GI/Neuro Med Surg
Detailed Answer Key 100%
1.
, GI/Neuro Med Surg
Detailed Answer Key 100%
A. Flush the peripheral IV line with 0.9% sodium chloride to await further instructions from the physician.
Rationale: This is not the appropriate intervention for the nurse to take.
B. Change the tubing and filter on the TPN.
Rationale: Changing the tubing and filter is not the appropriate intervention for the nurse to
take.
C. Hang an infusion 10% dextrose.
Rationale: The sudden withdrawal from the TPN (hypertonic solution) can cause the client to be
experiencing hypoglycemia. Administering an infusion of 10% dextrose will adjust
the client’s blood glucose levels.
D. Notify the pharmacy.
Rationale: This is not the appropriate intervention for the nurse to take.
2. A nurse is caring for a child with a suspected diagnosis of bacterial meningitis. Which of the following is the
priority action by the nurse?
A. Administer antibiotics when available.
Rationale: The priority nursing action is to administer antibiotics when available. Bacterial
meningitis is an acute inflammation of the meninges and the CNS, and antibiotic
therapy has a marked effect on the course and prognosis of the illness.
B. Reduce environmental stimuli.
Rationale: Reducing environmental stimuli is an appropriate action by the nurse; however, this
is not the priority.
C. Document intake and output.
Rationale: Documenting intake and output is an appropriate action by the nurse; however, this
is not the priority.
D. Maintain seizure precautions.
Rationale: Maintaining seizure precautions is an appropriate action by the nurse; however, this is
not the priority.
3. A nurse is caring for a client whose total parenteral nutrition (TPN) was stopped for an hour by mistake. After
restarting the infusion pump, the nurse should watch the client carefully for the development of
, GI/Neuro Med Surg
Detailed Answer Key 100%
A. excessive thirst and urination.
Rationale: Excessive thirst and urination are manifestations of hyperglycemia, which is a
complication of TPN related to the high proportion of glucose in the infusion.
Hyperglycemia would not occur secondary to an interruption in the TPN
administration.
B. shakiness and diaphoresis.
Rationale: When a sudden interruption in the infusion of TPN occurs, the client is at risk for
hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia.
C. fever and chills.
Rationale: Fever and chills are manifestations of infection.
D. hypertension and crackles.
Rationale: Hypertension and crackles are manifestations of fluid overload, which is a
complication of TPN related to the fluid infusion rate.
4. A nurse on a pediatric unit is caring for a client who has a brain tumor. To help ensure the client’s safety,
which of the following actions should the nurse take?
A. Do not allow the child to ambulate in his room alone.
Rationale: Allowing the child to ambulate in his room alone does not increase the child’s safety
risk appreciably and has other benefits for the client.
B. Limit contact with other pediatric clients.
Rationale: Contact with other clients on the pediatric unit does not increase the child’s safety
risk appreciably and has other benefits for the client.
C. Initiate seizure precautions for the child.
Rationale: A client who has a brain tumor is at risk for seizures. It is imperative for the nurse to
implement seizure precautions for this client.
D. Have the child use a wheelchair for all out-of-bed activities.
Rationale: Having the child use a wheelchair is unnecessary and does not ensure the child’s
safety.
5. A client has right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions
should the nurse implement to prevent foot-drop?
, GI/Neuro Med Surg
Detailed Answer Key 100%
A. Place sandbags to maintain right plantar flexion.
Rationale: Sandbags can be used to support the foot in a dorsiflexion position. Plantar flexion
positions the foot with toes down, contributing to foot-drop.
B. Position soft pillows against the bottom of the feet.
Rationale: Placing firm pillows against the bottom of the feet will help to maintain a position of
dorsiflexion. Soft pillows will not provide a firm enough surface to prevent foot-drop.
C. Support the right foot in dorsiflexion with a footboard.
Rationale: The foot should be positioned in a dorsiflexion position using a firm surface, such as a
footboard. When foot-drop occurs, the foot is permanently fixed in plantar flexion
with toes pointing downward.
D. Splint the right lower extremity to maintain proper alignment.
Rationale: The leg should not be splinted. Support the foot in dorsiflexion with ankle-foot
orthotic or high-top tennis shoes.
6. A nurse is collaborating on care for a client following a cerebrovascular accident (CVA). Which of the following
should be addressed by an occupational therapist?
A. Using assistive devices
Rationale: As a member of the interdisciplinary team, the physical therapist would help the
client achieve gross mobility skills, such as facilitating ambulation and teaching the
client to use a walker or crutches. The physical therapist also may assist with ADLs,
such as transferring from bed to chair, ambulating, and toileting.
B. Completing self-care
Rationale: As a member of the interdisciplinary team, the occupational therapist works with the
client to develop fine motor skills and coordination, such as improving hand strength
and hand movements. The occupational therapist focuses on self-management of
ADLs, such as skills needed for eating, hygiene, and dressing. Occupational
therapists also can teach clients to perform other independent living skills, such as
cooking and shopping.
C. Thickening clear liquids
Rationale: As a member of the interdisciplinary team, the speech-language pathologist would
provide screening for clients who have dysphagia. The speech-language pathologist
evaluates and retrains clients who have speech, language, or swallowing problems.
If the client has a problem with swallowing, appropriate food and feeding techniques
would be recommended. Thickening clear liquids would reduce the risk of aspiration
Detailed Answer Key 100%
1.
, GI/Neuro Med Surg
Detailed Answer Key 100%
A. Flush the peripheral IV line with 0.9% sodium chloride to await further instructions from the physician.
Rationale: This is not the appropriate intervention for the nurse to take.
B. Change the tubing and filter on the TPN.
Rationale: Changing the tubing and filter is not the appropriate intervention for the nurse to
take.
C. Hang an infusion 10% dextrose.
Rationale: The sudden withdrawal from the TPN (hypertonic solution) can cause the client to be
experiencing hypoglycemia. Administering an infusion of 10% dextrose will adjust
the client’s blood glucose levels.
D. Notify the pharmacy.
Rationale: This is not the appropriate intervention for the nurse to take.
2. A nurse is caring for a child with a suspected diagnosis of bacterial meningitis. Which of the following is the
priority action by the nurse?
A. Administer antibiotics when available.
Rationale: The priority nursing action is to administer antibiotics when available. Bacterial
meningitis is an acute inflammation of the meninges and the CNS, and antibiotic
therapy has a marked effect on the course and prognosis of the illness.
B. Reduce environmental stimuli.
Rationale: Reducing environmental stimuli is an appropriate action by the nurse; however, this
is not the priority.
C. Document intake and output.
Rationale: Documenting intake and output is an appropriate action by the nurse; however, this
is not the priority.
D. Maintain seizure precautions.
Rationale: Maintaining seizure precautions is an appropriate action by the nurse; however, this is
not the priority.
3. A nurse is caring for a client whose total parenteral nutrition (TPN) was stopped for an hour by mistake. After
restarting the infusion pump, the nurse should watch the client carefully for the development of
, GI/Neuro Med Surg
Detailed Answer Key 100%
A. excessive thirst and urination.
Rationale: Excessive thirst and urination are manifestations of hyperglycemia, which is a
complication of TPN related to the high proportion of glucose in the infusion.
Hyperglycemia would not occur secondary to an interruption in the TPN
administration.
B. shakiness and diaphoresis.
Rationale: When a sudden interruption in the infusion of TPN occurs, the client is at risk for
hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia.
C. fever and chills.
Rationale: Fever and chills are manifestations of infection.
D. hypertension and crackles.
Rationale: Hypertension and crackles are manifestations of fluid overload, which is a
complication of TPN related to the fluid infusion rate.
4. A nurse on a pediatric unit is caring for a client who has a brain tumor. To help ensure the client’s safety,
which of the following actions should the nurse take?
A. Do not allow the child to ambulate in his room alone.
Rationale: Allowing the child to ambulate in his room alone does not increase the child’s safety
risk appreciably and has other benefits for the client.
B. Limit contact with other pediatric clients.
Rationale: Contact with other clients on the pediatric unit does not increase the child’s safety
risk appreciably and has other benefits for the client.
C. Initiate seizure precautions for the child.
Rationale: A client who has a brain tumor is at risk for seizures. It is imperative for the nurse to
implement seizure precautions for this client.
D. Have the child use a wheelchair for all out-of-bed activities.
Rationale: Having the child use a wheelchair is unnecessary and does not ensure the child’s
safety.
5. A client has right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions
should the nurse implement to prevent foot-drop?
, GI/Neuro Med Surg
Detailed Answer Key 100%
A. Place sandbags to maintain right plantar flexion.
Rationale: Sandbags can be used to support the foot in a dorsiflexion position. Plantar flexion
positions the foot with toes down, contributing to foot-drop.
B. Position soft pillows against the bottom of the feet.
Rationale: Placing firm pillows against the bottom of the feet will help to maintain a position of
dorsiflexion. Soft pillows will not provide a firm enough surface to prevent foot-drop.
C. Support the right foot in dorsiflexion with a footboard.
Rationale: The foot should be positioned in a dorsiflexion position using a firm surface, such as a
footboard. When foot-drop occurs, the foot is permanently fixed in plantar flexion
with toes pointing downward.
D. Splint the right lower extremity to maintain proper alignment.
Rationale: The leg should not be splinted. Support the foot in dorsiflexion with ankle-foot
orthotic or high-top tennis shoes.
6. A nurse is collaborating on care for a client following a cerebrovascular accident (CVA). Which of the following
should be addressed by an occupational therapist?
A. Using assistive devices
Rationale: As a member of the interdisciplinary team, the physical therapist would help the
client achieve gross mobility skills, such as facilitating ambulation and teaching the
client to use a walker or crutches. The physical therapist also may assist with ADLs,
such as transferring from bed to chair, ambulating, and toileting.
B. Completing self-care
Rationale: As a member of the interdisciplinary team, the occupational therapist works with the
client to develop fine motor skills and coordination, such as improving hand strength
and hand movements. The occupational therapist focuses on self-management of
ADLs, such as skills needed for eating, hygiene, and dressing. Occupational
therapists also can teach clients to perform other independent living skills, such as
cooking and shopping.
C. Thickening clear liquids
Rationale: As a member of the interdisciplinary team, the speech-language pathologist would
provide screening for clients who have dysphagia. The speech-language pathologist
evaluates and retrains clients who have speech, language, or swallowing problems.
If the client has a problem with swallowing, appropriate food and feeding techniques
would be recommended. Thickening clear liquids would reduce the risk of aspiration
