Nurs-172 Exam 5 (A+ GUARANTEED)
The nurse performs a detailed assessment of the abdomen of a client with a possible bowel
obstruction, knowing that a manifestation of an obstruction in the large intestine is (Select all that
apply) (There are 2 correct answers)
A. a largely distended abdomen.
B. diarrhea that is loose or liquid.
C. persistent, colicky abdominal pain.
D. profuse vomiting that relieves abdominal pain. correct answers A. a largely distended
abdomen.
C. persistent, colicky abdominal pain.
Rationale: Persistent, colicky abdominal pain is seen with lower intestinal obstruction.
Abdominal distention is markedly increased in lower intestinal obstructions. Onset of a large
intestine obstruction is gradual, vomiting is rare, and there is usually absolute constipation.
The nurse is caring for a patient admitted with abdominal pain, nausea, and vomiting. The patient
has an abdominal mass and a bowel obstruction is suspected. The nurse auscultating the
abdomen listens for which of the following types of bowel sounds that is consistent with the
patient's clinical picture? (Select one answer)
A. Low pitched and rumbling above the area of obstruction
B. High pitched and hypoactive below the area of obstruction
C. Low pitched and hyperactive below the area of obstruction
D. High pitched and hyperactive above the area of obstruction correct answers D. High pitched
and hyperactive above the area of obstruction
Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high pitched,
sometimes referred to as "tinkling" above the level of the obstruction. This occurs because
peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes
complete, bowel sounds decrease and finally become absent.
The nurse is preparing to insert a nasogastric tube into a patient with an abdominal mass and
suspected bowel obstruction. The patient asks the nurse why this procedure is necessary. Which
of the following responses is most appropriate? (Select one answer)
A. "The tube will help to drain the stomach contents and prevent further vomiting."
B. "The tube will push past the area that is blocked, and thus help to stop the vomiting."
C. "The tube is just a standard procedure before many types of surgery to the abdomen."
D. "The tube will let us measure your stomach contents, so that we can plan what type of IV
fluid replacement would be best." correct answers A. "The tube will help to drain the stomach
contents and prevent further vomiting."
The nasogastric tube is used to decompress the stomach by draining stomach contents, and
thereby prevent further vomiting.
,Following bowel resection, a patient has a nasogastric tube to suction, but complains of nausea
and abdominal distention. The nurse checks the placement of the NG tube and irrigates the tube
with normal saline as ordered, but the irrigating fluid does not return. Which of the following
should be the priority action by the nurse? (Select one answer)
A. Notify the physician/surgeon.
B. Auscultate for bowel sounds.
C. Reposition the tube and check for placement.
D. Remove the tube and replace it with a new one. correct answers C. Reposition the tube and
check for placement.
The tube may be resting against the stomach wall. The first action by the nurse, since this
intestinal surgery (not gastric surgery), is to reposition the tube and check it again for placement.
The nurse asks an adult patient scheduled for colectomy to sign the operative permit as directed
in the physician's/surgeon's preoperative orders. The patient states that the physician/surgeon has
not really explained well what is involved in the surgical procedure. Which of the following is
the most appropriate action by the nurse? (Select one answer)
A. Ask family members whether they have discussed the surgical procedure with the
physician/surgeon.
B. Have the patient sign the form and state the physician/surgeon will visit to explain the
procedure before surgery.
C. Explain the planned surgical procedure as well as possible, and have the patient sign the
consent form.
D. Delay the patient's signature on the consent and notify the physician/surgeon about the
conversation with the patient. correct answers D. Delay the patient's signature on the consent and
notify the physician/surgeon about the conversation with the patient.
The patient should not be asked to sign a consent form unless the procedure has been explained
to the satisfaction of the patient. The nurse should notify the physician/surgeon, who has the
responsibility for obtaining consent.
Which of the following nursing diagnoses is a priority in the care of a patient with renal calculi?
(Select one answer)
A. Acute pain
B. Deficient fluid volume
C. Risk for constipation
D. Risk for powerlessness correct answers A. Acute pain
Urinary stones are associated with severe abdominal or flank pain. Deficient fluid volume is
unlikely to result from urinary stones, whereas constipation is more likely to be an indirect
consequence rather than a primary clinical manifestation of the problem. The presence of pain
supersedes powerlessness as an immediate focus of nursing care.
, A patient is admitted to the hospital with severe renal colic pain caused by renal lithiasis. The
nurse's first priority in management of the patient is to (Select one answer)
A. obtain supplies for straining all urine.
B. administer opioids as prescribed.
C. encourage fluid intake of 3 to 4 L/day.
D. keep the patient NPO in preparation for surgery. correct answers B. administer opioids as
prescribed.
Rationale: Pain management and patient comfort are primary nursing responsibilities when
managing an obstructing stone and renal colic.
A patient with a ureterolithotomy returns from surgery with a nephrostomy tube in place.
Postoperative nursing care of the patient includes (Select one answer)
A. forcing fluids of at least 2 to 3 L per day after nausea has subsided.
B. encouraging the patient to drink fruit juices and milk.
C. irrigating the nephrostomy tube with 10 mL of normal saline solution as needed.
D. notifying the physician/surgeon if nephrostomy tube drainage is more than 30 mL per hour.
correct answers A. forcing fluids of at least 2 to 3 L per day after nausea has subsided.
Rationale: The nephrostomy tube is inserted directly into the pelvis of the kidney and attached to
connecting tubing for closed drainage. The catheter should never be kinked, compressed, or
clamped. If the patient complains of excessive pain in the area or if there is excessive drainage
around the tube, check the catheter for patency. If irrigation is ordered, strict aseptic technique is
required. No more than 5 mL of sterile saline solution is gently instilled at one time to prevent
overdistention of the kidney pelvis and renal damage. Infection and secondary stone formation
are complications associated with the insertion of a nephrostomy tube. Patients should drink 2 to
3 liters of fluid per day to reduce risk of infection and stone formation.
The nurse identifies a risk for urinary calculi in a patient who relates (Select one answer)
A. adrenal insufficiency.
B. serotonon deficiency.
C. hyperaldosteronism.
D. hyperparathyroidism. correct answers D. hyperparathyroidism.
Rationale: Excessive levels of circulating parathyroid hormone (PTH) usually lead to
hypercalcemia and hypophosphatemia. In the kidneys, the excess calcium cannot be reabsorbed,
leading to increased levels of calcium in the urine (i.e., hypercalciuria). This urinary calcium,
along with a large amount of urinary phosphate, can lead to calculi formation.
A diagnostic study that indicates renal blood flow, glomerular filtration rate, tubular function,
and excretion is a (n) (Select one answer)
The nurse performs a detailed assessment of the abdomen of a client with a possible bowel
obstruction, knowing that a manifestation of an obstruction in the large intestine is (Select all that
apply) (There are 2 correct answers)
A. a largely distended abdomen.
B. diarrhea that is loose or liquid.
C. persistent, colicky abdominal pain.
D. profuse vomiting that relieves abdominal pain. correct answers A. a largely distended
abdomen.
C. persistent, colicky abdominal pain.
Rationale: Persistent, colicky abdominal pain is seen with lower intestinal obstruction.
Abdominal distention is markedly increased in lower intestinal obstructions. Onset of a large
intestine obstruction is gradual, vomiting is rare, and there is usually absolute constipation.
The nurse is caring for a patient admitted with abdominal pain, nausea, and vomiting. The patient
has an abdominal mass and a bowel obstruction is suspected. The nurse auscultating the
abdomen listens for which of the following types of bowel sounds that is consistent with the
patient's clinical picture? (Select one answer)
A. Low pitched and rumbling above the area of obstruction
B. High pitched and hypoactive below the area of obstruction
C. Low pitched and hyperactive below the area of obstruction
D. High pitched and hyperactive above the area of obstruction correct answers D. High pitched
and hyperactive above the area of obstruction
Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high pitched,
sometimes referred to as "tinkling" above the level of the obstruction. This occurs because
peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes
complete, bowel sounds decrease and finally become absent.
The nurse is preparing to insert a nasogastric tube into a patient with an abdominal mass and
suspected bowel obstruction. The patient asks the nurse why this procedure is necessary. Which
of the following responses is most appropriate? (Select one answer)
A. "The tube will help to drain the stomach contents and prevent further vomiting."
B. "The tube will push past the area that is blocked, and thus help to stop the vomiting."
C. "The tube is just a standard procedure before many types of surgery to the abdomen."
D. "The tube will let us measure your stomach contents, so that we can plan what type of IV
fluid replacement would be best." correct answers A. "The tube will help to drain the stomach
contents and prevent further vomiting."
The nasogastric tube is used to decompress the stomach by draining stomach contents, and
thereby prevent further vomiting.
,Following bowel resection, a patient has a nasogastric tube to suction, but complains of nausea
and abdominal distention. The nurse checks the placement of the NG tube and irrigates the tube
with normal saline as ordered, but the irrigating fluid does not return. Which of the following
should be the priority action by the nurse? (Select one answer)
A. Notify the physician/surgeon.
B. Auscultate for bowel sounds.
C. Reposition the tube and check for placement.
D. Remove the tube and replace it with a new one. correct answers C. Reposition the tube and
check for placement.
The tube may be resting against the stomach wall. The first action by the nurse, since this
intestinal surgery (not gastric surgery), is to reposition the tube and check it again for placement.
The nurse asks an adult patient scheduled for colectomy to sign the operative permit as directed
in the physician's/surgeon's preoperative orders. The patient states that the physician/surgeon has
not really explained well what is involved in the surgical procedure. Which of the following is
the most appropriate action by the nurse? (Select one answer)
A. Ask family members whether they have discussed the surgical procedure with the
physician/surgeon.
B. Have the patient sign the form and state the physician/surgeon will visit to explain the
procedure before surgery.
C. Explain the planned surgical procedure as well as possible, and have the patient sign the
consent form.
D. Delay the patient's signature on the consent and notify the physician/surgeon about the
conversation with the patient. correct answers D. Delay the patient's signature on the consent and
notify the physician/surgeon about the conversation with the patient.
The patient should not be asked to sign a consent form unless the procedure has been explained
to the satisfaction of the patient. The nurse should notify the physician/surgeon, who has the
responsibility for obtaining consent.
Which of the following nursing diagnoses is a priority in the care of a patient with renal calculi?
(Select one answer)
A. Acute pain
B. Deficient fluid volume
C. Risk for constipation
D. Risk for powerlessness correct answers A. Acute pain
Urinary stones are associated with severe abdominal or flank pain. Deficient fluid volume is
unlikely to result from urinary stones, whereas constipation is more likely to be an indirect
consequence rather than a primary clinical manifestation of the problem. The presence of pain
supersedes powerlessness as an immediate focus of nursing care.
, A patient is admitted to the hospital with severe renal colic pain caused by renal lithiasis. The
nurse's first priority in management of the patient is to (Select one answer)
A. obtain supplies for straining all urine.
B. administer opioids as prescribed.
C. encourage fluid intake of 3 to 4 L/day.
D. keep the patient NPO in preparation for surgery. correct answers B. administer opioids as
prescribed.
Rationale: Pain management and patient comfort are primary nursing responsibilities when
managing an obstructing stone and renal colic.
A patient with a ureterolithotomy returns from surgery with a nephrostomy tube in place.
Postoperative nursing care of the patient includes (Select one answer)
A. forcing fluids of at least 2 to 3 L per day after nausea has subsided.
B. encouraging the patient to drink fruit juices and milk.
C. irrigating the nephrostomy tube with 10 mL of normal saline solution as needed.
D. notifying the physician/surgeon if nephrostomy tube drainage is more than 30 mL per hour.
correct answers A. forcing fluids of at least 2 to 3 L per day after nausea has subsided.
Rationale: The nephrostomy tube is inserted directly into the pelvis of the kidney and attached to
connecting tubing for closed drainage. The catheter should never be kinked, compressed, or
clamped. If the patient complains of excessive pain in the area or if there is excessive drainage
around the tube, check the catheter for patency. If irrigation is ordered, strict aseptic technique is
required. No more than 5 mL of sterile saline solution is gently instilled at one time to prevent
overdistention of the kidney pelvis and renal damage. Infection and secondary stone formation
are complications associated with the insertion of a nephrostomy tube. Patients should drink 2 to
3 liters of fluid per day to reduce risk of infection and stone formation.
The nurse identifies a risk for urinary calculi in a patient who relates (Select one answer)
A. adrenal insufficiency.
B. serotonon deficiency.
C. hyperaldosteronism.
D. hyperparathyroidism. correct answers D. hyperparathyroidism.
Rationale: Excessive levels of circulating parathyroid hormone (PTH) usually lead to
hypercalcemia and hypophosphatemia. In the kidneys, the excess calcium cannot be reabsorbed,
leading to increased levels of calcium in the urine (i.e., hypercalciuria). This urinary calcium,
along with a large amount of urinary phosphate, can lead to calculi formation.
A diagnostic study that indicates renal blood flow, glomerular filtration rate, tubular function,
and excretion is a (n) (Select one answer)
