Free Gastrointestinal Systems practice for Gastrointestinal System ATI (ATI RN). Answer 85 nursing exam-style questions with rationales, exam mode, and progress
Risk factors for the development of hiatal hernias are those that lead to increased abdominal pressure. Which of the following complications DOES NOT cause increased abdominal pressure?
Select the best answer.
Explanation:
Obesity, constipation, and intestinal obstruction can all lead to increased abdominal pressure, which in turn can cause a hiatal hernia.
Which of the following tasks should be included in the immediate postoperative management of a client who has undergone gastric resection?
Select the best answer.
Explanation:
Monitoring for symptoms of hemorrhage is a crucial part of the immediate postoperative management of a client who has undergone gastric resection.
Which of the following dietary measures would be useful in preventing esophageal reflux?
Select the best answer.
Explanation:
Eating small, frequent meals helps prevent esophageal reflux.
The nurse is monitoring a client for the early signs of dumping syndrome. Which symptom indicates this occurrence?
Select the best answer.
Explanation:
Sweating and pallor are early signs of dumping syndrome, a condition where food moves too quickly from the stomach to the small intestine.
A client with irritable bowel syndrome is being prepared for discharge. Which of the following meal plans should the nurse give the client?
Select the best answer.
Explanation:
A high fiber, low-fat diet is recommended for clients with irritable bowel syndrome to promote bowel regularity and reduce symptoms.
The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?
Select the best answer.
Explanation:
The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. Repositioning the client to the right side will not alleviate the cramping. Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.
The nurse is evaluating the plan of care for a client with peptic ulcer disease with a nursing diagnosis of Acute Pain. The nurse would determine that the client has not met the expected outcomes if the client states
Select the best answer.
Explanation:
Expected outcomes for the client with peptic ulcer disease experiencing pain include elimination of irritating foods from the diet, ability to take prescribed medications that will reduce pain, reporting that the pain is relieved or prevented with medication, and an ability to sleep through the night without pain. The client who continues to be awakened by pain requires further modification of medication therapy, which may include adjustment of timing of histamine H2 receptor antagonist or an additional dose of antacid before the time when pain awakens the client.
The nurse would assess the client experiencing an acute episode of cholecystitis for pain that is located in the right:
Select the best answer.
Explanation:
Pain from cholecystitis is typically located in the right upper quadrant and may radiate to the right scapula and shoulder.
Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this indicate?
Select the best answer.
Explanation:
Coffee-ground emesis is a sign of upper gastrointestinal bleeding that occurred approximately 2 hours earlier. It results from the breakdown of blood in the stomach due to digestive enzymes, giving it a coffee-ground appearance. Choice A is incorrect because coffee-ground emesis indicates older, partially digested blood, not fresh active bleeding. Choice B is incorrect as gastric lavage is not indicated for coffee-ground emesis. Choice D is incorrect because a transfusion of packed RBCs is not the immediate management for this presentation.
After a subtotal gastrectomy, the nurse should anticipate that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?
Select the best answer.
Explanation:
Dark brown drainage is expected for about 12 to 24 hours after surgery.
A client had an abdominal perineal resection with a colostomy 4 days ago and is ready for discharge. Which of the following would be an appropriate expected outcome at this point?
Select the best answer.
Explanation:
Clients often have concerns about their sexuality after a fecal diversion. The nurse should encourage the client to discuss any questions about sexual functioning. The client will not need to maintain a high-fiber diet but will be encouraged to avoid any foods that cause odor and flatulence. The client should be able to ambulate and sit out of bed for several hours at a time at this point. Fluid intake will be encouraged, not restricted.
A client is admitted to the hospital with acute viral hepatitis. Which of the following signs or symptoms would the nurse expect to note based on this diagnosis?
Select the best answer.
Explanation:
Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis.
Matt is a 49 y.o. with a hiatal hernia that you are about to counsel. Health care counseling for Matt should include which of the following instructions?
Select the best answer.
Explanation:
For a patient with a hiatal hernia, it is important to eat three regular meals a day to prevent symptoms.
Which of the following symptoms indicates diverticulosis?
Select the best answer.
Explanation:
Diverticulosis often has no symptoms and is usually found incidentally during tests for other conditions.
A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need
Select the best answer.
Explanation:
A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Vitamin B6 is not necessarily needed for pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers.
A client with viral hepatitis has no appetite, and food makes the client nauseated. Which of the following interventions would be most appropriate?
Select the best answer.
Explanation:
If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. Explaining to the client that the majority of calories should be eaten in the morning hours is important because nausea occurs most often in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are tolerated better.
Which of the following diagnostic tests should be performed annually over age 50 to screen for colon cancer?
Select the best answer.
Explanation:
A fecal occult blood test should be performed annually for individuals over age 50 to screen for colon cancer.
The hospitalized client with GERD is complaining of chest discomfort that feels like heartburn following a meal. After administering an ordered antacid, the nurse encourages the client to lie in which of the following positions?
Select the best answer.
Explanation:
Lying on the left side with the head of the bed elevated 30 degrees helps prevent reflux by keeping stomach contents from moving up into the esophagus.
The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse would assess the client for which of the following most frequent symptom(s) of duodenal ulcer?
Select the best answer.
Explanation:
Pain that is relieved by food intake is the most frequent symptom of duodenal ulcers because the food neutralizes the stomach acid.
Hepatic encephalopathy develops when the blood level of which substance increases?
Select the best answer.
Explanation:
Hepatic encephalopathy develops when the blood level of ammonia increases.
An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate of 60ml/hr. Gastric residuals have been 30-40ml when monitored Q4H. You check the gastric residual and aspirate 220ml. What is your first response to this finding?
Select the best answer.
Explanation:
If gastric residuals are high during continuous enteral feedings, the first response is to stop the feeding and clamp the NG tube.
Which of the following techniques would the nurse use first to determine if a nasogastric tube is positioned in the stomach?
Select the best answer.
Explanation:
The initial way to determine if a nasogastric tube is in the stomach is to apply suction to the tube with a syringe and observe for the return of stomach contents. Then the pH of the aspirate can be measured. This is the method of choice. One would not irrigate until tube placement is confirmed. Observing for air bubbles when the free end of the tube is placed under water is an unacceptable, unsafe method of determining tube placement. Another method is to instill air into the tube with a syringe while auscultating over the epigastric area. Hearing the air enter the stomach helps ensure proper placement, but the method is not foolproof and is no longer considered an effective or preferred way to determine placement.
The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
Select the best answer.
Explanation:
A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in preventing rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals.
Which of the following tests should be administered to a client suspected of having diverticulosis?
Select the best answer.
Explanation:
A barium enema is a diagnostic test used to visualize the colon and can help diagnose diverticulosis.
A nurse is developing a teaching plan for the client with viral hepatitis. The nurse plans to tell the client which of the following in the teaching session?
Select the best answer.
Explanation:
The client with viral hepatitis should limit activity to avoid fatigue during the recuperation period. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per day. Alcohol is strictly forbidden.
Your patient with peritonitis is NPO and complaining of thirst. What is your priority?
Select the best answer.
Explanation:
The correct answer is C: Provide frequent mouth care. In a patient with peritonitis who is NPO and thirsty, the priority is to maintain oral hygiene and provide comfort by moistening the mouth with frequent mouth care. This helps alleviate the sensation of thirst and maintains oral health. Increasing the IV infusion rate (choice A) may not address the patient's discomfort directly related to thirst. Using diversion activities (choice B) is not as critical as addressing the patient's immediate need for oral care. Giving ice chips every 15 minutes (choice D) is not recommended for a patient with peritonitis who is NPO, as it can lead to complications or worsen the condition.
The home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need
Select the best answer.
Explanation:
A lack of intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Vitamin B6 is not necessarily needed for pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers.
The client with peptic ulcer disease is scheduled for a pyloroplasty. The client asks the nurse about the procedure. The nurse plans to respond knowing that a pyloroplasty involves:
Select the best answer.
Explanation:
A pyloroplasty involves making an incision in the pylorus (the opening from the stomach to the duodenum) and then resuturing it to relax the muscle and enlarge the opening.
Which of the following definitions best describes diverticulosis?
Select the best answer.
Explanation:
The correct answer is B: 'A noninflamed outpouching of the intestine.' Diverticulosis refers to the presence of small, bulging pouches (diverticula) that can form in the lining of the digestive system, especially the colon. These pouches are typically noninflamed. Choice A is incorrect because it describes diverticulitis, which is the inflammation of these pouches. Choice C is incorrect as it defines bowel obstruction, not diverticulosis. Choice D is incorrect as it refers to a hernia, not diverticulosis.
Your patient with peritonitis is NPO and complaining of thirst. What is your priority?
Select the best answer.
Explanation:
Providing frequent mouth care is the priority for a patient with peritonitis who is NPO and complaining of thirst.
The client is admitted to the hospital with viral hepatitis, complaining of 'no appetite' and 'losing my taste for food.' To provide adequate nutrition, the nurse would instruct the client to
Select the best answer.
Explanation:
Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a diet with low-fat content because fat may be tolerated poorly due to decreased bile production. Small, frequent meals are preferable and may prevent nausea. Appetite is often better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL per day that includes nutritional juices is also important.
The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician?
Select the best answer.
Explanation:
Rebound tenderness is a sign of peritonitis, a serious complication that needs to be reported to the physician immediately.
Which of the following diets is most commonly associated with colon cancer?
Select the best answer.
Explanation:
A low-fiber, high-fat diet is most commonly associated with an increased risk of colon cancer.
The nurse is caring for a client with a diagnosis of cirrhosis and is monitoring the client for signs of portal hypertension. Which initial sign, if noted in the client, indicates the presence of portal hypertension?
Select the best answer.
Explanation:
Clinical signs and symptoms or portal hypertension are identical to those of heart failure and include jugular vein distention, lung crackles, and decreased perfusion to all organs. Initially, the client may have hypertension, flushed skin, and a bounding pulse.
The nurse is caring for a client following a Billroth II procedure. On review of the postoperative orders, which of the following if prescribed, should the nurse question and verify?
Select the best answer.
Explanation:
In a Billroth II procedure the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically ordered by the physician. In this situation the nurse should clarify the order. Coughing and deep breathing exercises, leg exercises, and early ambulation are appropriate postoperative interventions.
Which of the following aspects is the priority focus of nursing management for a client with peritonitis?
Select the best answer.
Explanation:
The priority focus of nursing management for a client with peritonitis is fluid and electrolyte balance to prevent shock.
The nurse is teaching the client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do?
Select the best answer.
Explanation:
Increasing fluid intake helps to enhance the effectiveness of colostomy irrigation by softening the stool and promoting better fecal return.
Which of the following complications is thought to be the most common cause of appendicitis?
Select the best answer.
Explanation:
A fecalith is a hardened stool that can block the appendix, leading to inflammation and infection, which is the most common cause of appendicitis.
After gastric resection surgery, which of the following signs and symptoms would alert the nurse to the development of a leaking anastomosis?
Select the best answer.
Explanation:
Pain, fever, and abdominal rigidity are signs and symptoms of inflammation or peritonitis caused by the leaking anastomosis. Diarrhea with fat in the stool is steatorrhea and is not present in peritonitis. Palpitations, pallor, and diaphoresis after eating are vasomotor symptoms of gastric retention. Feelings of fullness and nausea after eating are not present in peritonitis.
The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient vitamin K absorption caused by this liver disease?
Select the best answer.
Explanation:
A liver disorder, such as cirrhosis, can disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Because of this, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.
The nurse is caring for a client who has had a gastroscopy. Which of the following symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply.
Select the best answer.
Explanation:
A temperature of 100°F, epigastric pain, and hematemesis are signs that may indicate a complication related to the gastroscopy procedure.
You're discharging Nathaniel with hepatitis B. Which statement suggests understanding by the patient?
Select the best answer.
Explanation:
Understanding that family needs to be aware of symptoms that may indicate a recurrence of hepatitis B shows proper understanding by the patient.
A client has been taking aluminum hydroxide 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client's constipation?
Select the best answer.
Explanation:
The client is experiencing a common side effect of aluminum hydroxide, which is constipation.
An enema is prescribed for a client with suspected appendicitis. Which of the following actions should the nurse take?
Select the best answer.
Explanation:
An enema is contraindicated in clients with suspected appendicitis because it can increase the risk of perforation. It is important to verify the appropriateness of this order with the physician.
The nurse is reviewing the medication record of a client with acute gastritis. Which medication if noted on the client's record, would the nurse question?
Select the best answer.
Explanation:
Indomethacin (Indocin) is a Nonsteroidal anti-inflammatory drug and can cause ulceration of the esophagus, stomach, duodenum, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Furosemide (Lasix) is a loop diuretic. Digoxin is an antidysrhythmic. Propranolol (Inderal) is a B- adrenergic blocker. Furosemide, digoxin, and propranolol are not contraindicated in clients with gastric disorders.
You're developing the plan of care for a patient experiencing dumping syndrome after a Billroth II procedure. Which dietary instructions do you include?
Select the best answer.
Explanation:
To manage dumping syndrome, it is important to omit fluids with meals to slow gastric emptying.
The nurse instructs the nursing assistant on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the assistant to incorporate into the client's daily care?
Select the best answer.
Explanation:
Swabbing the client's tongue, gums, and lips with a soft foam applicator every 2 hours helps maintain oral hygiene for a client who cannot perform this task.
Which of the following symptoms best describes Murphy's sign?
Select the best answer.
Explanation:
Murphy's sign is described as pain elicited on deep inspiration when the examiner's fingers are placed under the right costal margin.
You're caring for Lewis, a 67 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Relief of which symptom indicated that the paracentesis was effective?
Select the best answer.
Explanation:
Dyspnea relief indicates that the paracentesis was effective in reducing ascites.
The nurse evaluates the client's stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?
Select the best answer.
Explanation:
A dark red to purple stoma may indicate compromised blood flow or ischemia, which requires immediate medical attention. This color change could be a sign of inadequate blood supply to the stoma tissue, leading to tissue damage or necrosis. Reporting this observation promptly is crucial to prevent further complications. Choices A, C, and D are not indicative of immediate medical concern. A slightly edematous stoma, oozing a small amount of blood, or not expelling stool may not be uncommon findings during the initial post-op period and can be managed without urgent intervention.
Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which of the following points do you include?
Select the best answer.
Explanation:
Instruct the patient to lie on their right side after the biopsy to apply pressure and prevent bleeding.
During the assessment of a client's mouth, the nurse notes the absence of saliva. The client is also complaining of pain near the area of the ear. The client has been NPO for several days because of the insertion of an NG tube. Based on these findings, the nurse suspects that the client is developing which of the following mouth conditions?
Select the best answer.
Explanation:
The correct answer is C, Parotitis. Parotitis, inflammation of the parotid glands, can occur due to the absence of saliva and dehydration, often associated with being NPO and having an NG tube. Stomatitis (choice A) is inflammation of the oral mucosa, not specifically related to absent saliva. Oral candidiasis (choice B) is a fungal infection that can occur in the mouth, not directly related to the absence of saliva. Gingivitis (choice D) is inflammation of the gums and is not typically associated with the absence of saliva and dehydration.
The client with Crohn's disease has a nursing diagnosis of Acute Pain. The nurse would teach the client to avoid which of the following in managing this problem?
Select the best answer.
Explanation:
In managing acute pain associated with Crohn's disease, the client should avoid lying supine with the legs straight. This position increases muscle tension in the abdomen, potentially aggravating inflamed intestinal tissues as the abdominal muscles are stretched. Massaging the abdomen, using antispasmodic medication, and employing relaxation techniques are beneficial in alleviating pain. Massaging can help relax abdominal muscles, antispasmodic medication can reduce spasms contributing to pain, and relaxation techniques aid in overall pain management. Therefore, choices B, C, and D are appropriate interventions for managing pain in clients with CroCrohn's disease.
You're caring for a 28 y.o. woman with hepatitis B. She's concerned about the duration of her recovery. Which response isn't appropriate?
Select the best answer.
Explanation:
Encouraging the patient to not worry about the future is not appropriate. Instead, address her concerns and provide information.
You're patient is complaining of abdominal pain during assessment. What is your priority?
Select the best answer.
Explanation:
When a patient is complaining of abdominal pain, the priority is to auscultate to determine changes in bowel sounds.
You're patient, post-op drainage of a pelvic abscess secondary to diverticulitis, begins to cough violently after drinking water. His wound has ruptured and a small segment of the bowel is protruding. What's your priority?
Select the best answer.
Explanation:
For a patient with a ruptured wound and protruding bowel, call the doctor while remaining with the patient, flex the patient's knees, and cover the wound with sterile towels soaked in sterile saline solution.
The nurse is reviewing the record of a client with Crohn's disease. Which of the following stool characteristics would the nurse expect to note documented in the client's record?
Select the best answer.
Explanation:
Crohn's disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Chronic constipation (Choice A), constipation alternating with diarrhea (Choice C), and stool constantly oozing from the rectum (Choice D) are not characteristics typically associated with Crohn's disease.
The nurse aspirates 40 mL of undigested formula from the client's nasogastric tube. Before administering an intermittent tube feeding, the nurse understands that the 40 mL of gastric aspirate should be
Select the best answer.
Explanation:
After checking the residual feeding contents, the gastric contents are reinstalled into the stomach by removing the syringe bulb or plunger and pouring the gastric contents into the syringe and through the nasogastric tube. Gastric contents should be reinstalled to maintain the client's electrolyte balance. The gastric contents should be poured into the nasogastric tube through a syringe without a plunger and not injected by putting pressure on the plunger. Gastric contents do not need to be mixed with water or should the contents be discarded.
A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient's blood pressure because of which change that is associated with the liver failure?
Select the best answer.
Explanation:
Abnormal peripheral vasodilation is a change associated with liver failure that requires close monitoring of the patient's blood pressure.
The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the patient's diet?
Select the best answer.
Explanation:
For a patient with liver failure, it is important to limit the intake of meats and beans to reduce the risk of hepatic encephalopathy.
A nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen is distended and the bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?
Select the best answer.
Explanation:
The symptoms suggest possible perforation or peritonitis, which are serious complications requiring immediate medical attention. The nurse should promptly notify the physician.
You're preparing a teaching plan for a 27 y.o. named Jeff who underwent surgery to close a temporary ileostomy. Which nutritional guideline do you include in this plan?
Select the best answer.
Explanation:
After ileostomy closure surgery, it is recommended to eat six small meals a day to aid digestion and absorption.
The client with a colostomy has an order for irrigation of the colostomy. The nurse uses which solution for the irrigation?
Select the best answer.
Explanation:
The correct solution to use for the irrigation of a colostomy is warm tap water or saline solution. If tap water is not suitable for drinking, bottled water can be used. Distilled water, sterile water, and Lactated Ringer's are not appropriate solutions for colostomy irrigation. Distilled water lacks essential minerals, sterile water may not provide adequate cleaning, and Lactated Ringer's is not indicated for this procedure.
You're discharging Nathaniel with hepatitis B. Which statement suggests understanding by the patient?
Select the best answer.
Explanation:
Understanding that family needs to be aware of symptoms that may indicate a recurrence of hepatitis B shows proper understanding by the patient.
A client has been taking aluminum hydroxide 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client's constipation?
Select the best answer.
Explanation:
The client is experiencing a common side effect of aluminum hydroxide, which is constipation.
An enema is prescribed for a client with suspected appendicitis. Which of the following actions should the nurse take?
Select the best answer.
Explanation:
An enema is contraindicated in clients with suspected appendicitis because it can increase the risk of perforation. It is important to verify the appropriateness of this order with the physician.
The nurse is reviewing the medication record of a client with acute gastritis. Which medication if noted on the client's record, would the nurse question?
Select the best answer.
Explanation:
Indomethacin (Indocin) is a Nonsteroidal anti-inflammatory drug and can cause ulceration of the esophagus, stomach, duodenum, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Furosemide (Lasix) is a loop diuretic. Digoxin is an antidysrhythmic. Propranolol (Inderal) is a B- adrenergic blocker. Furosemide, digoxin, and propranolol are not contraindicated in clients with gastric disorders.
You're developing the plan of care for a patient experiencing dumping syndrome after a Billroth II procedure. Which dietary instructions do you include?
Select the best answer.
Explanation:
To manage dumping syndrome, it is important to omit fluids with meals to slow gastric emptying.
The nurse instructs the nursing assistant on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the assistant to incorporate into the client's daily care?
Select the best answer.
Explanation:
Swabbing the client's tongue, gums, and lips with a soft foam applicator every 2 hours helps maintain oral hygiene for a client who cannot perform this task.
Which of the following symptoms best describes Murphy's sign?
Select the best answer.
Explanation:
Murphy's sign is described as pain elicited on deep inspiration when the examiner's fingers are placed under the right costal margin.
You're caring for Lewis, a 67 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Relief of which symptom indicated that the paracentesis was effective?
Select the best answer.
Explanation:
Dyspnea relief indicates that the paracentesis was effective in reducing ascites.
The nurse evaluates the client's stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?
Select the best answer.
Explanation:
A dark red to purple stoma may indicate compromised blood flow or ischemia, which requires immediate medical attention. This color change could be a sign of inadequate blood supply to the stoma tissue, leading to tissue damage or necrosis. Reporting this observation promptly is crucial to prevent further complications. Choices A, C, and D are not indicative of immediate medical concern. A slightly edematous stoma, oozing a small amount of blood, or not expelling stool may not be uncommon findings during the initial post-op period and can be managed without urgent intervention.
Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which of the following points do you include?
Select the best answer.
Explanation:
Instruct the patient to lie on their right side after the biopsy to apply pressure and prevent bleeding.
During the assessment of a client's mouth, the nurse notes the absence of saliva. The client is also complaining of pain near the area of the ear. The client has been NPO for several days because of the insertion of an NG tube. Based on these findings, the nurse suspects that the client is developing which of the following mouth conditions?
Select the best answer.
Explanation:
The correct answer is C, Parotitis. Parotitis, inflammation of the parotid glands, can occur due to the absence of saliva and dehydration, often associated with being NPO and having an NG tube. Stomatitis (choice A) is inflammation of the oral mucosa, not specifically related to absent saliva. Oral candidiasis (choice B) is a fungal infection that can occur in the mouth, not directly related to the absence of saliva. Gingivitis (choice D) is inflammation of the gums and is not typically associated with the absence of saliva and dehydration.
The client with Crohn's disease has a nursing diagnosis of Acute Pain. The nurse would teach the client to avoid which of the following in managing this problem?
Select the best answer.
Explanation:
In managing acute pain associated with Crohn's disease, the client should avoid lying supine with the legs straight. This position increases muscle tension in the abdomen, potentially aggravating inflamed intestinal tissues as the abdominal muscles are stretched. Massaging the abdomen, using antispasmodic medication, and employing relaxation techniques are beneficial in alleviating pain. Massaging can help relax abdominal muscles, antispasmodic medication can reduce spasms contributing to pain, and relaxation techniques aid in overall pain management. Therefore, choices B, C, and D are appropriate interventions for managing pain in clients with CroCrohn's disease.
You're caring for a 28 y.o. woman with hepatitis B. She's concerned about the duration of her recovery. Which response isn't appropriate?
Select the best answer.
Explanation:
Encouraging the patient to not worry about the future is not appropriate. Instead, address her concerns and provide information.
You're patient is complaining of abdominal pain during assessment. What is your priority?
Select the best answer.
Explanation:
When a patient is complaining of abdominal pain, the priority is to auscultate to determine changes in bowel sounds.
You're patient, post-op drainage of a pelvic abscess secondary to diverticulitis, begins to cough violently after drinking water. His wound has ruptured and a small segment of the bowel is protruding. What's your priority?
Select the best answer.
Explanation:
For a patient with a ruptured wound and protruding bowel, call the doctor while remaining with the patient, flex the patient's knees, and cover the wound with sterile towels soaked in sterile saline solution.
The nurse is reviewing the record of a client with Crohn's disease. Which of the following stool characteristics would the nurse expect to note documented in the client's record?
Select the best answer.
Explanation:
Crohn's disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Chronic constipation (Choice A), constipation alternating with diarrhea (Choice C), and stool constantly oozing from the rectum (Choice D) are not characteristics typically associated with Crohn's disease.
The nurse aspirates 40 mL of undigested formula from the client's nasogastric tube. Before administering an intermittent tube feeding, the nurse understands that the 40 mL of gastric aspirate should be
Select the best answer.
Explanation:
After checking the residual feeding contents, the gastric contents are reinstalled into the stomach by removing the syringe bulb or plunger and pouring the gastric contents into the syringe and through the nasogastric tube. Gastric contents should be reinstalled to maintain the client's electrolyte balance. The gastric contents should be poured into the nasogastric tube through a syringe without a plunger and not injected by putting pressure on the plunger. Gastric contents do not need to be mixed with water or should the contents be discarded.
A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient's blood pressure because of which change that is associated with the liver failure?
Select the best answer.
Explanation:
Abnormal peripheral vasodilation is a change associated with liver failure that requires close monitoring of the patient's blood pressure.
The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the patient's diet?
Select the best answer.
Explanation:
For a patient with liver failure, it is important to limit the intake of meats and beans to reduce the risk of hepatic encephalopathy.
A nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen is distended and the bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?
Select the best answer.
Explanation:
The symptoms suggest possible perforation or peritonitis, which are serious complications requiring immediate medical attention. The nurse should promptly notify the physician.
You're preparing a teaching plan for a 27 y.o. named Jeff who underwent surgery to close a temporary ileostomy. Which nutritional guideline do you include in this plan?
Select the best answer.
Explanation:
After ileostomy closure surgery, it is recommended to eat six small meals a day to aid digestion and absorption.
The client with a colostomy has an order for irrigation of the colostomy. The nurse uses which solution for the irrigation?
Select the best answer.
Explanation:
The correct solution to use for the irrigation of a colostomy is warm tap water or saline solution. If tap water is not suitable for drinking, bottled water can be used. Distilled water, sterile water, and Lactated Ringer's are not appropriate solutions for colostomy irrigation. Distilled water lacks essential minerals, sterile water may not provide adequate cleaning, and Lactated Ringer's is not indicated for this procedure.
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