Assessment and Meds
The nurse is performing an abdominal assessment and inspects the skin of the abdomen. The nurse performs which assessment technique next?
A) Percuss the abdomen
B) Palpate abdomen for size
C) Listen to bowel sounds in all four quadrants
D) Palpate liver at the right rib margin.
Correct Answer: C. Listens to bowel sounds in all four quadrants
Option C: The appropriate sequence for abdominal examination is inspection, auscultation, percussion, and palpation. Auscultation is performed after inspection to ensure that the motility of the bowel and bowel sounds are not altered by percussion or palpation. Therefore, after inspecting the skin on the abdomen, the nurse should listen for bowel sounds.
A female client being seen in a physician’s office has just been scheduled for a barium swallow the next day. The nurse writes down which instruction for the client to follow before the test?
A) Fast for 8 hours before the test
B) Eat breakfast prior to the test
C) Take all oral medications prior to the test
D) Perform a tap water enema prior to the test
Correct Answer: A. Fast for 8 hours before the test
Option A: A barium swallow is an x-ray study that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal tract. The client should fast for 8 to 12 hours before the test, depending on physician instructions.
Option C: Most oral medications also are withheld before the test.
Option D: This is not required for a barium swallow test.
The nurse is monitoring a female client with a diagnosis of peptic ulcer. Which assessment findings would most likely indicate perforation of the ulcer?
A) Tachycardia
B) Numbness in the legs
C) Nausea and vomiting
D) A rigid, board-like abdomen
Correct Answer: D. A rigid, board-like abdomen
Option D: Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the mid epigastric area and spreading over the abdomen, which becomes rigid and board-like.
Option A: Tachycardia may occur as hypovolemic shock develops.
Option B: Numbness in the legs is not an associated finding.
Option C: Nausea and vomiting may occur.
The nurse is caring for a hospitalized female client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician?
A) Hypotension
B) Bloody diarrhea
C) Rebound tenderness
D) Hemoglobin of 12 mg/dL
Correct Answer: C. Rebound tenderness
Option C: Rebound tenderness may indicate peritonitis.
Option B: Bloody diarrhea is expected to occur in ulcerative colitis.
Options A & D: Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the physician.
A male client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been “bored” with the clear liquid diet. The nurse would offer which full liquid item to the client?
A) Tea
B) Gelatin
C) Custard
D) Popsicle
Correct Answer: C. Custard
Option C: Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, and strained vegetable juices. A clear liquid diet consists of foods that are relatively transparent.
A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated?
A. Sudden decrease in abdominal pain
B. Absent Rovsing's sign
C. Flaccid abdomen
D. Low-grade fever
Correct Answer: A
A sudden decrease in abdominal pain should indicate to the nurse that the appendix might be ruptured. If the appendix ruptures, the pain can disappear for a short period and the client might feel suddenly better. However, once peritonitis sets in, the pain returns and can spread into the whole abdomen.
Polyethylene glycol-electrolyte solution (GoLYTELY) is prescribed for the female client scheduled for a colonoscopy. The client begins to experience diarrhea following the administration of the solution. What action by the nurse is appropriate?
A) Start an IV infusion
B) Administer an enema
C) Cancel the diagnostic test
D) Explain that diarrhea is expected.
Correct Answer: D. Explain that diarrhea is expected
Option D: The solution GoLYTELY is a bowel evacuant used to prepare a client for a colonoscopy by cleansing the bowel. The solution is expected to cause mild diarrhea and will clear the bowel in 4 to 5 hours.
Options A, B, & C: These are inappropriate actions.
The nurse is preparing a discharge teaching plan for the male client who had umbilical hernia repair. What should the nurse include in the plan?
A) Irrigating the drain
B) Avoiding coughing
C) Maintaining bed rest
D) Restricting pain medication
Correct Answer: B. Avoiding coughing
Option B: Coughing is avoided following umbilical hernia repair to prevent disruption of tissue integrity, which can occur because of the location of this surgical procedure.
Option A: A drain is not used in this surgical procedure, although the client may be instructed in simple dressing changes.
Option C: Bed rest is not required following this surgical procedure.
Option D: The client should take analgesics as needed and as prescribed to control pain.
The nurse is caring for a male client postoperatively following creation of a colostomy. Which nursing diagnosis should the nurse include in the plan of care?
A) Sexual dysfunction
B) Disturbed body image
C) Fear related to poor prognosis
D) Imbalanced nutrition: more than body requirements
Correct Answer: B. Body image, disturbed
Option B: Body image, disturbed relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch).
Options A & C: No data in the question support options A and C.
Option D: Nutrition: less than body requirements, imbalanced is the more likely nursing diagnosis.
A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? Select all that apply.
A. Administer furosemide.
B. Administer warfarin. C. Implement a low-sodium diet. D. Measure the client's abdominal girth. E. Encourage weight lifting during physical therapy.
Correct Answers: A, C, D.
Administer furosemide is correct. The nurse should administer furosemide to the client to reduce fluid accumulation in the abdomen.
Administer warfarin is incorrect. The nurse should avoid administering warfarin to the client due to possible destruction of platelets caused by splenomegaly, which can result in spontaneous bleeding. Propranolol is prescribed instead to discourage bleeding.
Implement a low-sodium diet is correct. The nurse should implement a low-sodium diet to control fluid accumulation in the abdomen.
Measure the client's abdominal girth is correct. The nurse should measure the client's abdominal girth. Daily weights are an even more reliable indicator of fluid accumulation.
Encourage weight lifting during physical therapy is incorrect. The nurse should understand weight lifting can cause bleeding.
The nurse is caring for a patient with suspected acute pancreatitis. Upon assessment, the nurse notes ecchymoses surrounding the periumbilical area. The nurse knows this finding is called:
A) Grey-Turner's sign
B) Chvostek's sign
C) Cullen's sign
D) Homan's sign
CORRECT ANSWER: C. Cullens Sign
Option A: This is seen as ecchymoses in one or both flanks. Can be seen with Cullen's sign.
Option B: This is a muscular twitch that is elicited when the facial nerve is lightly tapped. This is an indication of hypocalcemia.
Option D: This is a painful sensation in the calf/knee elicited through passive dorsiflexion of the client's ankle. This may indicate the presence of a DVT.
A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?
A. Decreased WBC
B. Increased serum amylase
C. Decreased serum lipase
D. Increased serum calcium
Correct Response: B. Increased amylase. Serum amylase rises within 24 hr of the start of the client’s symptoms.
Option A: With acute pancreatitis, WBC is generally elevated.
Option C: With acute pancreatitis, serum lipase is generally elevated.
Option D: Hypocalcemia is common with acute pancreatitis.
The nurse is reviewing the medication record of a female client with acute gastritis. Which medication, if noted on the client’s record, would the nurse question?
A) Digoxin
B) Furosemide
C) Indomethacin
D) Propranolol
Correct Answer: C. Indomethacin (Indocin)
Option C: Indomethacin (Indocin) is a nonsteroidal anti-inflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Furosemide (Lasix) is a loop diuretic.
Option A: Digoxin is a cardiac medication.
Option B: Furosemide, digoxin, and propranolol are not contraindicated in clients with gastric disorders.
Option D: Propranolol (Inderal) is a alpha-adrenergic blocker.
The nurse is caring for a patient with Chron's disease. Which item found on the patient's food tray should be of concern to the nurse?
A. Fresh Salad
B. White rice
C. Baked chicken
D. Cooked skinless apples
CORRECT ANSWER: A. Patients who are experiencing flare-ups of Crohn's Disease should avoid high fiber foods, foods that are hard to digest, spicy foods, dairy products etc. Therefore, the patient should avoid a fresh salad.
White rice and fruits/vegetables that are cooked/skinless are low in fiber. Baked chicken is a good source of protein for the patient.
The nurse is educating a 51-year-old female patient diagnosed with cholecystitis. Which diet, when selected by the client, indicates that the nurse’s teaching has been successful?
A) 4-6 small meals of low-carbohydrate foods daily
B) High-fat, high-carbohydrate meals
C) Low-fat, high-carbohydrate meals
D) High-fat, low protein meals
Correct Answer: C. Low-fat, high-carbohydrate meals
Option C: For the client with cholecystitis, fat intake should be reduced. The calories from fat should be substituted with carbohydrates.
Option A: Reducing carbohydrate intake would be contraindicated.
Options B & D: Any diet high in fat may lead to another attack of cholecystitis.
A patient reports frequent heartburn twice a week for the past 4 months. What other symptoms reported by the patient may indicate the patient has GERD? Select all that apply.
A. Bitter taste in mouth
B. Dry cough
C. Melena
D. Difficulty swallowing
E. Smooth, red tongue
F. Murphy's Sign
CORRECT Answers: A, B, D. These are signs and symptoms seen with GERD.
Melena is seen with gastrointestinal bleeding as in peptic ulcer disease. Smooth, red tongue is seen with vitamin B12 deficiency, and Murphy's Signs is seen with cholecystitis
A nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure. Which of the following assessments is the nurse's priority?
A. Pain
B. Nausea
C. Gag reflex
D. Level of consciousness
Correct response: C. Gag Reflex
The greatest risk to the client's safety following an EGD is aspiration. Until the client's gag reflex returns, the nurse must keep the client NPO and prepare to intervene to keep the airway open and unobstructed.
The nurse is caring for an oncology patient with stomatitis. To promote oral hygiene and comfort, nurse should perform which intervention?
A. Provide frequent mouthwash with normal saline.
B. Apply viscous Lidocaine to oral ulcers as needed.
C. Use lemon glycerine swabs every 2 hours.
D. Rinse mouth with Hydrogen Peroxide.
Correct Answer: B. Stomatitis can cause pain and this can be relieved by applying topical anesthetics such as lidocaine before mouth care.
Options A, C, and D: When the patient is already comfortable, the nurse can proceed with providing the patient with oral rinses of saline solution mixed with equal part of water or hydrogen peroxide mixed water in 1:3 concentrations to promote oral hygiene. Every 2-4 hours.
The nurse is caring for a patient with ulcerative colitis. Which of the following stool characteristics are associated with UC?
A. Loose and semiformed
B. Chalky, clay colored
C. Maroon
D. Frequent, watery, with blood and mucus
Correct Response: D.
When planning home care for a client with hepatitis A, which preventive measure should be emphasized to protect the client’s family?
A. Keeping the client in complete isolation
B. Using good sanitation with dishes and shared bathrooms
C. Avoiding contact with blood-soiled clothing or dressing
D. Forbidding the sharing of needles or syringes
Correct Answer: B. Using good sanitation with dishes and shared bathrooms
Option B: Hepatitis A is transmitted through the fecal-oral route or from contaminated water or food. Measures to protect the family include good handwashing, personal hygiene and sanitation, and the use of standard precautions.
Option A: Complete isolation is not required.
Options C & D: Avoiding contact with blood-soiled clothing or dressings or avoiding the sharing of needles or syringes are precautions needed to prevent transmission of hepatitis B.
A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect?
A. Ulcerative colitis
B. Cholecystitis
C. Paralytic ileus
D. Wound dehiscence
Correct Answer: C. Paralytic Ileus.
A paralytic ileus in a postoperative client is indicated by the absence of bowel sounds, abdominal distention, and the client passing no stool or flatus. It is often caused by bowel handling during surgery and opioid analgesic use.
A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse understanding of the procedure?
A. "They are going to examine my gallbladder and ducts."
B."Soon those shock waves will get rid of my gallstones."
C. "I'll have a camera put down my throat so they can see my gallbladder."
D. "They'll put medication into my gallbladder to dissolve the stones."
Correct Answer: A. With oral cholangiography, the client receives an iodide-containing contrast agent 10 to 12 hr before the procedure. Then, the examiner can evaluate the gallbladder for filling, contracting, and emptying and can also see the gallstones on the x-rays.
Option B: Shock waves are used in lithotripsy, not cholangiogram.
Option C: The camera is used during an ERCP, not cholangiogram.
Option D: IV contrast is used to enhance visualization of stones, not to dissolve them.
A nurse is teaching a client who has stomatitis. Which of the following instructions should the nurse include?
A. Rinse with a commercial mouthwash.
B. Use toothpaste that contains sodium laurel sulfate
C. Use toothpaste that contains sodium laurel sulfate
D. Brush teeth with a soft toothbrush
Correct Response: D. The client should use a soft toothbrush and gently brush after each meal to reduce mouth irritation and prevent superinfections.
Option A: Many commercial mouthwashes contain alcohol, which can irritate stomatitis
Option B: Sodium laurel sulfate is associated with stomatitis. The client should avoid toothpastes that contain sodium laurel sulfate
Option C: Lemon-glycerine swabs can irritate stomatitis.
The nurse is caring for a patient with Chron's disease. Which of the following complications are associated with Chron's disease? Select all that apply.
A. FistulasB. Strictures
C. Abcesses
D. Peritonitis
E. Adhesions
ALL OF THE ABOVE!
Mr. Hasakusa is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? Select all that apply.
A. Assessing the client's neurologic status every 2 hours
B. Monitoring the client's hemoglobin and hematocrit levels
C. Evaluating the client's serum ammonia level
D. Monitoring the client's handwriting daily
E. Preparing to insert an esophageal tamponade tube
F. Making sure the client's fingernails are short
Correct Answer: A, C, & D
Options A, C, & D: Hepatic encephalopathy results from an increased ammonia level due to the liver’s inability to convert ammonia to urea, which leads to neurologic dysfunction and possible brain damage. The nurse should monitor the client’s neurologic status, serum ammonia level, and handwriting. Monitoring the client’s hemoglobin and hematocrit levels and insertion of an esophageal tamponade tube address esophageal bleeding. Keeping fingernails short address jaundice.