Download GI/Neuro Med Surg Detailed Answer Key: Multiple Choice Questions and Answers and more Exams Nursing in PDF only on Docsity!
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- A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The pharmacy is delayed in supplying the client’s next container of TPN. Which of the following fluids should the nurse infuse until the next container arrives? A. Dextrose 5% in water Rationale: TPN contains high concentrations of certain nutrients. Infusing dextrose 5% in water could cause rapid shifts in serum levels of some substances. B. 0.9% sodium chloride Rationale: TPN contains high concentrations of certain nutrients. Infusing 0.9% sodium chloride could cause rapid shifts in serum levels of some substances. C. Dextrose 10% in water Rationale: TPN contains high concentrations of dextrose and proteins. To avoid hypoglycemia, the nurse should infuse dextrose 10% or 20% in water until the next container of TPN solution arrives. D. Lactated Ringer’s solution Rationale: TPN contains high concentrations of certain nutrients. Infusing lactated Ringer’s solution could cause rapid shifts in serum levels of some substances.
- A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the following statements by the nurse is appropriate? A. “You should decrease your caloric intake when abdominal pain is present.” Rationale: Clients who have chronic pancreatitis are at risk for malnutrition and should increase their caloric intake in order to maintain weight. B. “You should increase your daily intake of protein.” Rationale: Clients who have chronic pancreatitis should consume a diet that is high in protein. C. “You should increase fat intake when experiencing loose stools.” Rationale: Clients who have chronic pancreatitis should consume a low-fat diet to prevent stimulation of the pancreas and steatorrhea. D. “You should limit alcohol intake to 2-3 drinks per week.”
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Rationale: Clients who have chronic pancreatitis should avoid alcohol intake to prevent stimulation of the pancreas.
- A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral aneurysm. If the client manifests increased intracranial pressure, which of the following findings should the nurse expect? (Select all that apply) A. Violent headache B. Neck pain and stiffness C. Slurred speech D. Projectile vomiting E. Rapid loss of consciousness Rationale: Violent headache is correct. The client who manifests ICP should display a violent headache Neck pain and stiffness is incorrect. The client who manifests ICP should not display neck pain and stiffness Slurred speech is correct. The client who manifests ICP may display slurred speech. Projectile vomiting is correct. The client who manifests ICP may display sudden onset of projectile vomiting. Rapid loss of consciousness is correct. The client who manifests ICP may display a sudden rapid loss of consciousness.
- A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an appropriate finding by the nurse? A. Severe headache Rationale: The nurse should find as a sign of meningococcal meningitis severe headache due to meningeal inflammation. B. Bradycardia Rationale: The nurse should find as a sign of meningococcal meningitis tachycardia not bradycardia.
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Rationale: Supplements via nasogastric tube provide enteral nutrition for clients who are at risk for aspiration caused by a diminished gag reflex or difficulty swallowing. This nutritional therapy will likely be prescribed. C. Initiation of total parenteral nutrition Rationale: Total parenteral nutrition is initiated when the GI tract cannot be used for the ingestion, digestion, and absorption of essential nutrients. This nutritional therapy will not likely be prescribed. D. Soft residue diet Rationale: A soft residue diet would place the client at risk for aspiration due to difficulty swallowing solids; therefore, this nutritional therapy will not likely be prescribed.
- A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following is an appropriate response by the nurse? A. "Incorporate nonverbal cues in the conversation." Rationale: Nonverbal cues enhance the client’s ability to comprehend and use language. B. "Ask multiple choice questions as part of the conversation." Rationale: Simple questions requiring yes/no responses are better understood by the client. C. "Use a higher-pitched tone of voice when speaking." Rationale: Tone of voice is understood by clients with aphasia, unless they have a hearing impairment. D. "Use simple child-like statements when speaking." Rationale: It is important to respect the client and use age-appropriate communication.
- A nurse is caring for a client in liver failure with ascites who is receiving spironolactone (Aldactone). Which of the following outcomes should the nurse expect from this client’s medication therapy? A. Increased sodium excretion Rationale: The primary action of spironolactone is to increase sodium excretion in the urines. B. Decreased urinary output Rationale: Spironolactone is a diuretic, thus it should increase urine output.
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C. Increased potassium excretion Rationale: Spironolactone is potassium-sparing. D. Decreased chloride excretion Rationale: Spironolactone promotes the excretion of chloride in the urine.
- A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? A. Dehydration Rationale: Dehydration is not considered a complication of the hypothermia blanket therapy. B. Seizures Rationale: Seizures are not considered a complication of the hypothermia blanket therapy. C. Burns Rationale: Burns are associated with the improper use of heating pads, not a hypothermia blanket. D. Shivering Rationale: The hypothermia (cooling) blanket, if used improperly (at inappropriately low temperatures, or without skin protection), can cause the client to cool too fast, leading to shivering. To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in an attempt to reduce heat loss. The body will also try to increase heat production by shivering, which can increase the metabolic rate by two to five times and in doing so greatly raise oxygen consumption.
- An acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain tumor. When performing a neurological examination, which of following is the most reliable indicator of cerebral status? A. Pupil response Rationale: The nurse should include pupil response as part of a neurological examination; however, it is not the most reliable indicator of cerebral status. B. Deep tendon reflexes Rationale: The nurse should include deep tendon reflexes as part of a neurological examination; however, it is not the most reliable indicator of cerebral status.
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Rationale: It may be necessary to notify the provider, but this is not the first action the nurse should take. C. Remove the PICC line. Rationale: It may be necessary to remove the PICC line, but this is not the first action the nurse should take. D. Apply a cold pack to the client's upper arm. Rationale: It may be necessary to apply a cold pack to the client's upper arm, but this is not the first action the nurse should take.
- A nurse is planning care for a client who has a GI bleed. Which of the following actions should the nurse take first? A. Assess orthostatic blood pressure. Rationale: The first action the nurse should take using the nursing process is to assess the client; therefore, assessing the orthostatic blood pressure is the first priority to determine if the client is hypovolemic. B. Explain the procedure for an upper GI series. Rationale: The nurse should explain the procedure for an upper GI series, but this is not the priority. C. Administer pain medication. Rationale: The nurse should administer pain medication as needed, but this is not the priority. D. Test the emesis for blood. Rationale: The nurse should test the emesis for blood if the client vomits, but this is not the priority.
- A nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for fatsoluble vitamin supplements. The nurse should instruct the client to take a supplement for which of the following? A. Vitamin A Rationale: The nurse should instruct the client that fat-soluble vitamins include vitamins A, D, E, and K. B. Vitamin B
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Rationale: itamin B1 is not a fat-soluble vitamin. C. Vitamin C Rationale: Vitamin C is not a fat-soluble vitamin. D. Vitamin B Rationale: Vitamin B12 is not a fat-soluble vitamin.
- A nurse is caring for a client who has acute pancreatitis. After the client's pain has been addressed, which of the following is the next intervention to include in the plan of care? A. Monitor respiratory status every 8 hr. Rationale: Monitoring respiratory status is an appropriate intervention, but it is not the next intervention. B. Encourage a side-lying position with knees flexed. Rationale: Encouraging a side-lying position with knees flexed status is an appropriate intervention, but it is not the next intervention. C. Provide frequent oral hygiene. Rationale: Providing frequent oral hygiene status is an appropriate intervention, but it is not the next intervention. D. Maintain NPO status. Rationale: To rest the pancreas and reduce secretion of pancreatic enzymes, oral fluids and food are withheld during the acute phase of pancreatitis. This is the next intervention to be included in the plan of care.
- A nurse is caring for a client at a rehabilitation center 3 weeks after a cerebrovascular accident (CVA). Because the client's CVA affected the left side of the brain, which of the following goals should the nurse anticipate including in the client's rehabilitation program? A. Establish the ability to communicate effectively. Rationale: A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication.
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E. Restlessness Rationale: Tachycardia is correct. Increases in pulse and respiratory rates are indications of impending airway obstruction. Nausea is incorrect. Gastrointestinal upset is not an indication of impending airway obstruction. Retractions is correct. Substernal, suprasternal, and intercostal retractions and flaring nares are indications of impending airway obstruction. Muscle tremors is incorrect. Muscle tremors are not an indication of impending airway obstruction. Restlessness is correct. Restlessness is an indication of impending airway obstruction.
- A nurse is assessing a client who has meningitis and notes when passively flexing the client’s neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying? A. Kernig’s sign Rationale: The client who displays the Kernig’s sign is unable to extend the leg completely when the thigh is flexed on the abdomen, which is not the condition manifested but is a common sign of meningitis. B. Nuchal rigidity Rationale: The client who displays nuchal rigidity has a stiff painful neck when the head is flexed, which is not the condition manifested but is a common sign of meningitis. C. Brudzinski sign Rationale: The client was manifesting Brudzinski sign, flexes hips and knees when neck is flexed, a common sign of meningitis. D. Bradykinesia Rationale: The client who displays bradykinesia, slow or no movement of extremities is a sign of Parkinson disease.
- A nurse is caring for a client who has a history of pancreatitis. Which of the following food choices should the client avoid?
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A. Noodles Rationale: Clients who have a history of pancreatitis should avoid foods high in fat. Noodles are low in fat and are therefore an appropriate food choice for clients with pancreatitis. B. Vegetable soup Rationale: Clients who have a history of pancreatitis should avoid foods high in fat. Vegetable soup is low in fat and is therefore an appropriate food choice for clients with pancreatitis. C. Baked fish Rationale: Clients who have a history of pancreatitis should avoid foods high in fat. Baked fish is low in fat and is therefore an appropriate food choice for clients with pancreatitis. D. Cheddar cheese Rationale: Clients who have pancreatitis should avoid foods high in fat. Cheddar cheese is high in fat content and the client should avoid this food choice.
- A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate in the client’s history? A. Gallstones Rationale: The client’s history may reveal biliary obstruction from a gallstone causing bile to inflame the pancreas. B. Hypolipidemia Rationale: The client’s history may reveal hyperlipidemia, not hypolipidemia, a metabolic disturbance causing an inflamed pancreas. C. COPD Rationale: The client’s history of COPD would not cause pancreatitis. D. Diabetes mellitus Rationale: The client’s history of diabetes mellitus may be a result of pancreatitis, not cause the disorder.
- A nurse is anticipating the provider’s orders for a client who has a paralytic ileus following an appendectomy. Which of the following are expected nursing actions? A. Administer antacids.
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A. Flush the peripheral IV line with 0.9% sodium chloride to await further instructions from the physician. Rationale: This is not the appropriate intervention for the nurse to take. B. Change the tubing and filter on the TPN. Rationale: Changing the tubing and filter is not the appropriate intervention for the nurse to take. C. Hang an infusion 10% dextrose. Rationale: The sudden withdrawal from the TPN (hypertonic solution) can cause the client to be experiencing hypoglycemia. Administering an infusion of 10% dextrose will adjust the client’s blood glucose levels. D. Notify the pharmacy. Rationale: This is not the appropriate intervention for the nurse to take.
- A nurse is caring for a child with a suspected diagnosis of bacterial meningitis. Which of the following is the priority action by the nurse? A. Administer antibiotics when available. Rationale: The priority nursing action is to administer antibiotics when available. Bacterial meningitis is an acute inflammation of the meninges and the CNS, and antibiotic therapy has a marked effect on the course and prognosis of the illness. B. Reduce environmental stimuli. Rationale: Reducing environmental stimuli is an appropriate action by the nurse; however, this is not the priority. C. Document intake and output. Rationale: Documenting intake and output is an appropriate action by the nurse; however, this is not the priority. D. Maintain seizure precautions. Rationale: Maintaining seizure precautions is an appropriate action by the nurse; however, this is not the priority.
- A nurse is caring for a client whose total parenteral nutrition (TPN) was stopped for an hour by mistake. After restarting the infusion pump, the nurse should watch the client carefully for the development of
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A. excessive thirst and urination. Rationale: Excessive thirst and urination are manifestations of hyperglycemia, which is a complication of TPN related to the high proportion of glucose in the infusion. Hyperglycemia would not occur secondary to an interruption in the TPN administration. B. shakiness and diaphoresis. Rationale: When a sudden interruption in the infusion of TPN occurs, the client is at risk for hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia. C. fever and chills. Rationale: Fever and chills are manifestations of infection. D. hypertension and crackles. Rationale: Hypertension and crackles are manifestations of fluid overload, which is a complication of TPN related to the fluid infusion rate.
- A nurse on a pediatric unit is caring for a client who has a brain tumor. To help ensure the client’s safety, which of the following actions should the nurse take? A. Do not allow the child to ambulate in his room alone. Rationale: Allowing the child to ambulate in his room alone does not increase the child’s safety risk appreciably and has other benefits for the client. B. Limit contact with other pediatric clients. Rationale: Contact with other clients on the pediatric unit does not increase the child’s safety risk appreciably and has other benefits for the client. C. Initiate seizure precautions for the child. Rationale: A client who has a brain tumor is at risk for seizures. It is imperative for the nurse to implement seizure precautions for this client. D. Have the child use a wheelchair for all out-of-bed activities. Rationale: Having the child use a wheelchair is unnecessary and does not ensure the child’s safety.
- A client has right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions should the nurse implement to prevent foot-drop?
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in a client who has dysphagia by increasing the liquid’s viscosity and making it easier to swallow. D. Transferring from chair to bed Rationale: As a member of the interdisciplinary team, the physical therapist would help the client achieve gross mobility skills, such as facilitating ambulation and teaching the client to use a walker or crutches. The physical therapist also assists with ADLs, such as moving in and out of the bed, ambulating, and toileting.
- A nurse is caring for a conscious client who has an airway obstruction. Which of the following is an appropriate intervention? A. Tilt the head and lift the chin. Rationale: Tilting the head and lifting the chin is an appropriate intervention to open the airway if the client loses consciousness. B. Begin the Heimlich maneuver. Rationale: The nurse should immediately begin the Heimlich maneuver on a conscious client who has an airway obstruction and should continue until the obstruction is clear or the client loses consciousness. C. Turn the client to the side. Rationale: Turning the client to the side is an appropriate intervention if the client is unconscious and breathing. D. Perform a blind finger sweep. Rationale: Performing a blind finger sweep creates a risk of worsening the obstruction.
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- A nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following should the nurse recognize as a complication of this therapy? A. Polyuria Rationale: TPN is prescribed when extensive nutritional support for prolonged periods of time is required. It is delivered through a central venous access device, usually via the internal jugular or subclavian vein. TPN contains a high concentration of dextrose, which can result in hyperglycemia. Clinical manifestations of hyperglycemia include polydipsia, polyphagia, and polyuria. Frequent glucose monitoring should be implemented in clients receiving TPN. Administering regular insulin according to a sliding scale will help control glucose levels. B. Aspiration Rationale: Aspiration is a complication of total enteral nutrition (TEN). During TEN, a tube is placed in the client’s GI tract, often via the nasal passage. One of the complications of TEN is pulmonary aspiration. This can occur if the tube is not placed correctly (e.g., in the lungs instead of the stomach) or if feedings are administered too rapidly or in too large a volume. Ensuring the tube is placed correctly and maintaining the client in a Fowler’s position will minimize this risk. Because TPN is not administered via the GI tract, aspiration is not a complication. C. Diarrhea Rationale: Diarrhea is a complication of total enteral nutrition (TEN). During TEN, a tube is placed in the client’s GI tract, often via the nasal passage. Diarrhea can occur if the feedings are delivered too rapidly. Feedings should be started slowly and advanced as tolerated. Because TPN is not administered via the GI tract, diarrhea is not a complication. D. Stomatitis Rationale: Although mouth care is important for clients who are receiving supplemental nutrition, stomatitis is not expected. Stomatitis is an inflammation of the lining of the mouth that may include the inside of the cheeks, gums, and tongue. It can be caused by chemotherapy. It is not caused by TPN.
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expected reference range and indicates the client is receiving adequate amounts of protein. D. Calcium 9.4 mg/dL Rationale: A calcium level of 9.4 mg/dL is within the expected reference range but this does not indicate the TPN therapy is effective. Clients receiving TPN are at high risk for developing hypercalcemia.
- A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). The nurse should know that which of the following client findings supports this suspicion? A. Cyanotic fingertips. Rationale: Cyanotic fingertips is not an indicator that a client is experiencing increased intracranial pressure. B. Nuchal rigidity. Rationale: Nuchal rigidity is not an indicator that a client is experiencing increased intracranial pressure. C. Fever. Rationale: Fever is not an indicator that a client is experiencing increased intracranial pressure. D. Diplopia. Rationale: Clients who have meningitis can be at risk for developing increased intracranial pressure (ICP). The classic triad of manifestations for increased ICP consists of headache, nausea/vomiting, and diplopia, or double vision. The client who has meningitis and reports diplopia must be carefully monitored for other manifestations of increased ICP.
- A nurse is providing nutritional teaching to a client who has dumping syndrome following a hemi-colectomy. Which of the following foods should the nurse instruct the client to avoid? A. Rice Rationale: Clients with dumping syndrome following a hemi-colectomy should include high protein, high fat, low-to-moderate carbohydrate, and low fiber foods. Rice is low in fiber and provides carbohydrates. B. Poached eggs
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Rationale: Clients with dumping syndrome following a hemi-colectomy should include high protein, high fat, low-to-moderate carbohydrate, and low fiber foods. Poached eggs are low in fiber and a good source of protein. C. Fresh apples Rationale: Clients with dumping syndrome following a hemi-colectomy should avoid fresh fruits and choose canned or well-cooked fruits instead. D. White bread Rationale: Clients with dumping syndrome following a hemi-colectomy should include high protein, high fat, low-to-moderate carbohydrate, and low fiber foods. White bread is low in fiber and provides carbohydrates.
- A nurse is caring for a client receiving total parenteral nutrition (TPN) therapy via an infusion pump. When assessing the client receiving this therapy, which of the following observations by the nurse is of least importance? A. IV site Rationale: It is essential that the nurse assess the IV site, regardless of the fluid delivery system. B. Height of IV pole Rationale: Since the TPN is infusing via an IV infusion pump, the height of the IV pole is irrelevant. Gravity is not an issue with an infusion pump, which controls the flow of the solution via mechanical means. C. Date on tubing Rationale: It is essential that the nurse assess the date on the IV tubing. The tubing for a TPN infusion must be changed daily. In addition, the tubing itself should be assessed thoroughly. Tubing can become kinked, leading to an obstructed flow of IV fluid. If the connections are not secure, breaks in the system are potential portals of entry for infection. D. Contents of solution bag Rationale: It is essential that the nurse verify that the solution infusing is the solution ordered.
- A nurse is caring for a client following surgical treatment for a brain tumor near the hypothalamus. For which of the following is the client at risk? A. Inability to regulate body temperature
