GI/Neuro Med Surg
Detailed Answer Key 100%
1. A nurse is caring for a conscious client who has an airway obstruction. Which of the following is an appropriate
intervention?
A. Tilt the head and lift the chin.
Rationale: Tilting the head and lifting the chin is an appropriate intervention to open the airway if
the client loses consciousness.
B. Begin the Heimlich maneuver.
Rationale: The nurse should immediately begin the Heimlich maneuver on a conscious client
who has an airway obstruction and should continue until the obstruction is clear or
the client loses consciousness.
C. Turn the client to the side.
Rationale: Turning the client to the side is an appropriate intervention if the client is
unconscious and breathing.
D. Perform a blind finger sweep.
Rationale: Performing a blind finger sweep creates a risk of worsening the obstruction.
, GI/Neuro Med Surg
Detailed Answer Key 100%
2. A nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following should the nurse
recognize as a complication of this therapy?
A. Polyuria
Rationale: TPN is prescribed when extensive nutritional support for prolonged periods of time is
required. It is delivered through a central venous access device, usually via the
internal jugular or subclavian vein. TPN contains a high concentration of dextrose,
which can result in hyperglycemia. Clinical manifestations of hyperglycemia include
polydipsia, polyphagia, and polyuria. Frequent glucose monitoring should be
implemented in clients receiving TPN. Administering regular insulin according to a
sliding scale will help control glucose levels.
B. Aspiration
Rationale: Aspiration is a complication of total enteral nutrition (TEN). During TEN, a tube is
placed in the client’s GI tract, often via the nasal passage. One of the complications
of TEN is pulmonary aspiration. This can occur if the tube is not placed correctly
(e.g., in the lungs instead of the stomach) or if feedings are administered too rapidly
or in too large a volume. Ensuring the tube is placed correctly and maintaining the
client in a Fowler’s position will minimize this risk. Because TPN is not administered
via the GI tract, aspiration is not a complication.
C. Diarrhea
Rationale: Diarrhea is a complication of total enteral nutrition (TEN). During TEN, a tube is
placed in the client’s GI tract, often via the nasal passage. Diarrhea can occur if the
feedings are delivered too rapidly. Feedings should be started slowly and advanced
as tolerated. Because TPN is not administered via the GI tract, diarrhea is not a
complication.
D. Stomatitis
Rationale: Although mouth care is important for clients who are receiving supplemental
nutrition, stomatitis is not expected. Stomatitis is an inflammation of the lining of
the mouth that may include the inside of the cheeks, gums, and tongue. It can be
caused by chemotherapy. It is not caused by TPN.
, GI/Neuro Med Surg
Detailed Answer Key 100%
3. A nurse is caring for an adolescent client in the emergency department who sustained a head injury. The nurse
notes the client’s IV fluids are infusing at 125 mL/hour. Which of the following is an appropriate action by the
nurse?
A. Slow the rate to 20 mL/hr.
Rationale: The nurse who slows the IV rate to 20mL/hr may compromise volume resuscitation
and cause hypotension.
B. Continue the rate at 125 mL/hr.
Rationale: The nurse who continues the IV rate at 125 mL/hr may worsen the client’s condition
by rapidly expanding the client’s plasma volume.
C. Slow the rate to 50 mL/hr.
Rationale: The nurse should decrease the rate to 50 mL/hr to minimize cerebral edema and
prevent increased intracranial pressure.
D. Increase the rate to 250 mL/hr.
Rationale: The nurse who continues the IV rate at 250 mL/hr may worsen the client’s condition
by rapidly expanding the client’s plasma volume and causing increased intracranial
pressure.
4. A nurse is caring for a client who has cancer and is receiving total parenteral nutrition (TPN). Which of the
following lab values indicates the treatment is effective?
A. Hct 43%
Rationale: An Hct of 43% is within the expected reference range but this does not indicate the
TPN therapy is effective. Clients with cancer are likely to have a low Hct due to
anemia.
B. WBC 8,000/uL
Rationale: A WBC count of 8,000/uL is within the expected reference range but this does not
indicate the TPN therapy is effective. Clients receiving TPN are at risk for
developing infection.
C. Albumin 4.2 g/dL
Rationale: Clients who have cancer can receive TPN to provide needed proteins and glucose
they are otherwise unable to obtain. An albumin level of 4.2 g/dL is within the
, GI/Neuro Med Surg
Detailed Answer Key 100%
expected reference range and indicates the client is receiving adequate amounts of
protein.
D. Calcium 9.4 mg/dL
Rationale: A calcium level of 9.4 mg/dL is within the expected reference range but this does not
indicate the TPN therapy is effective. Clients receiving TPN are at high risk for
developing hypercalcemia.
5. A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased
intracranial pressure (ICP). The nurse should know that which of the following client findings supports this
suspicion?
A. Cyanotic fingertips.
Rationale: Cyanotic fingertips is not an indicator that a client is experiencing increased
intracranial pressure.
B. Nuchal rigidity.
Rationale: Nuchal rigidity is not an indicator that a client is experiencing increased intracranial
pressure.
C. Fever.
Rationale: Fever is not an indicator that a client is experiencing increased intracranial pressure.
D. Diplopia.
Rationale: Clients who have meningitis can be at risk for developing increased intracranial
pressure (ICP). The classic triad of manifestations for increased ICP consists of
headache, nausea/vomiting, and diplopia, or double vision. The client who has
meningitis and reports diplopia must be carefully monitored for other manifestations
of increased ICP.
6. A nurse is providing nutritional teaching to a client who has dumping syndrome following a hemi-colectomy.
Which of the following foods should the nurse instruct the client to avoid?
A. Rice
Rationale: Clients with dumping syndrome following a hemi-colectomy should include high
protein, high fat, low-to-moderate carbohydrate, and low fiber foods. Rice is low in
fiber and provides carbohydrates.
B. Poached eggs
Detailed Answer Key 100%
1. A nurse is caring for a conscious client who has an airway obstruction. Which of the following is an appropriate
intervention?
A. Tilt the head and lift the chin.
Rationale: Tilting the head and lifting the chin is an appropriate intervention to open the airway if
the client loses consciousness.
B. Begin the Heimlich maneuver.
Rationale: The nurse should immediately begin the Heimlich maneuver on a conscious client
who has an airway obstruction and should continue until the obstruction is clear or
the client loses consciousness.
C. Turn the client to the side.
Rationale: Turning the client to the side is an appropriate intervention if the client is
unconscious and breathing.
D. Perform a blind finger sweep.
Rationale: Performing a blind finger sweep creates a risk of worsening the obstruction.
, GI/Neuro Med Surg
Detailed Answer Key 100%
2. A nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following should the nurse
recognize as a complication of this therapy?
A. Polyuria
Rationale: TPN is prescribed when extensive nutritional support for prolonged periods of time is
required. It is delivered through a central venous access device, usually via the
internal jugular or subclavian vein. TPN contains a high concentration of dextrose,
which can result in hyperglycemia. Clinical manifestations of hyperglycemia include
polydipsia, polyphagia, and polyuria. Frequent glucose monitoring should be
implemented in clients receiving TPN. Administering regular insulin according to a
sliding scale will help control glucose levels.
B. Aspiration
Rationale: Aspiration is a complication of total enteral nutrition (TEN). During TEN, a tube is
placed in the client’s GI tract, often via the nasal passage. One of the complications
of TEN is pulmonary aspiration. This can occur if the tube is not placed correctly
(e.g., in the lungs instead of the stomach) or if feedings are administered too rapidly
or in too large a volume. Ensuring the tube is placed correctly and maintaining the
client in a Fowler’s position will minimize this risk. Because TPN is not administered
via the GI tract, aspiration is not a complication.
C. Diarrhea
Rationale: Diarrhea is a complication of total enteral nutrition (TEN). During TEN, a tube is
placed in the client’s GI tract, often via the nasal passage. Diarrhea can occur if the
feedings are delivered too rapidly. Feedings should be started slowly and advanced
as tolerated. Because TPN is not administered via the GI tract, diarrhea is not a
complication.
D. Stomatitis
Rationale: Although mouth care is important for clients who are receiving supplemental
nutrition, stomatitis is not expected. Stomatitis is an inflammation of the lining of
the mouth that may include the inside of the cheeks, gums, and tongue. It can be
caused by chemotherapy. It is not caused by TPN.
, GI/Neuro Med Surg
Detailed Answer Key 100%
3. A nurse is caring for an adolescent client in the emergency department who sustained a head injury. The nurse
notes the client’s IV fluids are infusing at 125 mL/hour. Which of the following is an appropriate action by the
nurse?
A. Slow the rate to 20 mL/hr.
Rationale: The nurse who slows the IV rate to 20mL/hr may compromise volume resuscitation
and cause hypotension.
B. Continue the rate at 125 mL/hr.
Rationale: The nurse who continues the IV rate at 125 mL/hr may worsen the client’s condition
by rapidly expanding the client’s plasma volume.
C. Slow the rate to 50 mL/hr.
Rationale: The nurse should decrease the rate to 50 mL/hr to minimize cerebral edema and
prevent increased intracranial pressure.
D. Increase the rate to 250 mL/hr.
Rationale: The nurse who continues the IV rate at 250 mL/hr may worsen the client’s condition
by rapidly expanding the client’s plasma volume and causing increased intracranial
pressure.
4. A nurse is caring for a client who has cancer and is receiving total parenteral nutrition (TPN). Which of the
following lab values indicates the treatment is effective?
A. Hct 43%
Rationale: An Hct of 43% is within the expected reference range but this does not indicate the
TPN therapy is effective. Clients with cancer are likely to have a low Hct due to
anemia.
B. WBC 8,000/uL
Rationale: A WBC count of 8,000/uL is within the expected reference range but this does not
indicate the TPN therapy is effective. Clients receiving TPN are at risk for
developing infection.
C. Albumin 4.2 g/dL
Rationale: Clients who have cancer can receive TPN to provide needed proteins and glucose
they are otherwise unable to obtain. An albumin level of 4.2 g/dL is within the
, GI/Neuro Med Surg
Detailed Answer Key 100%
expected reference range and indicates the client is receiving adequate amounts of
protein.
D. Calcium 9.4 mg/dL
Rationale: A calcium level of 9.4 mg/dL is within the expected reference range but this does not
indicate the TPN therapy is effective. Clients receiving TPN are at high risk for
developing hypercalcemia.
5. A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased
intracranial pressure (ICP). The nurse should know that which of the following client findings supports this
suspicion?
A. Cyanotic fingertips.
Rationale: Cyanotic fingertips is not an indicator that a client is experiencing increased
intracranial pressure.
B. Nuchal rigidity.
Rationale: Nuchal rigidity is not an indicator that a client is experiencing increased intracranial
pressure.
C. Fever.
Rationale: Fever is not an indicator that a client is experiencing increased intracranial pressure.
D. Diplopia.
Rationale: Clients who have meningitis can be at risk for developing increased intracranial
pressure (ICP). The classic triad of manifestations for increased ICP consists of
headache, nausea/vomiting, and diplopia, or double vision. The client who has
meningitis and reports diplopia must be carefully monitored for other manifestations
of increased ICP.
6. A nurse is providing nutritional teaching to a client who has dumping syndrome following a hemi-colectomy.
Which of the following foods should the nurse instruct the client to avoid?
A. Rice
Rationale: Clients with dumping syndrome following a hemi-colectomy should include high
protein, high fat, low-to-moderate carbohydrate, and low fiber foods. Rice is low in
fiber and provides carbohydrates.
B. Poached eggs
