to undergo a colon resection for cancer of the
2
(NSAIDs). colon asks about the elevated carcinoembryonic antigen (CEA) test
d. Teach the patient about the use of alosetron (Lotronex) to reduce result. The nurse explains that the test is used to
IBS symptoms. a. identify any metastasis of the cancer.
b. monitor the tumor status after surgery.
. A patient being admitted with an acute exacerbation of ulcerative
9 c. confirm the diagnosis of a specific type of cancer.
colitis reports crampy abdominal pain and passing 15 or more bloody d. determine the need for postoperative chemotherapy.
stools a day. The nurse will plan to
a. administer IV metoclopramide (Reglan). 1. A 71-yr-old patient had an abdominal-perineal resection for colon
2
b. discontinue the patient’s oral food intake. cancer. Which nursing action is most important to include in the plan of
c. administer cobalamin (vitamin B12) injections. care for the day after surgery?
d. teach the patient about total colectomy surgery. a. Teach about a low-residue diet.
b. Monitor output from the stoma.
0. Which nursing action will the nurse include in the plan of care for a
1 c. Assess the perineal drainage and incision.
35-yr-old male patient admitted with an exacerbation of inflammatory d. Encourage acceptance of the colostomy stoma.
bowel disease (IBD)?
a. Restrict oral fluid intake. c. Ambulate six times daily.
b. Monitor stools for blood. d. Increase dietary fiber intake.
2. A patient is transferred from the recovery room to a surgical unit
2 d. “How long have you had abdominal pain?”
after a transverse colostomy. The nurse observes the stoma to be
deep pink with edema and a small amount of sanguineous 4. A patient in the emergency department has just been diagnosed
3
drainage. The nurse should with peritonitis caused by a ruptured diverticulum. Which prescribed
a. place ice packs around the stoma. intervention will the nurse implement first?
b. notify the surgeon about the stoma. a. Insert a urinary catheter to drainage.
c. monitor the stoma every 30 minutes. b. Infuse metronidazole (Flagyl) 500 mg IV.
d. document stoma assessment findings. c. Send the patient for a computerized tomography scan.
d. Place a nasogastric (NG) tube to intermittent low suction.
3. Which information will the nurse include in teaching a patient who
2
had a proctocolectomy and ileostomy for ulcerative colitis? 5. A 25-yr-old male patient calls the clinic complaining of diarrhea for
3
a. Restrict fluid intake to prevent constant liquid drainage from the 24 hours. Which action should the nurse take first?
stoma. a. Inform the patient that laboratory testing of blood and stools will be
b. Use care when eating high-fiber foods to avoid obstruction of the necessary.
ileum. b. Ask the patient to describe the character of the stools and any
c. Irrigate the ileostomy daily to avoid having to wear a drainage associated symptoms.
appliance. c. Suggest that the patient drink clear liquid fluids with electrolytes,
d. Change the pouch every day to prevent leakage of contents onto the such as Gatorade or Pedialyte.
skin. d. Advise the patient to use over-the-counter loperamide (Imodium) to
slow gastrointestinal (GI) motility.
4. A patient with a new ileostomy asks how much drainage to expect.
2
The nurse explains that after the bowel adjusts to the ileostomy, the 6. A patient is admitted to the emergency department with severe
3
usual drainage will be about cups daily. abdominal pain and rebound tenderness. Vital signs include
a. 2 c. 4 temperature 102°F (38.3°C), pulse 120 beats/min, respirations
b. 3 d. 5 32 breaths/min, and blood pressure (BP) 82/54 mm Hg. Which
prescribed intervention should the nurse implement first?
5. The nurse admitting a patient with acute diverticulitis explains that
2 a. Administer IV ketorolac 15 mg for pain relief.
the initial plan of care is to b. Draw a blood sample for a complete blood count (CBC).
a. administer IV fluids. c. Infuse a liter of lactated Ringer’s solution over 30 minutes.
b. prepare for colonoscopy. d. Send the patient for an abdominal computed tomography (CT) scan.
c. give stool softeners and enemas.
d. order a diet high in fiber and fluids. 7. Four hours after a bowel resection, a 74-yr-old male patient with a
3
nasogastric tube to suction complains of nausea and abdominal
6. A 40-yr-old male patient has had a herniorrhaphy to repair an
2 distention. The first action by the nurse should be to
incarcerated inguinal hernia. Which patient teaching will the nurse a. auscultate for hypotonic bowel sounds.
provide before discharge? b. notify the patient’s health care provider.
a. Soak in sitz baths several times each day. c. check for tube placement and reposition it.
b. Cough 5 times each hour for the next 48 hours. d. remove the tube and replace it with a new one.
c. Avoid use of acetaminophen (Tylenol) for pain.
d. Apply a scrotal support and ice to reduce swelling. 8. A 19-yr-old woman is brought to the emergency department with a
3
knife handle protruding from her abdomen. During the initial
7. Which breakfast choice indicates a patient’s good understanding of
2 assessment of the patient, the nurse should
information about a diet for celiac disease? a. remove the knife and assess the wound.
a. Oatmeal with nonfat milk c. Bagel with low-fat cream cheese b. determine the presence of Rovsing sign.
b. wheat toast with butter d. Corn tortilla with scrambled eggs c. check for circulation and tissue perfusion.
d. insert a urinary catheter and assess for hematuria.
8. After a patient has had a hemorrhoidectomy at an outpatient
2
surgical center, which instructions will the nurse include in discharge 9. Which activity in the care of a patient with a new colostomy could
3
teaching? the nurse delegate to unlicensed assistive personnel (UAP)?
a. Maintain a low-residue diet until the surgical area is healed. a. Document the appearance of the stoma.
b. Use ice packs on the perianal area to relieve pain and swelling. b. Place a pouching system over the ostomy.
c. Take prescribed pain medications before you expect a bowel c. Drain and measure the output from the ostomy.
movement. d. Check the skin around the stoma for breakdown.
d. Delay having a bowel movement for several days until you are well
healed. 0. Which information obtained by the nurse interviewing a 30-yr-old
4
male patient is most important to communicate to the health care
9. A patient calls the clinic to report a new onset of severe diarrhea.
2 provider?
The nurse anticipates that the patient will need to a. The patient has a history of constipation.
a. collect a stool specimen. c. schedule a barium enema. b. The patient has noticed blood in the stools.
b. prepare for colonoscopy. d. have blood cultures drawn. c. The patient had an appendectomy at age 27.
d. The patient smokes a pack/day of cigarettes.
0. The nurse will plan to teach a patient with Crohn’s disease who has
3
megaloblastic anemia about the need for 1. Which care activity for a patient with a paralytic ileus is appropriate
4
a. iron dextran infusions for the registered nurse (RN) to delegate to unlicensed assistive
b. oral ferrous sulfate tablets. personnel (UAP)?
c. routine blood transfusions. a. Auscultation for bowel sounds
d. cobalamin (B12) supplements. b. Nasogastric (NG) tube irrigation
c. Applying petroleum jelly to the lips
1. The nurse is assessing a patient with abdominal pain. The nurse,
3 d. Assessment of the nares for irritation
who notes that there is ecchymosis around the area of umbilicus, will
document this finding as 2. After several days of antibiotic therapy, an older hospitalized
4
a. Cullen sign. c. McBurney sign. patient develops watery diarrhea. Which action should the nurse take
b. Rovsing sign. d. Grey-Turner’s sign. first?
a. Notify the health care provider.
2. A critically ill patient with sepsis is frequently incontinent of watery
3 b. Obtain a stool specimen for analysis.
stools. What action by the nurse will prevent complications associated c. Teach the patient about handwashing.
with ongoing incontinence? d. Place the patient on contact precautions.
a. Apply incontinence briefs.
b. Use a fecal management system 3. Which patient should the nurse assess first after receiving
4
c. Insert a rectal tube with a drainage bag. change-of-shift report?
d. Assist the patient to a commode frequently. a. A 60-yr-old patient whose new ileostomy has drained 800 mL over
the previous 8 hours
3. Which question from the nurse would help determine if a patient’s
3 b. A 50-yr-old patient with familial adenomatous polyposis who has
abdominal pain might indicate irritable bowel syndrome (IBS)? occult blood in the stool
a. “Have you been passing a lot of gas?” c. A 40-yr-old patient with ulcerative colitis who has had six liquid
b. “What foods affect your bowel patterns?” stools in the previous 4 hours
c. “Do you have any abdominal distention?”
. A 30-yr-old patient who has abdominal distention and an apical
d d. Diphenoxylate with atropine (Lomotil) prn loose stools
heart rate of 136 beats/minute
nswer key
a
4. A patient with Crohn’s disease who is taking infliximab (Remicade)
4 1. ANS: C Because C. difficile is highly contagious, the patient should
calls the nurse in the outpatient clinic about new symptoms. Which be placed in a private room, and contact precautions should be used.
symptom is most important to communicate to the health care There is no need to restrict dairy products for this type of diarrhea.
provider? Metronidazole (Flagyl) is frequently used to treat C. difficile infections.
a. Fever c. Joint pain Improper food handling and storage do not cause C. difficile.
b. Nausea d. Headache 2. ANS: B The nurse’s initial action should be further assessment of
the patient for risk factors for constipation and for his usual bowel
5. A 33-yr-old male patient with a gunshot wound to the abdomen
4 pattern. The other actions may be appropriate but will be based on the
undergoes surgery, and a colostomy is formed as shown in the assessment.
accompanying figure. Which information will be included in patient 3.ANS: D A high fluid intake is needed when patients are using
teaching? bulk-forming laxatives to avoid worsening constipation. Although
a. Stool will be expelled from both stomas. bulk-forming laxatives are generally safe, the nurse should emphasize
b. This type of colostomy is usually temporary. the possibility of constipation or obstipation if inadequate fluid intake
c. Soft, formed stool can be expected as drainage. occurs. Although increased gas formation is likely to occur with
d. Irrigations can regulate drainage from the stomas. increased dietary fiber, the patient should gradually increase dietary
fiber and eventually may not need the psyllium. Fat-soluble vitamin
6. A 76-yr-old patient with obstipation has a fecal impaction and is
4 absorption is blocked by stool softeners and lubricants, not by
incontinent of liquid stool. Which action should the nurse take first? bulk-forming laxatives.
a. Administer bulk-forming laxatives. 4.ANS: C A complete description of the pain provides clues about the
b. Assist the patient to sit on the toilet. cause of the problem. Although the nurse should ask whether the
c. Manually remove the impacted stool. patient is pregnant to determine whether the patient might have an
d. Increase the patient’s oral fluid intake ectopic pregnancy and before any radiology studies are done, this
information is not the most useful in determining the cause of the pain.
7. A patient is awaiting surgery for acute peritonitis. Which action will
4 The usual diet and elimination patterns are less helpful in determining
the nurse include in the plan of care? the reason for the patient’s symptoms.
a. Position patient with the knees flexed. 5.ANS: A Ambulation will improve peristalsis and help the patient
b. Avoid use of opioids or sedative drugs. eliminate flatus and reduce gas pain. A mineral oil retention enema is
c. Offer frequent small sips of clear liquids. helpful for constipation with hard stool. A return-flow enema might be
d. Assist patient to breathe deeply and cough used to relieve persistent gas pains. Morphine will further reduce
peristalsis. Promethazine is used as an antiemetic rather than to
8. A 72-yr-old male patient with dehydration caused by an
4 decrease gas pains or distention.
exacerbation of ulcerative colitis is receiving 5% dextrose in normal 6.ANS: B Return of brown drainage and fecal material suggests
saline at 125 mL/hour. Which assessment finding by the nurse is most perforation of the bowel and the need for immediate surgery.
important to report to the health care provider? Auscultation of bowel sounds, checking the temperature, and obtaining
a. Patient has not voided for the last 4 hours. information about the accident are appropriate actions, but the priority
b. Skin is dry with poor turgor on all extremities. is to prepare to send the patient for emergency surgery.
c. Crackles are heard halfway up the posterior chest. 7.ANS: C The patient’s clinical manifestations are consistent with
d. Patient has had 5 loose stools over the previous 6 hours. appendicitis. Lying still with the right leg flexed is often the most
comfortable position. Checking for rebound tenderness frequently is
9. A new 19-yr-old male patient has familial adenomatous polyposis
4 unnecessary and uncomfortable for the patient. The patient should be
(FAP). Which action will the nurse in the gastrointestinal clinic include NPO in case immediate surgery is needed. The patient will need to
in the plan of care? know how to cough and deep breathe postoperatively, but coughing
a. Obtain blood samples for DNA analysis. will increase pain at this time.
b. Schedule the patient for yearly colonoscopy. 8.ANS: A Because psychologic and emotional factors can affect the
c. Provide preoperative teaching about total colectomy. symptoms for IBS, encouraging the patient to discuss emotions and
d. Discuss lifestyle modifications to decrease cancer risk. ask questions is an important intervention. Alosetron has serious side
effects and is used only for female patients who have not responded to
0. Which menu choice by the patient with diverticulosis is best for
5 other therapies. Although yogurt may be beneficial, milk is avoided
preventing diverticulitis? because lactose intolerance can contribute to symptoms in some
a. Navy bean soup and vegetable salad patients. NSAIDs can be used by patients with IBS.
b. Whole grain pasta with tomato sauce 9. ANS: B An initial therapy for an acute exacerbation of inflammatory
c. Baked potato with low-fat sour cream bowel disease (IBD) is to rest the bowel by making the patient NPO.
d. Roast beef sandwich on whole wheat bread Metoclopramide increases peristalsis and will worsen symptoms.
Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected
1. After change-of-shift report, which patient should the nurse assess
5 by ulcerative colitis. Although total colectomy is needed for some
first? patients, there is no indication that this patient is a candidate.
a. A 40-yr-old male patient with celiac disease who has frequent frothy 10.ANS: B Because anemia or hemorrhage may occur with IBD, stools
diarrhea should be assessed for the presence of blood. The other actions would
b. A 30-yr-old female patient with a femoral hernia who has abdominal not be appropriate for the patient with IBD. Dietary fiber may increase
pain and vomiting gastrointestinal motility and exacerbate the diarrhea, severe fatigue is
c. A 30-yr-old male patient with ulcerative colitis who has severe common with IBD exacerbations, and dehydration may occur.
perianal skin breakdown 11. ANS: B Sulfasalazine may cause photosensitivity in some patients.
d. A 40-yr-old female patient with a colostomy bag that is pulling away It is not used to treat infections. Sulfasalazine does not reduce immune
from the adhesive wafer function. Unlike corticosteroids, tapering of sulfasalazine is not needed.
12. ANS: B Witch hazel compresses are suggested to reduce anal
2. The nurse is admitting a 67-yr-old patient with new-onset
5 irritation and discomfort. Incontinence briefs may trap diarrhea and
steatorrhea. Which question is most important for the nurse to ask? increase the incidence of skin breakdown. Antidiarrheal medications
a. “How much milk do you usually drink?” are not given 15 to 20 times a day. The perianal area should be
b. “Have you noticed a recent weight loss?” washed with plain water or pH balanced cleanser after each stool.
c. “What time of day do your bowels move?” 13. ANS: C During acute exacerbations of IBD, the patient should
d. “Do you eat meat or other animal products?” avoid high-fiber foods such as whole grains. High-fat foods also may
cause diarrhea in some patients. The other choices are low residue
3. Which information will the nurse teach a patient with lactose
5 and would be appropriate for this patient.
intolerance? 14. ANS: B Encouraging the patient to share concerns assists in
a. Ice cream is relatively low in lactose. helping the patient adjust to the body changes. Acknowledgment of the
b. Live-culture yogurt is usually tolerated. patient’s feelings and concerns is important rather than offering false
c. Heating milk will break down the lactose. reassurance. Because the patient indicates that the feelings about the
d. Nonfat milk is tolerated better than whole milk ostomy are the reason for the difficulty with the many changes,
development of a detailed ostomy care plan will not improve the
4. Which prescribed intervention for a patient with chronic short bowel
5 patient’s ability to manage the ostomy. Although detailed ostomy
syndrome will the nurse question? teaching may be postponed, the nurse should offer teaching about
a. Senna 1 tablet every day some aspects of living with an ostomy.
b. Ferrous sulfate 325 mg daily 15. ANS: A Medications are used to induce and maintain remission in
c. Psyllium (Metamucil) 3 times daily patients with inflammatory bowel disease (IBD). Decreased activity
level is indicated only if the patient has severe fatigue and weakness. ecause of possible damage to the anal sphincter and ulceration of the
b
Fluids are needed to prevent dehydration. There is no advantage to rectal mucosa. A critically ill patient will not be able to tolerate getting
enteral feedings. up frequently to use the commode or bathroom.
16.ANS: B Fistulas between the bowel and bladder occur in Crohn’s 33.ANS: D One criterion for the diagnosis of irritable bowel syndrome
disease and can lead to UTI. Teaching for UTI prevention in general is the presence of abdominal discomfort or pain for at least 3 months.
includes good hygiene, adequate fluid intake, and voiding before and Abdominal distention, flatulence, and food intolerance are associated
after intercourse. with IBS but are not diagnostic criteria.
17.ANS: D Abdominal distention is seen in lower intestinal obstruction. 34.ANS: B Because peritonitis can be fatal if treatment is delayed, the
Referred back pain is not a common clinical manifestation of intestinal initial action should be to start antibiotic therapy (after any ordered
obstruction. Metabolic alkalosis is common in high intestinal cultures are obtained). The other actions can be done after antibiotic
obstruction because of the loss of HCl acid from vomiting. Projectile therapy is initiated.
vomiting is associated with higher intestinal obstruction. 35.ANS: B The initial response by the nurse should be further
18.ANS: B At age 50 years, individuals with an average risk for assessment of the patient. The other responses may be appropriate,
colorectal cancer (CRC) should begin screening for CRC. Colonoscopy depending on what is learned in the assessment.
is the gold standard for CRC screening. The other diagnostic tests are 36.ANS: C The priority for this patient is to treat the patient’s
not recommended as part of a routine annual physical exam at age 50 hypovolemic shock with fluid infusion. The other actions should be
years. implemented after starting the fluid infusion.
19.ANS: D A WOCN should select the site where the ostomy will be 37.ANS: C Repositioning the tube will frequently facilitate drainage.
positioned and mark the abdomen preoperatively. The site should be Because this is a common occurrence, it is not appropriate to notify the
within the rectus muscle, on a flat surface, and in a place that the health care provider unless other interventions do not resolve the
patient is able to see. A permanent colostomy is created with this problem. Information about the presence or absence of bowel sounds
surgery. Sitting is contraindicated after an abdominal-perineal will not be helpful in improving drainage. Removing the tube and
resection. Oral antibiotics (rather than IV antibiotics) are given to replacing it are unnecessarily traumatic to the patient, so that would
reduce colonic and rectal bacteria only be done if the tube was completely occluded.
20.ANS: B CEA is used to monitor for cancer recurrence after surgery. 38.ANS: C The initial assessment is focused on determining whether
CEA levels do not help to determine whether there is metastasis of the the patient has hypovolemic shock. The knife should not be removed
cancer. Confirmation of the diagnosis is made on the basis of biopsy. until the patient is in surgery, where bleeding can be controlled.
Chemotherapy use is based on factors other than CEA. Rovsing sign is assessed in the patient with suspected appendicitis.
21.ANS: C Because the perineal wound is at high risk for infection, the Assessment for bladder trauma is not part of the initial assessment.
initial care is focused on assessment and care of this wound. Teaching 39.ANS: C Draining and measuring the output from the ostomy is
about diet is best done closer to discharge from the hospital. There will included in UAP education and scope of practice. The other actions
be very little drainage into the colostomy until peristalsis returns. The should be implemented by LPNs or RNs.
patient will be encouraged to assist with the colostomy, but this is not 40.ANS: B Blood in the stools is a possible clinical manifestation of
the highest priority in the immediate postoperative period. colorectal cancer and requires further assessment by the health care
22.ANS: D The stoma appearance indicates good circulation to the provider. The other patient information will also be communicated to
stoma. There is no indication that surgical intervention is needed or the health care provider, but does not indicate an urgent need for
that frequent stoma monitoring is required. Swelling of the stoma is further testing or intervention
normal for 2 to 3 weeks after surgery, and an ice pack is not needed. 41. ANS: C UAP education and scope of practice include patient
23.ANS: B High-fiber foods are introduced gradually and should be hygiene such as oral care. The other actions require education and
well chewed to avoid obstruction of the ileostomy. Patients with scope of practice appropriate to the RN.
ileostomies lose the absorption of water in the colon and need to take 42. ANS: D The patient’s history and new onset diarrhea suggest a C.
in increased amounts of fluid. The pouch should be drained frequently difficile infection, which requires implementation of contact precautions
but is changed every 5 to 7 days. The drainage from an ileostomy is to prevent spread of the infection to other patients. The other actions
liquid and continuous, so control by irrigation is not possible. are also appropriate but can be accomplished after contact precautions
24.ANS: A After the proximal small bowel adapts to reabsorb more are implemented.
fluid, the average amount of ileostomy drainage is about 500 mL daily. 43.ANS: D The patient’s abdominal distention and tachycardia suggest
One cup is about 240 mL. hypovolemic shock caused by problems such as peritonitis or intestinal
25.ANS: A A patient with acute diverticulitis will be NPO and given obstruction, which will require rapid intervention. The other patients
parenteral fluids. A diet high in fiber and fluids will be implemented should also be assessed as quickly as possible, but the data do not
before discharge. Bulk-forming laxatives, rather than stool softeners, indicate any life-threatening complications associated with their
are usually given, and these will be implemented later in the diagnoses.
hospitalization. The patient with acute diverticulitis will not have 44.ANS: A Since infliximab suppresses the immune response, rapid
enemas or a colonoscopy because of the risk for perforation and treatment of infection is essential. The other patient complaints are
peritonitis. common side effects of the medication, but they do not indicate any
26.ANS: D A scrotal support and ice are used to reduce edema and potentially life-threatening complications.
pain. Coughing will increase pressure on the incision. Sitz baths will 45. ANS: B A loop, or double-barrel stoma, is usually temporary. Stool
not relieve pain and would not be of use after this surgery. will be expelled from the proximal stoma only. The stool from the
Acetaminophen can be used for postoperative pain. transverse colon will be liquid and regulation through irrigations will not
27.ANS: D Avoidance of gluten-containing foods is the only treatment be possible.
for celiac disease. Corn does not contain gluten, but oatmeal and 46.ANS: C The initial action with a fecal impaction is manual
wheat do. disimpaction. The other actions will be used to prevent future
28.ANS: C Bowel movements may be very painful, and patients may constipation and impactions.
avoid defecation unless pain medication is taken before the bowel 47. ANS: A There is less peritoneal irritation with the knees flexed,
movement. A high-residue diet will increase stool bulk and prevent which will help decrease pain. Opioids and sedatives are typically
constipation. Delay of bowel movements is likely to lead to given to control pain and anxiety. Preoperative patients with peritonitis
constipation. Warm sitz baths rather than ice packs are used to relieve are given IV fluids for hydration. Deep breathing and coughing will
pain and keep the surgical area clean. increase the patient’s discomfort.
29.ANS: A Acute diarrhea is usually caused by an infectious process, 48. ANS: C The presence of crackles in an older patient receiving IV
and stool specimens are obtained for culture and examined for fluids at a high rate suggests volume overload and a need to reduce
parasites or white blood cells. There is no indication that the patient the rate of the IV infusion. The other data will also be reported but are
needs a colonoscopy, blood cultures, or a barium enema. consistent with the patient’s age and diagnosis and do not require a
30.ANS: D Crohn’s disease frequently affects the ileum, where change in the prescribed treatment.
absorption of cobalamin occurs. Cobalamin must be administered 49. ANS: B Patients with FAP should have annual colonoscopy starting
regularly by nasal spray or IM to correct the anemia. Iron deficiency at age 16 years and usually have total colectomy by age 25 years to
does not cause megaloblastic anemia. The patient may need avoid developing colorectal cancer. DNA analysis is used to make the
occasional transfusions but not regularly scheduled transfusions. diagnosis but is not needed now for this patient. Lifestyle modifications
31.ANS: A Cullen sign is ecchymosis around the umbilicus. Rovsing will not decrease cancer risk for this patient.
sign occurs when palpation of the left lower quadrant causes pain in 50. ANS: A . A diet high in fiber and low in fats and red meat is
the right lower quadrant. Grey Turner’s sign is bruising over the flanks. recommended to prevent diverticulitis. Although all of the choices have
Deep tenderness at McBurney’s point (halfway between the umbilicus some fiber, the bean soup and salad will be the highest in fiber and the
and the right iliac crest), known as McBurney’s sign, is a sign of acute lowest in fat.
appendicitis. 51. ANS: B Pain and vomiting with a femoral hernia suggest possible
32.ANS: B Fecal management systems are designed to contain loose strangulation, which will necessitate emergency surgery. The other
stools and can be in place for as long as 4 weeks without causing patients have less urgent problems.
damage to the rectum or anal sphincters. Although incontinence briefs 52. ANS: B Although all of the questions provide useful information, it
may be helpful, unless they are changed frequently, they are likely to is most important to determine if the patient has an imbalance in
increase the risk for skin breakdown. Rectal tubes are avoided nutrition because of the steatorrhea.
3. ANS: B Lactose-intolerant individuals can usually eat yogurt
5
without experiencing discomfort. Ice cream, nonfat milk, and milk that 2. Which finding indicates to the nurse that lactulose is effective for an
1
has been heated are all high in lactose. older adult who has advanced cirrhosis?
54.ANS: A Patients with short bowel syndrome have diarrhea because a. The patient is alert and oriented.
of decreased nutrient and fluid absorption and would not need b. The patient denies nausea or anorexia.
stimulant laxatives. Iron supplements are used to prevent c. The patient’s bilirubin level decreases.
iron-deficiency anemia, bulk-forming laxatives help make stools less d. The patient has at least one stool daily.
watery, and opioid antidiarrheal drugs are helpful in slowing intestinal
transit time. 3. A patient is being treated for bleeding esophageal varices with
1
balloon tamponade. Which nursing action will be included in the plan of
care?
a. Instruct the patient to cough every hour.
hapter 43: Liver, Pancreas, and Biliary Tract Problems Lewis:
C b. Monitor the patient for shortness of breath.
Medical-Surgical Nursing, 10th Edition c. Verify the position of the balloon every 4 hours.
d. Deflate the gastric balloon if the patient reports nausea.
. A young adult contracts hepatitis from contaminated food. During the
1
acute (icteric) phase of the patient’s illness, the nurse would expect 4. To detect possible complications in a patient with severe cirrhosis
1
serologic testing to reveal who has bleeding esophageal varices, it is most important for the nurse
a. antibody to hepatitis D (anti-HDV). to monitor
b. hepatitis B surface antigen (HBsAg). a. bilirubin levels . c. potassium levels.
c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG). b. ammonia levels. d. prothrombin time.
d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).
5. A patient with cirrhosis has ascites and 4+ edema of the feet and
1
. The nurse evaluates that administration of hepatitis B vaccine to a
2 legs. Which nursing action will be included in the plan of care?
healthy patient has been effective when the patient’s blood specimen a. Restrict daily dietary protein intake.
reveals b. Reposition the patient every 4 hours.
a. HBsAg. c. anti-HBc IgG. c. Perform passive range of motion twice daily.
b. anti-HBs. d. anti-HBc IgM. d. Place the patient on a pressure-relief mattress.
. A patient in the outpatient clinic is diagnosed with acute hepatitis C
3 6. Which finding indicates to the nurse that a patient’s transjugular
1
(HCV) infection. Which action by the nurse is appropriate? intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been
a. Schedule the patient for HCV genotype testing. effective?
b. Administer the HCV vaccine and immune globulin. a. Increased serum albumin level
c. Teach the patient about ribavirin (Rebetol) treatment. b. Decreased indirect bilirubin level
d. Explain that the infection will resolve over a few months c. Improved alertness and orientation
d. Fewer episodes of bleeding varices
. The nurse will plan to teach the patient diagnosed with acute
4
hepatitis B about 7. To prepare a patient with ascites for paracentesis, the nurse
1
a. administering -interferon a. places the patient on NPO status.
b. side effects of nucleotide analogs. b. assists the patient to lie flat in bed.
c. measures for improving the appetite. c. asks the patient to empty the bladder.
d. ways to increase activity and exercise. d. positions the patient on the right side.
. The nurse administering -interferon and ribavirin (Rebetol) to a
5 8. Which finding is most important for the nurse to communicate to
1
patient with chronic hepatitis C will plan to monitor for the health care provider about a patient who received a liver transplant
a. leukopenia. c. polycythemia. 1 week ago?
b. hypokalemia. d. hypoglycemia. a. Dry palpebral and oral mucosa c. Temperature 100.8° F (38.2° C)
b. Crackles at bilateral lung bases d. No bowel movement for 4 days
. Which information given by a 70-yr-old patient during a health
6
history indicates to the nurse that the patient should be screened for 9. Which laboratory test result will the nurse monitor when evaluating
1
hepatitis C? the effects of therapy for a patient who has acute pancreatitis?
a. The patient had a blood transfusion in 2005. a. Calcium c. Amylase
b. The patient used IV drugs about 20 years ago. b. Bilirubin d. Potassium
c. The patient frequently eats in fast-food restaurants.
d. The patient traveled to a country with poor sanitation. 0. Which assessment finding would the nurse need to report most
2
quickly to the health care provider regarding a patient with acute
. A patient admitted with an abrupt onset of jaundice and nausea has
7 pancreatitis?
abnormal liver function studies but serologic testing is negative for viral a. Nausea and vomiting
causes of hepatitis. Which question by the nurse is appropriate? b. Hypotonic bowel sounds
a. “Do you have a history of IV drug use?” c. Muscle twitching and finger numbness
b. “Do you use any over-the-counter drugs?” d. Upper abdominal tenderness and guarding
c. “Have you used corticosteroids for any reason?”
d. “Have you recently traveled to a foreign country?” 1. The nurse will ask a patient being admitted with acute pancreatitis
2
specifically about a history of
. Which focused data will the nurse monitor in relation to the 4+ pitting
8 a. diabetes mellitus. c. cigarette smoking.
edema assessed in a patient with cirrhosis? b. high-protein diet. d. alcohol consumption.
a. Hemoglobin c. Activity level
b. Temperature d. Albumin level 2. The nurse will teach a patient with chronic pancreatitis to take the
2
prescribed pancrelipase (Viokase)
. Which topic is most important to include in patient teaching for a
9 a. at bedtime. c. in the morning.
41-yr-old patient diagnosed with early alcoholic cirrhosis? b. with meals. d. for abdominal pain.
a. Taking lactulose c. Avoiding alcohol ingestion
b. Maintaining good nutrition d. Using vitamin B supplements 3. The nurse recognizes that teaching a patient following a
2
laparoscopic cholecystectomy has been effective when the patient
0. A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for
1 makes which statement?
a patient with cirrhosis who has scheduled doses of spironolactone a. “I can expect yellow-green drainage from the incision for a few
(Aldactone) and furosemide (Lasix) due. Which action should the nurse days.”
take? b. “I can remove the bandages on my incisions tomorrow and take a
a. Withhold both drugs. c. Administer the furosemide. shower.”
b. Administer both drugs d. Administer the spironolactone. c. “I should plan to limit my activities and not return to work for 4 to 6
weeks.”
1. Which action should the nurse take to evaluate treatment
1 d. “I will need to maintain a low-fat diet for life because I no longer have
effectiveness for a patient who has hepatic encephalopathy? a gallbladder.”
a. Request that the patient stand on one foot.
b. Ask the patient to extend both arms forward. 4. The nurse is caring for a patient who has cirrhosis. Which data
2
c. Request that the patient walk with eyes closed. obtained by the nurse during the assessment will be of most concern?
d. Ask the patient to perform the Valsalva maneuver. a. The patient complains of right upper-quadrant pain with palpation.
. The patient’s hands flap back and forth when the arms are
b . maintaining normal respiratory function.
a
extended. b. expressing satisfaction with pain control.
c. The patient has ascites and a 2-kg weight gain from the previous c. developing no ongoing pancreatic disease.
day. d. having adequate fluid and electrolyte balance.
d. The patient’s abdominal skin has multiple spider-shaped blood
vessels. 6. The nurse is caring for a patient with pancreatic cancer. Which
3
nursing action is the highest priority?
5. A patient with cirrhosis and esophageal varices has a new
2 a. Offer psychologic support for depression.
prescription for propranolol (Inderal). Which finding is the best indicator b. Offer high-calorie, high-protein dietary choices.
to the nurse that the medication has been effective? c. Administer prescribed opioids to relieve pain as needed.
a. The patient reports no chest pain. d. Teach about the need to avoid scratching any pruritic areas.
b. Blood pressure is 140/90 mm Hg.
c. Stools test negative for occult blood. 7. Which assessment information will be most important for the nurse
3
d. The apical pulse rate is 68 beats/minute. to report to the health care provider about a patient with acute
cholecystitis?
6. Which response by the nurse best explains the purpose of
2 a. The patient’s urine is bright yellow.
ranitidine (Zantac) for a patient admitted with bleeding esophageal b. The patient’s stools are tan colored.
varices? c. The patient has increased pain after eating.
a. The medication will reduce the risk for aspiration. d. The patient complains of chronic heartburn.
b. The medication will inhibit development of gastric ulcers.
c. The medication will prevent irritation of the enlarged veins. 8. A patient had an incisional cholecystectomy 6 hours ago. The
3
d. The medication will decrease nausea and improve the appetite. nurse will place the highest priority on assisting the patient to
a. perform leg exercises hourly while awake.
7. When taking the blood pressure (BP) on the right arm of a patient
2 b. ambulate the evening of the operative day.
with severe acute pancreatitis, the nurse notices carpal spasms of the c. turn, cough, and deep breathe every 2 hours.
patient’s right hand. Which action should the nurse take next? d. choose preferred low-fat foods from the menu.
a. Ask the patient about any arm pain.
b. Retake the patient’s blood pressure. 9. For a patient with cirrhosis, which nursing action can the registered
3
c. Check the calcium level in the chart. nurse (RN) delegate to unlicensed assistive personnel (UAP)?
d. Notify the health care provider immediately. a. Assessing the patient for jaundice
b. Providing oral hygiene after a meal
8. A patient with acute pancreatitis is NPO and has a nasogastric
2 c. Palpating the abdomen for distention
(NG) tube to suction. Which information obtained by the nurse d. Teaching the patient the prescribed diet
indicates that these therapies have been effective?
a. Bowel sounds are present. c. Electrolyte levels are normal. 0. Which action will the nurse include in the plan of care for a patient
4
b. Grey Turner sign resolves. d. Abdominal pain is decreased. who has been diagnosed with chronic hepatitis B?
a. Advise limiting alcohol intake to 1 drink daily.
9. Which assessment finding is of most concern for a patient with
2 b. Schedule for liver cancer screening every 6 months.
acute pancreatitis? c. Initiate administration of the hepatitis C vaccine series.
a. Absent bowel sounds c. Left upper quadrant pain d. Monitor anti-hepatitis B surface antigen (anti-HBs) levels.
b. Abdominal tenderness d. Palpable abdominal mass
1. A patient born in 1955 had hepatitis A infection 1 year ago.
4
0. Which action will be included in the care for a patient who has
3 According to Centers for Disease Control and Prevention (CDC)
recently been diagnosed with asymptomatic nonalcoholic fatty liver guidelines, which action should the nurse include in care when
disease (NAFLD)? the patient is seen for a routine annual physical examination?
a. Teach symptoms of variceal bleeding. a. Start the hepatitis B immunization series.
b. Draw blood for hepatitis serology testing. b. Teach the patient about hepatitis A immune globulin.
c. Discuss the need to increase caloric intake. c. Ask whether the patient has been screened for hepatitis C.
d. Review the patient’s current medication list. d. Test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM).
1. A patient with chronic hepatitis C infection has several medications
3 2. A patient has been admitted with acute liver failure. Which
4
prescribed. Which medication requires further discussion with the assessment data are most
health care provider before administration? important for the nurse to communicate to the health care provider?
a. Ribavirin (Rebetol, Copegus) 600 mg PO bid a. Asterixis and lethargy c. Elevated total bilirubin level
b. Diphenhydramine 25 mg PO every 4 hours PRN itching b. Jaundiced sclera and skin d. Liver 3 cm below costal margin
c. Pegylated -interferon (PEG-Intron, Pegasys) 1.5 mcg/kg PO daily
d. Dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea 3. A 36-yr-old female patient is receiving treatment for chronic
4
hepatitis C with pegylated interferon (PEG-Intron, Pegasys), ribavirin
2. During change-of-shift report, the nurse learns about the following
3 (Rebetol), and telaprevir (Incivek). Which finding is important to
four patients. Which patient requires assessment first? communicate to the health care provider to suggest a change in
a. A 40-yr-old patient with chronic pancreatitis who has gnawing therapy?
abdominal pain a. Weight loss of 2 lb (1 kg)
b. A 58-yr-old patient who has compensated cirrhosis and is b. Positive urine pregnancy test
complaining of anorexia c. Hemoglobin level of 10.4 g/dL
c. A 55-yr-old patient with cirrhosis and ascites who has an oral d. Complaints of nausea and anorexia
temperature of 102°
F (38.8° C) 4. A nurse is considering which patient to admit to the same room as
4
d. A 36-yr-old patient recovering from a laparoscopic cholecystectomy a patient who had a liver transplant 3 weeks ago and is now
who has severe shoulder pain hospitalized with acute rejection. Which patient would be the best
choice?
3. Which goal has the highest priority in the plan of care for a
3 a. Patient who is receiving chemotherapy for liver cancer
26-yr-old patient who is homeless who was admitted with viral hepatitis b. Patient who is receiving treatment for acute hepatitis C
who has severe anorexia and fatigue? c. Patient who has a wound infection after cholecystectomy
a. Increase activity level. d. Patient who requires pain management for chronic pancreatitis
b. Maintain adequate nutrition.
c. Establish a stable environment. 5. In reviewing the medical record shown in the accompanying figure
4
d. Identify source of hepatitis exposure. for a patient admitted with acute pancreatitis, the nurse sees that the
patient has a positive Cullen’s sign. Indicate the area where the nurse
4. Which action should the nurse in the emergency department take
3 will assess for this change.
first for a new patient who is vomiting blood? a. 1 c. 3
a. Insert a large-gauge IV catheter. b. 2 d. 4
b. Draw blood for coagulation studies.
c. Check blood pressure and heart rate.
d. Place the patient in the supine position.
5. The nurse is planning care for a patient with acute severe
3
pancreatitis. The highest priority patient outcome is
8.ANS: C The risk of infection is high in the first few months after liver
1
nswer key
a transplant, and fever is frequently the only sign of infection. The other
1. ANS: D Hepatitis A is transmitted through the oral-fecal route, and patient data indicate the need for further assessment or nursing actions
antibody to HAV IgM appears during the acute phase of hepatitis A. and might be communicated to the health care provider, but they do
The patient would not have antigen for hepatitis B or antibody for not indicate a need for urgent action.
hepatitis D. Anti-HAV IgG would indicate past infection and lifelong 19.ANS: C Amylase is elevated in acute pancreatitis. Although
immunity. changes in the other values may occur, they would not be useful in
2.ANS: B The presence of surface antibody to HBV (anti-HBs) is a evaluating whether the prescribed therapies have been effective.
marker of a positive response to the vaccine. The other laboratory 20. ANS: C Muscle twitching and finger numbness indicate
values indicate current infection with HBV. hypocalcemia, which may lead to tetany unless calcium gluconate is
3.ANS: A Genotyping of HCV has an important role in managing administered. Although the other findings should also be reported to
treatment and is done before drug therapy is initiated. Because most the health care provider, they do not indicate complications that require
patients with acute HCV infection convert to the chronic state, the rapid action.
nurse should not teach the patient that the HCV will resolve in a few 21. ANS: D Alcohol use is one of the most common risk factors for
months. Immune globulin or vaccine is not available for HCV. Ribavirin pancreatitis in the United States. Cigarette smoking, diabetes, and
is used for chronic HCV infection. high-protein diets are not risk factors.
4.ANS: C Maintaining adequate nutritional intake is important for 22. ANS: B Pancreatic enzymes are used to help with digestion of
regeneration of hepatocytes. Interferon and antivirals may be used for nutrients and should be taken with every meal.
chronic hepatitis B, but they are not prescribed for acute hepatitis B 23.ANS: B After a laparoscopic cholecystectomy, the patient will have
infection. Rest is recommended. Band-Aids in place over the incisions. Patients are discharged the
5.ANS: A Therapy with ribavirin and -interferon may cause leukopenia. same (or next) day and have few restrictions on activities of daily living.
The other problems are not associated with this drug therapy. Drainage from the incisions would be abnormal, and the patient should
6.ANS: B Any patient with a history of IV drug use should be tested for be instructed to call the health care provider if this occurs. A low-fat
hepatitis C. Blood transfusions given after 1992 (when an antibody test diet may be recommended for a few weeks after surgery but will not be
for hepatitis C became available) do not pose a risk for hepatitis C. a lifelong requirement.
Hepatitis C is not spread by the oral-fecal route and therefore is not 24.ANS: B Asterixis indicates that the patient has hepatic
caused by contaminated food or by traveling in underdeveloped encephalopathy, and hepatic coma may occur. The spider angiomas
countries. DIF: Cognitive Level: Apply (application) REF: 976 and right upper quadrant abdominal pain are not unusual for the
7.ANS: B The patient’s symptoms, lack of antibodies for hepatitis, and patient with cirrhosis and do not require a change in treatment. The
the abrupt onset of symptoms suggest toxic hepatitis, which can be ascites and weight gain indicate the need for treatment but not as
caused by commonly used over-the-counter drugs such as urgently as the changes in neurologic status.
acetaminophen (Tylenol). Travel to a foreign country and a history of IV 25.ANS: C Because the purpose of -blocker therapy for patients with
drug use are risk factors for viral hepatitis. Corticosteroid use does not esophageal varices is to decrease the risk for bleeding from
cause the symptoms listed. esophageal varices, the best indicator of the effectiveness for
8.ANS: D The low oncotic pressure caused by hypoalbuminemia is a propranolol is the lack of blood in the stools. Although propranolol is
major pathophysiologic factor in the development of edema. The other used to treat hypertension, angina, and tachycardia, the purpose for
parameters are not directly associated with the patient’s edema. use in this patient is to decrease the risk for bleeding from esophageal
9.ANS: C The disease progression can be stopped or reversed by varices.
alcohol abstinence. The other interventions may be used when 26.ANS: C Esophageal varices are dilated submucosal veins. The
cirrhosis becomes more severe to decrease symptoms or therapeutic action of H2-receptor blockers in patients with esophageal
complications, but the priority for this patient is to stop the progression varices is to prevent irritation and bleeding from the varices caused by
of the disease. reflux of acid gastric contents. Although ranitidine does decrease the
10.ANS: D Spironolactone is a potassium-sparing diuretic and will help risk for peptic ulcers, reduce nausea, and help prevent aspiration
increase the patient’s potassium level. The nurse does not need to talk pneumonia, these are not the primary purposes for H2-receptor
with the doctor before giving the spironolactone, although the health blockade in this patient.
care provider should be notified about the low potassium value. The 27.ANS: C The patient with acute pancreatitis is at risk for
furosemide will further decrease the patient’s potassium level and hypocalcemia, and the assessment data indicate a positive
should be held until the nurse talks with the health care provider. Trousseau’s sign. The health care provider should be notified after the
11.ANS: B Extending the arms allows the nurse to check for asterixis, a nurse checks the patient’s calcium level. There is no indication that the
classic sign of hepatic encephalopathy. The other tests might also be patient needs to have the BP rechecked or that there is any arm pain.
done as part of the neurologic assessment but would not be diagnostic 28.ANS: D NG suction and NPO status will decrease the release of
for hepatic encephalopathy. pancreatic enzymes into the pancreas and decrease pain. Although
12.ANS: A The purpose of lactulose in the patient with cirrhosis is to bowel sounds may be hypotonic with acute pancreatitis, the presence
lower ammonia levels and prevent encephalopathy. Although lactulose of bowel sounds does not indicate that treatment with NG suction and
may be used to treat constipation, that is not the purpose for this NPO status has been effective. Electrolyte levels may be abnormal
patient. Lactulose will not decrease nausea and vomiting or lower with NG suction and must be replaced by appropriate IV infusion.
bilirubin levels. Although Grey Turner sign will eventually resolve, it would not be
13.ANS: B The most common complication of balloon tamponade is appropriate to wait for this to occur to determine whether treatment
aspiration pneumonia. In addition, if the gastric balloon ruptures, the was effective.
esophageal balloon may slip upward and occlude the airway. Coughing 29.ANS: D A palpable abdominal mass may indicate the presence of a
increases the pressure on the varices and increases the risk for pancreatic abscess, which will require rapid surgical drainage to
bleeding. Balloon position is verified after insertion and does not prevent sepsis. Absent bowel sounds, abdominal tenderness, and left
require further verification. Balloons may be deflated briefly every 8 to upper quadrant pain are common in acute pancreatitis and do not
12 hours to avoid tissue necrosis, but if only the gastric balloon is require rapid action to prevent further complications.
deflated, the esophageal balloon may occlude the airway. Balloons are 30.ANS: D Some medications can increase the risk for NAFLD, and
not deflated for nausea. they should be eliminated. NAFLD is not associated with hepatitis,
14.ANS: B The protein in the blood in the gastrointestinal tract will be weight loss is usually indicated, and variceal bleeding would not be a
absorbed and may result in an increase in the ammonia level because concern in a patient with asymptomatic NAFLD.
the liver cannot metabolize protein very well. The prothrombin time, 31.ANS: C Pegylated -interferon is administered subcutaneously, not
bilirubin, and potassium levels should also be monitored, but they will orally. The medications are all appropriate for a patient with chronic
not be affected by the bleeding episode. hepatitis C infection.
15.ANS: D The pressure-relieving mattress will decrease the risk for 32.ANS: C This patient’s history and fever suggest possible
skin breakdown for this patient. Adequate dietary protein intake is spontaneous bacterial peritonitis, which would require rapid
necessary in patients with ascites to improve oncotic pressure. assessment and interventions such as antibiotic therapy. The clinical
Repositioning the patient every 4 hours will not be adequate to manifestations for the other patients are consistent with their diagnoses
maintain skin integrity. Passive range of motion will not take the and do not indicate complications are occurring.
pressure off areas such as the sacrum that are vulnerable to 33.ANS: B The highest priority outcome is to maintain nutrition
breakdown. because adequate nutrition is needed for hepatocyte regeneration.
16.ANS: D TIPS is used to lower pressure in the portal venous system Finding a home for the patient and identifying the source of the
and decrease the risk of bleeding from esophageal varices. Indirect infection would be appropriate activities, but they do not have as high a
bilirubin level and serum albumin levels are not affected by shunting priority as ensuring adequate nutrition. Although the patient’s activity
procedures. TIPS will increase the risk for hepatic encephalopathy. level will be gradually increased, rest is indicated during the acute
17.ANS: C The patient should empty the bladder to decrease the risk phase of hepatitis.
of bladder perforation during the procedure. The patient would be 34.ANS: C The nurse’s first action should be to determine the patient’s
positioned in Fowler’s position and would not be able to lie flat without hemodynamic status by assessing vital signs. Drawing blood for
compromising breathing. Because no sedation is required for coagulation studies and inserting an IV catheter are also appropriate.
paracentesis, the patient does not need to be NPO. However, the vital signs may indicate the need for more urgent actions.
ecause aspiration is a concern for this patient, the nurse will need to
B
assess the patient’s vital signs and neurologic status before placing the
patient in a supine position.
35.ANS: A Respiratory failure can occur as a complication of acute
pancreatitis and maintenance of adequate respiratory function is the
priority goal. The other outcomes would also be appropriate for the
patient.
36.ANS: C Effective pain management will be necessary in order for
the patient to improve nutrition, be receptive to teaching, or manage
anxiety or depression.
37.ANS: B Tan or gray stools indicate biliary obstruction, which
requires rapid intervention to resolve. The other data are not unusual
for a patient with this diagnosis, although the nurse would also report
the other assessment information to the health care provider.
38.ANS: C Postoperative nursing care after a cholecystectomy focuses
on prevention of respiratory complications because the surgical
incision is high in the abdomen and impairs coughing and deep
breathing. The other nursing actions are also important to implement
but are not as high a priority as ensuring adequate ventilation.
39.ANS: B Providing oral hygiene is within the scope of UAP.
Assessments and assisting patients to choose therapeutic diets are
nursing actions that require higher level nursing education and scope
of practice and would be delegated to licensed practical/vocational
nurses (LPNs/LVNs) or RNs.
40.ANS: B Patients with chronic hepatitis are at higher risk for
development of liver cancer and should be screened for liver cancer
every 6 to 12 months. Patients with chronic hepatitis are advised to
completely avoid alcohol. There is no hepatitis C vaccine. Because
anti-HBs is present whenever there has been a past hepatitis B
infection or vaccination, there is no need to regularly monitor for this
antibody.
41.ANS: C Current CDC guidelines indicate that all patients who were
born between 1945 and 1965 should be screened for hepatitis C
because many individuals who are positive have not been diagnosed.
Although routine hepatitis B immunization is recommended for infants,
children, and adolescents, vaccination for hepatitis B is recommended
only for adults at risk for blood-borne infections. Because the patient
has already had hepatitis A, immunization and anti-HAV IgM levels will
not be needed.
42.ANS: A The patient’s findings of asterixis and lethargy are
consistent with grade 2 hepatic encephalopathy. Patients with acute
liver failure can deteriorate rapidly from grade 1 or 2 to grade 3 or 4
hepatic encephalopathy and need early transfer to a transplant center.
The other findings are typical of patients with hepatic failure and would
be reported but would not indicate a need for an immediate change in
the therapeutic plan.
43.ANS: B Because ribavirin is teratogenic, the medication will need to
be discontinued immediately. Anemia, weight loss, and nausea are
common adverse effects of the prescribed regimen and may require
actions such as patient teaching, but they would not require immediate
cessation of the therapy.
44.ANS: D The patient with chronic pancreatitis does not present an
infection risk to the immunosuppressed patient who had a liver
transplant. The other patients either are at risk for infection or currently
have an infection, which will place the immunosuppressed patient at
risk for infection.
45.ANS: C The area around the umbilicus should be indicated. Cullen’s
sign consists of ecchymosis around the umbilicus. Cullen’s sign occurs
because of seepage of bloody exudates from the inflamed pancreas
and indicates severe acute pancreatitis.
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