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.
Which patient is most susceptible to acquiring secondary stomatitis?
Correct Answer
A. An AIDS patient suffering from pneumonia
Explanation
Secondary stomatitis results from infection by opportunistic viruses or bacteria. In this case, the patient with AIDS is, most likely, immunosuppressed.
3.
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.
4.
Which item is unnecessary when examining 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 primarily affects the mucous membranes, such as the mouth. It does not pose a risk of bodily fluid exposure, so there is no need for a gown. However, gloves are necessary to prevent the spread of infection, a penlight is useful for proper visualization, and a tongue blade can help to examine the tongue and oral tissues.
5.
Which of the following is an inappropriate nursing diagnosis for a client with malignant tumors of the oral cavity?
Correct Answer
B. Deficient fluid volume
Explanation
The nursing diagnosis "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 tissues in the mouth, not the fluid volume in the body. Therefore, this diagnosis would not be relevant or helpful in addressing the client's needs.
6.
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 the feeding tube residual in the client with continuous tube feedings.
7.
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.
8.
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.
9.
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.
10.
Which drug class does not treat GERD?
Correct Answer
C. Beta blockers
Explanation
Beta-blockers do not treat GERD (gastroesophageal reflux disease) because they primarily work to block the effects of adrenaline on the heart and blood vessels. They are commonly used to treat conditions such as high blood pressure and heart disease, but they do not have any direct effect on reducing stomach acid production or relieving the symptoms of GERD. Antacids, histamine receptor antagonists, and proton pump inhibitors are all commonly used to treat GERD by reducing stomach acid production or neutralizing the acid already present in the stomach.
11.
Which of the following has the least important role in terms of peptic ulcer formation?
Correct Answer
D. Hypertension
Explanation
Hypertension, or high blood pressure, has the least important role in terms of peptic ulcer formation compared to the other options. Peptic ulcers are mainly caused by factors such as excessive acid production, the use of nonsteroidal anti-inflammatory drugs (NSAIDs), and the presence of Helicobacter pylori bacteria. Hypertension is not directly linked to peptic ulcers, although it may contribute to the overall health of the gastrointestinal system. However, it is not a primary factor in the formation of peptic ulcers.
12.
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.
13.
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.
14.
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
15.
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
16.
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.
17.
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
18.
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.
19.
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
20.
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 can have a significant impact on a patient's body image, causing distress and a negative self-perception. Deficient fluid volume may occur due to factors such as vomiting, diarrhea, or inadequate intake. Acute or chronic pain is common in colorectal cancer patients due to the disease itself or as a result of treatments such as surgery or radiation. These nursing diagnoses address important aspects of care for patients with colorectal cancer.
21.
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.
22.
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.
23.
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 regulate bowel movements. It promotes regularity and prevents constipation by softening the stool and allowing it to pass through the digestive system more easily. On the other hand, being over 75, overuse of laxatives, and immobilization can all contribute to constipation.
24.
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.
25.
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.
26.
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 for the location of pain in the lower, right abdominal quadrant in relation to appendicitis. This point is located approximately two-thirds of the distance between the umbilicus and the anterior superior iliac spine. It is a key landmark used by healthcare professionals to identify the potential presence of appendicitis.
27.
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
28.
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.
29.
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 refers to a person's perception of their own physical appearance, which is not directly affected by appendicitis. Appendicitis is characterized by symptoms such as acute pain, risk for infection due to rupture, and a potential lack of knowledge about the condition. Therefore, disturbed body image does not align with the specific physiological and psychological effects of appendicitis.
30.
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.
31.
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.
32.
How are ulcerative colitis and Chron's disease definitively diagnosed?
Correct Answer
D. Colonoscopy
Explanation
Ulcerative colitis and Crohn's disease are both inflammatory bowel diseases that can have similar symptoms. To definitively diagnose these conditions, a colonoscopy is often performed. During a colonoscopy, a long, flexible tube with a camera is inserted into the colon to examine the lining and detect any abnormalities or inflammation. This procedure allows for direct visualization and biopsy of the affected areas, providing a more accurate diagnosis compared to other tests such as EGD (esophagogastroduodenoscopy), CBC (complete blood count), or stool sample analysis. Therefore, colonoscopy is the preferred method for definitive diagnosis of ulcerative colitis and Crohn's disease.
33.
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 that occurs as a complication of ulcerative colitis. It is characterized by the dilation and paralysis of the colon, leading to a significant enlargement of the colon. This condition can be life-threatening and requires immediate medical intervention. It is not a fistula, which is an abnormal connection between two organs, and it is not a risk factor for pancreatitis, which is inflammation of the pancreas.
34.
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.
35.
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.
36.
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.
37.
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.