Question 1The physician orders intestinal decompression witha Cantor tube for a client with an intestinalobstruction. In order to determine effectiveness ofintestinal decompression the nurse should evaluatethe client to determine if:A.Fluid and gas have been removed from theintestineB.The client has had a bowel movement.C.The client’s urinary output is adequateD.The client can sit up without pain.
AnswerAnswer A:Intestinal decompression is accomplished with aCantor, Harris, or Miller-Abbott tube. These 6-10foot tubes are passed into the small intestine tothe obstruction. They remove accumulated fluidand gas, relieving the pressure.
Question 2The client with an intestinal obstructioncontinues to have acute pain even though thenasogastric tube is patent and draining. Whichaction by the nurse would be most appropriate?A.Reassure the client that the nasogastric tubeis functioning.B.Assess the client for a rigid abdomenC.Administer an opioid as ordered.D.Reposition the client on the left side.
AnswerAnswer B. The client’s pain may be indicative ofperitonitis, and the nurse should assess for signsand symptoms, such as a rigid abdomen,elevated temperature, and increasing pain.Reassuring the client is important, but accurateassessment of the client is essential. The fullassessment should occur before pain reliefmeasures are employed. Repositioning theclient to the left side will not resolve the pain.
Question 3A client has advanced cirrhosis of the liver. The client’s spouseasks the nurse why his abdomen is swollen, making it verydifficult for him to fasten his pants. How should the nurserespond to provide the most accurate explanation of thedisease process?A.“He must have been eating too many foods with salt inthem. Salt pulls water with it.”B.“The swelling in his ankles must have moved up closer to hisheart so the fluid circulates better.”C.“He must have forgotten to take his daily water pill.”D.“Blood is not able to flow readily through the liver now, andthe liver cannot make protein to keep fluid inside the bloodvessels.”
AnswerAnswer D:Portal hypertension and hypoalbuminemia as aresult of cirrhosis cause a fluid shift into theperitoneal space causing ascites. Althoughdiuretics promote the excretion of excess fluid,occasionally forgetting or omitting a dose willnot yield the ascites found in cirrhosis of theliver.
Question 4A client with cirrhosis begins to develop ascites.Spironolactone (Aldactone) is prescribed totreat the ascites. The nurse should monitor theclient closely for which of the following drug-related adverse effects?A.ConstipationB.HyperkalemiaC.Irregular pulseD.Dysuria
AnswerAnswer B:Spironolactone (Aldactone) is a potassium-sparing diuretic; therefore, clients should bemonitored closely for hyperkalemia. Othercommon adverse effects include abdominalcramping, diarrhea, dizziness, headache, andrash.
Question 5Which of the following interventions should thenurse anticipate incorporating into the client’splan of care when hepatic encephalopathyinitially develops?A.Inserting a NG tubeB.Restricting fluids to 1000 mL/dayC.Administering IV salt-poor albuminD.Implementing a low-protein diet
AnswerAnswer D. When hepatic encephalopathydevelops, measures are taken to reduceammonia formation. Protein is restricted in thediet. Fluid restriction and salt-poor albumin areincorporated into the treatment of ascites, butnot hepatic encephalopathy.
Question 6A client has been admitted to the ED with acuterenal failure. What should the nurse do? Selectall that apply:A.Take vital signsB.Establish an IV access siteC.Call the admitting physician for orders.D.Contact the hemodialysis unit.
AnswerAnswers A, B, C:The nurse should assess the vital signs becausethe pulse and respirations will be elevated.Establishing a site for IV therapy will becomeimportant because fluids will be administered IVin addition to orally. The physician will need tobe contacted for further orders; there is no needto contact the hemodialysis unit.
Question 7The client with acute renal failure asks the nursefor a snack. Because the client’s potassium levelis elevated, which of the following snacks ismost appropriate?A.A gelatin dessertB.YogurtC.An orangeD.Peanuts
AnswerAnswer A:Gelatin desserts contain little or no potassiumand can be served to a client on potassium-restricted diet. Foods high in potassium includebran and whole grains; most dried, raw, andfrozen fruits and vegetables; most milk and milkproducts; chocolate, nuts, raisins, coconut andstrong brewed coffee.
Question 8Which of the following abnormal blood valueswould not be improved by dialysis treatment?A.Elevated serum creatinine levelB.HyperkalemiaC.Decrease hemoglobin concentrationD.Hypernatremia
AnswerAnswer C: Dialysis has no effect on anemia.Because some red blood cells are injured duringthe procedure, dialysis aggravates a lowhemoglobin concentration. Dialysis will clearmetabolic waste products from the body andcorrect electrolyte imbalances.
Question 9Which of the following symptoms would mostlikely indicate that the client has pyelonephritis?A.AscitesB.Costovertebral angle (CVA) tendernessC.PolyuriaD.Nausea and vomiting
AnswerAnswer B:Common symptoms of pyelonephritis includeCVA tenderness, burning on urination, urinaryurgency or frequency, chills, fever, and fatigue.Ascites, polyuria, and nausea and vomiting arenot indicative of pyelonephritis.
Question 10After completion of peritoneal dialysis, thenurse should expect the client to exhibit whichof the following characteristics?A.HematuriaB.Weight lossC.HypertensionD.Increased urine output
AnswerAnswer B:Weight loss is expected because of the removalof fluid. The client’s weight before and afterdialysis is one measure of the effectiveness oftreatment. Blood pressure usually decreasesbecause of the removal of fluid. Hematuriawould not occur after completion of peritonealdialysis. Dialysis only minimally affects thedamaged kidneys’ ability to manufacture urine.
Question 11The nurse is doing an admission assessment ona client with a history of duodenal ulcer. Todetermine whether the problem is currentlyactive, the nurse should assess the client forwhich symptom(s) of duodenal ulcer?A.Weight lossB.Nausea and vomitingC.Pain relieved by food intakeD.Pain radiating down the right arm
AnswerAnswer C: A frequent symptom of duodenalulcer is pain that is relieved food intake. Theseclients generally describe the pain as a burning,heavy, sharp, or “hungry” pain that oftenlocalizes in the midepigastric area. The clientwith duodenal ulcers usually does notexperience weight loss or nausea and vomiting.These symptoms are more typical in the clientwith a gastric ulcer.
Question 12A client with a peptic ulcer is diagnosed with a Helicobacter pyloriinfection. The nurse is teaching the client about the medicationsprescribed, including clarithromycin (Biaxin), esomeprazole (Nexium),and amoxicillin (Amoxil). Which statement by the client indicates thebest understanding of the medication regimen?A.“My ulcer will heal because these medications will kill the bacteria.”B.These medications are only taken when I have pain from my ulcer.”C.“The medications will kill the bacteria and stop the act acidproduction.D.“These medications will coat the ulcer and decrease the acidproduction in my stomach.”
AnswerAnswer C: Triple therapy for Helicobacter pyloriinfection usually includes two antibacterialdrugs and a proton pump inhibitorClarithromycin and amoxicillin areantibacterials. Esomeprozole is a proton pumpinhibitor. These medications will kill the bacteriaand decrease acid production.
Question 13The client with chronic renal failure returns tothe nursing unit following a hemodialysistreatment. On assessment, the nurse notes thatthe client’s temperature 100.2 F. Which of thefollowing is the appropriate nursing action?A.Monitor the clientB.Notify the physicianC.Elevate the head of the bedD.Medicate the client for nausea.
AnswerAnswer A:The client may have an elevated temperaturefollowing dialysis because the dialysis machinewarms the blood slightly. If the temperature iselevated excessively and remains elevated,sepsis would be suspected and a blood samplewould be obtained as prescribed for culture andsensitivity determinations.
Question 14The nurse is reviewing the record of a client witha diagnosis of cirrhosis and notes that there isdocumentation of the presence of asterixis. Howshould the nurse assess for its presence?A.Dorsiflex the client’s foot.B.Measure the abdominal girth.C.Ask the client to extend the arms.D.Instruct the client to lean forward.
AnswerAnswer C:Asterixis is irregular flapping movements of thefingers and wrists when the hands and arms areoutstretched, with the palms down, wrists bentup, and fingers spread. Asterixis is the mostcommon and reliable sign and the hepaticencephalopathy is developing. Options 1, 2, and4 are incorrect.
Question 15The client with a gastric ulcer has a prescriptionfor sucralfate (Carafate), 1 g by mouth 4 timesdaily. The nurse schedules the medication forwhich times?A.With meals and at bedtime.B.Every 6 hours around the clock.C.One hour after meals and at bed time.D.One hour before meals and at bedtime.
AnswerAnswer D: Sucralfate is a gastric protectant. Themedication should be scheduled foradministration 1 hour before meals and atbedtime. The medication is timed to allow it toform a protective covering over the ulcer beforefood intake stimulates gastric acid productionand mechanical irritation. The other options areincorrect.
Question 16The nurse is caring for a male client withcirrhosis. Which assessment findings indicatethat the client has deficient vitamin K absorptioncaused by this hepatic disease?A. Dyspnea and fatigueB. Ascites and orthopneaC. Purpura and petechiaeD. Gynecomastia and testicular atrophy•
AnswerAnswer C. A hepatic disorder, such as cirrhosis,may disrupt the liver’s normal use of vitamin Kto produce prothrombin (a clotting factor).Consequently, the nurse should monitor theclient for signs of bleeding, including purpuraand petechiae. Dyspnea and fatigue suggestanemia. Ascites and orthopnea are unrelated tovitamin K absorption. Gynecomastia andtesticular atrophy result from decreasedestrogen metabolism by the diseased liver.
Question 17A female client is admitted for treatment of chronickidney disease (CKD). Nurse Juliet knows that thisdisorder increases the client’s risk of:A. Water and sodium retention secondary to a severedecrease in the glomerular filtration rate.B. A decreased serum phosphate level secondary tokidney failure.C. An increased serum calcium level secondary tokidney failure.D. Metabolic alkalosis secondary to retention ofhydrogen ions.
AnswerAnswer A. A client with CKD is at risk for fluidimbalance — fluid retention if the kidneys fail toproduce urine. Electrolyte imbalances associated withthis disorder result from the kidneys’ inability toexcrete phosphorus; such imbalances may lead tohyperphosphatemia with reciprocal hypocalcemia. CKDmay cause metabolic acidosis, not metabolic alkalosis,secondary to inability of the kidneys to excretehydrogen ions.
Question 18A female client with acute renal failure is undergoingdialysis for the first time. The nurse in charge monitorsthe client closely for dialysis equilibrium syndrome, acomplication that is most common during the first fewdialysis sessions. Typically, dialysis equilibriumsyndrome causes:A. confusion, headache, and seizures.B. acute bone pain and confusion.C. weakness, tingling, and cardiac arrhythmias.D. hypotension, tachycardia, and tachypnea.
AnswerAnswer A. Dialysis equilibrium syndrome causesconfusion, a decreasing level of consciousness,headache, and seizures. These findings, whichmay last several days, probably result from arelative excess of interstitial or intracellularsolutes caused by rapid solute removal from theblood.
Question 19The client who has a history of gout also isdiagnosed with nephrolithiasis and the stonesare determined to be of uric acid type. Thenurse gives the client instructions in which foodsto limit, including:A. milkB. liverC. applesD. carrots
Answer B. The client with uric acid stones shouldavoid foods containing high amounts of purines.This includes limiting or avoiding organ meatssuch as liver, brain, heart, kidney, andsweetbreads. Other foods to avoid includeherring, sardines, anchovies, meat extracts,consommés, and gravies.
Question 20A client has been diagnosed with urolothiasis inthe right ureter. The nurse would expect theclient to describe the pain (renal colic) as:A. located in the upper right epigastric area,radiating to the shoulder or backB. occurring 2 to 3 hours after mealC. intermittent in the right upper abdominalquadrant, radiating to the groinD. worsening with the ingestion of food
AnswerAnswer C. Renal colic is generally associated with acuteobstruction of a ureter and resulting ureteral spasm. As thestone moves along the ureter, the pain can be excruciating,is intermittent in character, and is located in the flank andupper abdominal quadrant of the affected side. It is causedby the spasm of the ureter and anoxia of the ureter wallfrom the pressure of the stone. The pain follows theanterior course of the ureter down to the suprapubic areaand radiates to the external genitalia (groin). Options A, B,and D describe pain characteristic of gastrointestinalproblems (cholecystitis, duodenal and gastric ulcers,respectively).