Med-Surg Exam #5 Practice Questions
1. A nurse is collecting data from a client who has peptic ulcer disease. Which of the following finding is a
... [Show More] manifestation of gastrointestinal perforation?
A. Hyperactive bowel sounds
B. Severe upper abdominal pain
C. Report of epigastric fullness
D. Bradycardia
ANS: Severe upper abdominal pain.
Sudden, severe abdominal pain that radiates to the shoulder is a manifestation of gastrointestinal perforation.
2. A nurse is reinforcing dietary teaching with a client who tells the nurse she would like to reduce her solid fat intake and increase oil intake in her diet. Which of the following instructions should the nurse include in her teaching?
A. Replace tub margarine with stick margarine
B. Use safflower oil instead of butter when baking
C. Consume 2% or whole milk
D. Choose ground beef that is at least 80% lean meat
ANS: Use safflower oil instead of butter when baking
The client should replace butter with safflower oil when baking to decrease solid fats and increase oil intake.
3. A nurse is administering a tap water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client’s discomfort?
A. Lower the height of the solution container
B. Encourage the client to bear down
C. Allow the client to expel some fluid before continuing
D. Stop the enema and document that the client did not tolerate the procedure
ANS: Lower the height of the solution container
If nausea or cramping occurs, the nurse should slow the flow of water, leaving the tube in place. The nurse should then raise the solution container when the cramping has passed.
4. A nurse is reinforcing teaching with a client how has Cron’s Disease and is experiencing frequent cramping and diarrhea. Which of the following statements should the nurse include in the teaching?
A. Increase your caloric intake by eating foods high in protein
B. Include fresh fruits and vegetables at each meal
C. Maintain your weight by eating high fat foods
D. Drink whole milk to ensure adequate calcium intake
ANS: Increase your caloric intake by eating foods high in protein
Clients who have Crohn's disease are at risk for malnutrition; therefore, they should eat a diet high in protein to help maintain their weight and promote healing and recovery.
5. A nurse is reinforcing teaching with a client that reports having constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply)
A. Excessive laxative use
B. Ignoring the urge to defecate
C. Inadequate fluid intake
D. Increased fiber in the diet
E. Increased activity
ANS: Excessive laxative use. Chronic use of laxatives causes the large intestine to lose muscle tone and become less responsive to stimulation by laxatives. Ignoring the urge to defecate. Anything that prevents the client from responding to the urge to defecate and disrupts regular habits can cause possible alterations in bowel habits, such as constipation. Inadequate fluid intake. Reduced fluid intake slows the passage of food through the intestine and can result in hardening of stool.
6. A nurse is reinforcing teaching for a client who has a duodenal ulcer and a new prescriptions for sucralfate. The client asks the nurse how sucralfate works. Which of the following statements should the nurse take?
A. This medication prevents gastric acid secretion in the stomach
B. This medication neutralizes gastric acid after it is secreted
C. This medication kills the bacteria which causes ulcers
D. This medication adheres to the ulcer and protects it from gastric acid
ANS: This medication adheres to the ulcer and protects it from gastric acid Sucralfate creates a protective coating over the ulcer that lasts about 6 hrs.
7. A charge nurse is reinforcing teaching with a newly licensed nurse about the common link between ulcerative colitis and Crohn’s disease. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. Both illnesses are inflammatory in nature
B. Both illnesses begin in the rectum
C. Both illnesses manifest fistula formation
D. Both illnesses result in malabsorption of nutrients
ANS: Both illnesses are inflammatory in nature
The nurse should reinforce that there are many linking components between ulcerative colitis and Crohn's disease, one of them being the inflammatory nature of the illnesses. Other similarities include a genetic component, the chronicity of the illnesses, and the predominant manifestation of both diseases is diarrhea.
8. A nurse is reinforcing teaching about a high-fiber diet with a client who has constipation. Which of the following statement indicates the client understands the best choice for a high-fiber diet?
A. One medium apple would be a good snack option
B. I will select a ½ cup of sweet potatoes for my starch
C. My breakfast is ½ cup of bran cereal
D. I should choose 1 ounce of almonds when I am hungry midday
ANS: My breakfast is ½ cup of bran cereal
The client who selects ½ cup of bran cereal is selecting the best source of fiber. A ½ cup of bran cereal contains 8.8 g per serving of fiber; therefore, it is the best food choice for the client.
9. A nurse is reinforcing teaching with a client who has GERD. Which of the following statements should the nurse include in the teaching?
A. Elevate the head of the bed by 18 inches
B. Avoid snacking between meals
C. Use a straw to consume liquids
D. Avoid wearing constricting clothing
ANS: Avoid wearing constricting clothing
The nurse should instruct the client to wear clothing that is comfortably fitting and not restrictive around the middle of the body. This increases the abdominal pressure and reflux.
10. A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestation should the nurse expect to find?
A. Spider angioma
B. Dark colored stools
C. Weak pulse
D. Increase body hair
ANS: Spider angioma
The nurse should expect to find spider angioma, which indicates portal hypertension, on the client who has advanced cirrhosis.
11. A nurse is collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease?
A. The pain is worse after I eat a meal high in fat
B. My pain is relieved by having a bowel movement
C. I feel so much better after eating
D. The pain radiates down to my lower back
ANS: I feel so much better after eating
A client who has peptic ulcer disease usually experiences pain when the stomach is empty, 2 to 3 hr after meals or in the middle of the night. It is usually relieved by eating.
12. A nurse is contributing to the plan of care of a client who has had a stroke. The client is experiencing severe dysphagia with chocking and coughing while eating. Which of the following nutritional therapies should the nurse expect to include in the plan of care?
A. NPO until dysphagia subsides
B. Supplements via NG tube
C. Initiation of total parenteral nutrition
D. Mechanical soft diet
ANS: Supplements via NG tube
Delivering supplements via an NG tube provides enteral nutrition for clients who are at risk for aspiration caused by a diminished gag reflex or difficulty swallowing.
13. A nurse is collecting data from an infant who has gastroesophageal reflux. Which of the following findings should the nurse expect? (Select all that apply)
A. Vomiting
B. Weight loss
C. Rigid abdomen
D. Wheezing
E. Pallor
ANS: Vomiting. Vomiting is a finding associated with gastroesophageal reflux. Weight loss. Weight loss is a finding associated with gastroesophageal reflux. Wheezing. Wheezing is a finding associated with gastroesophageal reflux.
14. A nurse is contributing to a plan of care for a client who has Hepatitis B. Which of the following should the nurse include in the plan?
A. Administer antibiotics
B. Provide a high-fat diet
C. Use disposable plates and utensils
D. Limit activity
ANS: Limit activity
The nurse should recognize that the client who has hepatitis experience fatigue and weakness. It is necessary to limit activity for this client to promote immune function and recovery for the client who has Hepatitis B.
15. A nurse is collecting data from a client who has obstruction and inflammation of the common bile duct due to cholelithiasis. Which of the finding is expected for this condition?
A. Fatty stools
B. Straw-colored urine
C. Tenderness in the left upper abdomen
D. Ecchymosis of the extremities
ANS: Fatty stools
An expected client finding is fatty stools due to biliary obstruction, causing a lack of bile for the absorption of fats in the intestines
16. A nurse is assisting with the implementation of a bowel training program for a client. For the program to be effective, te nurse should take the client to the bathroom at which of the following times?
A. When the client has the urge to defecate
B. Every 2 hr while the patient is awake
c. Immediately before meals
D. After the client feels abdominal cramping
ANS: When the client has the urge to defecate
When implementing a bowel training program, the nurse should take the client to the bathroom when the client reports the urge to defecate. Failure to heed the call to defecate can lead to overdistention of the rectum with hardening of the stool and constipation.
17. A nurse is caring for a client who requires a clear liquid diet. Which of the following foods should the nurse allow the client to have?
A. Grape juice
B. Lemon sherbet
C. Skim milk
D. Carrot juice
ANS: Grape juice
A clear liquid diet includes foods that are fluids and clear at body and room temperatures. This includes apple and grape juices, broth, black coffee, and plain gelatin.
18. A nurse is reinforcing discharge teaching with a client who has a new diagnosis of GERD. Which of the following foods should the nurse include in the list of foods the client should avoid?
A. Nonfat milk
B. Chocolate
C. Apples
D. Oatmeal
ANS: Chocolate
The client should avoid foods that reduce pressure on the lower esophageal sphincter. These include fatty and fried foods, chocolate, caffeine, alcohol, and carbonated drinks.
19. A nurse is contributing to the plan of care for a client who is postoperative following a gastrectomy and has a double-lumen nasogastric (NG) tube. Which of the following interventions should the nurse include in the plan?
A. Irrigate the blue pigtail port with sterile saline.
B. Verify tube placement by injecting air into the larger lumen.
C. Avoid replacing the NG tube if it is accidentally dislodged.
D. Avoid the nares when providing hygiene care.
ANS: Avoid replacing the NG tube if it is accidentally dislodged.
The nurse providing care for the client who has an NG tube following a gastrectomy must be careful to avoid dislodging or moving the NG tube, as this can disrupt the sutures between the esophagus and the jejunum. If the NG tube is dislodged, the provider should be notified.
20. A nurse is caring for a newly admitted adolescent who has anorexia nervosa. Which of the following findings should the nurse expect?
A. Diarrhea
B. Hypertension
C. Tachycardia
D. Lanugo
ANS: Lanugo
Lanugo is a finding associated with anorexia nervosa.
21. A nurse is reinforcing teaching about dietary recommendations for a client who has a hiatal hernia. Which of the following client statements indicate understanding of the teaching? (Select all that apply)
A. "I will lie down for one half hour after meals."
B. "I will consume less caffeine and spicy foods."
C. "I will sleep with the head of my bed elevated."
D. "I will try not to gain weight."
E. "I will drink less fluid."
ANS: “I will consume less caffeine and spicy foods.”. These foods and beverages can worsen the symptoms of a hiatal hernia. “I will sleep with the head of my bed elevated.” The client should raise the head of the bed on blocks to avoid lying flat when sleeping. “I will try not to gain weight.” Obesity raises intra-abdominal pressure and makes the hernia worse.
22. A nurse is administering a cleansing enema for a client how has constipation. Which of the following actions should the nurse take?
A. Keep the container of solution at a level that is comfortable for the client.
B. Hold the container of solution 30 cm (12 in) above the anus.
C. Hold the container of solution level with the upper hip.
D. Slowly lower the container of solution 61 cm (24 in) below the anus.
ANS: Hold the container of solution 30 cm (12 in) above the anus.
Holding the container of solution 30 to 49 cm (12 to 18 in) above t [Show Less]