Question 1

Mr) Mitchell, a 61-year-old retired banker, is diagnosed with cancer and has been immunocompromised and malnourished due to decreased intake because of nausea, anorexia, and a feeling of fullness. A Salem sump tube had been draining the stomach and has been discontinued. The initial nursing action to manage malnutrition would be:

Accepted Answer

The goal is to promote adequate nutrition through oral intake. Symptom management would be the initial nursing action. Choice A is incorrect because the goal is to resume oral intake. Parenteral nutrition would not be the initial action following removal of the Salem sump. Choice B is incorrect because the goal is to support oral intake. Insertion of a percutaneous endoscopic gastrostomy (PEG) would not be the next step after removal of the Salem sump. Choice D is incorrect because an antacid would not diminish the nausea, anorexia, or the fullness that the client is experiencing.

Question 2

After EGD, Edna was diagnosed to have gastroesophageal reflux disease (GERD). The nurse teaches Edna about ways to minimize symptoms. Which of the following statements made by Edna indicates that more teaching is needed?

Accepted Answer

The client with GERD is encouraged to eat smaller, low-fat frequent meals and to avoid lying down after eating. Clients are instructed not to eat for at least 2 hours before bedtime and avoid foods that decrease lower esophageal pressure, such as anything containing caffeine (coffee, tea, cola, and chocolate).

Question 3

Fluid intake for clients suffering from dumping syndrome should be:

Accepted Answer

Clients experiencing dumping syndrome should be advised to ingest liquids between meals rather than with meals (Choice B) or any time they desire (Choice C). Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in preventing rapid gastric emptying. Six small meals rather than three large meals, as well as resting after eating, are also measures used to prevent the occurrence of symptoms, which usually disappear over time. There is no need to restrict the quantity of fluids (Choice D), just the timing.

Question 4

A child admitted to rule out intussusception is scheduled for a barium enema. The nurse should teach the child's parents that the major purpose of this procedure is to:

Accepted Answer

The definitive diagnosis of intussusception is based on a barium enema, which clearly demonstrates the telescoping of the bowel wall, which blocks the flow of the barium. Choice B is incorrect because although a secondary effect may be a nonsurgical reduction of the telescoping (which may occur due to hydrostatic pressure), this is uncertain and is not the main reason the procedure is performed. Choices C and D are incorrect because a barium enema is not administered to ease passage of stool or to provide symptomatic relief.

Question 5

You are teaching Mr. Joseph dela Rosa, a 36-year-old taxi driver who was diagnosed with a new onset of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following statements by the client best indicates that he correctly understands how to manage this disease?

Accepted Answer

"I should limit my fluid intake to approximately 800 cc or 4 glasses of water daily." In SIADH there is excess secretion of ADH that causes fluid retention, dilutes the plasma causing suppression of aldosterone, and increases renal excretion of sodium. Water then moves into the cells from the plasma and interstitial spaces causing cellular edema. The treatment is fluid restriction and hypertonic saline infusion. Choices A and C are the opposite of standard treatment and are incorrect. Choice B is unrelated to this client.

Question 6

The nurse has just received instructions for an oral glucose tolerance test (OGTT) with a client. Which of the following statements made by the client indicates a need for more teaching?

Accepted Answer

"I will eat a light breakfast the morning of the test " would indicate a need for more teaching. An oral glucose tolerance test (OGTT) is a fasting test and the client will be NPO after midnight prior to the test. All other responses identify appropriate client responses regarding to the test.

Question 7

A diabetic client with the flu asks why he should drink juices, check his finger stick glucose every 4 hours, and take insulin when he is not eating and is vomiting. Which of the following would be the best explanation by the nurse?

Accepted Answer

He needs to prevent dehydration, excessive breakdown of fats for glucose, and monitor for hyperglycemia. Starvation-induced ketosis can be prevented by drinking juices that equal the prescribed carbohydrate meal pattern. Fluids are needed to prevent dehydration and hyperosmolality, which could result from large fluid losses from persistent vomiting. The liver breaks down fat to form glucose for energy and ketones, leading to DKA. The other options do not address the key issue of dehydration and hyperglycemia.

Question 8

Which of the following evaluation data would best lead the nurse to conclude that the client with hyperglycemic hyperosmolar nonketotic coma (HHNK) has demonstrated improvement during the first 24 hours?

Accepted Answer

Alert and oriented, balanced intake and output, and moist mucous membranes. HHNK results from hyperglycemia, causing excessive loss of water and retention of glucose that leads to dehydration, hypernatremia, and hypokalemia. Symptoms are dry, tenting skin, dry mucous membranes, altered level of consciousness, and hyperthermia. Ketones are not present in HHNK; thus, monitoring for ketones is inappropriate (Choice C). Choices B and D do not address the primary problems that occur with HHNK.

Question 9

A client underwent Billroth surgery for gastric ulcer. Post-operatively, the drainage from his NGT is thick and the volume of secretions has dramatically reduced in the last 2 hours and the client feels like vomiting. The most appropriate nursing action is to:

Accepted Answer

Notify the MD of your findings. The client's feeling of vomiting and the reduction in the volume of NGT drainage that is thick are signs of possible abdominal distention caused by obstruction of the NGT. This should be reported immediately to the MD to prevent tension and rupture on the site of anastomosis caused by gastric distention.

Question 10

The client presents with severe rectal bleeding, 16 diarrheal stools a day, severe abdominal pain, tenesmus, and dehydration. Because of these symptoms, the nurse should be alert for other problems associated with what disease?

Accepted Answer

Ulcerative colitis. Ulcerative colitis is a chronic inflammatory condition producing edema and ulceration affecting the entire colon. Ulcerations lead to sloughing that causes stools as many as 10-20 times a day that is filled with blood, pus, and mucus. The other symptoms mentioned accompany the problem.

Question 11

J) Chan, a 30-year-old bartender, receives a positive antinuclear antibody (ANA) test result with a titer level > 1:40. He does not understand what the test result means and asks the nurse for an explanation. Which of the following responses to the client would be most appropriate in this situation?

Accepted Answer

Antinuclear antibodies indicate the presence of an autoimmune disorder. They are not considered specific for systemic lupus, because many other autoimmune disorders have significant numbers of these antibodies. This reported titer is suggestive of the presence of ANA antibodies and therefore, it is an abnormal response.

Question 12

Steven, 38 years old, was diagnosed with rheumatoid arthritis and was given acetylsalicylic acid (aspirin) as part of his medications. He asked the nurse why aspirin was ordered and even added "this is a child's medication." The nurse would explain that the main reason that aspirin is used in the treatment of rheumatoid arthritis is to:

Accepted Answer

Aspirin acts as an anti-inflammatory drug and thus, reduces inflammation of the joints. In doing so, it also relieves pain. Aspirin does not prevent extension of the disease. While aspirin reduces fever, this is not a major reason for its use in the treatment of rheumatoid arthritis.

Question 13

The nurse has given postprocedure instructions to a client who has undergone a colonoscopy. Which statement by the client indicates the need for further teaching?

Accepted Answer

"It is alright to drive once I've been home for an hour or so." The client should not drive for several hours after discharge because the client would have received sedative medications during the procedure. The client should resume intake slowly and progress as tolerated. The client may experience gas, bloating, or abdominal tenderness for a short while after the procedure and this is normal.

Question 14

The nurse is preparing a client with hiatal hernia for discharge. Which of the following statements made by the client would indicate that teaching has been effective?

Accepted Answer

Conservative treatment for a hiatal hernia consists of lifestyle changes including remaining upright after eating; avoiding straining, tight clothing, and vigorous exercise; and eating small, frequent, low-fat meals.

Question 15

After surgery, Gina returns from the Post-anesthesia Care Unit (Recovery Room) with a nasogastric tube in place following a gall bladder surgery. She continues to complain of nausea. Which action would the nurse take?

Accepted Answer

Check the patency of the nasogastric tube for any obstruction. Nausea is one of the common complaints of a patient after receiving general anesthesia. But this complaint could be aggravated by gastric distention, especially in a patient who has undergone abdominal surgery. Insertion of the NGT helps relieve the problem. Checking on the patency of the NGT for any obstruction will help the nurse determine the cause of the problem and institute the necessary intervention.

Question 16

The nurse is caring for a client following a Billroth II procedure. Which operative order should the nurse question and verify?

Accepted Answer

In Billroth II procedure, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery unless specifically ordered by the physician. In this situation, the nurse should clarify the order.

Question 17

The nurse is caring for a client with new onset of atrial fibrillation. The nurse anticipates that which of the following is a possible treatment for this dysrhythmia when it first develops?

Accepted Answer

Synchronized cardioversion is most effective with new-onset atrial fibrillation. Pacemakers are indicted for heart block. AICDs are used for ventricular dysrhythmias and defibrillation is indicated for ventricular tachycardia.

Question 18

Thirty minutes after left-heart catheterization, the client's blood pressure begins to drop. Which potential complication explains this?

Accepted Answer

Loss of circulating volume from the puncture site or into tissues surrounding the site can result in decreased blood pressure. Choice A is incorrect because absent distal pulses indicate a blockage in the artery, but will not necessarily be accompanied by decreased blood pressure. Choice B is incorrect because increased pain is more likely to result in increased blood pressure. Choice C is incorrect because nausea is more likely to result in increased blood pressure.

Question 19

In preparation for discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include:

Accepted Answer

The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful in preventing vasoconstriction, but TED (thrombo-embolic deterrent) hose would not be therapeutic. Walking will most likely increase pain.

Question 20

A client tells the nurse that he has leg pains that begin when he walks, but cease when he stops walking. Which of the following conditions would the nurse assess for?

Accepted Answer

Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. If an obstruction were present, the leg pain would persist when the client stops walking. Low calcium level may cause leg cramps, but would not necessarily be related to walking.

Quiz 1: Medical Surgical Nursing Practice

After EGD, Edna was diagnosed to have gastroesophageal reflux disease (GERD) . The nurse teaches Edna about ways to minimize symptoms. Which of the following statements made by Edna indicates that more teaching is needed?