50 Gastrointestinal Health Problems with Answers and Rationales

This is a test drill on gastrointestinal health problems.
The questions are in line with the framework of Nurse Licensure Exam and derived from Lippincot's and Springhouse Review Book.
These are common board questions for you to study
Next post will be the answers and rationales. You're all free to post a comment and please rep me up.
Good luck guys and have fun with the test drill.

biobio,

Post Merge: 11 years ago

Answers and Rationales

Situation 1: Children have a special fascination with the workings of the digestive system. To fully understand the digestive processes, Nurse Lavigña must be knowledgeable of the anatomy and physiology of the gastrointestinal system.

1. The alimentary canal is a continuous, coiled, hollow muscular tube that winds through the ventral cavity and is open at both ends. Its solid organs include all of the following except:
a. liver
b. gall bladder
c. stomach
d. pancreas

Answer: C. stomach
Rationale: Stomach is a hollow digestive organ in the GI tract. The liver, gall baldder and pancreas are all solid organs which are part of the hepato-biliary system. Test taking skills: which does not belong to the group?

2. Pharynx is lined with mucous membranes and mucous secreting glands to ease the passage of food. The larygngopharynx serves as passageway for:
a. air only
b. air and water
c. food, fluids and air
d. air and food

Answer: D. air and food
Rationale: The laryngopharynx serves as passageway for air and food and so as with the oropharynx. Option a is nasopharynx. Answers b and c may be correct but air and food is more accuarte.

3. Once food has been placed in the mouth, both mechanical and chemical digestions begin. The six activities of the digestive process are:
a. ingestion, mastication, digestion, deglutition, absorption, egestion
b. ingestion, mastication, deglutition, digestion, absorption, egestion
c. deglutition, ingestion, mastication, egestion, absorption, defecation
d. ingestion, digestion, mastication, deglutition, absorption, defecation

Answer: B. ingestion, mastication, deglutition, digestion, absorption, egestion
Rationale: The digestive processes involve six steps. Ingestion is taking in of food in the mouth; mastication is the mechanical process where food is converted into bolus; deglutition is the act of swallowing; digestion is the chemical breakdown of food into chime; absorption occurs in the small intestines (solutes) and large intestines (water) and egestion/defecation where elimination of feces occur.

4. Most digestive activity occurs in the pyloric region of the stomach. What hormone stimulates the chief cells to produce pepsinogen?
a. Gastrin
b. Pepsin
c. HCl
d. Insulin

Answer: A. Gastrin
Rationale: Gastrin stimulates chief cells to produce pepsinogen when foods enter and suppression of pepsinogen when it leaves and enters the small intestines; it is the major hormone that regulates acid secretion in the stomach. Pepsin; a gastric protease secreted in an inactive form, pepsinogen, which is activated by stomach acid that acts to degrade protein. HCl is produced by the parietal cells. Insulin is a pancreatic hormone.

5. What pancreatic enzyme aids in the digestion of carbohydrates?
a. Lipase
b. Trypsin
c. Amylase
d. Chymotrypsin

Answer: C. Amylase
Rationale: Amylase aids in the digestion of carbohydrates. Trypsin/Chymotrypsin aids in the digestion of proteins. Lipase aids in the digestion of fats.

Situation 2: Nurse Dorina is going to perform an abdominal examination to Mr. Lim who was admitted due to on and off pain since yesterday.

6. How will you position Mr. Lim prior to procedure?
a. supine with knees flexed
b. prone
c. lying on back
d. sim’s

Answers: A. supine with knees flexed
Rationale: During abdominal examination, positioning the client in supine with knees flexed will promote relaxation of abdominal muscles. Options b and d are inaccurate in this type of procedure. Lying on back or supine may be correct but option a is the best answer.

7. To identify any localized bulging, distention and peristaltic waves, Nurse Dorina must perform which of the following?
a. Auscultation
b. Inspection
c. Palpation
d. Percussion

Answer: B. Inspection
Rationale: Inspection is the first step in abdominal exam to note the contour and symmetry of abdomen as well as localized bulging, distention and peristaltic waves. Auscultation is done to determine the character, location and frequency of bowel sounds. Percussion is to assess tympany or dullness. Palpation is to asses areas of tenderness and discomfort. Note: In abdominal exam: Inspection, Auscultation, Percussion and Palpation are the correct order.

8. In order to identify areas of tenderness and swelling, Nurse Dorina must do:
a. deep palpation
b. light palpation
c. percussion
d. palpation

Answer: B. Light palpation
Rationale: Light palpation is done to identify areas of tenderness and swelling. Deep palpation is done to identify masses in all four quadrants. Test taking skills: one of the opposite is the correct answer

9. Mr. Lim verbalized pain on the right iliac region. Nurse Dorina knows that the organ affected would be the:
a. liver
b. sigmoid colon
c. appendix
d. duodenum

Answer: C. Appendix
Rationale: Appendix and cecum is located in the right iliac region. Liver and gall baldder is at the right hypochondriac. Sigmoid colon is at the left iliac. Duodenum, stomach and pancreas is in the epigastric region.

10. Mr. Lim felt pain upon release of Nurse Dorina’s hand. This can be referred as:
a. referred pain
b. rebound tenderness
c. direct tenderness
d. indirect tenderness

Answer: B. Rebound Tenderness
Rationale: Rebound tenderness is pain felt upon sudden release of the examiners hand which in most cases suggest peritonitis. Referred pain is pain felt in an area remote from the site of origin. Direct tenderness is localized pain upon palpation. Indirect tenderness is pain outside the area of palpation.

Situation 3: Mrs. Cruz was admitted in the Medical Floor due to pyrosis, dyspepsia and difficulty of swallowing.

11. Based from the symptoms presented, Nurse Yoshi might suspect:
a. Esophagitis
b. Hiatal hernia
c. GERD
d. Gastric Ulcer

Answer: C. Gastroesophageal Reflux Disease (GERD)
Rationale: GERD is the backflow of gastric or duodenal contents into the esophagus caused by incompetent lower esophageal sphincter. Pyrosis or heartburn, dyspepsia and dysphagia are cardinal symptoms.

12. What diagnostic test would confirm the type of problem Mrs. Cruz have?
a. barium enema
b. barium swallow
c. colonoscopy
d. lower GI series

Answer: B. Barium swallow
Rationale: Barium swallow or upper GI series would confirm GERD. Endoscopy is another diagnostic test. Options a and d are the same. Option c is incorrect.

13. Mrs. Cruz complained of pain and difficulty in swallowing. This term is referred as:
a. Odynophagia
b. Dysphagia
c. Pyrosis
d. Dyspepsia

Answer: A. Odynophagia
Rationale: When difficulty of swallowing is accompanied with pain this is now referred as odynophagia. Dysphagia is difficulty of swallowing alone.

14. To avoid acid reflux, Nurse Yoshi should advice Mrs. Cruz to avoid which type of diet?
a. cola, coffee and tea
b. high fat, carbonated and caffeinated beverages
c. beer and green tea
d. lechon paksiw and bicol express

Answer: B. High fat, carbonated and caffeinated beverages
Rationale: All are correct but option b is the best answer. In patients with GERD, this type of diet must be avoided to avoid backflow of gastric contents. Excessive caffeine reduces the tone of lower esophageal sphincter. Test Taking Skills: look for the umbrella effect

15. Mrs. Cruz’ body mass index (BMI) is 25. You can categorized her as:
a. normal
b. overweight
c. underweight
d. obese

Answer: B. Overweight
Rationale: Mr. Cruz’ BMI belongs to the overweight category (24 – 26), malnourished (less than 17), underweight (17 – 19), normal (20 – 23), obese (27 – 30) and morbidly obese (greater than 30). BMI is weight in kilograms divided by height in square meters.

Situation 4: Nurse Gloria is the staff nurse assigned at the Emergency Department. During her shift, a patient was rushed – in the ED complaining of severe heartburn, vomiting and pain that radiates to the flank. The doctor suspects gastric ulcer.

16. What other symptoms will validate the diagnosis of gastric ulcer?
a. right epigastric pain
b. pain occurs when stomach is empty
c. pain occurs immediately after meal
d. pain not relieved by vomiting

Answer: C. Pain occurs immediately after meal.
Rationale: In gastric ulcer food intake aggravates pain which usually occur ½ - 1 hour before meal or immediately during or after food intake. Options a, b, c suggests duodenal ulcer.

17. What diagnostic test would yield good visualization of the ulcer crater?
a. Endoscopy
b. Gastroscopy
c. Barium Swallow
d. Histology

Answer: A. Endoscopy
Rationale: Endoscopy determines bleeding, pain, difficulty swallowing, and a change in bowel habits. This would yield good visualization of the ulcer crater. Other options are also diagnostic tests in PUD.
18. Peptic ulcer disease particularly gastric ulcer is thought to be cause by which of the following microorgamisms?
a. E. coli
b. H. pylori
c. S. aureus
d. K. pnuemoniae

Answer: B. H. pylori
Rationale: Helicobacter pylori (H. pylori) is a bacteria responsible for most ulcers and many cases of chronic gastritis (inflammation of the stomach). This organism can weaken the protective coating of the stomach and duodenum (first part of the small intestines), allowing the damaging digestive juices to irritate the sensitive lining of these body parts.

19. She is for occult blood test, what specimen will you collect?
a. Blood
b. Urine
c. Stool
d. Gastric Juice

Answer: C. Stool
Rationale: Occult blood test or stool guiac test is a test that detects the presence of hidden (occult) blood in the stool (bowel movement). The stool guaiac is the most common form of fecal occult blood test (FOBT) in use today. So stool specimen will be collected.

20. Preparation of the client for occult blood examination is:
a. Fluid intake limited only to 1 liter/day
b. NPO for 12 hours prior to obtaining of specimen
c. Increase fluid intake
d. Meatless diet for 48 hours prior to obtaining of specimen

Answer: D. Meatless diet for 48 hours prior to obtaining of specimen
Rationale: Eating meat can cause false positive test result. Using proper stool collection technique, avoiding certain drugs, and observing dietary restrictions can minimize these measurement errors.

Situation 5: IBD is a common inflammatory functional bowel disorder also known as spastic bowel, functional colitis and mucous colitis.

21. The client with IBS asks Nurse June what causes the disease. Which of the following responses by Nurse June would be most appropriate?
a. “This is an inflammation of the bowel caused by eating too much roughage”
b. “IBS is caused by a stressful lifestyle”
c. “The cause of this condition is unknown”
d. “There is thinning of the intestinal mucosa caused by ingestion of gluten”

Answer: C. “The cause of this condition is unknown”
Rationale: There is no known cause of IBS, and diagnosis is made by excluding all the other diseases that cause the symptoms. There is no inflammation if the bowel. Some factors exacerbate the symptoms including anxiety, fear, stress, depression, some foods and drugs but there do not cause the disease.

22. Which of the following alimentary canal is the most common location for Chron’s disease?
a. Descending colon
b. Jejunum
c. Sigmoid Colon
d. Terminal Ileum

Answer: D. Terminal Ileum
Rationale: Chronic inflammatory of GI mucosa occurs anywhere from the mouth to anus but most often in terminal ileum. Inflammatory lesions are local and involve all layers of the intestinal wall.

23. Which of the following factors is believed to be linked to Chron’s disease?
a. Diet
b. Constipation
c. Heredity
d. Lack of exercise

Answer: C. Heredity
Rationale: The cause is unknown but is thought to be multifactorial. Heredity, infectious agents, altered immunity or autoimmune and environmental are factors to be considered. Test taking skill: which does not belong? Options a, b, and d are all modifiable factors.

24. How about ulcerative colitis, which of the following factors is believed to cause it?
a. Acidic diet
b. Altered immunity
c. Chronic constipation
d. Emotional stress

Answer: B. Altered immunity
Rationale: refer to rationale for number 23. Test taking skill: which does notbelong? Options a, c and d are all modifiable factors.

25. Mr. Jung, had ulcerative colitis for 5 years and was admitted to the hospital. Which of the following factors was most likely of greatest significance in causing an exacerbation of the disease?
a. A demanding and stressful job
b. Changing to a modified vegetarian diet
c. Beginning a weight training program
d. Walking 2 miles everyday

Answer: A. A demanding and stressful job.
Rationale: Stress is an environmental factor that is thought to cause ulcerative colitis. Test taking skill: options b, c, and d are all healthy lifestyles.

Situation 6: A patient was admitted in the Medical Floor at St. Luke’s Hospital. He was asymptomatic. The doctor suspects diverticulosis.

26. Which of the following definitions best describes diverticulosis?
a. An inflamed outpouching of the intestine
b. A non – inflamed outpouching of the intestine
c. The partial impairment of the forward flow of instestinal contents
d. An abnormal protrusions of an oxygen through the structure that usually holds it

Answer: B. A non – inflamed outpouching of the intestine.
Rationale: An increase intraluminal pressure causes the outpouching of the colon wall resulting to diverticulosis. Option a suggests diverticulitis. Test taking skill: one of the opposite is the correct answer.

27. Which of the following types of diet is implicated in the development of diverticulosis?
a. Low – fiber diet
b. High – fiber diet
c. High – protein diet
d. Low – carbohydrate diet

Answer: A. Low – Fiber Diet
Rationale: A lack of adequate blood supply and nutrients from the diet such as low fiber foods may contribute to the development of the disease. Test taking skill: one of the opposite is the correct answer.

28. Which of the following tests should be administered to client with diverticulosis?
a. Proctosocpy
b. Barium enema
c. Barium swallow
d. Gastroscopy

Answer: B. Barium enema
Rationale: Barium enema is used to diagnose diverticulosis, however, this is contraindicated when diverticulitis is present because of the risk of rupturing the diverticulum. Test taking skill: options b and c are opposite; one may be the correct answer.

29. To improve Mr. Trinidad’s condition, your best nursing intervention and teaching is:
a. Reduce fluid intake
b. Increase fiber in the diet
c. Administering of antibiotics
d. Exercise to increase intraabdominal pressure

Answer: B. Increase fiber in the diet.
Rationale: Patient with diverticulosis must be encouraged to increase roughage in diet such as fruits and vegetables rich in fiber. Increasing fluid intake 2 – 3 liters/day unless contraindicated rather reducing. Administering antibiotics can decrease bowel flora and infection but this is a dependent function of a nurse.

30. Upon review of Mr. Trinidad’s chart, Nurse Drew noticed that he weighs 121 lbs and his height is 5 ft, 4 in. After computing for his Body Mass Index (BMI), you can categorize him as:
a. obese
b. normal
c. obese
d. underweight

Answer: B. Normal
Rationale: Mr. Trinidad’s BMI is 23 which is normal. Refer to rationale number 15.

Situation 7: Manny, 6 years old was admitted at Cardinal Santos Hospital due to increasing frequency of bowel movements, abdominal cramps and distension.

31. Diarrhea is said to be the leading cause of morbidity in the Philippines. Nurse Harry knows that diarrhea is present if:
a. passage of stool is more than 3 bowel movements per week
b. passage of stool is less than 3 bowel movements per day
c. passage of stool is more than 3 bowel movements per day
d. passage of stool is less than 3 bowel movements per week

Answer: C. passage of stool is more than 3 bowel movements per day (thanks to Budek for the correction)

32. Diarrhea is believed to be caused by all of the following except
a. increase intestinal secretions
b. altered immunity
c. decrease mucosal absorption
d. altered motility

Answer: B. Altered Immunity
Rationale: Diarhhea is an intestinal disorder that is self – limiting. Options a, c and d are etiological factors of diarrhea.

33. What life threatening condition may result in persistent diarrhea?
a. hypokalemia
b. dehydration
c. cardiac dysrhytmias
d. leukocytosis

Answer: C. Cardiac dysrhytmias
Rationale: Due to increase frequency and fluid content in the stools, diarrhea may cause fluid and electrolyte imbalance such as hypokalemia. Once potassium is depleted, this will affect the contractility of the heart causing cardiac arrhythmia leading to death.

34. Voluminous, watery stools can deplete fluids and electrolytes. The acid base imbalance that can occur is:
a. metabolic alkalosis
b. metabolic acidosis
c. respiratory acidosis
d. respiratory alkalosis

Answer: B. Metabolic acidosis
Rationale: In diarrhea, metabolic acidosis is the acid – base imbalance that occurs while in vomiting, metabolic alkalosis occur. This is a metabolic disorder that’s why eliminate options c and d. Tip: Just remember the sound when you’re vomiting (alk alk alk alosis) and the sound of passage of watery stool (uhhhm uhhh ashhi dosis) hehehe

35. What is the immediate home care management for diarrhea?
a. Milk
b. Imodium
c. Water
d. Oresol

Answer: D. Oresol
Rationale: In the DOH book, oresol is the immediate home care management for diarrhea to prevent dehydration. Water may not be enough to prevent diarrhea.

Situation 8: Mr. Sean is admitted to the hospital with a bowel obstruction. He complained of colicky pain and inability to pass stool.

36. Which of these findings by Nurse Leonard, would indicate that the obstruction is in the early stages?
a. high pitched tinkling or rumbling bowel sounds
b. hypoactive bowel sounds
c. no bowel sounds auscultated
d. normal bowel sounds heard in all four quadrants

Answer: A. High pitched tinkling or rumbling bowel sounds
Rationale: Early in the bowel obstruction, the bowel attempts to move the contents past the obstruction and this is heard as high pitched tinkling bowel sounds. As the obstruction progresses, bowel sounds will diminish and may finally become absent.

37. Nasogastric tube was inserted to Mr. Sean. The NGT’s primary purpose is:
a. nutrition
b. decompression of bowel
c. passage for medication
d. aspiration of gastric contents

Answer: B. Decompression of bowel
Rationale: The NGT’s primary purpose is for bowel decompression especially for clients suffering from obstruction.

38. Mr. Sean has undergone surgery. Post – operatively, which of the following findings is normal?
a. absent bowel sounds
b. bleeding
c. hemorrhage
d. bowel movement

Answer: A. Absent bowel sounds
Rationale: Post – operatively, no bowel sounds are present so this is a normal finding. Bleeding and hemorrhage must be prevented to avoid complications. Bowel movement occurs only after flatus and bowel sounds are noted.

39. Client education should be given in order to prevent constipation. Nurse Leonard’s health teaching should include which of the following?
a. use of natural laxatives
b. fluid intake of 6 glasses per day
c. use of OTC laxatives
d. complete bed rest

Answer: A. Use of natural laxatives
Rationale: The use of natural laxatives such as foods and fruits high in fiber is still the best way of preventing constipation Increasing fluid intake, taking laxatives judiciously and exercise also can prevent this.

40. Four hours post – operatively, Mr. Sean complains of guarding and rigidity of the abdomen. Nurse Leonard’s initial intervention is:
a. assess for signs of peritonitis
b. call the physician
c. administer pain medication
d. ignore the client

Answer: A. Assess for signs of peritonitis
Rationale: Assessment precedes intervention. Symptoms presented are signs of peritonitis. Assessment will provide you the data for prompt intervention.

Situation 9: Mr. Gerald Liu, 19 y/o, is being admitted to a hospital unit complaining of severe pain in the lower abdomen. Admission vital signs reveal an oral temperature of 101.2 0F.

41. Which of the following would confirm a diagnosis of appendicitis?
a. The pain is localized at a position halfway between the umbilicus and the right iliac crest.
b. Mr. Liu describes the pain as occurring 2 hours after eating
c. The pain subsides after eating
d. The pain is in the left lower quadrant

Answer: A. The pain is localized at a position halfway between the umbilicus and the right iliac crest. Rationale: Pain over McBurney’s point, the point halfway between the umbilicus and the iliac crest, is diagnosis for appendicitis. Options b and c are common with ulcers; option d may suggest ulcerative colitis or diverticulitis.

42. Which of the following complications is thought to be the most common cause of appendicitis?
a. A fecalith
b. Internal bowel occlusion
c. Bowel kinking
d. Abdominal wall swelling

Answer: A. A fecalith
Rationale: A fecalith is a hard piece of stool which is stone like that commonly obstructs the lumen. Due to obstruction, inflammation and bacterial invasion can occur. Tumors or foreign bodies may also cause obstruction.

43. The doctor ordered for a complete blood count. After the test, Nurse Ray received the result from the laboratory. Which laboratory values will confirm the diagnosis of appendicitis?
a. RBC 5.5 x 106/mm3
b. Hct 44 %
c. WBC 13, 000/mm3
d. Hgb 15 g/dL

Answer: C. WBC 13, 000/mm3
Rationale: Increase in WBC counts is suggestive of appendicitis because of bacterial invasion and inflammation. Normal WBC count is 5, 000 – 10, 000/mm3. Other options are normal values.

44. Signs and symptoms include pain in the RLQ of the abdomen that may be localize at McBurney’s point. To relieve pain, Mr. Liu should assume which position?
a. Prone
b. Supine, stretched out
c. Sitting
d. Lying with legs drawn upl

Answer: D. Lying with legs drawn up
Rationale: Posturing by lying with legs drawn up can relax the abdominal muscle thus relieve pain.

45. After a few minutes, the pain suddenly stops without any intervention. Nurse Ray might suspect that:
a. the appendix is still distended
b. the appendix may have ruptured
c. an increased in intrathoracic pressure will occur
d. signs and symptoms of peritonitis occur

Answer: B. The appendix may have ruptured
Rationale: If a confirmed diagnosis is made and the pain suddenly without any intervention, the appendix may have ruptured; the pain is lessened because the appendix is no longer distended thus surgery is still needed.

Situation 10: Nurse Nico is caring to a 38-year-old female, G3P3 client who has been diagnosed with hemorrhoids.

46. Which of the following factors would most likely be a primary cause of her hemorrhoids?
a. Her age
b. Three vaginal delivery pregnancies
c. Her job as a school teacher
d. Varicosities in the legs

Answer: B. Three vaginal delivery pregnancies
Rationale: Hemorrhoids are associated with prolonged sitting, or standing, portal hypertension, chronic constipation and prolonged intra abdominal pressure as associated with pregnancy and the strain of vaginal delivery. Her job as a schoolteacher does not require prolong sitting or standing. Age and leg varicosities are not related to the development of hemorrhoids.

47. Client education should include minimizing client discomfort due to hemorrhoids. Nursing management should include:
a. Suggest to eat low roughage diet
b. Advise to wear silk undergarments
c. Avoid straining during defecation
d. Use of sitz bath for 30 minutes

Answer: C. Avoid strainining during defecation
Rationale: Straining can increase intra abdominal pressure. Health teachings also include: suggest to eat high roughage diet, wearing of cotton undergarments and use of sitz bath for 15 minutes.

48. The doctor orders for Witch Hazel 5 %. Nurse Nico knows that the action of this astringent is:
a. temporarily relieves pain, burning, and itching by numbing the nerve endings
b. causes coagulation (clumping) of proteins in the cells of the perianal skin or the lining of the anal canal
c. inhibits the growth of bacteria and other organisms
d. causes the outer layers of skin or other tissues to disintegrate

Answer: B. causes coagulation (clumping) of proteins in the cells of the perianal skin or the lining of the anal canal
Rationale: Option a are local anesthetics; c are antiseptics and d are keratolytics.

49. Which position would be ideal for the client in the early postoperative period after hemorrhoidectomy?
a. High Fowler’s
b. Supine
c. Side – lying
d. Trendelenburg’s

Answer: C. Side – lying
Rationale: Positioning in the early postoperative phase should avoid stress and pressure on the operative site. The prone and side – lying are ideal from a comfort perspective. A high Fowler’s or supine position will place pressure on the operative site and is not recommended. There is no need for trendelenburg’s position.

50. Nurse Nico instructs her client who has had a hemorrhoidectomy not to used sitz bath until at least 12 hours postoperatively to avoid which of the following complications?
a. Hemorrhage
b. Rectal Spasm
c. Urinary retention
d. Constipation

Answer: A. Hemorrhage
Rationale: Applying heat during the immediate postoperative period may cause hemorrhage at the surgical site. Moist heat may relieve rectal spasms after bowel movements. Urinary retention caused by reflex spasm may also be relieved by moist heat. Increasing fiber and fluid in the diet can help constipation.

Post Merge: 11 years ago

ANSWERS AND RATIONALES

1. Which individual is at greatest risk for developing hypertension?
A) 45 year-old African American attorney
B) 60 year-old Asian American shop owner
C) 40 year-old Caucasian nurse
D)55 year-old Hispanic teacher

The correct answer is A: 45 year-old African American attorney The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.

2. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first?
A) Gastric lavage PRN
B) Acetylcysteine (mucomyst) for age per pharmacy
C) Start an IV Dextrose 5% with 0.33% normal saline to keep vein open
D) Activated charcoal per pharmacy

The correct answer is A: Gastric lavage PRN Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids.

3. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?
A) angina at rest
B) thrombus formation
C) dizziness
D) falling blood pressure

The correct answer is B: thrombus formation Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure.

4. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is
A) Maintain fluid and electrolyte balance
B) Control nausea
C) Manage pain
D) Prevent urinary tract infection

The correct answer is C: Manage pain The immediate goal of therapy is to alleviate the client’s pain.

5. What would the nurse expect to see while assessing the growth of children during their school age years?
A) Decreasing amounts of body fat and muscle mass
B) Little change in body appearance from year to year
C) Progressive height increase of 4 inches each year
D) Yearly weight gain of about 5.5 pounds per year

The correct answer is D: Yearly weight gain of about 5.5 pounds per year School age children gain about 5.5 pounds each year and increase about 2 inches in height.

6. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to
A) go get a blood pressure check within the next 48 to 72 hours
B) check blood pressure again in 2 months
C) see the health care provider immediately
D) visit the health care provider within 1 week for a BP check

The correct answer is A: go get a blood pressure check within the next 48 to 72 hours The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke. However immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.

7. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?
A) A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago
B) A young adult with diabetes mellitus Type 2 for over 10 years and admitted with antibiotic induced diarrhea 24 hours ago
C) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was admitted with Stevens-Johnson syndrome that morning
D) An adolescent with a positive HIV test and admitted for acute cellulitus of the lower leg 48 hours ago

The correct answer is A: A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.

8. A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:
A) Should be taken in the morning
B) May decrease the client's energy level
C) Must be stored in a dark container
D) Will decrease the client's heart rate

The correct answer is A: Should be taken in the morning Thyroid supplement should be taken in the morning to minimize the side effects of insomnia

9. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?
A) Prepare the child for x-ray of upper airways
B) Examine the child's throat
C) Collect a sputum specimen
D) Notify the healthcare provider of the child's status

The correct answer is D: Notify the health care provider of the child''s status These findings suggest a medical emergency and may be due to epiglottises. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.

10. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation?
A) Polyphagia
B) Dehydration
C) Bed wetting
D) Weight loss

The correct answer is C: Bed wetting In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents

11. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?
A) Trichomoniasis
B) Chlamydia
C) Staphylococcus
D) Streptococcus

The correct answer is B: Chlamydia Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.

12. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
A) A middle-aged client who says "I took too many diet pills" and "my heart feels like it is racing out of my chest."
B) A young adult who says "I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?"
C) An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10
D) An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room

The correct answer is c: An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opoid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.

13. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize
A) Eating 3 balanced meals a day
B) Adding complex carbohydrates
C) Avoiding very heavy meals
D) Limiting sodium to 7 gms per day

The correct answer is C: Avoiding very heavy meals Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease.

14. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working?
A) The client complains of discomfort at the IV insertion site
B) The client states "I just can't get relief from my pain."
C) The level of drug is 100 ml at 8 AM and is 80 ml at noon
D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon

The correct answer is C: The level of drug is 100 ml at 8 AM and is 80 ml at noon The minimal dose of 10 ml per hour which would be 40 ml given in a 4 hour period. Only 60 ml should be left at noon. The pump is not functioning when more than expected medicine is left in the container.

15. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response? A) Electrical energy fields
B) Spinal column manipulation
C) Mind-body balance
D) Exercise of joints

The correct answer is B: Spinal column manipulation The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation.

16. The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention?
A) Decrease in level of consciousness
B) Loss of bladder control
C) Altered sensation to stimuli
D) Emotional lability

The correct answer is A: Decrease in level of consciousness A further decrease in the level of consciousness would be indicative of a further progression of the CVA.

17. A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time?
A) Positive sweat test
B) Bulky greasy stools
C) Moist, productive cough
D) Meconium ileus

The correct answer is C: Moist, productive cough Option c is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.

18. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should
A) Place a call to the client's health care provider for instructions
B) Send him to the emergency room for evaluation
C) Reassure the client's wife that the symptoms are transient
D) Instruct the client's wife to call the doctor if his symptoms become worse

The correct answer is B: Send him to the emergency room for evaluation This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client''s best interest.

19. Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test?
A) Client must be NPO before the examination
B) Enema to be administered prior to the examination
C) Medicate client with Lasix 20 mg IV 30 minutes prior to the examination
D) No special orders are necessary for this examination

The correct answer is D: No special orders are necessary for this examination No special preparation is necessary for this examination.

20. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question?
A) "You need to regain your strength before attempting such exertion." B) "When you can climb 2 flights of stairs without problems, it is generally safe."
C) "Have a glass of wine to relax you, then you can try to have sex."
D) "If you can maintain an active walking program, you will have less risk."
The correct answer is B: "When you can climb 2 flights of stairs without problems, it is generally safe." There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.

21. A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?
A) A 2 month old infant with a history of rolling off the bed and has buldging fontanels with crying
B) A teenager who got a singed beard while camping
C) An elderly client with complaints of frequent liquid brown colored stools
D) A middle aged client with intermittent pain behind the right scapula

The correct answer is B: A teenager who got singed a singed beard while camping This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.

22. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs?
A) "I want to protect my child from any falls."
B) "I will set limits on exploring the house."
C) "I understand the need to use those new skills."
D) "I intend to keep control over our child."

The correct answer is C: "I understand the need to use those new skills." Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.

23. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is
A) Verify correct placement of the tube
B) Check that the feeding solution matches the dietary order
C) Aspirate abdominal contents to determine the amount of last feeding remaining in stomach
D) Ensure that feeding solution is at room temperature

The correct answer is A: Verify correct placement of the tube Proper placement of the tube prevents aspiration.

24. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued? A) Narrowed QRS complex
B) Shortened "PR" interval
C) Tall peaked T waves
D) Prominent "U" waves

The correct answer is C: Tall peaked T waves A tall peaked T wave is a sign of hyperkalemia. The health care provider should be notified regarding discontinuing the medication.

25. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?
A) All striated muscles
B) The cerebellum
C) The kidneys
D) The leg bones

The correct answer is A: All striated muscles Rhabdomyosarcoma is the most common children''s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is “myo” which typically means muscle.

26. The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to
A) Achieve harmony
B) Maintain a balance of energy
C) Respect life
D) Restore yin and yang

The correct answer is D: Restore yin and yang For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang.

27. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to A) Increase fluids that are high in protein
B) Restrict fluids
C) Force fluids and reassess blood pressure
D) Limit fluids to non-caffeine beverages

The correct answer is C: Force fluids and reassess blood pressure Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.

28. A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure
A) Right heart function
B) Left heart function
C) Renal tubule function
D) Carotid artery function

The correct answer is B: Left heart function The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. The pressure readings are inferred from pressure measurements obtained on the right side of the circulation. Right-sided heart function is assessed through the evaluation of the central venous pressures (CVP).

29. A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is
A) Start a peripheral IV
B) Initiate closed-chest massage
C) Establish an airway
D) Obtain the crash cart

The correct answer is C: Establish an airway Establishing an airway is always the primary objective in a cardiopulmonary arrest.

30. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?
A) Blood pressure 94/60
B) Heart rate 76
C) Urine output 50 ml/hour
D) Respiratory rate 16

The correct answer is A: Blood pressure 94/60 Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic B/P over 100) in order to safely administer both medications.

31. While assessing a 1 month-old infant, which finding should the nurse report immediately?
A) Abdominal respirations
B) Irregular breathing rate
C) Inspiratory grunt
D) Increased heart rate with crying

The correct answer is C: Inspiratory grunt Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant.

32. The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to
A) Excessive fetal weight
B) Low blood sugar levels
C) Depletion of subcutaneous fat
D) Progressive placental insufficiency

The correct answer is D: Progressive placental insufficiency The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia.

33. The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse’s immediate attention? A) I have bad muscle spasms in my lower leg of the affected extremity.
B) "I just can't 'catch my breath' over the past few minutes and I think I am in grave danger."
C) "I have to use the bedpan to pass my water at least every 1 to 2 hours." D) "It seems that the pain medication is not working as well today."

The correct answer is B: "I just can''t ''catch my breath'' over the past few minutes and I think I am in grave danger." The nurse would be concerned about all of these comments. However the most life threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of post operative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. And option D requires further investigation and is not life threatening.

34. A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?
A) Weight gain of 5 pounds
B) Edema of the ankles
C) Gastric irritability
D) Decreased appetite

The correct answer is D: Decreased appetite Lasix causes a loss of po

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50 Gastrointestinal Health Problems with Answers and Rationales

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