G.1 paper

G.1 1. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled forsurgery in 2 hours. The client beginsto complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? 1. Administer the prescribed pain medication. 2. Notify the primary health care provider (PHCP). 3. Call and ask the operating room team to perform surgery as soon as possible. 4. Reposition the client and apply a heating pad on the warm setting to the client’s abdomen. Answer: 2 Rationale: On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the PHCP. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the PHCP probably would perform the surgery earlier than the prescheduled time. 2. A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. 1. Diarrhea 2. Black, tarry stools 3. Hyperactive bowel sounds 4. Gray-blue color at the flank 5. Abdominal guarding and tenderness 6. Left upper quadrant pain with radiation to the back Answer: 4, 5, 6 Rationale: Grayish-blue discoloration at the flank is known as Grey-Turner’s sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity. The client may demonstrate abdominal guarding and may complain of tenderness with palpation. The pain associated with acute pancreatitis is often sudden in onset and is located in the epigastric region or left upper quadrant with radiation to the back. The other options are incorrect. 3. The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. 1. Fever 2. Positive Cullen’ssign 3. Complaints of indigestion 4. Palpable mass in the left upper quadrant 5. Pain in the upper right quadrant after a fatty meal 6. Vague lower right quadrant abdominal discomfort Answer: 1, 3, 5 Rationale: During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiatesto the rightscapula orshoulder or experience epigastric pain after a fatty or high-volume meal. Fever and signs of dehydration would also be expected, as well as complaints of indigestion, belching, 1533 flatulence, nausea, and vomiting. Options 4 and 6 are incorrect because they are inconsistent with the anatomical location of the gallbladder. Option 2 (Cullen’s sign) is associated with pancreatitis. 4. A client is diagnosed with viral hepatitis, complaining of “no appetite” and “losing my taste for food.” What instruction should the nurse give the client to provide adequate nutrition? 1. Select foods high in fat. 2. Increase intake of fluids, including juices. 3. Eat a good supper when anorexia is not as severe. 4. Eat less often, preferably only 3 large meals daily. Answer: 2 Rationale: Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet, as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important 5. A client has developed hepatitis A after eating contaminated oysters. The nurse assessesthe client for which expected assessment finding? 1. Malaise 2. Dark stools 3. Weight gain 4. Left upper quadrant discomfort Answer: 1 Rationale: Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts. 6. A client hasjust had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. 1. Administerstoolsofteners as prescribed. 2. Instruct the client to limit fluid intake to avoid urinary retention. 3. Encourage a high-fiber diet to promote bowel movements withoutstraining. 4. Apply cold packs to the anal-rectal area over the dressing until the packing is removed. 5. Help the client to a Fowler’s position to place pressure on the rectal area and decrease bleeding. Answer: 1, 3, 4 Rationale: Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance of bleeding and incision rupture. Stoolsofteners and a high-fiber diet will help the client avoid straining, thereby reducing the chances of rupturing the incision. An ice pack will increase comfort and decrease bleeding. Options 2 and 5 are incorrect interventions. 7. The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply. 1. Coffee 2. Chocolate 3. Peppermint 4. Nonfat milk 5. Fried chicken 6. Scrambled eggs Answer: 1, 2, 3, 5 Rationale: Foods that decrease lower esophagealsphincter (LES) pressure and irritate the esophagus will increase reflux and exacerbate the symptoms of GERD and therefore should be avoided. Aggravating substances include coffee, chocolate, peppermint, fried or fatty foods, carbonated beverages, and alcohol. Options 4 and 6 do not promote this effect. 8. A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client’s care plan? 1. Monitoring the temperature 2. Monitoring complaints of heartburn 3. Giving warm gargles for a sore throat 4. Assessing for the return of the gag reflex Answer: 4 Rationale: The nurse places highest priority on assessing for return of the gag reflex. This assessment addresses the client’s airway. The nurse also monitorsthe client’s vitalsigns and for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also 1535 important; however, the client’s airway is the priority. 9. The nurse hastaught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement? 1. “I know I must sign the consent form.” 2. “I hope the throatspray keeps me from gagging.” 3. “I’m glad I don’t have to lie still for this procedure.” 4. “I’m glad some intravenous medication will be given to relax me.” Answer: 3 Rationale: The client does have to lie still for ERCP, which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed. Test-Taking Strategy: Note the strategic words, needs further information. These words indicate a negative event query and ask you to select an option that is incorrect. Invasive procedures require consent, so option 1 can be eliminated. Noting the name of the procedure and considering the anatomical location will assist you in eliminating options 2 and 4. 10. The primary health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis? 1. “I have had unprotected sex with multiple partners.” 2. “I ate shellfish about 2 weeks ago at a local restaurant.” 3. “I was an intravenous drug abuser in the past and shared needles.” 4. “I had a blood transfusion 30 years ago after major abdominalsurgery.” Answer: 2 Rationale: Hepatitis A istransmitted by the fecal-oral route via contaminated water or food (improperly cooked shellfish), or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids, such as in the cases of intravenous drug abuse, history of blood transfusion, or unprotected sex with multiple partners 12. The nurse is assessing a client 24 hoursfollowing a cholecystectomy. The nurse notesthat the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? 1. Clamp the T-tube. 2. Irrigate the T-tube. 3. Document the findings. 4. Notify the primary health care provider. Answer: 3 Rationale: Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output. 13. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? 1. Bradycardia 2. Numbness in the legs 3. Nausea and vomiting 4. A rigid, board-like abdomen Answer: 4 Rationale: Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomesrigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding. 14. The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? 1. Leg exercises 2. Early ambulation 3. Irrigating the nasogastric tube 4. Coughing and deep-breathing exercises Answer: 3 Rationale: In a gastrojejunostomy (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 prescribed by the primary health care provider. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions. 15. The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? 1. Ambulate following a meal. 2. Eat high-carbohydrate foods. 3. Limit the fluids taken with meals. 4. Sit in a high-Fowler’s position during meals. Answer: 3 Rationale: Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a gastrojejunostomy (Billroth II procedure). Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low-Fowler’s position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed. 16. The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Maintain NPO (nothing by mouth) status. 2. Encourage coughing and deep breathing. 3. Give small, frequent high-calorie feedings. 4. Maintain the client in a supine and flat position. 5. Give hydromorphone intravenously as prescribed for pain. 6. Maintain intravenous fluids at 10 mL/hr to keep the vein open. Answer: 1, 2, 5 Rationale: The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinalsecretions,so adequate intravenous hydration is necessary. Because abdominal pain is a prominent symptom of pancreatitis, pain medications such as morphine or hydromorphone are prescribed. Meperidine is avoided, as it may cause seizures. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted. 17. The nurse is providing discharge teaching for a client with newly diagnosed Crohn’s disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? 1. “I should increase the fiber in my diet.” 2. “I will need to avoid caffeinated beverages.” 3. “I’m going to learn some stressreduction techniques.” 4. “I can have exacerbations and remissions with Crohn’s disease.” Answer: 1 Rationale: Crohn’s disease is an inflammatory disease that can occur anywhere in the gastrointestinal tract but most often affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses. It is characterized by exacerbations and remissions. If stress increases the symptoms of the disease, the client is taught stress management techniques and may require additional counseling. The client istaught to avoid gastrointestinalstimulants containing caffeine and to follow a high-calorie and high-protein diet. A low-fiber diet may be prescribed, especially during periods of exacerbation. 18. The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1. Dorsiflex the client’sfoot. 2. Measure the abdominal girth. 3. Ask the client to extend the arms. 4. Instruct the client to lean forward. Answer: 3 Rationale: Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sig 19. The nurse is reviewing the laboratory resultsfor a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? 1. Roast pork 2. Cheese omelet 3. Pasta with sauce 4. Tuna fish sandwich Answer: 3 Rationale: Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. The serum ammonia level assesses the ability of the liver to deaminate protein byproducts. Normal reference interval is 10 to 80 mcg/dL (6 to 47 mcmol/L). Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. Foods high in protein should be avoided since the client’s ammonia level is elevated above the normal range; therefore, pasta with sauce would be the best selection. 20.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 should assess the client for which manifestation of duodenal ulcer? 1. Weight loss 2. Nausea and vomiting 3. Pain relieved by food intake 4. Pain radiating down the right arm Answer: 3 Rationale: A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or “hungry” pain that often localizes in the midepigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer. Test-Taking Strategy: Eliminate options 1 and 2 because they are comparable or alike; if the client is vomiting, weight loss will occur. Next, think about the symptoms of duodenal and gastric ulcer. Choose the correct option over option 4, knowing that the pain does not radiate down the right arm and that a pattern of pain-foodrelief occurs with duodenal ulcer. 21. A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? 1. Lying recumbent following meals 2. Consuming small, frequent, bland meals 3. Taking H2 -receptor antagonist medication 4. Raising the head of the bed on 6-inch (15 cm) blocks Answer: 1 Rationale: Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm where the esophagus usually is positioned. The client usually experiences pain from reflux caused by ingestion of irritating foods, lying flat following meals or at night, and eating large or fatty meals. Relief is obtained with the intake of small, frequent, and bland meals; use of H2 -receptor antagonists and antacids; and elevation of the thorax following meals and during sleep. 22. The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the primary health care provider? 1. Stoma is beefy red and shiny 2. Purple discoloration of the stoma 3. Skin excoriation around the stoma 4. Semiformed stool noted in the ostomy pouch Answer: 2 Rationale: Ischemia of the stoma would be associated with a dusky or bluish or purple color. A beefy red and shiny stoma is normal and expected. Skin excoriation needs to be addressed and treated but does not require as immediate attention as purple discoloration of the stoma. Semiformed stool is a normal finding. 23. A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1. This is a normal, expected event. 2. The client is experiencing early signs of ischemic bowel. 3. The client should not have the nasogastric tube removed. 4. Thisindicatesinadequate preoperative bowel preparation. Answer: 1 Rationale: As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours ofsurgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect interpretations. 24. A client hasjust had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? 1. Folate deficiency 2. Malabsorption of fat 3. Intestinal obstruction 4. Fluid and electrolyte imbalance Answer: 4 Rationale: A frequent complication that occursfollowing ileostomy isfluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period. 25. The nurse provides instructions to a client about measures to treat inflammatory bowelsyndrome (IBS). Which statement by the client indicates a need for further teaching? 1. “I need to limit my intake of dietary fiber.” 2. “I need to drink plenty, at least 8 to 10 cups daily.” 3. “I need to eat regular meals and chew my food well.” 4. “I will take the prescribed medications because they will regulate my bowel patterns.” Answer: 1 Rationale: IBS is a functional gastrointestinal disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. Dietary fiber and bulk help produce bulky, soft stools and establish regular bowel elimination habits. Therefore, the client should consume a high-fiber diet. Eating regular meals, drinking 8 to 10 cups of liquid a day, and chewing food slowly help promote normal bowel function. Medication therapy depends on the main symptoms of IBS. Bu 26. The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? 1. Sweating and pallor 2. Bradycardia and indigestion 3. Double vision and chest pain 4. Abdominal cramping and pain Answer: 1 Rationale: Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.