A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and
is receiving intermittent feedings. Prior to initiating the
... [Show More] feeding, which of the following actions
should the nurse take first?
A. Flush the tube with water.
B. Place the client in semi-Fowler's position.
C. Cleanse the skin around the tube site.
D. Aspirate the tube for residual contents.
- CORRECT ANSWER B. Place the client in semi-Fowler's position.
A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy
(EGD). The nurse should identify that this procedure is used to do which of the following?
A. To visualize polyps in the colon
B. To detect an ulceration in the stomach
C. To identify an obstruction in the biliary tract
D. To determine the presence of free air in the abdomen - CORRECT ANSWER A. A
sigmoidoscopy or barium enema is used to visualize the lower gastrointestinal tract, where
polyps are found.
B. CORRECT: An EGD is used to visualize the esophagus, stomach, and duodenum with a
lighted tube to detect a tumor, ulceration, or obstruction.
C. Identifying an obstruction in the biliary tract is performed during endoscopic retrograde
cholangiopancreatography (ERCP).
D. The measurement of free air, which is a gas, is obtained using fluoroscopy or an x-ray, not
an EGD.
A nurse is teaching a client who has Barrett's esophagus and is scheduled to undergo an
esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse
include in the teaching?
A. "This procedure is performed to measure the presence of acid in your esophagus."
1470 ALL PRACTICE EXAM QUESTIONS AND ANSWERS FOR PN
MEDICAL SURGICAL ADULT MEDICAL SURGICAL 2022 (Q&A
EXPLAINED)B. "This procedure can determine how well the lower part of your esophagus works."
C. "This procedure is performed while you are under general anesthesia."
D. "This procedure can determine if you have colon cancer." - CORRECT ANSWER A. A pH
probe study, which involves the insertion of a specially designed probe into the distal
esophagus. is performed to monitor for the presence of acid in the normally alkaline esophagus.
B. CORRECT: An EGD is useful in determining the function of the esophageal lining and the
extent of inflammation, potential scarring, and strictures.
C. An EGD is performed while the client receives moderate sedation.
D. A colonoscopy is performed to detect colon cancer.
A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through
a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings
requires intervention by the nurse?
A. A full pitcher of water is sitting on the clients bedside table within the clients reach.
B. The disposable feeding bag from the previous day at 1000, and contains 200 mL of feeding.
C. The client is lying on the right side with a visible dependent loop in the feeding tube.
D. The head of the bed is elevated 20 degrees. - CORRECT ANSWER A. the nurse should
monitor the clients intake and output and should observe the client for manifestations of
dehydration, such as dry mucous membranes, thirst, and decreased urinary output. A pitcher of
water at the clients bedside does not require intervention by the nurse.
B. The clients feeding bag should be changed every 24 hrs. The 200 mL remaining in the bag is
sufficient to last until the bag needs to be changed. Because the rate is 75 mL/hr, the nurse will
need 150 mL to cover the 2 hr until the bag needs to be changed. The 50 mL left in the bag will
ensure that the bag does not run dry, causing air to enter the clients stomach.
C. This observation does not require intervention because the feeding is not by gravity, but by a
pump. and is set at a constant rate. The clients side-lying position will not affect the pump's rate
of flow unless the client is lying on the tubing.
D. CORRECT: The head of the bed should be elevated at least 30. (Semi-Fowler's position)
while the tube feeding is administered. This position uses gravity to help the feeding move down
through the digestive system and lessens the possibility of regurgitation.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has
just returned to the room following physical therapy. The nurse notes that the infusion pump for
the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the
client for which of the following findings?A. Hypertension
B. Excessive thirst
C. Fever
D. Diaphoresis - CORRECT ANSWER A. A client experiencing fluid volume overload will exhibit
hypertension.
B. A client experiencing hyperglycemia will exhibit excessive thirst.
C. A client who has an infection will have an increased temperature.
D. CORRECT: The nurse should recognize that the client has the potential for the development
of hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis.
other potential manifestations of hypoglycemia can include weakness, anxiety, confusion. and
hunger.
A nurse is caring for a client who has celiac disease. which of the following foods should the
nurse remove from the client's meal tray?
A. Wheat toast
B. Tapioca pudding
C. Hard-boiled egg
D. Mashed potatoes - CORRECT ANSWER A. CORRECT: Celiac disease is an autoimmune
disorder characterized by a permanent intolerance to wheat, barley, and rye. Wheat toast
contains gluten and should be removed from the clients tray.
B. Tapioca pudding is rich in dairy and does not contain gluten. Therefore, it is an acceptable
food to include in the clients diet.
C. A hard-boiled egg does not contain gluten and is a good source of protein. Therefore, it is an
acceptable food to include in the client's diet.
D. Mashed potatoes do not contain gluten and are a good source of protein and potassium.
Therefore mashed potatoes are an acceptable food to include in the clients diet.
A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected
malignancy. which of the following laboratory findings should the nurse monitor prior to the
procedure?
A. Prothrombin timeB. Serum lipase
C. Bilirubin
D. Calcium - CORRECT ANSWER A. CORRECT: A major complication following a liver biopsy
is hemorrhage. Many clients who have liver disease have clotting defects and are at risk for
bleeding. Along with the prothrombin time (PT), the activated partial thromboplastin time (aPTT)
and the platelet count should be monitored. Liver dysfunction causes the production of blood
clotting factors to be reduced, which leads to an increased incidence of bruising nosebleeds,
bleeding from wounds, and gastrointestinal bleeding. This is due to a deficient absorption of
vitamin K from the gastrointestinal tract caused by the inability of liver cells to use vitamin K to
make prothrombin.
B. Serum lipase is monitored to detect pancreatic disease and does not need to be monitored
prior to this procedure.
C. Bilirubin is monitored to detect biliary obstruction and does not need to be monitored prior to
this procedure.
D. Calcium is monitored to detect kidney failure or pancreatitis and does not need to be
monitored prior to this procedure.
A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the
following manifestations should the nurse expect?
A. Increased blood pressure
B. Decreased heart rate
C. Yellowing of the skin
D. Boardlike abdomen - CORRECT ANSWER A. The nurse should expect the client who is
experiencing perforation of a peptic ulcer to exhibit manifestations of shock, including
hypotension.
B. The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit
manifestations of shock, including tachycardia.
C. The nurse should expect a client who has liver disease to exhibit jaundice, or yellowing of the
skin.
D. CORRECT: The nurse should expect the client who is experiencing perforation of a peptic
ulcer to exhibit manifestations of a boardlike abdomen and severe pain in the abdomen or back
that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation
causes hemorrhagingB. "This procedure can determine how well the lower part of your esophagus works."
C. "This procedure is performed while you are under general anesthesia."
D. "This procedure can determine if you have colon cancer." - CORRECT ANSWER A. A pH
probe study, which involves the insertion of a specially designed probe into the distal
esophagus. is performed to monitor for the presence of acid in the normally alkaline esophagus.
B. CORRECT: An EGD is useful in determining the function of the esophageal lining and the
extent of inflammation, potential scarring, and strictures.
C. An EGD is performed while the client receives moderate sedation.
D. A colonoscopy is performed to detect colon cancer.
A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through
a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings
requires intervention by the nurse?
A. A full pitcher of water is sitting on the clients bedside table within the clients reach.
B. The disposable feeding bag from the previous day at 1000, and contains 200 mL of feeding.
C. The client is lying on the right side with a visible dependent loop in the feeding tube.
D. The head of the bed is elevated 20 degrees. - CORRECT ANSWER A. the nurse should
monitor the clients intake and output and should observe the client for manifestations of
dehydration, such as dry mucous membranes, thirst, and decreased urinary output. A pitcher of
water at the clients bedside does not require intervention by the nurse.
B. The clients feeding bag should be changed every 24 hrs. The 200 mL remaining in the bag is
sufficient to last until the bag needs to be changed. Because the rate is 75 mL/hr, the nurse will
need 150 mL to cover the 2 hr until the bag needs to be changed. The 50 mL left in the bag will
ensure that the bag does not run dry, causing air to enter the clients stomach.
C. This observation does not require intervention because the feeding is not by gravity, but by a
pump. and is set at a constant rate. The clients side-lying position will not affect the pump's rate
of flow unless the client is lying on the tubing.
D. CORRECT: The head of the bed should be elevated at least 30. (Semi-Fowler's position)
while the tube feeding is administered. This position uses gravity to help the feeding move down
through the digestive system and lessens the possibility of regurgitation.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has
just returned to the room following physical therapy. The nurse notes that the infusion pump for
the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the
client for which of the following findings?A. Hypertension
B. Excessive thirst
C. Fever
D. Diaphoresis - CORRECT ANSWER A. A client experiencing fluid volume overload will exhibit
hypertension.
B. A client experiencing hyperglycemia will exhibit excessive thirst.
C. A client who has an infection will have an increased temperature.
D. CORRECT: The nurse should recognize that the client has the potential for the development
of hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis.
other potential manifestations of hypoglycemia can include weakness, anxiety, confusion. and
hunger.
A nurse is caring for a client who has celiac disease. which of the following foods should the
nurse remove from the client's meal tray?
A. Wheat toast
B. Tapioca pudding
C. Hard-boiled egg
D. Mashed potatoes - CORRECT ANSWER A. CORRECT: Celiac disease is an autoimmune
disorder characterized by a permanent intolerance to wheat, barley, and rye. Wheat toast
contains gluten and should be removed from the clients tray.
B. Tapioca pudding is rich in dairy and does not contain gluten. Therefore, it is an acceptable
food to include in the clients diet.
C. A hard-boiled egg does not contain gluten and is a good source of protein. Therefore, it is an
acceptable food to include in the client's diet.
D. Mashed potatoes do not contain gluten and are a good source of protein and potassium.
Therefore mashed potatoes are an acceptable food to include in the clients diet.
A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected
malignancy. which of the following laboratory findings should the nurse monitor prior to the
procedure?
A. Prothrombin timeB. Serum lipase
C. Bilirubin
D. Calcium - CORRECT ANSWER A. CORRECT: A major complication following a liver biopsy
is hemorrhage. Many clients who have liver disease have clotting defects and are at risk for
bleeding. Along with the prothrombin time (PT), the activated partial thromboplastin time (aPTT)
and the platelet count should be monitored. Liver dysfunction causes the production of blood
clotting factors to be reduced, which leads to an increased incidence of bruising nosebleeds,
bleeding from wounds, and gastrointestinal bleeding. This is due to a deficient absorption of
vitamin K from the gastrointestinal tract caused by the inability of liver cells to use vitamin K to
make prothrombin.
B. Serum lipase is monitored to detect pancreatic disease and does not need to be monitored
prior to this procedure.
C. Bilirubin is monitored to detect biliary obstruction and does not need to be monitored prior to
this procedure.
D. Calcium is monitored to detect kidney failure or pancreatitis and does not need to be
monitored prior to this procedure.
A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the
following manifestations should the nurse expect?
A. Increased blood pressure
B. Decreased heart rate
C. Yellowing of the skin
D. Boardlike abdomen - CORRECT ANSWER A. The nurse should expect the client who is
experiencing perforation of a peptic ulcer to exhibit manifestations of shock, including
hypotension.
B. The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit
manifestations of shock, including tachycardia.
C. The nurse should expect a client who has liver disease to exhibit jaundice, or yellowing of the
skin.
D. CORRECT: The nurse should expect the client who is experiencing perforation of a peptic
ulcer to exhibit manifestations of a boardlike abdomen and severe pain in the abdomen or back
that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation
causes hemorrhaging [Show Less]