1.
Which of the following is not an education tool required prior to an endoscopic procedure?
Correct Answer
C. How long the procedure will take
Explanation
The length of endoscopies varies and it is also the least important education tool for the patient.
2.
All are complications of endoscopic procedures EXCEPT?
Correct Answer
D. Paracentesis
Explanation
Paracentesis is a diagnostic tool, not a complication.
3.
Which patient is most susceptible for acquiring secondary stomatitis?
Correct Answer
A. An AIDs patient suffering from pneumonia
Explanation
Secondary stomatitis results from infection by oppourtunistic viruses or bacteria. In this case, the patient with AIDs is, likely, the most immunosuppressed.
4.
When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as:
Correct Answer
A. A canker sore of the oral soft tissues
Explanation
Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks.
5.
Which item is unneccessary when examing the oral cavity of a patient with candidiasis?
Correct Answer
C. Gown
Explanation
When examining the oral cavity of a patient with candidiasis, a gown is unnecessary. Candidiasis is a fungal infection that affects the mouth, and it does not pose a risk of transmission through contact with clothing. However, gloves are essential to prevent the spread of infection, as candidiasis can be contagious. A penlight is necessary to provide proper illumination for the examination, and a tongue blade is used to hold the patient's tongue down for better visibility.
6.
Which of the following is an inappropriate nursing diagnosis for a client with malignant tumors of the oral cavity?
Correct Answer
B. Defieceint fluid volume
Explanation
The nursing diagnosis of Deficient fluid volume is inappropriate for a client with malignant tumors of the oral cavity because it does not directly relate to the condition. Malignant tumors of the oral cavity primarily affect the oral mucous membranes and can cause impaired oral mucous membranes, acute pain, and risk for ineffective airway clearance. However, deficient fluid volume is not directly associated with this condition and may not be a priority concern for the client.
7.
The graduate nurse and her preceptor are establishing priorities for their morning assessments. Which client should they assess first?
Correct Answer
A. The newly admitted client with acute abdominal pain
Explanation
The graduate nurse and her preceptor should assess the new admission with acute abdominal pain first because he just arrived on the floor and might be unstable. Next, they should change the abdominal dressing for the postoperative client or measure feeding tube residual in the client with continuous tube feedings.
8.
Gastroesophageal reflux disease is the abnormal _____ of the lower esophageal sphincter.
Correct Answer
A. Relaxation
Explanation
The correct answer is relaxation because gastroesophageal reflux disease is caused by the abnormal relaxation of the lower esophageal sphincter. This relaxation allows stomach acid and partially digested food to flow back into the esophagus, causing symptoms such as heartburn and acid reflux.
9.
Which foods should a patient with GERD stay away from (multiple answers)?
Correct Answer(s)
A. Burger King double cheeseburger
C. Candy canes
D. Chocolate espresso
Explanation
Patients with GERD should avoid peppermint, alcohol, caffeinated beverages, chocolate, tea, and coffee
10.
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?
Correct Answer
B. Avoid coffee and alcoholic beverages
Explanation
To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol.
11.
Which of the following is not a common symptom of GERD?
Correct Answer
D. Hyposalivation
Explanation
Hypersalivation, aka water brash, occurs in response to reflux, not hyposalivation.
12.
Which drug class isn't used to treat GERD?
Correct Answer
C. Beta blockers
Explanation
Beta blockers are not used to treat GERD because they primarily work by blocking the effects of adrenaline on the heart and blood vessels, reducing heart rate and blood pressure. They do not directly affect the production of stomach acid or the function of the esophagus, which are the main targets for treating GERD. Antacids, histamine receptor antagonists, and proton pump inhibitors, on the other hand, are commonly used to treat GERD as they help reduce stomach acid production or neutralize existing acid in the stomach.
13.
Which of the following has the least important role in terms of peptic ulcer formation?
Correct Answer
D. Hypertension
Explanation
Hypertension has the least important role in terms of peptic ulcer formation. Peptic ulcers are primarily caused by the presence of Helicobacter pylori bacteria, acid secretion in the stomach, and the use of non-steroidal anti-inflammatory drugs (NSAIDs). Hypertension, or high blood pressure, does not directly contribute to the development of peptic ulcers. While it may indirectly affect the healing process of ulcers by increasing the risk of complications and delaying recovery, it is not a significant factor in their formation.
14.
A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this client's stools to be:
Correct Answer
C. Black and tarry
Explanation
Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes on the blood.
15.
Which diagnostic test would be used first to evaluate a client with upper GI bleeding?
Correct Answer
C. Hemoglobin (Hb) levels and hematocrit (HCT
Explanation
Hemoglobin and hematocrit are typically performed first in clients with upper GI bleeding to evaluate the extent of blood loss. Endoscopy is then performed to directly visualize the upper GI tract and locate the source of bleeding.
16.
Which of the following isn't a complication of peptic ulcer disease?
Correct Answer
D. Pain
Explanation
Pain is a symptom of PUD, not a complication
17.
Which of the following are goals of drug therapy in the treatment of PUD (multiple answers)?
Correct Answer(s)
A. Provide pain relief
B. Prevent recurrence
C. Heal ulcerations
D. Eradicate H. pylori infection
Explanation
All are goals
18.
An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse should be concerned most with the potential for:
Correct Answer
C. Aspiration
Explanation
Of the choices listed, aspiration is the most serious potential complication of tube feedings. Dehydration — not fluid volume excess — is a concern because of decreased free water intake.
19.
A client who underwent abdominal surgery who has a nasogastric (NG) tube in place begins to complain of abdominal pain that he describes as "feeling full and uncomfortable." Which assessment should the nurse perform first?
Correct Answer
C. Assess patency of the NG tube
Explanation
When an NG tube is no longer patent, stomach contents collect in the stomach giving the client a sensation of fullness
20.
To verify the placement of a gastric feeding tube, the nurse should perform at least two tests. One test requires instilling air into the tube with a syringe and listening with a stethoscope for air passing into the stomach. Which is another test method?
Correct Answer
A. Aspiration of gastric contents and testing for a pH less than 6
Explanation
Aspiration of gastric secretions with a pH less than 6 indicates placement in the stomach.
21.
The nurse is performing an assessment on a client who has developed a paralytic ileus. The client's bowel sounds will be:
Correct Answer
B. Hypoactive
Explanation
If a paralytic ileus occurs, bowel sounds will be hypoactive or absent. Hyperactive bowel sounds may signify hunger, intestinal obstruction, or diarrhea.
22.
Which of the following would you NOT teach a patient recently diagnosed with irritable bowel syndrome?
Correct Answer
B. Decreasing fiber intake
Explanation
Fiber supplements are usually recommended
23.
Which of the following are appropriate nursing diagnoses for patients with colorectal cancer (multiple answers)?
Correct Answer(s)
B. Disturbed body image
C. Deficient fluid volume
D. Acute/ chronic pain
Explanation
The appropriate nursing diagnoses for patients with colorectal cancer include disturbed body image, deficient fluid volume, and acute/chronic pain. Colorectal cancer and its treatments can have a significant impact on a patient's body image, causing distress and a need for emotional support. Additionally, the disease and its treatments can lead to fluid imbalances, requiring careful monitoring and intervention to maintain adequate hydration. Finally, patients with colorectal cancer often experience pain, both acute and chronic, which requires assessment and management to improve their comfort and quality of life.
24.
Which of the following is not a complication of colorectal cancer?
Correct Answer
C. Seizures
Explanation
Seizures are not a complication of colorectal cancer. Colorectal cancer is a type of cancer that affects the colon or rectum, and it can lead to various complications such as metastases (spreading of cancer to other parts of the body), bleeding, and infection. However, seizures are not directly associated with colorectal cancer. Seizures are more commonly seen in conditions such as epilepsy, brain tumors, or certain neurological disorders.
25.
Which foods should patients with colorectal cancer avoid (multiple answers)?
Correct Answer(s)
A. Fish and chips
C. Beef and cabbage
D. Concentrated sweets
Explanation
Patients should avoid red meat, animal fat, fatty foods, fried meats/ fish, and concentrated sweets.
26.
A client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to:
Correct Answer
B. Place saline-soaked sterile dressings on the wound
Explanation
The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the client's vital signs.
27.
For a client who must undergo colon surgery, the physician orders preoperative cleansing enemas and neomycin sulfate (Mycifradin). The rationale for neomycin use in this client is to:
Correct Answer
B. Decrease the intestinal bacteria count
Explanation
The antibiotic neomycin sulfate (Mycifradin) is prescribed to decrease the bacterial count and reduce the risk of fecal contamination during surgery.
28.
Which is the least likely to cause constipation?
Correct Answer
A. High fiber intake
Explanation
High fiber intake is least likely to cause constipation because fiber adds bulk to the stool and helps to move it through the digestive system. It promotes regular bowel movements and prevents constipation. On the other hand, being over 75, overuse of laxatives, and immobilization can all contribute to constipation. Being older can lead to slower digestion and decreased muscle tone in the intestines, while overuse of laxatives can cause the body to become reliant on them for bowel movements. Immobilization, such as being bedridden or sedentary, can also slow down digestion and lead to constipation.
29.
A 72-year-old client seeks help for chronic constipation. This is a common problem for elderly clients due to several factors related to aging. Which is one such factor?
Correct Answer
B. Decreased abdominal strength
Explanation
Decreased abdominal strength, muscle tone of the intestinal wall, and motility all contribute to chronic constipation in the elderly.
30.
Which medication should the nurse expect to administer to a client with constipation?
Correct Answer
D. Docusate sodium (Colace)
Explanation
Docusate sodium, a laxative, is used to treat constipation. It softens the stool by stimulating the secretion of intestinal fluid into the stool.
31.
Which outcome indicates effective client teaching to prevent constipation?
Correct Answer
D. The client reports engaging in a regular exercise regimen
Explanation
A regular exercise regimen promotes peristalsis and contributes to regular bowel elimination patterns. A low-fiber diet, a sedentary lifestyle, and limited water intake would predispose the client to constipation.
32.
In regards to appendicitis, the location of pain in the lower, right abdominal quadrant is called:
Correct Answer
B. Mc Burney's point
Explanation
Mc Burney's point is the correct answer because it refers to the location of pain in the lower, right abdominal quadrant in cases of appendicitis. This point is located between the umbilicus and the anterior superior iliac spine, approximately one-third of the distance. It is a significant clinical finding used to diagnose appendicitis and is named after the American surgeon Charles McBurney.
33.
When preparing a client, age 50, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?
Correct Answer
B. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
Explanation
A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up
34.
Which of the following assessment findings suggests early appendicitis?
Correct Answer
B. Periumbilical pain
Explanation
Periumbilical pain is the initial symptom, followed by nausea and vomiting.
35.
Which of the following is not an appropriate nursing diagnosis related to appendicitis?
Correct Answer
A. Disturbed body image
Explanation
Disturbed body image is not an appropriate nursing diagnosis related to appendicitis because it is not directly associated with the physical condition of the appendix. Appendicitis primarily involves symptoms such as acute pain, risk for infection due to rupture, and potential lack of knowledge about the condition and its management. Disturbed body image is more commonly associated with conditions that affect one's physical appearance or bodily functions, rather than a specific organ inflammation like appendicitis.
36.
While preparing a client for cholecystectomy, the nurse explains that incentive spirometry will be used after surgery primarily to:
Correct Answer
A. Increase respiratory effectiveness.
Explanation
The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis.
37.
Which task can the nurse delegate to a nursing assistant?
Correct Answer
B. Assisting a client who had surgery three days ago walk down the hallway
Explanation
Because the client had surgery three days ago, the nurse can safely delegate the task of helping the client walk down the hallway.
38.
How are ulcerative colitis and Chron's disease definitively diagnosed?
Correct Answer
D. Colonoscopy
Explanation
Colonoscopy is the correct answer because it is the most definitive diagnostic test for both ulcerative colitis and Crohn's disease. It allows direct visualization of the colon and rectum, enabling the detection of characteristic signs such as inflammation, ulcers, and strictures. EGD (esophagogastroduodenoscopy) is used to examine the upper gastrointestinal tract and is not specific for these conditions. CBC (complete blood count) can show signs of inflammation but is not specific enough for a definitive diagnosis. Stool samples can help identify infections or other causes of gastrointestinal symptoms but are not definitive for ulcerative colitis or Crohn's disease.
39.
What is toxic megacolon (mulitple answers)?
Correct Answer(s)
A. A complication of ulcerative colitis
B. Dilation and paralysis of the colon
Explanation
Toxic megacolon is a condition characterized by the dilation and paralysis of the colon, which is a complication of ulcerative colitis. It is not a fistula or a risk factor for pancreatitis. Ulcerative colitis causes inflammation and ulcers in the colon, and in severe cases, it can lead to the colon becoming enlarged and losing its ability to contract and move stool. This can result in life-threatening complications such as perforation or rupture of the colon.
40.
A 28-year-old client is admitted with inflammatory bowel syndrome (Crohn's disease). Which therapies should the nurse expect to be part of the care plan? Check all that apply
Correct Answer(s)
D. Corticosteroid therapy
E. Antidiarrheal medications
Explanation
Corticosteroids, such as prednisone, reduce the signs and symptoms of diarrhea, pain, and bleeding by decreasing inflammation. Antidiarrheals, such as diphenoxylate (Lomotil), combat diarrhea by decreasing peristalsis.
41.
A client is diagnosed with Crohn's disease after undergoing two weeks of testing. The client's boss calls the medical-surgical floor requesting to speak with the nurse manager. He expresses concern over the client and explains that he must know the client's diagnosis for insurance purposes. Which response by the nurse is best?
Correct Answer
B. "I appreciate your concern, but I can't give out any information."
Explanation
The nurse may not release any confidential information to unauthorized individuals, such as the client's boss. Options 1, 3, and 4 breech client confidentiality.
42.
A client with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse position the client for this test initially?
Correct Answer
B. Lying on the left side with knees bent
Explanation
For a colonoscopy, the nurse initially should position the client on the left side with knees bent to allow proper visualization of the large intestine.
43.
A client has a newly created colostomy. After participating in counseling with the nurse and receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which behavior suggests that the client is beginning to accept the change in body image?
Correct Answer
D. The client touches the altered body part
Explanation
By touching the altered body part, the client recognizes the body change and establishes that the change is real. Closing the eyes, not looking at the abdomen when the colostomy is exposed, or avoiding talking about the surgery reflects denial.