Which topic would the nurse anticipate teaching to a patient who has a new report of
heartburn?
a. Radionuclide tests
b. Barium swallow exam
c. Endoscopy procedures
d. Proton pump inhibitors
Give this one a try later!
, ANS: D
Because diagnostic testing for heartburn that is probably caused by
gastroesophageal reflux disease (GERD) is expensive and uncomfortable,
proton pump inhibitors are frequently used for a short period as the first
step in the diagnosis of GERD. The other tests may be used but are not
usually the first step in diagnosis.
DIF:CognitiveLevel: Apply (Application) MSC:NCLEX: PhysiologicalIntegrity
TOP: NursingProcess: Planning
The nurse is assessing a patient who had a total gastrectomy 8 hours ago. Which
information is most important to report to the health care provider?
a. Hemoglobin (Hgb) 10.8 g/dL
b. Temperature 102.1F (38.9C)
c. Absent bowel sounds in all quadrants
d. Scant nasogastric (NG) tube drainage
Give this one a try later!
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.
DIF:CognitiveLevel: Analyze (Analysis) TOP: NursingProcess: Assessment
MSC:NCLEX: PhysiologicalIntegrity
A patient is transferred from the recovery room to a surgical unit after a transverse
colostomy. The nurse observes the stoma to be deep pink with edema and a small
amount of sanguineous drainage. Which action would the nurse take?
a. Place ice packs around the stoma.
,b. Notify the surgeon about the stoma.
c. Monitor the stoma every 30 minutes.
d. Document stoma assessment findings.
Give this one a try later!
ANS: D \
The stoma appearance indicates good circulation to the stoma. There is no
indication that surgical intervention is needed or that frequent stoma
monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks
after surgery. An ice pack is not needed.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess:
Implementation MSC:NCLEX: PhysiologicalIntegrity
After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I
cannot manage all this. I don't want to look at the stoma." Which action would the
nurse take?
a. Reassure the patient that ileostomy care will become easier.
b. Ask the patient about the concerns with stoma management.
c. Postpone any teaching until the patient adjusts to the ileostomy.
d. Develop a detailed written list of ostomy care tasks for the patient.
Give this one a try later!
ANS: B
Encouraging the patient to share concerns assists in helping the patient
adjust to the body changes. Acknowledgment of the patient's feelings and
concerns is important rather than offering false reassurance. Because the
patient indicates that the feelings about the ostomy are the reason for the
difficulty with the many changes, development of a detailed ostomy care
plan will not improve the patient's ability to manage the ostomy. Although
detailed ostomy teaching could be postponed, the nurse should begin to
offer teaching about some aspects of living with an ostomy.
, DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess:
Implementation MSC:NCLEX: Psychosocial Integrity
Which information will the nurse include when teaching a patient how to avoid
chronic constipation? (Select all that apply.)
a. Stimulant and saline laxatives can be used regularly.
b. Bulk-forming laxatives are an excellent source of fiber.
c. Walking or cycling frequently will help bowel motility.
d. A good time for a bowel movement may be after breakfast.
e. Some over-the-counter (OTC) medications cause constipation.
Give this one a try later!
ANS: B, C, D, E
Stimulant and saline laxatives should be used infrequently. Use of bulk-
forming laxatives, regular early morning timing of defecation, regular
exercise, and avoiding many OTC medications will help the patient avoid
constipation.
Which care activity for a patient with a paralytic ileus is appropriate for the registered
nurse (RN) to delegate to assistive personnel (AP)?
a. Auscultating for bowel sounds
b. Brushing the teeth and tongue
c. Assessing the nares for irritation
d. Irrigating the nasogastric (NG) tube
Give this one a try later!
ANS: B
AP education and scope of practice include patient hygiene such as oral
care. The other actions require education and scope of practice
appropriate to the RN.
heartburn?
a. Radionuclide tests
b. Barium swallow exam
c. Endoscopy procedures
d. Proton pump inhibitors
Give this one a try later!
, ANS: D
Because diagnostic testing for heartburn that is probably caused by
gastroesophageal reflux disease (GERD) is expensive and uncomfortable,
proton pump inhibitors are frequently used for a short period as the first
step in the diagnosis of GERD. The other tests may be used but are not
usually the first step in diagnosis.
DIF:CognitiveLevel: Apply (Application) MSC:NCLEX: PhysiologicalIntegrity
TOP: NursingProcess: Planning
The nurse is assessing a patient who had a total gastrectomy 8 hours ago. Which
information is most important to report to the health care provider?
a. Hemoglobin (Hgb) 10.8 g/dL
b. Temperature 102.1F (38.9C)
c. Absent bowel sounds in all quadrants
d. Scant nasogastric (NG) tube drainage
Give this one a try later!
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.
DIF:CognitiveLevel: Analyze (Analysis) TOP: NursingProcess: Assessment
MSC:NCLEX: PhysiologicalIntegrity
A patient is transferred from the recovery room to a surgical unit after a transverse
colostomy. The nurse observes the stoma to be deep pink with edema and a small
amount of sanguineous drainage. Which action would the nurse take?
a. Place ice packs around the stoma.
,b. Notify the surgeon about the stoma.
c. Monitor the stoma every 30 minutes.
d. Document stoma assessment findings.
Give this one a try later!
ANS: D \
The stoma appearance indicates good circulation to the stoma. There is no
indication that surgical intervention is needed or that frequent stoma
monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks
after surgery. An ice pack is not needed.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess:
Implementation MSC:NCLEX: PhysiologicalIntegrity
After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I
cannot manage all this. I don't want to look at the stoma." Which action would the
nurse take?
a. Reassure the patient that ileostomy care will become easier.
b. Ask the patient about the concerns with stoma management.
c. Postpone any teaching until the patient adjusts to the ileostomy.
d. Develop a detailed written list of ostomy care tasks for the patient.
Give this one a try later!
ANS: B
Encouraging the patient to share concerns assists in helping the patient
adjust to the body changes. Acknowledgment of the patient's feelings and
concerns is important rather than offering false reassurance. Because the
patient indicates that the feelings about the ostomy are the reason for the
difficulty with the many changes, development of a detailed ostomy care
plan will not improve the patient's ability to manage the ostomy. Although
detailed ostomy teaching could be postponed, the nurse should begin to
offer teaching about some aspects of living with an ostomy.
, DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess:
Implementation MSC:NCLEX: Psychosocial Integrity
Which information will the nurse include when teaching a patient how to avoid
chronic constipation? (Select all that apply.)
a. Stimulant and saline laxatives can be used regularly.
b. Bulk-forming laxatives are an excellent source of fiber.
c. Walking or cycling frequently will help bowel motility.
d. A good time for a bowel movement may be after breakfast.
e. Some over-the-counter (OTC) medications cause constipation.
Give this one a try later!
ANS: B, C, D, E
Stimulant and saline laxatives should be used infrequently. Use of bulk-
forming laxatives, regular early morning timing of defecation, regular
exercise, and avoiding many OTC medications will help the patient avoid
constipation.
Which care activity for a patient with a paralytic ileus is appropriate for the registered
nurse (RN) to delegate to assistive personnel (AP)?
a. Auscultating for bowel sounds
b. Brushing the teeth and tongue
c. Assessing the nares for irritation
d. Irrigating the nasogastric (NG) tube
Give this one a try later!
ANS: B
AP education and scope of practice include patient hygiene such as oral
care. The other actions require education and scope of practice
appropriate to the RN.
