Exam Review
ATI Med Surg Exam 6
Total Questions : 49
Showing 49 questions, Sign in for moreA patient's new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patient's care plan accordingly. What intervention should the nurse include in the patient's plan of care?
Explanation
Choice A reason:
Keeping the patient in a low Fowler's position may not directly address the management of the NG tube and dysphagia.
Choice B reason:
Connecting the tube to continuous wall suction when not in use is not a standard intervention for NG tube feeding.
Choice C reason:
This statement is correct. Confirming placement of the tube prior to each medication
administration is crucial to ensure safe and effective delivery of medications and nutrition.
Choice D reason:
Having the patient sip cool water, while a general recommendation for some patients, does not specifically address the care of the NG tube.
A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?
Explanation
Choice A reason:
This statement is correct. The laxative helps eliminate the barium contrast material from the body after a barium swallow procedure.
Choice B reason:
Simply stating that it is protocol does not provide the client with a clear understanding of the rationale for the laxative.
Choice C reason:
This statement does not accurately explain the purpose of the laxative after a barium swallow.
Choice D reason:
The laxative's primary purpose in this context is to aid in the elimination of barium, not to prevent magnesium absorption.
A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)
Explanation
Choice A reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice B reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice C reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice D reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?
Explanation
Choice A reason:
Asterixis is a characteristic sign of hepatic encephalopathy, characterized by a flapping tremor of the hands. It is associated with liver dysfunction and is indicative of impaired ammonia metabolism in the brain.
Choice B reason:
Fetor hepaticus refers to a musty, sweet odor of the breath that is associated with severe liver disease. It is not related to the flapping tremor observed in this case.
Choice C reason:
Palmar erythema is a reddening of the palms and is associated with various conditions, including liver disease. However, it is not the sign described in the scenario.
Choice D reason:
Constructional apraxia is a neurological deficit characterized by difficulty in copying or constructing simple drawings or designs. It is not related to the flapping tremor seen in hepatic encephalopathy.
A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client s understanding of the teaching? (Select all that apply)
Explanation
Choice A reason:
This statement demonstrates the client's understanding of the need to reduce intake of caffeine and spicy foods, which can exacerbate symptoms of hiatal hernia.
Choice B reason:
This statement shows the client's awareness of the importance of maintaining a healthy weight, which can help manage hiatal hernia symptoms.
Choice C reason:
This statement is not related to the dietary recommendations for hiatal hernia.
Choice D reason:
Limiting fluid intake can help prevent excessive stomach distension, which may aggravate hiatal hernia symptoms.
The nurse is completing the intake and output record for a preschool-age client admitted for fluid volume deficit.
The client has had the following intake and output during the shift:
Intake:
- 4 oz of Pedialyte
- 1/2 of an 8-oz cup of clear orange Jell-O
- 2 graham crackers
- 200 mL of D 5-1/2 sodium chloride IV
Output:
- 345 mL of urine
- 50 mL of loose stool
The nurse documents the client's intake as milliliters. How much liquid intake did the client have in Milliliters?
Round the answer to the nearest whole number.
Explanation
- To convert ounces to milliliters, multiply by 29.57
- 4 oz of Pedialyte = 118.28 mL
- 1/2 of an 8-oz cup of clear orange Jell-O = 118.28 mL
- 2 graham crackers = no liquid intake
- 200 mL of D 5-1/2 sodium chloride IV = 200 mL
- Total intake = 118.28 + 118.28 + 200 = 436.56 mL
- Round to the nearest whole number = 437 mL
- The nurse documents the client's intake as 437 mL
A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis.
Which of the following instructions should the nurse include in the teaching plan?
Explanation
Choice A reason:
While foods high in fiber are generally healthy, they may not specifically address the issue of biliary colic related to cholecystitis.
Choice B reason:
Foods high in starch and proteins are important for overall nutrition, but they may not directly impact biliary colic.
Choice C reason:
This statement is correct. Avoiding foods high in fat is crucial for managing biliary colic in clients with chronic cholecystitis.
Choice D reason:
Avoiding foods high in sodium is important for cardiovascular health, but it is not the primary dietary modification for cholecystitis.
A patient's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next?
Explanation
Choice A reason:
Removing the NG tube without further attempts to unclog it may not be necessary and could be an unnecessary intervention.
Choice B reason:
This statement is correct. Attempting to unclog the NG tube with warm water and an in-and-out motion is an appropriate next step.
Choice C reason:
Flicking the tube with the fingers may not be effective in dislodging the clog, and it could potentially cause harm to the patient.
Choice D reason:
Withdrawing the tube 3 to 5 cm may not effectively address the clog and could potentially lead to complications.
A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?
Explanation
Choice A reason:
While assessing for signs of infection is important, ensuring a patent airway takes precedence immediately following surgery.
Choice B reason:
This statement is correct. Assessing for a patent airway is the top priority in postoperative care to ensure the patient can breathe effectively.
Choice C reason:
Assessing the ability to clear oral secretions is important, but it is secondary to ensuring a patent airway.
Choice D reason:
Assessing the ability to communicate is important, but it is not the immediate priority after surgical resection for oropharyngeal cancer.
A nurse is caring for a client who has acute pancreatitis.
Nurses Notes
Diagnostic Results
- Amylase 450 units/L (20 to 220 units/L)
- Lipase 280 units/L (0 to 160 units/L)
- WBC count 12.500/mm3 (5,000 to 10,000/mm3) RBC count 3.9 (4.2 to 5.4)
- Hemoglobin 8 g/dL (12 g/dL to 16 g/dL for female: 14 to 18 g/dL for male)
- Hematocrit 24% (37% to 47% for female: 42% to 52% for male) Platelet count 160,000/mm3 (150,000 to 400,000/mm3)
- Blood glucose level 250 mg/dL (less than 200 mg/dL)
Complete the following sentence.
When prioritizing client needs, the nurse should first address the _______________ followed by ______________________
Explanation
-blood glucose level of 250 mg/dL, which indicates hyperglycemia and can worsen the inflammation of the pancreas
- hemoglobin level of 8 g/dL and hematocrit of 24%, which indicate anemia and can impair oxygen delivery to the tissues
A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?
Explanation
Choice A reason:
Increased blood pressure is not typically associated with gastrointestinal perforation; hypotension may be more indicative.
Choice B reason:
Hyperactive bowel sounds may be present in various gastrointestinal conditions, but they are not specific to perforation.
Choice C reason:
Bradycardia is not a typical sign of gastrointestinal perforation; tachycardia may be more indicative of this condition.
Choice D reason:
This statement is correct. Sudden abdominal pain is a key indication of gastrointestinal perforation, and it should be monitored closely.
A patient's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease, rather than ulcerative colitis, as the cause of the patient's signs and symptoms?
Explanation
Choice A reason:
Severe diarrhea can be a symptom of both Crohn's disease and ulcerative colitis and does not specifically indicate one over the other.
Choice B reason:
Involvement of the rectal mucosa is more indicative of ulcerative colitis rather than Crohn's disease, as Crohn's disease can affect any part of the digestive tract.
Choice C reason:
The presence or absence of blood in stool is not a definitive indicator of either Crohn's disease or ulcerative colitis, as both conditions can involve bleeding.
Choice D reason:
This statement is correct. A pattern of distinct exacerbations and remissions is more characteristic of Crohn's disease, whereas ulcerative colitis often presents with continuous, chronic symptoms.
A nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurse should describe which of the following as the most common sign of possible colon cancer?
Explanation
Choice A reason:
Abdominal bloating and flank pain may be associated with various gastrointestinal conditions, but they are not the most common signs of possible colon cancer.
Choice B reason:
This statement is correct. A change in bowel habits, such as persistent constipation, diarrhea, or a change in stool consistency, is the most common sign of possible colon cancer.
Choice C reason:
Unexplained weight gain is not typically associated with colon cancer; unexplained weight loss may be more indicative.
Choice D reason:
The development of new hemorrhoids is not a common sign of possible colon cancer.
A nurse is caring for an older adult who has been experiencing severe Clostridium difficile- related diarrhea. When reviewing the patient's most recent laboratory tests, the nurse should prioritize which of the following?
Explanation
Choice A reason:
Monitoring creatinine levels is important, but it may not be the top priority in this situation.
Choice B reason:
This statement is correct. Given the severe diarrhea associated with Clostridium difficile infection, monitoring potassium levels is crucial to identify and address potential electrolyte imbalances, which can lead to serious complications.
Choice C reason:
Monitoring white blood cell levels is important in the context of infection, but potassium levels are more directly relevant to managing severe diarrhea associated with Clostridium difficile.
Choice D reason:
Hemoglobin levels are important for assessing anemia, but in this context, monitoring potassium levels takes precedence due to the potential for electrolyte imbalances from severe diarrhea.
A child is to receive dexamethasone (Decadron) intravenously at the ordered dosage of 7.6 mg. The drug concentration in the vial is 4 mg/mL. The nurse should administer how many ml?
Explanation
Calculation:
Dosage ordered = 7.6 mg
Drug concentration = 4 mg/mL
7.6 mg / 4 mg/mL = 1.9 mL
A patient with a diagnosis of peptic ulcer disease has just been prescribed omeprazole (Prilosec). How should the nurse best describe this medication's therapeutic action?
Explanation
Choice A reason:
Omeprazole is a proton pump inhibitor that reduces acid secretion in the stomach, but it doesn't directly make the stomach lining more resistant to damage.
Choice B reason:
While omeprazole can alleviate pain associated with peptic ulcer disease, its primary action is related to acid reduction.
Choice C reason:
Omeprazole primarily reduces acid secretion and doesn't directly facilitate the repair of the stomach lining.
Choice D reason:
This statement is correct. Omeprazole belongs to a class of medications known as proton pump inhibitors, which work by reducing the amount of acid produced in the stomach. This helps to alleviate symptoms and promote healing in conditions like peptic ulcer disease.
A patient seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education?
Explanation
Choice A reason:
Drinking beverages after a meal, rather than with it, can help minimize reflux symptoms in individuals with hiatal hernias.
Choice B reason:
Dry foods are not specifically contraindicated for individuals with hiatal hernias, and this statement does not directly address reflux symptoms.
Choice C reason:
Eating smaller, more frequent meals is a helpful dietary modification for individuals with hiatal hernias to reduce the likelihood of reflux.
Choice D reason:
While antacids can provide relief for acid reflux symptoms, this statement doesn't address the timing of meals and beverages, which is more relevant to hiatal hernia management.
A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?
Explanation
Choice A reason:
Gallstones are a common cause of acute pancreatitis, as they can obstruct the pancreatic duct and lead to inflammation.
Choice B reason:
While diabetes mellitus can be a risk factor for pancreatitis, it is not specific to acute pancreatitis.
Choice C reason:
Chronic obstructive pulmonary disease (COPD) is not directly related to acute pancreatitis.
Choice D reason:
Hypolipidemia (low blood lipid levels) is not a common risk factor for acute pancreatitis.
A nurse is performing an abdominal assessment of an older adult patient. When collecting and analyzing data, the nurse should be cognizant of what age-related change in gastrointestinal structure and function?
Explanation
Choice A reason:
In older adults, gastric motility tends to decrease rather than increase.
Choice B reason:
The gag reflex may diminish with age, making older adults more prone to swallowing difficulties.
Choice C reason:
This statement is correct. With aging, there is a decrease in mucus secretion in the gastrointestinal tract, which can lead to dryness and potential discomfort.
Choice D reason:
Gastric pH tends to increase with age, which can affect the digestion and absorption of certain nutrients.
The physician has ordered Ceclor 0.5 g to be administered orally now. Below you will see the medication label for this medication.
How many milliliters of this medication will this patient receive?
Explanation
- Read the medication label carefully and check the dosage and concentration of Ceclor.
- The label shows that Ceclor is available as a suspension with 250 mg/5 mL.
- To calculate the volume of medication needed, use the formula: Volume = Dose / Concentration
- Plug in the values from the order and the label: Volume = 0.5 g / (250 mg/5 mL)
- Convert grams to milligrams by multiplying by 1000: Volume = 500 mg / (250 mg/5 mL)
- Simplify the fraction by dividing both numerator and denominator by 250: Volume = 2 / (1/5)
- Invert and multiply the fractions: Volume = 2 x 5
- Solve for volume: Volume = 10 mL
- The patient will receive 10 mL of Ceclor suspension.
An adult patient has been diagnosed with diverticular disease after ongoing challenges with constipation. The patient will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply.
Explanation
Choice A reason:
Anticholinergic medications: These are not a component of treatment for diverticular disease. Anticholinergic medications can reduce intestinal motility and cause dry mouth, constipation, and urinary retention, which can aggravate the diverticula and increase the risk of complications. The patient should avoid these medications unless prescribed by a doctor for another condition.
Choice B reason:
Increasing fiber intake is a common component of treatment for diverticular disease as it can help prevent constipation and reduce the risk of diverticulitis.
Choice C reason:
Reducing fat intake is also important in the treatment of diverticular disease, as a low-fat diet can help prevent further irritation of the colon.
Choice D reason:
This is not a component of treatment for diverticular disease. On the contrary, adequate fluid intake is essential to prevent dehydration and constipation, which can worsen the condition. The patient should drink at least eight glasses of water per day or more if they have a high-fiber diet.
Choice E reason:
These are not a component of treatment for diverticular disease. Enemas can irritate the colon and increase the pressure in the diverticula, which can lead to perforation or bleeding. The patient should avoid enemas unless instructed by a doctor for a specific reason.
A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?
Explanation
Choice A reason:
While diarrhea can be a symptom of peptic ulcer disease, it is not typically considered a priority over more severe symptoms.
Choice B reason:
Dyspepsia (indigestion) is a common symptom of peptic ulcer disease, but it is not the priority over more concerning symptoms.
Choice C reason:
Epigastric discomfort is a symptom of peptic ulcer disease, but it is not the priority over more severe symptoms like hematemesis.
Choice D reason:
Hematemesis (vomiting blood) is a serious and potentially life-threatening symptom of peptic ulcer disease. It is the top priority for assessment and intervention.
A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?
Explanation
Choice A reason:
This statement is correct. Providing information about the sedative is appropriate and reassuring for the client who is anxious about pain during the procedure.
Choice B reason:
While discussing the procedure after obtaining consent is important, addressing the client's anxiety at this stage is also crucial.
Choice C reason:
Although providing information about the importance of the procedure for the client's age group is relevant, it does not directly address the client's immediate concern about pain.
Choice D reason:
While it's true that many clients find the bowel preparation for a colonoscopy to be the most challenging aspect, this statement does not directly address the client's anxiety about pain during the procedure.
A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities.
Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy?
Explanation
Choice A reason:
This presentation of hepatic encephalopathy includes severe manifestations, such as profound confusion, difficulty in arousal, and the presence of rigidity, indicating advanced neurological impairment. This places the patient in Stage 4, which is the most severe stage of hepatic encephalopathy.
Choice B reason:
Stage 3 is characterized by severe symptoms, such as drowsiness, anxiety, seizures, severe personality changes, confused speech, and shaky hands.
Choice C reason:
Stage 1 is characterized by mild symptoms, such as difficulty thinking, personality changes, poor concentration, and problems with handwriting.
Choice D reason
Stage 2 is characterized moderate symptoms, such as confusion, forgetfulness, poor judgment, and a musty or sweet breath odor.
A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?
Explanation
Choice A reason:
A shiny, moist stoma is generally a healthy sign, indicating good blood supply and adequate hydration of the stoma tissue. It is not a cause for concern.
Choice B reason:
A rosebud-like stoma orifice is a normal appearance for some types of stomas. It indicates a healthy stoma with good blood supply. This finding is expected and does not warrant concern.
Choice C reason:
A purplish-colored stoma may indicate compromised blood supply to the stoma, which is a serious concern and should be reported to the provider promptly. It may suggest inadequate blood flow to the stoma, which could lead to tissue necrosis.
Choice D reason:
Stoma oozing red drainage may be normal immediately postoperatively. It can be due to some oozing from the surgical site, and if it's minimal and stops after a short while, it's generally not a cause for concern.
A patient has been diagnosed with acute pancreatitis. The nurse is addressing the diagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention is most likely to be ordered for this patient?
Explanation
Choice A reason:
IV hydromorphone is an opioid analgesic that can provide effective pain relief and can be titrated to the patient's needs. It's commonly used for severe pain associated with conditions like acute pancreatitis.
Choice B reason:
Oral naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that may be used for pain relief, but it's not the first-line treatment for acute pancreatitis. NSAIDs can potentially worsen the condition due to their effects on the gastrointestinal tract.
Choice C reason:
IM meperidine is an opioid analgesic that can be used for pain relief. However, in severe cases of acute pancreatitis, IV opioids are often preferred for more immediate and precise pain control.
Choice D reason:
Oral oxycodone is another opioid analgesic. However, in cases of acute pancreatitis, especially when pain is severe, IV opioids are often the preferred route of administration for more rapid and reliable pain relief.
A patient with a peptic ulcer disease has had metronidazole (Flagyl) added to his current medication regimen. What health education related to this medication should the nurse provide?
Explanation
Choice A reason:
Taking metronidazole with food can help reduce stomach upset. It is not typically recommended to take on an entirely empty stomach.
Choice B reason:
Metronidazole can cause drowsiness, but taking it at bedtime specifically for this reason is not a standard recommendation. It's more important to focus on avoiding alcohol.
Choice C reason:
Taking an extra dose without specific medical advice is not recommended. It's important to follow the prescribed dosing regimen.
Choice D reason:
Avoiding alcohol while taking metronidazole is crucial. The combination of metronidazole and alcohol can cause severe reactions, including nausea, vomiting, abdominal cramps, headache, and flushing. This interaction can occur for several days after discontinuing metronidazole, so it's essential to abstain from alcohol throughout the course of treatment.
A patient's new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patient's care plan accordingly. What intervention should the nurse
include in the patient's plan of care?
Explanation
Choice A reason:
Keeping the patient in a low Fowler's position may be helpful for some patients with dysphagia, but it is not a specific intervention related to NG tube care.
Choice B reason:
Connecting the tube to continuous wall suction when not in use is not a standard practice for NG tube care. Continuous suction can cause mucosal damage and discomfort for the patient.
Choice C reason:
Confirming the placement of the NG tube prior to each medication administration is a crucial safety measure. Incorrect placement can lead to serious complications.
Choice D reason:
Sipping cool water to stimulate saliva production may be beneficial for some patients with dysphagia, but it is not a specific intervention related to NG tube care. The focus should be on confirming the placement of the tube.
The nurse's comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?
Explanation
Choice A reason:
A painless sore with raised edges is a characteristic early sign of oral cancer. It may appear as a small, painless lump or sore in the mouth, often with raised edges. This finding should raise suspicion and prompt further evaluation.
Choice B reason:
Diffuse inflammation of the buccal mucosa is a non-specific finding and can be caused by various factors, including infection or irritation. While it's important to assess the oral mucosa for any abnormalities, it is not specific to oral cancer.
Choice C reason:
Dull pain radiating to the ears and teeth is not a characteristic early sign of oral cancer. Pain associated with oral cancer may occur in later stages or if there is local invasion of nerves.
Choice D reason:
Areas of tenderness that make chewing difficult may occur for various reasons, including dental issues or other oral health problems. While this can be distressing for the patient, it is not specific to oral cancer.
A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a
contributing factor to the development of the anemia?
Explanation
Choice A reason:
Chronic blood loss is a common complication of ulcerative colitis. Inflammation and ulcers in the colon can lead to ongoing bleeding, resulting in iron deficiency anemia.
Choice B reason:
While intestinal malabsorption can occur in some gastrointestinal disorders, it is not a primary mechanism in ulcerative colitis. In ulcerative colitis, the main factor leading to anemia is chronic blood loss.
Choice C reason:
Dietary iron restrictions may exacerbate anemia in individuals with ulcerative colitis, but the primary cause of anemia in this condition is chronic blood loss.
Choice D reason:
Intestinal parasites are not a common factor in ulcerative colitis and are not a primary cause of anemia in this condition. Chronic blood loss is the main contributing factor.
During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus?
Explanation
Choice A reason:
Avoiding chemicals that are toxic to the liver is a valid recommendation for liver health, but it is not specific to preventing hepatitis E virus infection.
Choice B reason:
Limiting alcohol intake is an important measure for maintaining liver health, but it is not a specific prevention measure for hepatitis E virus.
Choice C reason:
Wearing a condom during sexual contact is an important measure to prevent the transmission of certain sexually transmitted infections (STIs), but hepatitis E is primarily transmitted through contaminated water and not through sexual contact.
Choice D reason:
Following proper hand-washing techniques is a crucial preventive measure for hepatitis E virus. This virus is primarily transmitted through the fecal-oral route, often via contaminated water or food. Proper hand hygiene can significantly reduce the risk of transmission.
A nurse is providing care for a patient who is postoperative day 2 following gastric surgery.
The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply.
Explanation
Choice A reason:
Chronic gastritis is not a common immediate postoperative complication of gastric surgery. It is more related to long-term gastric health.
Choice B reason:
Correct. Atelectasis, or partial lung collapse, is a potential complication postoperatively, especially in abdominal surgery. The nurse should assess for signs such as decreased breath sounds and reduced oxygen saturation.
Choice C reason:
Correct. Pneumonia is a potential complication due to reduced lung function and shallow breathing after surgery. The nurse should monitor for signs like fever, increased respiratory rate, and abnormal breath sounds.
Choice D reason:
Malignant hyperthermia is a rare complication related to certain types of anesthesia agents. It is not a common complication after gastric surgery
Choice E reason:
Correct. Metabolic imbalances, such as electrolyte disturbances or changes in blood glucose levels, can occur after gastric surgery. The nurse should monitor for signs like weakness, confusion, and abnormal laboratory values.
The nurse's comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?
Explanation
Choice A reason:
A painless sore with raised edges is a characteristic early sign of oral cancer. It may appear as a small, painless lump or sore in the mouth, often with raised edges. This finding should raise suspicion and prompt further evaluation.
Choice B reason:
Diffuse inflammation of the buccal mucosa is a non-specific finding and can be caused by various factors, including infection or irritation. While it's important to assess the oral mucosa for any abnormalities, it is not specific to oral cancer.
Choice C reason:
Dull pain radiating to the ears and teeth is not a characteristic early sign of oral cancer. Pain associated with oral cancer may occur in later stages or if there is local invasion of nerves.
Choice D reason:
Areas of tenderness that make chewing difficult may occur for various reasons, including dental issues or other oral health problems. While this can be distressing for the patient, it is not specific to oral cancer.
Give Ceclor 45mg/kg/day p.o. in 3 divided doses for a patient who weighs 66 pounds. A 75mL stock medication is labeled Ceclor 125mg/mL. How many mLs would the nurse administer per dose?
Units in mL. (Please record your exact answer)
Explanation
- To calculate the dose of Ceclor in mg, multiply the weight in kg by the dosage in mg/kg/day and divide by the number of doses per day.
- To convert pounds to kg, divide by 2.2.
- To calculate the volume of Ceclor in mL, divide the dose in mg by the concentration in mg/mL.
- Convert 66 pounds to kg: 66 / 2.2 = 30 kg
- Calculate the dose of Ceclor in mg: 30 x 45 / 3 = 450 mg
- Calculate the volume of Ceclor in mL: 450 / 125 = 3.6 mL
- The nurse would administer 3.6 mL per dose.
A nurse is providing care for a patient who is postoperative day 2 following gastric surgery.
The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply.
Explanation
Choice A reason:
Chronic gastritis is not a common immediate postoperative complication of gastric surgery. It is more related to long-term gastric health.
Choice B reason:
Correct. Atelectasis, or partial lung collapse, is a potential complication postoperatively, especially in abdominal surgery. The nurse should assess for signs such as decreased breath sounds and reduced oxygen saturation.
Choice C reason:
Correct. Pneumonia is a potential complication due to reduced lung function and shallow breathing after surgery. The nurse should monitor for signs like fever, increased respiratory rate, and abnormal breath sounds.
Choice D reason:
Malignant hyperthermia is a rare complication related to certain types of anesthesia agents. It is not a common complication after gastric surgery.
Choice E reason:
Correct. Metabolic imbalances, such as electrolyte disturbances or changes in blood glucose levels, can occur after gastric surgery. The nurse should monitor for signs like weakness, confusion, and abnormal laboratory values.
A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?
Explanation
Choice A reason:
Blood in the urine (hematuria) is not typically associated with cirrhosis. It may be related to other underlying conditions.
Choice B reason:
Spider angiomas (also known as spider nevi) are expected findings in clients with cirrhosis.
They are small, dilated blood vessels near the surface of the skin that resemble a spider's web. They can be found on the face, neck, upper trunk, and arms.
Choice C reason:
Tarry stools (melena) can occur in individuals with gastrointestinal bleeding, which can be a complication of cirrhosis. However, it is not a specific finding for cirrhosis itself.
Choice D reason:
Moist skin is not a characteristic finding associated with cirrhosis. It may be related to other factors such as environmental humidity or individual factors like sweating.
The management of the patient's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly?
Explanation
Choice A reason:
Flushing the tube only when administering medications is not sufficient for proper maintenance. Regular flushing with water helps prevent clogs and ensures tube patency.
Choice B reason:
Cleaning the stoma with alcohol is not necessary and can be irritating to the skin. Mild soap and water are typically recommended for stoma care.
Choice C reason:
While being cautious to avoid dislodging the tube is important, it is not the primary indicator of correct tube management. Proper flushing and care are essential components of tube
maintenance.
Choice D reason:
Flushing the tube with water before and after each medication administration is a crucial step in maintaining tube patency and preventing clogs. This indicates that the patient is managing the
tube correctly.
A patient, admitted with a head injury, has an order for DSNS at 125 ml/hour. The IV tubing has a calibration of 15gtt/mL.
What is the correct rate of flow for this patient in gtt/min?
Explanation
- To calculate the correct rate of flow for this patient, we need to use the formula: Rate (gtt/min) = Volume (mL) x Calibration (gtt/mL) / Time (min)
- Plugging in the given values, we get: Rate (gtt/min) = 125 mL x 15 gtt/mL / 60 min
- Simplifying, we get: Rate (gtt/min) = 31.25 gtt/min
- Therefore, the correct rate of flow for this patient is 31.25 gtt/min
A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link with Crohn's disease. Which of the following information should the nurse
include?
Explanation
Choice A reason:
Both ulcerative colitis and Crohn's disease can require surgery in some cases, but it is not a common link that defines both conditions.
Choice B reason:
This is the correct answer. Both ulcerative colitis and Crohn's disease are types of inflammatory bowel disease (IBD). They share the common feature of chronic inflammation of the digestive tract.
Choice C reason:
Fistula formation is more commonly associated with Crohn's disease than ulcerative colitis. It is not a defining characteristic of both conditions.
Choice D reason:
Ulcerative colitis primarily affects the colon and rectum, but Crohn's disease can affect any part of the digestive tract from the mouth to the anus. Therefore, both conditions do not necessarily begin in the rectum.
A patient is receiving education about his upcoming Billroth I procedure (gastroduodenostomy). This patient should be informed that he may experience which of the following adverse effects associated with this procedure?
Explanation
Choice A Reason:
After a Billroth I procedure, where the stomach is anastomosed directly to the duodenum, some patients may experience diarrhea and feelings of fullness due to the direct passage of food into the small intestine without the buffering effect of the pyloric valve.
Choice B reason:
Gastric reflux and belching are not typically associated with a Billroth I procedure.
Choice C reason:
Persistent feelings of hunger and thirst are not common adverse effects associated specifically with a Billroth I procedure.
Choice D reason:
Constipation or bowel incontinence are not typically associated with a Billroth I procedure, as this surgery involves the upper gastrointestinal tract.
A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make?
Explanation
Choice A reason:
This statement is not directly related to the client's use of bisacodyl tablets. It addresses irregular bowel movements in a general sense.
Choice B reason:
Decreasing fiber intake is not a recommended approach, especially for an older adult who may benefit from a balanced diet with adequate fiber.
Choice C reason:
This is the correct answer. Excessive use of laxatives, including bisacodyl, can lead to electrolyte imbalances. Bisacodyl is a stimulant laxative that can cause excessive fluid loss and potentially
disrupt electrolyte levels.
Choice D reason:
While chronic use of laxatives can lead to various complications, including potential harm to the rectal mucosa, this choice is not the most appropriate response to the client's current situation.
A patient has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The patient is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond?
Explanation
Choice A reason:
This statement may not be entirely accurate. While other parts of the digestive system can compensate to some extent, the primary function of the appendix is not related to the large intestine's adaptation.
Choice B reason:
This is the correct answer. The appendix is considered a vestigial organ, meaning it doesn't have a major function in humans. Its removal typically doesn't lead to noticeable changes in overall health or digestion.
Choice C reason:
While the appendix does have some immune functions, the impact on nutrient absorption is minimal, and its removal is unlikely to lead to a significant difference in nutrient absorption.
Choice D reason:
Limiting fat intake after surgery is not a standard recommendation following an appendectomy. The statement may cause unnecessary concern for the patient.
A patient who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the patient's condition is stable. For the next several hours, the nurse caring for this patient should assess for what signs and symptoms of recurrence?
Explanation
Choice A reason:
While thirst can be a sign of dehydration, it is not specific to recurrence of a GI bleed.
Choice B reason:
This is the correct answer. Tachycardia (rapid heart rate), hypotension (low blood pressure), and tachypnea (rapid breathing) are signs of potential recurrence of a GI bleed and should be closely monitored.
Choice C reason:
Diaphoresis (excessive sweating) and sudden onset of abdominal pain could be indicative of various conditions, but they are not specific to recurrence of a GI bleed.
Choice D reason:
Tarry, foul-smelling stools are indicative of melena, which is a sign of a GI bleed. However, in this scenario, the bleeding has been controlled, so this is not an expected sign of recurrence.
A client is prescribed lansoprazole 15 mg PO once a day. At which of the following times should the nurse administer the medication?
Explanation
Choice A reason:
While lansoprazole can be taken with or without food, it is generally recommended to take it before a meal for optimal effectiveness in reducing stomach acid.
Choice B reason:
This is the correct answer. Taking lansoprazole 30 minutes before breakfast allows it to be most effective in reducing stomach acid production.
Choice C reason:
Taking lansoprazole after lunch may not provide the same level of effectiveness in reducing stomach acid as taking it before a meal.
Choice D reason:
Taking lansoprazole with a bedtime snack may not be as effective in reducing stomach acid as taking it before a meal. Additionally, it is generally recommended to take it in the morning.
A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make?
Explanation
Choice A reason:
This statement does not address the client's use of bisacodyl tablets and instead provides general information about irregular bowel movements.
Choice B reason:
Decreasing fiber intake is not a recommended approach, especially for an older adult who may benefit from a balanced diet with adequate fiber.
Choice C reason:
This is the correct answer. Excessive use of laxatives, including bisacodyl, can lead to electrolyte imbalances. Bisacodyl is a stimulant laxative that can cause excessive fluid loss and potentially disrupt electrolyte levels.
Choice D reason:
While chronic use of laxatives can lead to various complications, including potential harm to the rectal mucosa, this choice is not the most appropriate response to the client's current situation.
A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?
Explanation
Choice A reason:
A dinner roll is a generally well-tolerated food option and is unlikely to exacerbate gallbladder inflammation.
Choice B reason:
Tapioca pudding is a soft and easily digestible food, which is suitable for a patient with acute gallbladder inflammation.
Choice C reason:
Mashed potatoes are typically considered a bland and easily digestible food, suitable for a patient with gallbladder inflammation.
Choice D reason:
Fried chicken is high in fat, which can trigger gallbladder symptoms and exacerbate
inflammation. Therefore, it is not an appropriate choice for a patient with acute gallbladder inflammation. The nurse should question this item on the tray.
A patient who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the patient's condition is now stable. For the next several hours, the nurse caring for this
patient should assess for what signs and symptoms of recurrence?
Explanation
Choice A reason:
Sudden thirst, unrelieved by oral fluid administration, may indicate dehydration, but it is not specific to a recurrence of upper GI bleeding.
Choice B reason:
This is the correct answer. Tachycardia (rapid heart rate), hypotension (low blood pressure), and tachypnea (rapid breathing) are signs of potential recurrence of upper GI bleeding and should be closely monitored.
Choice C reason:
Diaphoresis (excessive sweating) and sudden onset of abdominal pain could be indicative of various conditions, but they are not specific to a recurrence of upper GI bleeding.
Choice D reason:
Tarry, foul-smelling stools (melena) are indicative of upper GI bleeding. However, in this scenario, the bleeding has been controlled, so this is not an expected sign of recurrence.
A patient has been scheduled for a urea breath test in one month's time. What nursing diagnosis most likely prompted this diagnostic test?
Explanation
Choice A reason:
The urea breath test is typically used to diagnose Helicobacter pylori (H. pylori) infection in the stomach. H. pylori can lead to gastritis and ulcers, which can interfere with nutrient absorption and contribute to imbalanced nutrition.
Choice B reason:
Impaired dentition related to gingivitis is not directly related to the need for a urea breath test. This diagnosis pertains to dental health, not gastric health.
Choice C reason:
Diarrhea related to Clostridium difficile infection is not directly related to the need for a urea
breath test. This diagnosis pertains to a bacterial infection in the colon, not H. pylori infection in the stomach.
Choice D reason:
Risk for impaired skin integrity related to peptic ulcers is also not directly related to the need for a urea breath test. This diagnosis pertains to potential skin breakdown due to ulcers, not the
assessment of H. pylori infection.
A nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure.
Which of the following assessments is the nurse's priority?
Explanation
Choice A reason:
While assessing the client's level of consciousness is important, it is not the priority after an EGD procedure. Ensuring the client's airway and protective reflexes is more crucial.
Choice B reason:
This is the correct answer. After an EGD, the client may have residual effects from sedation. Assessing the gag reflex helps ensure that the client's airway is protected.
Choice C reason:
Nausea is a common side effect after an EGD, but it is not the priority assessment. Ensuring the client's airway and safety come first.
Choice D reason:
Assessing pain is important for the client's comfort, but it is not the priority assessment after an EGD. Ensuring the client's airway and protective reflexes is more crucial.
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