Chapter 41: Upper Gastrointestinal Problems Lewis: Medical-Surgical Nursing, 10th Edition.

Chapter 41: Upper Gastrointestinal Problems Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A 53-yr-old male patient with deep partial-thickness burns from a chemical spill in the workplace expe ...

Chapter 41: Upper Gastrointestinal Problems Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A 53-yr-old male patient with deep partial-thickness burns from a chemical spill in the workplace experiences severe pain followed by nausea during dressing changes. Which action will be most useful in decreasing the patient’s nausea? a. Keep the patient NPO for 2 hours before dressing changes. b. Give the ordered prochlorperazine before dressing changes. c. Administer the prescribed morphine sulfate before dressing changes. d. Avoid performing dressing changes close to the patient’s mealtimes. ANS: C Because the patient’s nausea is associated with severe pain, it is likely that it is precipitated by stress and pain. The best treatment will be to provide adequate pain medication before dressing changes. The nurse should avoid doing painful procedures close to mealtimes, but nausea or vomiting that occur at other times also should be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patient’s nutrition. Administration of antiemetics is not the best choice for a patient with nausea caused by pain. However, an antiemetic may be added later if the nausea persists despite pain management. DIF: Cognitive Level: Analyze (analysis) REF: 894 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. Which item should the nurse offer to the patient who is to restart oral intake after being NPO due to nausea and vomiting? a. Glass of orange juice c. Cup of coffee with cream b. Dish of lemon gelatin d. Bowl of hot chicken broth ANS: B Clear cool liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated. DIF: Cognitive Level: Apply (application) REF: 894 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 3. A 38-year old woman receiving chemotherapy for breast cancer develops a Candida albicans oral infection. The nurse will anticipate the need for a. hydrogen peroxide rinses. b. the use of antiviral agents. c. administration of nystatin tablets. d. referral to a dentist for professional tooth cleaning. ANS: C Candida albicans infections are treated with an antifungal such as nystatin. Peroxide rinses would be painful. Oral saltwater rinses may be used but will not cure the infection. Antiviral agents are used for viral infections such as herpes simplex. Referral to a dentist is indicated for gingivitis but not for Candida infection. DIF: Cognitive Level: Apply (application) REF: 897 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 4. Which finding in the mouth of a patient who uses smokeless tobacco is suggestive of oral cancer? a. Bleeding during tooth brushing b. Painful blisters at the lip border c. Red, velvety patches on the buccal mucosa d. White, curdlike plaques on the posterior tongue ANS: C A red, velvety patch suggests erythroplasia, which has a high incidence (>50%) of progression to squamous cell carcinoma. The other lesions are suggestive of acute processes (e.g., gingivitis, oral candidiasis, herpes simplex). DIF: Cognitive Level: Understand (comprehension) REF: 898 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 5. Which information will the nurse include when teaching adults to decrease the risk for cancers of the tongue and buccal mucosa? a. Avoid use of cigarettes and smokeless tobacco. b. Use sunscreen when outside even on cloudy days. c. Complete antibiotic courses used to treat throat infections. d. Use antivirals to treat herpes simplex virus (HSV) infections. ANS: A Tobacco use greatly increases the risk for oral cancer. Acute throat infections do not increase the risk for oral cancer, although chronic irritation of the oral mucosa does increase risk. Sun exposure does not increase the risk for cancers of the buccal mucosa. Human papillomavirus (HPV) infection is associated with an increased risk, but HSV infection is not a risk factor for oral cancer. DIF: Cognitive Level: Apply (application) REF: 898 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 6. A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement to the nurse indicates that additional teaching about GERD is needed? a. “I take antacids between meals and at bedtime each night.” b. “I sleep with the head of the bed elevated on 4-inch blocks.” c. “I eat small meals during the day and have a bedtime snack.” d. “I quit smoking several years ago, but I still chew a lot of gum.” ANS: C GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD. DIF: Cognitive Level: Apply (application) REF: 902 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 7. A 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), the nurse will plan to do frequent assessments of the patient’s a. apical pulse. c. breath sounds. b. bowel sounds. d. abdominal girth. ANS: C Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient’s stroke or GERD and do not require more frequent monitoring than the routine. DIF: Cognitive Level: Apply (application) REF: 905 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 8. The nurse explaining esomeprazole (Nexium) to a patient with recurring heartburn describes that the medication a. reduces gastroesophageal reflux by increasing the rate of gastric emptying. b. neutralizes stomach acid and provides relief of symptoms in a few minutes. c. coats and protects the lining of the stomach and esophagus from gastric acid. d. treats gastroesophageal reflux disease by decreasing stomach acid production. ANS: D The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly. DIF: Cognitive Level: Understand (comprehension) REF: 903 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. Which patient choice for a snack 3 hours before bedtime indicates that the nurse’s teaching about gastroesophageal reflux disease (GERD) has been effective? a. Chocolate pudding c. Cherry gelatin with fruit b. Glass of low-fat milk d. Peanut butter and jelly sandwich ANS: C Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods such as chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure. DIF: Cognitive Level: Apply (application) REF: 902 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 10. The nurse will anticipate teaching a patient experiencing frequent heartburn about a. a barium swallow. c. endoscopy procedures. b. radionuclide tests. d. proton pump inhibitors. ANS: D Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis. DIF: Cognitive Level: Apply (application) REF: 902 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 11. A 58-yr-old woman who was recently diagnosed with esophageal cancer tells the nurse, “I do not feel ready to die yet.” Which response by the nurse is most appropriate? a. “You may have quite a few years still left to live.” b. “Thinking about dying will only make you feel worse.” c. “Having this new diagnosis must be very hard for you.” d. “It is important that you be realistic about your prognosis.” ANS: C This response is open ended and will encourage the patient to further discuss feelings of anxiety or sadness about the diagnosis. Patients with esophageal cancer have a low survival rate, so the response “You may have quite a few years still left to live” is misleading. The response beginning, “Thinking about dying” indicates that the nurse is not open to discussing the patient’s fears of dying. The response beginning, “It is important that you be realistic” discourages the patient from feeling hopeful, which is important to patients with any life- threatening diagnosis. DIF: Cognitive Level: Analyze (analysis) REF: 907 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 12. Which information will the nurse include for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a. “Peppermint tea may reduce your symptoms.” b. “Keep the head of your bed elevated on blocks.” c. “You should avoid eating between meals to reduce acid secretion.” d. “Vigorous physical activities may increase the incidence of reflux.” ANS: B Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will decrease lower esophageal sphincter (LES) pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD. DIF: Cognitive Level: Apply (application) REF: 902 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 13. Which nursing action should be included in the postoperative plan of care for a patient after a laparoscopic esophagectomy? a. Reposition the NG tube if drainage stops. b. Elevate the head of the bed to at least 30 degrees. c. Start oral fluids when the patient has active bowel sounds. d. Notify the doctor for any bloody nasogastric (NG) drainage. ANS: B Elevation of the head of the bed decreases the risk for reflux and aspiration of gastric secretions. The NG tube should not be repositioned without consulting with the health care provider. Bloody NG drainage is expected for the first 8 to 12 hours. A swallowing study is needed before oral fluids are started. DIF: Cognitive Level: Apply (application) REF: 907 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 14. When a patient is diagnosed with achalasia, the nurse will teach the patient that a. lying down after meals is recommended. b. a liquid or blenderized diet will be necessary. c. drinking fluids with meals should be avoided. d. treatment may include endoscopic procedures. ANS: D Endoscopic and laparoscopic procedures are the most effective therapy for improving symptoms caused by achalasia. Keeping the head elevated after eating will improve esophageal emptying. A semisoft diet is recommended to improve esophageal emptying. Patients are advised to drink fluid with meals. DIF: Cognitive Level: Apply (application) REF: 908 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 15. A patient vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about a. the amount of saturated fat in the diet. b. a family history of gastric or colon cancer. c. a history of a large recent weight gain or loss. d. use of nonsteroidal antiinflammatory drugs (NSAIDs). ANS: D Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis. DIF: Cognitive Level: Understand (comprehension) REF: 909 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse determines that teaching regarding cobalamin injections has been effective when the patient with chronic atrophic gastritis states a. “The cobalamin injections will prevent gastric inflammation.” b. “The cobalamin injections will prevent me from becoming anemic.” c. “These injections will increase the hydrochloric acid in my stomach.” d. “These injections will decrease my risk for developing stomach cancer.” ANS: B Cobalamin supplementation prevents the development of pernicious anemia. Chronic gastritis may cause achlorhydria, but cobalamin does not correct this. The loss of intrinsic factor secretion with chronic gastritis is permanent, and the patient will need lifelong supplementation with cobalamin. The incidence of stomach cancer is higher in patients with chronic gastritis, but cobalamin does not reduce the risk for stomach cancer. DIF: Cognitive Level: Apply (application) REF: 910 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 17. A patient has peptic ulcer disease that has been associated with Helicobacter pylori. About which medications will the nurse plan to teach the patient? a. Sucralfate (Carafate), nystatin, and bismuth (Pepto-Bismol) b. Metoclopramide (Reglan), bethanechol (Urecholine), and promethazine c. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec) d. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix) ANS: C The drugs used in triple drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not included in the protocol for H. pylori infection. DIF: Cognitive Level: Apply (application) REF: 903 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 18. Which action should the nurse in the emergency department anticipate for a young adult patient who has had several episodes of bloody diarrhea? a. Obtain a stool specimen for culture. b. Administer antidiarrheal medication. c. Provide teaching about antibiotic therapy. d. Teach the adverse effects of acetaminophen (Tylenol). ANS: A Patients with bloody diarrhea should have a stool culture for Escherichia coli O157:H7. Antidiarrheal medications are usually avoided for possible infectious diarrhea to avoid prolonging the infection. Antibiotic therapy in the treatment of infectious diarrhea is controversial because it may precipitate kidney complications. Acetaminophen does not cause bloody diarrhea. DIF: Cognitive Level: Apply (application) REF: 925 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 19. The nurse will anticipate preparing an older patient who is vomiting “coffee-ground” emesis for a. endoscopy. c. barium studies. b. angiography. d. gastric analysis. ANS: A Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy cannot be done because it is more invasive and has more possible complications. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding. DIF: Cognitive Level: Apply (application) REF: 922 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 20. An adult with Escherichia coli O157:H7 food poisoning is admitted to the hospital with bloody diarrhea and dehydration. Which prescribed action will the nurse question? a. Infuse lactated Ringer’s solution at 250 mL/hr. b. Monitor blood urea nitrogen and creatinine daily. c. Administer loperamide (Imodium) after each stool. d. Provide a clear liquid diet and progress diet as tolerated. ANS: C Use of antidiarrheal agents is avoided with this type of food poisoning. The other orders are appropriate. DIF: Cognitive Level: Apply (application) REF: 926 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 21. Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)? a. “Ranitidine absorbs the excess gastric acid.” b. “Ranitidine decreases gastric acid secretion.” c. “Ranitidine constricts the blood vessels near the ulcer.” d. “Ranitidine covers the ulcer with a protective material.” ANS: B Ranitidine is a histamine-2 (H2) receptor blocker that decreases the secretion of gastric acid. The response beginning, “Ranitidine constricts the blood vessels” describes the effect of vasopressin. The response “Ranitidine absorbs the gastric acid” describes the effect of antacids. The response beginning “Ranitidine covers the ulcer” describes the action of sucralfate (Carafate). DIF: Cognitive Level: Understand (comprehension) REF: 903 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 22. A young adult patient is hospitalized with massive abdominal trauma from a motor vehicle crash. The patient asks the nurse about the purpose of receiving famotidine (Pepcid). The nurse will explain that the medication will a. decrease nausea and vomiting. b. inhibit development of stress ulcers. c. lower the risk for H. pylori infection. d. prevent aspiration of gastric contents. ANS: B Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent Helicobacter pylori infection. DIF: Cognitive Level: Apply (application) REF: 903 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 23. An older patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place. The health care provider prescribes 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse a. monitors arterial blood gas values daily. b. periodically aspirates and tests gastric pH. c. checks each stool for the presence of occult blood. d. measures the volume of residual stomach contents. ANS: B The purpose for antacids is to increase gastric pH. Checking gastric pH is the most direct way of evaluating the effectiveness of the medication. Arterial blood gases may change slightly, but this does not directly reflect the effect of antacids on gastric pH. Because the patient has upper gastrointestinal bleeding, occult blood in the stools will appear even after the acute bleeding has stopped. The amount of residual stomach contents is not a reflection of resolution of bleeding or of gastric pH. DIF: Cognitive Level: Apply (application) REF: 903 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 24. A patient admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take? a. Irrigate the NG tube. c. Give the ordered antacid. b. Check the vital signs. d. Elevate the foot of the bed. ANS: B The patient’s symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. Elevating the foot of the bed may increase abdominal pressure and discomfort, as well as making it more difficult for the patient to breathe. DIF: Cognitive Level: Apply (application) REF: 924 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 25. A patient who underwent a gastroduodenostomy (Billroth I) 12 hours ago complains of increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the past hour. The highest priority action by the nurse is to a. contact the surgeon. b. irrigate the NG tube. c. monitor the NG drainage. d. administer the prescribed morphine. ANS: A Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion or return to surgery are needed (or both). Because the NG is draining, there is no indication that irrigation is needed. Continuing to monitor the NG drainage is not an adequate response. The patient may need morphine, but this is not the highest priority action. DIF: Cognitive Level: Analyze (analysis) REF: 917 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 26. Which patient statement indicates that the nurse’s postoperative teaching after a gastroduodenostomy has been effective? a. “I will drink more liquids with my meals.” b. “I should choose high carbohydrate foods.” c. “Vitamin supplements may prevent anemia.” d. “Persistent heartburn is common after surgery.” ANS: C Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to receive cobalamin via injections or nasal spray. Although peptic ulcer disease may recur, persistent heartburn is not expected after surgery, and the patient should call the health care provider if this occurs. Ingestion of liquids with meals is avoided to prevent dumping syndrome. Foods that have moderate fat and low carbohydrate should be chosen to prevent dumping syndrome. DIF: Cognitive Level: Apply (application) REF: 919 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 27. At his first postoperative checkup appointment after a gastrojejunostomy (Billroth II), a patient reports that dizziness, weakness, and palpitations occur about 20 minutes after each meal. The nurse will teach the patient to a. increase the amount of fluid with meals. b. eat foods that are higher in carbohydrates. c. lie down for about 30 minutes after eating. d. drink sugared fluids or eat candy after meals. ANS: C The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome. DIF: Cognitive Level: Apply (application) REF: 918 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 28. A patient who requires daily use of a nonsteroidal antiinflammatory drug (NSAID) for the management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about a. substitution of acetaminophen (Tylenol) for the NSAID. b. use of enteric-coated NSAIDs to reduce gastric irritation. c. reasons for using corticosteroids to treat the rheumatoid arthritis. d. misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa. ANS: D Misoprostol, a prostaglandin analog, reduces acid secretion and the incidence of upper GI bleeding associated with NSAID use. Enteric coating of NSAIDs does not reduce the risk for GI bleeding. Corticosteroids increase the risk for ulcer development and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating rheumatoid arthritis. DIF: Cognitive Level: Apply (application) REF: 914 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 29. The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient’s peptic ulcer. The nurse will teach the patient to take a. sucralfate at bedtime and antacids before each meal. b. sucralfate and antacids together 30 minutes before meals. c. antacids 30 minutes before each dose of sucralfate is taken. d. antacids after meals and sucralfate 30 minutes before meals. ANS: D Sucralfate is most effective when the pH is low and should not be given with or soon after antacids. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications. DIF: Cognitive Level: Understand (comprehension) REF: 914 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 30. Which information about dietary management should the nurse include when teaching a patient with peptic ulcer disease (PUD)? a. “You will need to remain on a bland diet.” b. “Avoid foods that cause pain after you eat them.” c. “High-protein foods are least likely to cause you pain.” d. “You should avoid eating any raw fruits and vegetables.” ANS: B The best information is that each individual should choose foods that are not associated with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa, but chewing well seems to decrease this problem and some patients may tolerate these foods well. High-protein foods help neutralize acid, but they also stimulate hydrochloric (HCl) acid secretion and may increase discomfort for some patients. Bland diets may be recommended during an acute exacerbation of PUD, but there is little scientific evidence to support their use. DIF: Cognitive Level: Apply (application) REF: 918 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 31. A 73-yr-old patient is diagnosed with stomach cancer after an unintended 20-lb weight loss. Which nursing action will be included in the plan of care? a. Refer the patient for hospice services. b. Infuse IV fluids through a central line. c. Teach the patient about antiemetic therapy. d. Offer supplemental feedings between meals. ANS: D The patient data indicate a poor nutritional state and improvement in nutrition will be helpful in improving the response to therapies such as surgery, chemotherapy, or radiation. Nausea and vomiting are not common clinical manifestations of stomach cancer. There is no indication that the patient requires hospice or IV fluid infusions. DIF: Cognitive Level: Apply (application) REF: 920 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 32. A 26-yr-old patient with a family history of stomach cancer asks the nurse about ways to decrease the risk for developing stomach cancer. The nurse will teach the patient to avoid a. emotionally stressful situations. b. smoked foods such as ham and bacon. c. foods that cause distention or bloating. d. chronic use of H2 blocking medications. ANS: B Smoked foods such as bacon, ham, and smoked sausage increase the risk for stomach cancer. Stressful situations, abdominal distention, and use of H2 blockers are not associated with an increased incidence of stomach cancer. DIF: Cognitive Level: Apply (application) REF: 919 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 33. The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What information is most important to report to the health care provider? a. Hemoglobin (Hgb) 10.8 g/dL b. Temperature 102.1°F (38.9°C) c. Absent bowel sounds in all quadrants d. Scant nasogastric (NG) tube drainage ANS: B An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery and do not require any urgent action. DIF: Cognitive Level: Analyze (analysis) REF: 921 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 34. A 58-yr-old patient has just been admitted to the emergency department with nausea and vomiting. Which information requires the most rapid intervention by the nurse? a. The patient has been vomiting for 4 days. b. The patient takes antacids 8 to 10 times a day. c. The patient is lethargic and difficult to arouse. d. The patient has had a small intestinal resection. ANS: C A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information is also important to collect, but it does not require as quick action as the risk for aspiration. DIF: Cognitive Level: Analyze (analysis) REF: 896 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 35. A young adult been admitted to the emergency department with nausea and vomiting. Which action could the RN delegate to unlicensed assistive personnel (UAP)? a. Auscultate the bowel sounds. c. Assist the patient with oral care. b. Assess for signs of dehydration. d. Ask the patient about the nausea. ANS: C Oral care is included in UAP education and scope of practice. The other actions are all assessments that require more education and a higher scope of nursing practice. DIF: Cognitive Level: Apply (application) REF: 907 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 36. A 49-yr-old man has been admitted with hypotension and dehydration after 3 days of nausea and vomiting. Which prescribed action will the nurse implement first? a. Insert a nasogastric (NG) tube. b. Infuse normal saline at 250 mL/hr. c. Administer IV ondansetron (Zofran). d. Provide oral care with moistened swabs. ANS: B Because the patient has severe dehydration, rehydration with IV fluids is the priority. The other orders should be accomplished after the IV fluids are initiated. DIF: Cognitive Level: Analyze (analysis) REF: 915 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 37. Which patient should the nurse assess first after receiving change-of-shift report? a. A patient with nausea who has a dose of metoclopramide (Reglan) due b. A patient who is crying after receiving a diagnosis of esophageal cancer c. A patient with esophageal varices who has a blood pressure of 92/58 mm Hg d. A patient admitted yesterday with gastrointestinal (GI) bleeding who has melena ANS: C The patient’s history and blood pressure indicate possible hemodynamic instability caused by GI bleeding. The data about the other patients do not indicate acutely life-threatening complications. DIF: Cognitive Level: Analyze (analysis) REF: 922 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 38. A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours ago. Which assessment finding is most important for the nurse to address immediately? a. The patient is experiencing intermittent waves of nausea. b. The patient has no breath sounds in the left anterior chest. c. The patient complains of 7/10 (0 to 10 scale) abdominal pain. d. The patient has hypoactive bowel sounds in all four quadrants. ANS: B Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The nausea and abdominal pain should also be addressed, but they are not as high priority as the patient’s respiratory status. The patient’s decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action. DIF: Cognitive Level: Analyze (analysis) REF: 904 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 39. Which assessment should the nurse perform first for a patient who just vomited bright red blood? a. Measuring the quantity of emesis b. Palpating the abdomen for distention c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse ANS: D The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal bleeding. BP and pulse are the best indicators of these complications. The other information is important to obtain, but BP and pulse rate are the best indicators for assessing intravascular volume. DIF: Cognitive Level: Analyze (analysis) REF: 924 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 40. Which prescribed action will the nurse implement first for a patient who has vomited 1100 mL of blood? a. Give an IV H2 receptor antagonist. b. Draw blood for typing and crossmatching. c. Administer 1 L of lactated Ringer’s solution. d. Insert a nasogastric (NG) tube and connect to suction. ANS: C Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions also are important to implement quickly, but are not the highest priorities. DIF: Cognitive Level: Analyze (analysis) REF: 923 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 41. The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider? a. The bowel sounds are hyperactive in all four quadrants. b. The patient’s lungs have crackles audible to the midchest. c. The nasogastric (NG) suction is returning coffee-ground material. d. The patient’s blood pressure (BP) has increased to 142/84 mm Hg. ANS: B The patient’s lung sounds indicate that pulmonary edema may be developing as a result of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed. The return of coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when a patient has GI bleeding. DIF: Cognitive Level: Analyze (analysis) REF: 924 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 42. After the nurse has completed teaching a patient with newly diagnosed eosinophilic esophagitis about the management of the disease, which patient action indicates that the teaching has been effective? a. Patient orders nonfat milk for each meal. b. Patient uses the prescribed corticosteroid inhaler. c. Patient schedules an appointment for allergy testing. d. Patient takes ibuprofen (Advil) to control throat pain. ANS: C Eosinophilic esophagitis is frequently associated with environmental allergens, so allergy testing is used to determine possible triggers. Corticosteroid therapy may be prescribed, but the medication will be swallowed, not inhaled. Milk is a frequent trigger for attacks. NSAIDs are not used for eosinophilic esophagitis. DIF: Cognitive Level: Apply (application) REF: 907 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 43. An 80-yr-old patient who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration? a. Sucralfate (Carafate) c. Omeprazole (Prilosec) b. Aluminum hydroxide d. Metoclopramide (Reglan) ANS: D Metoclopramide can cause central nervous system side effects ranging from anxiety to hallucinations. Hallucinations are not a side effect of proton pump inhibitors, mucosal protectants, or antacids. DIF: Cognitive Level: Apply (application) REF: 895 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 44. The nurse and a licensed practical/vocational nurse (LPN/LVN) are working together to care for a patient who had an esophagectomy 2 days ago. Which action by the LPN/LVN requires that the nurse intervene? a. The LPN/LVN uses soft swabs to provide oral care. b. The LPN/LVN positions the head of the bed in the flat position. c. The LPN/LVN includes the enteral feeding volume when calculating intake. d. The LPN/LVN encourages the patient to use pain medications before coughing. ANS: B The patient’s bed should be in Fowler’s position to prevent reflux and aspiration of gastric contents. The other actions by the LPN/LVN are appropriate. DIF: Cognitive Level: Apply (application) REF: 907 OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment 45. After change-of-shift report, which patient should the nurse assess first? a. A 42-yr-old patient who has acute gastritis and ongoing epigastric pain b. A 70-yr-old patient with a hiatal hernia who experiences frequent heartburn c. A 60-yr-old patient with nausea and vomiting who has dry mucosa and lethargy d. 53-yr-old patient who has dumping syndrome after a recent partial gastrectomy ANS: C This patient is at high risk for problems such as aspiration, dehydration, and fluid and electrolyte disturbances. The other patients will also need to be assessed, but the information about them indicates symptoms that are typical for their diagnoses and are not life threatening. DIF: Cognitive Level: Apply (application) REF: 910 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment SHORT ANSWER 1. Vasopressin 0.1 unit/min infusion is prescribed for a patient with acute arterial gastrointestinal (GI) bleeding. The vasopressin label states vasopressin 100 units/250 mL normal saline. How many mL/hr will the nurse infuse? ANS: 15 There are 0.4 unit/1 mL. An infusion of 15 mL/hr will result in the patient receiving 0.1 units/min as prescribed. REF: 923 OTHER 1. The nurse is caring for a patient who develops watery diarrhea and a fever after prolonged omeprazole (Prilosec) therapy. In which order will the nurse take actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Contact the health care provider. b. Assess blood pressure and heart rate. c. Give the PRN acetaminophen (Tylenol). d. Place the patient on contact precautions. ANS: D, B, A, C Proton pump inhibitors including omeprazole (Prilosec) may increase the risk of Clostridium difficile–associated colitis. Because the patient’s history and symptoms are consistent with C. difficile infection, the initial action should be initiation of infection control measures to protect other patients. Assessment of blood pressure and pulse is needed to determine whether the patient has symptoms of hypovolemia or shock. The health care provider should be notified so that actions such as obtaining stool specimens and antibiotic therapy can be started. Tylenol may be administered but is the lowest priority of the actions. DIF: Cognitive Level: Analyze (analysis) REF: 902 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment