normal secondary to significant pancreatic

scarring and fibrosis. Of note, amylase and

Gastrointestinal System Disorders NCLEX
lipase values should not be considered
Practice Quiz
diagnostic or prognostic.
Correct Incorrect
Option A: 45 units/L is within normal limits.
1 1. Question 1 Serum amylase and lipase levels may be
slightly elevated in chronic pancreatitis;
Nurse Berlinda is assigned to a 41-year-old high levels are found only during acute
client who has a diagnosis of chronic attacks of pancreatitis. In the later stages of
pancreatitis. The nurse reviews the chronic pancreatitis, atrophy of the
laboratory result, anticipating a laboratory pancreatic parenchyma can result in normal
report that indicates a serum amylase level serum enzyme levels because of significant
of: fibrosis of the pancreas, resulting in
decreased concentrations of these enzymes
within the pancreas.
A. 45 units/L
Option B: 100 units/L is within normal
B. 100 units/L limits. When pancreatic tissue damage (eg.
pancreatitis) or pancreatic duct is blocked,
C. 300 units/L
serum amylase levels increased. In acute
D. 500 units/L pancreatitis, lipase levels are often very
high; 10.5 times the normal level can be
Correct increased
Correct Answer: C. 300 units/L Option D: 500 units/L is an extremely
elevated level seen in acute pancreatitis. In
acute pancreatitis, blood amylase
The normal serum amylase level is 25 to increased. Sometimes up to 4-6 times the
151 units/L. With chronic cases of highest normal level rises.
pancreatitis, the rise in serum amylase
2 2. Question 2
levels usually does not exceed three times
the normal value. In acute pancreatitis, the A male client who is recovering from
value may exceed five times the normal surgery has been advanced from a clear
value. Basic lab studies for chronic liquid diet to a full liquid diet. The client is
pancreatitis can include a CBC, BMP, LFTs, looking forward to the diet change because
lipase, amylase, lipid panel, and a fecal- he has been “bored” with the clear liquid
elastase-1 value. Lipase and amylase levels diet. The nurse would offer which full liquid
can be elevated, but they are usually item to the client?
 Option D: A popsicle is included in the clear
liquid diet. The clear liquid diet assists in
A. Tea
maintaining hydration, it provides
B. Gelatin electrolytes and calories, and offers some
level of satiety when a full diet is not
C. Custard appropriate, but may struggle to provide
adequate caloric needs if employed for
D. Popsicle
more than five days.
Incorrect
3 3. Question 3
Correct Answer: C. Custard
Nurse Juvy is caring for a client with
cirrhosis of the liver. To minimize the effects
of the disorder, the nurse teaches the client
Full liquid food items include items such as
about foods that are high in thiamine. The
plain ice cream, sherbet, breakfast drinks,
nurse determines that the client has the
milk, pudding, and custard, soups that are
best understanding of the dietary measures
strained, and strained vegetable juices. A
to follow if the client states an intention to
clear liquid diet consists of foods that are
increase the intake of:
relatively transparent. A patient prescribed
a full liquid diet follows a specific diet type
requiring all liquids and semi-liquids but no
A. Pork
forms of solid intake.
B. Milk

C. Chicken
Option A: Tea is included in the clear liquid
diet. Unlike a clear liquid diet, which D. Broccoli
includes only liquids and semi-liquids that
are non-opaque, a full liquid diet is more Incorrect
inclusive, as it allows all types of liquids.
Correct Answer: A. Pork
Option B: A clear liquid diet is a specific
dietary plan that only includes liquids that
are fully transparent at room temperature. The client with cirrhosis needs to consume
Some items that may be allowed include foods high in thiamine. Thiamine is present
water, ice, fruit juices without pulp, sports in a variety of foods of plant and animal
drinks, carbonated drinks, gelatin, tea, origin. Pork products are especially rich in
coffee, clear broths, and clear ice pops. this vitamin. Other good food sources
include nuts, whole grain cereals, and
legumes. Thiamine helps turn
carbohydrates into energy. It is required for B. Reinstill the amount and continue with
the metabolism of glucose, amino acids, administering the feeding
and lipids.
C. Elevate the client’s head at least 45
degrees and administer the feeding

Option B: Milk contains vitamins A, D, and D. Discard the residual amount and
B2. Milk and dairy foods provide the right proceed with administering the feeding
amount of bone-building nutrients,
Incorrect
specifically calcium, vitamin D, protein,
phosphorus, magnesium, potassium, Correct Answer: A. Hold the feeding
vitamin B12, and zinc.

Option C: Poultry contains niacin. Meat

represents an excellent source of the Unless specifically indicated, residual
majority of hydrophilic vitamins, and it is amounts more than 100 mL require holding
the ideal dietary source of vitamin B12. The the feeding. Gastric residual refers to the
amounts of B-group vitamins (e.g. niacin, volume of fluid remaining in the stomach at
vitamin B6, and pantothenic acid) in poultry a point in time during enteral nutrition
are very similar to those of other meats and feeding. Nurses withdraw this fluid via the
do not significantly diminish during cooking. feeding tube by pulling back on the plunger
of a large (usually 60 mL) syringe at
Option D: Broccoli contains vitamins C, E, intervals typically ranging from four to eight
and K, and folic acid. Broccoli is a rich hours.
source of multiple vitamins, minerals, and
fiber. Different cooking methods may affect
the vegetable’s nutrient composition, but
Option B: When interpreting GRV, clinicians
broccoli is a healthy addition to the diet
must keep in mind that the stomach has a
whether cooked or raw.
reservoir function and that the stomach
4 4. Question 4 fluid is a mixture of both the infused EN
formula and normal gastric secretions.
Nurse Oliver checks for residual before
administering a bolus tube feeding to a Option C: Patients at risk for delayed gastric
client with a nasogastric tube and obtains a emptying include those with gastroparesis,
residual amount of 150 mL. What is the poorly controlled diabetes mellitus, gastric
appropriate action for the nurse to take? outlet obstruction, ileus, recent surgery,
trauma, or sepsis, and those using a large
amount of narcotic pain medication. Efforts
to prevent aspiration of gastric contents are
A. Hold the feeding
important in these patients.
Option D: The feeding is not discarded wait until the distress subsides. The most
unless its contents are abnormal in color or common indication for placement of a
characteristics. In a review article, nasogastric tube is to decompress the
“Measurement of Gastric Residual Volume: stomach in the setting of distal obstruction.
State of the Science,” published in 2000 in Less commonly, nasogastric tubes can be
MEDSURG Nursing, Edwards and Metheny placed to administer medications or
reported that the literature contained a nutrition in patients who have a functional
variety of recommendations for what is gastrointestinal tract but are unable to
considered a high GRV, ranging from 100 to tolerate oral intake.
500 mL.

5 5. Question 5
Option A: Quickly inserting the tube is not
A nurse is inserting a nasogastric tube in an an appropriate action because, in this
adult male client. During the procedure, the situation, it may be likely that the tube has
client begins to cough and has difficulty entered the bronchus. A common error
breathing. Which of the following is the when placing the tube is to direct the tube
appropriate nursing action? in an upward direction as it enters the
nares; this will cause the tube to push
against the top of the sinus cavity and cause
A. Quickly insert the tube increased discomfort.

B. Notify the physician immediately Option B: Notifying the physician

immediately is unnecessary. If there is a
C. Remove the tube and reinsert when the great deal of difficulty in passing the tube, a
respiratory distress subsides helpful maneuver is to withdraw the tube
and attempt again after a short break in the
D. Pull back on the tube and wait until the
contralateral nares as the tube may have
respiratory distress subsides
become coiled in the oropharynx or nasal
Incorrect sinus.

Correct Answer: D. Pull back on the tube Option C: Removing the tube is
and wait until the respiratory distress unnecessary. The tip should instead be
subsides directed parallel to the floor, directly
toward the back of the patient’s throat. At
this time, the patient can be given a cup of
During the insertion of a nasogastric tube, if water with a straw in it to sip from to help
the client experiences difficulty breathing or ease the passage of the tube. The tube
any respiratory distress, withdraw the tube should be advanced with firm, constant
slightly, stop the tubing advancement, and pressure while the patient is sipping.
6 6. Question 6 the pH value and cause confusion in the
evaluation of gastric tube placement.
Nurse Ryan is assessing for correct
placement of a nasogastric tube. The nurse Option C: 7.35 indicates a neutral pH.
aspirates the stomach contents and checks Verifying the pH of the aspirated secretion
the contents for pH. The nurse verifies using reagent strips is a quick bedside test.
correct tube placement if which pH value is Currently, there is a consensus among
noted? experts that this is the safest method
available and is recommended as the first
choice when verifying gastric tube
A. 3.5 placement in adults and children.

B. 7.0 Option D: 7.5 indicates an alkaline pH. The

use of pH reagent strips is a sensitive but
C. 7.35 non-specific test to verify the placement of
the gastric tube in newborns in the sample
D. 7.5
studied. That is, pH values ???5.5 in the
Incorrect aspirated gastric tube secretion are
sensitive indicators of the correct
Correct Answer: A. 3.5
positioning of the tip of the tube.

7 7. Question 7
If the nasogastric tube is in the stomach,
A nurse is preparing to remove a
the pH of the contents will be acidic. Gastric
nasogastric tube from a female client. The
aspirates have acidic pH values and should
nurse should instruct the client to do which
be 3.5 or lower. The pH test performed with
of the following just before the nurse
reagent strips is sensitive to identify the
removes the tube?
correct placement of the gastric tube, so it
can be used as an adjuvant technique in the
evaluation of the gastric tube placement. In
A. Exhale
interpreting the results, pH ?5.5 points to
correct placement, and values > 5.5 require B. Inhale and exhale quickly
radiological confirmation.
C. Take and hold a deep breath

D. Perform a Valsalva maneuver

Option B: 7.0 indicates a slightly acidic pH.
There is evidence that the use of histamine Incorrect
H2 receptor antagonist drugs may increase
Correct Answer: C. Take and hold a deep
breath.
 Nurse Joy is preparing to administer
medication through a nasogastric tube that
When the nurse removes a nasogastric
is connected to suction. To administer the
tube, the client is instructed to take and
medication, the nurse would:
hold a deep breath. This will close the
epiglottis. This allows for easy withdrawal
through the esophagus into the nose. The
A. Position the client supine to assist in
nurse removes the tube with one smooth,
medication absorption
continuous pull.
B. Aspirate the nasogastric tube after
medication administration to maintain
Option A: The patient should take a deep patency
breath, and hold it, not exhale. An NG tube
C. Clamp the nasogastric tube for 30
should be removed if it is no longer
minutes following administration of the
required. The process of removal is usually
medication
very quick. Prior to removing an NG tube,
verify physician orders. If the NG tube was D. Change the suction setting to low
ordered to remove gastric content, the intermittent suction for 30 minutes after
physician’s order may state to “trial” medication administration
clamping the tube for a number of hours to
see if the patient tolerates its removal. Incorrect
During the trial, the patient should not
Correct Answer: C. Clamp the nasogastric
experience any nausea, vomiting, or
tube for 30 minutes following
abdominal distension.
administration of the medication.
Option B: Inhaling and exhaling quickly
could make the removal uncomfortable.
Instruct the patient to take a deep breath If a client has a nasogastric tube connected
and hold it. This prevents aspiration; to suction, the nurse should wait up to 30
holding the breath closes the glottis. minutes before reconnecting the tube to
the suction apparatus to allow adequate
Option D: Performing the Valsalva
time for medication absorption. Flush 10 ml
maneuver is inappropriate. Kink the NG
of water between medications. This step
tube near the nares and gently pull out the
prevents interactions between medications.
tube in a swift, steady motion, wrapping it
After the last medication has been given,
in hand as it is being pulled out. Dispose of
flush the tube with 30 ml of water. Flushing
the tube in a garbage bag.
prevents blocking of the tube.
8 8. Question 8
Option A: The client should not be placed in of the following items must be kept at the
the supine position because of the risk of bedside at all times?
aspiration. Help the patient to a high sitting
position unless contraindicated. This
position reduces the risk of aspiration A. An obturator
during swallowing. Pour medication and
water solution into the 60 ml syringe, B. Kelly clamp
release pinch, and allow fluid to drain
C. An irrigation set
slowly by gravity into the gastric tube.
D. A pair of scissors
Option B: Aspirating the nasogastric tube
will remove the medication just Incorrect
administered. Patients with a gastric tube
Correct Answer: D. A pair of scissors
(nasogastric, nasointestinal, percutaneous
endoscopic gastrostomy [PEG], or
jejunostomy [J] tube) will often receive
medication through this tube (Lynn, 2011). When the client has a Sengstaken-
Liquid medications should always be used Blakemore tube, a pair of scissors must be
when possible because absorption is better kept at the client’s bedside at all times. The
and less likely to cause blockage of the client needs to be observed for sudden
tube. respiratory distress, which occurs if the
gastric balloon ruptures and the entire tube
Option D: Low intermittent suction also will moves upward. If this occurs, the nurse
remove the medication just administered. immediately cuts all balloon lumens and
Determine if medication should be given removes the tube. Sengstaken-Blakemore
with or without food. If the medication is to tube placement is indicated for unstable
be given on an empty stomach, the enteral patients with uncontrolled hemorrhage.
feeding may need to be stopped from 30 Sengstaken-Blakemore tube placements
minutes before until 30 minutes after the can temporarily control the hemorrhage.
medication is given. Follow specific
medication guidelines to ensure adequate
absorption and distribution of the Option A: An obturator is kept at the
medication. bedside of a client with a tracheostomy.
9 9. Question 9 This is a piece of rigid plastic, silicone, or
metal that fits inside the outer cannula
A nurse is preparing to care for a female when a tracheostomy tube is being
client with esophageal varices who just had inserted. It helps guide the tracheostomy
a Sengstaken-Blakemore tube inserted. The tube into place, causing less damage to the
nurse gathers supplies, knowing that which tissues.
Option B: A Kelly clamp is kept at the Correct Answer: A. Hepatitis A
bedside of a client with a tracheostomy.
Clinicians must be prepared in case of
emergency as the medical condition of a Hepatitis A is transmitted by the fecal-oral
patient with tracheostomy and/or route via contaminated food or infected
mechanical ventilation may change quickly. food handlers. The most common mode of
Emergency equipment is necessary at the transmission of hepatitis A is via the fecal-
bedside as well as during the oral route from contact with food, water, or
transportation. objects contaminated by fecal matter from
an infected individual. It is more commonly
Option C: An irrigation set may be kept at
encountered in developing countries where
the bedside, but it is not the priority item.
due to poverty and lack of sanitation, there
Airway protection remains the foremost
is a higher chance of fecal-oral spread.
focus. If the patient is requiring a
Sengstaken-Blakemore tube placement,
they have likely already been intubated for
airway protection, but if not, endotracheal Option B: Hepatitis B is transmitted
intubation should be performed prior to parenterally and sexually when individuals
placement. Following intubation, the come in contact with mucous membranes
patient should be placed in the supine or body fluids of infected individuals.
position with the head of the bed elevated Transfusion of blood and blood products,
to 45 degrees. injection drug use with shared needles,
needlesticks, or wounds caused by other
10 10. Question 10 instruments in healthcare workers and
hemodialysis are all examples of parenteral
Dr. Smith has determined that the client
and percutaneous exposures, but
with hepatitis has contracted the infection
parenteral mode remains the dominant
from contaminated food. The nurse
mode of transmission both globally and in
understands that this client is most likely
the United States.
experiencing what type of hepatitis?
Option C: Transmission of Hepatitis C can be
parenteral, perinatal, and sexual, with the
A. Hepatitis A most common mode being the sharing of
contaminated needles among IV drug users.
B. Hepatitis B
Also, other high-risk groups include people
C. Hepatitis C who require frequent blood transfusions
and organ transplantation of organs from
D. Hepatitis D infected donors.
Incorrect
Option D: Hepatitis D is an RNA virus and a elevated total bilirubin levels. Typically,
single species in the Deltavirus genus. It levels of alkaline phosphatase (ALP) remain
contains the hepatitis D antigen and RNA in the reference range, but if it is elevated
strand and uses HBsAg as its envelope significantly, the clinician should consider
protein; therefore, those who get hepatitis biliary obstruction or liver abscess.
D virus infection have coinfection with the
hepatitis B virus as well. Hepatitis D virus
has similar modes of transmission as the Option A: A hemoglobin level is unrelated
hepatitis B virus, but perinatal transmission to this diagnosis. In advanced liver disease,
is uncommon. prothrombin time (PT) and international
normalized ratio (INR) may appear
11 11. Question 11
prolonged. Patients may also have
A client is suspected of having hepatitis. leukopenia and thrombocytopenia. Patients
Which diagnostic test result will assist in who suffer from easy bruising, variceal
confirming this diagnosis? bleed, or hemorrhoidal bleed due to
advanced liver disease may have anemia
with low hemoglobin and hematocrit levels.
A. Elevated hemoglobin level
Option C: An elevated blood urea nitrogen
B. Elevated serum bilirubin level level may indicate renal dysfunction. Blood
urea nitrogen (BUN) and serum creatinine
C. Elevated blood urea nitrogen level levels are also necessary for patients
suspected to have advanced liver disease to
D. Decreased erythrocyte sedimentation
look for renal impairment. Patients who
rate
present with altered mental status should
Incorrect have serum ammonia levels checked and
are usually elevated in the presence of
Correct Answer: B. Elevated serum bilirubin
hepatic encephalopathy.
level.
Option D: Elevated erythrocyte
sedimentation rate is a laboratory indicator
Laboratory indicators of hepatitis include of hepatitis. The increase in the ESR in type
elevated liver enzyme levels, elevated A hepatitis could be explained by changes in
serum bilirubin levels, elevated erythrocyte the serum protein levels in the course of
sedimentation rates, and leukopenia. acute viral hepatitis and/or by the different
Baseline evaluation in a patient suspected inflammatory activity of the underlying
to have viral hepatitis can be started by disease.
checking a hepatic function panel. Patients
12 12. Question 12
who have a severe disease can have
The nurse is reviewing the physician’s again, usually based on blood tests or the
orders written for a male client admitted to reported level of pain.
the hospital with acute pancreatitis. Which
Option B: NGT is used if vomiting is a
physician order should the nurse question if
problem. The tube can be used for a few
noted on the client’s chart?
weeks. It can be used to remove fluid and
air and give the pancreas more time to heal.
It can also be used to put liquid food into
A. NPO status
the stomach as the client heals.
B. Nasogastric tube inserted
Option D: Anticholinergics are used to a
C. Morphine sulfate for pain variable extent in the treatment of many
gastrointestinal conditions, including acute
D. An anticholinergic medication or relapsing chronic pancreatitis, acid-
peptic disorders of the upper
Incorrect
gastrointestinal tract, chronic
Correct Answer: C. Morphine sulfate for inflammations of the intestines, and so-
pain called functional gastrointestinal disorders
caused by excessive or abnormal motility.

13 13. Question 13
Meperidine (Demerol) rather than
morphine sulfate is the medication of A female client being seen in a physician’s
choice to treat pain because morphine office has just been scheduled for a barium
sulfate can cause spasms in the sphincter of swallow the next day. The nurse writes
Oddi. Histological data show that treatment down which instruction for the client to
with morphine after induction of acute follow before the test?
pancreatitis exacerbates the disease with
increased pancreatic neutrophilic
infiltration and necrosis in all three models A. Fast for 8 hours before the test
of acute pancreatitis. Morphine also
exacerbated acute pancreatitis-induced gut B. Eat a regular supper and breakfast
permeabilization and bacteremia.
C. Continue to take all oral medications as
scheduled

Option A: Historically, patients with acute D. Monitor own bowel movement pattern
pancreatitis would be kept without food by for constipation
mouth (nil per os or NPO) until their
Incorrect
physician team deemed them ready to eat
Correct Answer: A. Fast for 8 hours before Option D: After the procedure, the nurse
the test. must monitor for constipation, which can
occur as a result of the presence of barium
in the gastrointestinal tract. The barium
A barium swallow is an x-ray study that uses esophagogram is noninvasive and readily
a substance called barium for contrast to performed, requiring only radiographic still-
highlight abnormalities in the image capability and contrast medium. As
gastrointestinal tract. The client should fast such, it is a useful exam despite the current
for 8 to 12 hours before the test, depending wide availability of CT imaging.
on physician instructions. The barium
14 14. Question 14
swallow study, also known as a barium
esophagogram or esophagram, is a The nurse is performing an abdominal
contrast-enhanced radiographic study assessment and inspects the skin of the
commonly used to assess structural abdomen. The nurse performs which
characteristics of the entire esophagus. assessment technique next?

Option B: Patients must be capable of A. Palpates the abdomen for size

swallowing relatively large amounts of
B. Palpates the liver at the right rib margin
contrast without assistance and be able to
protect their airways. For visual studies C. Listens to bowel sounds in all four
focusing on the pharynx and esophagus, quadrants
minimal preparation is required. However,
patients should be able to tolerate D. Percusses the right lower abdominal
swallowing liquids. quadrant

Option C: Most oral medications also are Incorrect

withheld before the test. Oral barium
Correct Answer: C. Listens to bowel sounds
contrast has relatively few adverse effects
in all four quadrants
in standard practice. Most commonly,
patients complain of nausea and vomiting
within 30 minutes of ingestion.
The appropriate sequence for abdominal
Hypersensitivity reactions have been
examination is inspection, auscultation,
reported but are uncommon. Most adverse
percussion, and palpation. Auscultation is
effects are related to the extravasation of
performed after inspection to ensure that
contrast into the mediastinum or from
the motility of the bowel and bowel sounds
aspiration.
are not altered by percussion or palpation.
Therefore, after inspecting the skin on the
abdomen, the nurse should listen for bowel following the administration of the solution.
sounds. What action by the nurse is appropriate?

Option A: The ideal position for abdominal A. Start an IV infusion

examination is to sit or kneel on the right
B. Administer an enema
side of the patient with the hand and
forearm in the same horizontal plane as the C. Cancel the diagnostic test
patient’s abdomen. There are three stages
of palpation that include superficial or light D. Explain that diarrhea is expected
palpation, deep palpation, and organ
Incorrect
palpation and should be performed in the
same order. Correct Answer: D. Explain that diarrhea is
expected.
Option B: The examiner should begin with
superficial or light palpation from the area
furthest from the point of maximal pain and
The solution GoLYTELY is a bowel evacuant
move systematically through the nine
used to prepare a client for a colonoscopy
regions of the abdomen. If no pain is
by cleansing the bowel. The solution is
present, any starting point can be chosen.
expected to cause mild diarrhea and will
Several sources mention that the abdomen
clear the bowel in 4 to 5 hours.
should first gently be examined with the
Polyethylene glycol electrolyte (PEG) is
fingertips.
essential for a wide range of bowel
Option D: A proper technique of percussion preparation, with advantages such as high
is necessary to gain maximum information security, reliable effect, no dehydration,
regarding abdominal pathology. While and electrolyte disturbance.
percussing, it is important to appreciate
tympany over air-filled structures such as
the stomach and dullness to percussion Option A: Starting an IV is unnecessary.
which may be present due to an underlying Surveys, such as those conducted by Seo et
mass or organomegaly (for example, al., have shown that colon cleanliness was
hepatomegaly or splenomegaly). the highest at time intervals of 3–5 h after a
one-time oral administration of 4 L of PEG
15 15. Question 15
solution, whereas colon cleanliness was
Polyethylene glycol-electrolyte solution significantly decreased at time intervals of
(GoLYTELY) is prescribed for the female <3 or >7 h.
client scheduled for a colonoscopy. The
client begins to experience diarrhea
Option B: Administering an enema would be leading to the loss of the function of the
inappropriate. Bacteria in intestinal feces parietal cells. The source of the intrinsic
account for 20%–30% of the solid weight of factor is lost, which results in the inability to
feces. This also accords with earlier absorb vitamin B12. This leads to the
observations that the PEG solution can only development of pernicious anemia.
effectively remove solid residues in feces
and has no significant effect on colonic
bacteria and flora. Option A: Autoimmune gastritis (pernicious
anemia) is the most common cause of
Option C: Cancelling the test would be
severe vitamin B12 deficiency due to food-
inappropriate. PEG solution combined with
cobalamin malabsorption in the elderly,
lactulose improves the quality of bowel
nevertheless use of medications, as proton
preparation in patients with long interval P-
pump inhibitors, histamine H2 blockers,
C, which allows patients to have no
metformin, or cholestyramine can interfere
restriction on the time of colonoscopy, and
with or reduce vitamin B12 absorption.
benefits more patients who need a
colonoscopy. Option C: The most common is vitamin B12
deficiency, which results in megaloblastic
16 16. Question 16
anemia and iron malabsorption, leading to
The nurse is caring for a male client with a iron deficiency anemia. However, in recent
diagnosis of chronic gastritis. The nurse years the deficiency of several other
monitors the client knowing that this client vitamins and micronutrients, such as
is at risk for which vitamin deficiency? vitamin C, vitamin D, folic acid, and calcium,
has been increasingly described in patients
with chronic gastritis.
A. Vitamin A
Option D: The reduction of intrinsic factor
B. Vitamin B12 levels results in vitamin B12 malabsorption.
Indeed, the intrinsic factor has a key role in
C. Vitamin C binding vitamin B12 in the duodenum and
transporting it to the terminal ileum for
D. Vitamin E
absorption. More recently, iron deficiency
Incorrect and iron-deficiency anemia have been
reported in the setting of CAAG, particularly
Correct Answer: B. Vitamin B12
in younger patients.

17 17. Question 17
Chronic gastritis causes deterioration and
The nurse is reviewing the medication
atrophy of the lining of the stomach,
record of a female client with acute
gastritis. Which medication, if noted on the Option B: Furosemide (Lasix) is a loop
client’s record, would the nurse question? diuretic. Furosemide is not contraindicated
in clients with gastric disorders. Suppression
of prostaglandin synthesis in NSAIDs is
A. Digoxin (Lanoxin) associated with reduction of gastric
mucosal blood flow, disturbance of
B. Furosemide (Lasix) microcirculation, decrease in mucus
secretion, lipid peroxidation, and neutrophil
C. Indomethacin (Indocin)
activation, which are involved in the
D. Propranolol hydrochloride (Inderal) pathogenesis of gastrointestinal mucosal
disorders
Incorrect
Option D: Propranolol (Inderal) is a ?-
Correct Answer: C. Indomethacin (Indocin)
adrenergic blocker. While the presence of
acid in the lumen of the stomach may not
be a primary factor in the pathogenesis of
Indomethacin (Indocin) is a nonsteroidal NSAID-induced gastropathy, it can make an
anti-inflammatory drug and can cause important contribution to the severity of
ulceration of the esophagus, stomach, or these lesions by impairing the restitution
small intestine. Indomethacin is process, interfering with hemostasis, and
contraindicated in a client with inactivating several growth factors that are
gastrointestinal disorders. Nonsteroidal important in mucosal defense and repair.
anti-inflammatory drugs (NSAIDs) such as
indomethacin are capable of producing 18 18. Question 18
injury to gastrointestinal mucosa in
The nurse is assessing a male client 24
experimental animals and humans, and
hours following a cholecystectomy. The
their use is associated with a significant risk
nurse noted that the T-tube has drained
of hemorrhage, erosions, and perforation of
750 mL of green-brown drainage since the
both gastric and intestinal ulcers.
surgery. Which nursing intervention is
appropriate?

Option A: Digoxin is a cardiac medication.

The molecular basis for the gastrointestinal
A. Clamp the T-tube
toxicity of NSAIDs is widely believed to be
their inhibitory activity against B. Irrigate the T-tube
cyclooxygenase, which causes them to
C. Notify the physician
block the production of prostaglandins and
their therapeutic actions. D. Document the findings
Incorrect Option C: Notify the physician if the
drainage is more than 500 mL/day. Watch
Correct Answer: D. Document the findings.
for extremely thick, bad-smelling drainage
with a fever or extremely bloody like bright
red blood that looks fresh. Assess how well
Following cholecystectomy, drainage from the patient tolerated the t-tube being
the T-tube is initially bloody and then turns clamped. If the patient develops abdominal
to a greenish-brown color. The drainage is pain, nausea, vomiting, etc. unclamp it and
measured as output. The amount of notify the physician.
expected drainage will range from 500 to
1000 mL/day. The nurse would document 19 19. Question 19
the output. The fluid may appear bloody for
The nurse is monitoring a female client with
the first day or 2. The color will eventually
a diagnosis of peptic ulcer. Which
be golden yellow or greenish, depending on
assessment findings would most likely
exactly where the catheter is inside the
indicate perforation of the ulcer?
body.

A. Bradycardia
Option A: The doctor may order the t-tube
to be clamped at times so bile can drain to B. Numbness in the legs
the duodenum so fats can be digested
C. Nausea and vomiting
during meal times. If choledocholithiasis
persists, the T-tube can be clamped to D. A rigid, board-like abdomen
promote stone passage. If signs or
symptoms of cholangitis occur, the tube can Incorrect
be unclamped and repeat imaging is
Correct Answer: D. A rigid, board-like
obtained.
abdomen
Option B: The client will need to flush the
catheter with normal saline twice a day. If
the doctor instructed to flush with less than Perforation of an ulcer is a surgical
10 mL, squirt the extra saline out before emergency and is characterized by sudden,
connecting the syringe. Push the plunger of sharp, intolerable severe pain beginning in
the syringe to push 1/3 of the normal saline the mid epigastric area and spreading over
into the catheter, and then pause. Push in the abdomen, which becomes rigid and
another 1/3 of the normal saline, and pause board-like. Perforated peptic ulcer (PPU) is
again. Push in the rest of the normal saline a serious complication of PUD and patients
into the catheter. Never pull back on the with PPU often present with an acute
plunger. abdomen that carries a high risk for
morbidity and mortality. The lifetime
prevalence of perforation in patients with
A. Halts stress reactions
PUD is about 5%. PPU carries mortality
ranging from 1.3% to 20%. B. Heals the gastric mucosa

C. Reduces the stimulus to acid secretions

Option A: Tachycardia may occur as D. Decreases food absorption in the
hypovolemic shock develops. The classic stomach
triad of sudden onset of abdominal pain,
tachycardia, and abdominal rigidity is the Incorrect
hallmark of perforated peptic ulcers. Early
Correct Answer: C. Reduces the stimulus to
diagnosis, prompt resuscitation, and urgent
acid secretions.
surgical intervention are essential to
improve outcomes.

Option B: Numbness in the legs is not an A vagotomy, or cutting of the vagus nerve,
associated finding. Symptoms of PUD is done to eliminate parasympathetic
include abdominal pain, upper abdominal stimulation of gastric secretion. A vagotomy
discomfort, bloatedness, and feeling of is a type of surgery that removes all or part
fullness. When PUD worsens and eventually of the vagus nerve. This nerve runs from the
perforates, gastric juice and gas enter the bottom of the brain, through the neck, and
peritoneal cavity leading to chemical along the esophagus, stomach, and
peritonitis. intestines in the gastrointestinal (GI) tract.

Option C: Nausea and vomiting may occur.

Sudden onset of abdominal pain or acute
Option A: Vagotomy was once commonly
deterioration of the ongoing abdominal
performed to treat and prevent PUD;
pain is typical of PPU. Typically the pain
however, with the availability of excellent
never completely subsides despite usual
acid secretion control with H2-receptor
premedical remedies and forces the patient
antagonists, proton pump inhibitors, and
to seek medical attention.
anti–Helicobacter pylori medications, the
20 20. Question 20 need for surgical management of this
condition has greatly decreased.
A male client with a peptic ulcer is
scheduled for a vagotomy and the client Option B: The relevant physiology revolves
asks the nurse about the purpose of this around the mechanisms relating to stomach
procedure. Which response by the nurse acid secretion. Intraluminal gastric acid is
best describes the purpose of a vagotomy? released by the parietal cells, mainly
located in the body of the stomach. Parietal
cells are stimulated via 3 mechanisms: In a Billroth II procedure, the proximal
gastrin, acetylcholine, and histamine. All 3 remnant of the stomach is anastomosed to
mechanisms activate the hydrogen- the proximal jejunum. Patency of the
potassium ATPase-releasing hydrogen ion nasogastric tube is critical for preventing
into the stomach lumen. the retention of gastric secretions. The
nurse should never irrigate or reposition the
Option D: The indications for vagotomy are
gastric tube after gastric surgery unless
few with the advancements of medical
specifically ordered by the physician. In this
therapy. Generally, acid-reducing
situation, the nurse should clarify the order.
operations are reserved for complicated
ulcer disease in a stable patient who has
failed maximum medical therapy. The type
Option A: Leg exercises are allowed to
of surgery performed depends on the type
prevent thrombosis. Discuss the importance
of ulcer (duodenal versus gastric), the
of eating small, frequent meals slowly and
complication of PUD (bleeding, perforation,
in a relaxed atmosphere; resting after
obstruction, intractability), and the location
meals; avoiding extremely hot or cold food;
of the ulcer (types I to V gastric ulcers as
restricting high-fiber foods, caffeine, milk
described by the Modified Johnson
products, and alcohol, excess sugars and
Classification system).
salt; and taking fluids between meals,
21 21. Question 21 rather than with food.

The nurse is caring for a female client Option B: Early ambulation is recommended
following a Billroth II procedure. Which after the procedure. Also, discuss the
postoperative order should the nurse reasons for and importance of cessation of
question and verify? smoking. Smoking stimulates gastric acid
production and may cause vasoconstriction,
compromising mucous membranes and
A. Leg exercises increasing the risk of gastric irritation and
ulceration.
B. Early ambulation
Option D: The client may do coughing and
C. Irrigating the nasogastric tube deep breathing exercises. Discuss and
identify stressful situations and how to
D. Coughing and deep-breathing exercises
avoid them. Investigate job-related issues.
Incorrect This can alter gastric motility, interfering
with optimal digestion. The patient may
Correct Answer: C. Irrigating the nasogastric
require vocational counseling if a change in
tube.
employment is indicated.
22 22. Question 22 symptoms that may indicate dumping
syndrome, (weakness, profuse perspiration,
The nurse is providing discharge
epigastric fullness, nausea and vomiting,
instructions to a male client following
abdominal cramping, faintness, flushing,
gastrectomy and instructs the client to take
explosive diarrhea, and palpitations
which measure to assist in preventing
occurring within 15 min to 1 hr after
dumping syndrome?
eating).

Option B: The nurse should instruct the

A. Ambulate following a meal client to avoid high-carbohydrate foods,
including fluids such as fruit nectars. Review
B. Eat high carbohydrate foods dietary needs and regimen (low-
carbohydrate, low-fat, high-protein) and
C. Limit the fluid taken with meal
the importance of maintaining vitamin
D. Sit in a high-Fowler’s position during supplementation. This may prevent
meals deficiencies, enhance healing, and promote
cooperation with therapy. A low-fat diet
Incorrect
may be required to reduce the risk of
Correct Answer: C. Limit the fluid taken with alkaline reflux gastritis.
meals.
Option D: The nurse should instruct the
client to assume a low Fowler’s position
during meals. Avoid placing the patient in a
Dumping syndrome is a term that refers to supine position, have the patient sit upright
a constellation of vasomotor symptoms that after meals. Supine position after meals can
occurs after eating, especially following a increase regurgitation of acid. Instruct the
Billroth II procedure. Early manifestations patient to chew food thoroughly and eat
usually occur within 30 minutes of eating slowly. Well-masticated food is easier to
and include vertigo, tachycardia, syncope, swallow. Food should be cut into small
sweating, pallor, palpitations, and the pieces.
desire to lie down. The nurse should
instruct the client to decrease the amount 23 23. Question 23
of fluid taken at meals.
The nurse is monitoring a female client for
the early signs and symptoms of dumping
syndrome. Which of the following indicate
Option A: The nurse should instruct the this occurrence?
client to lie down for 30 minutes after
eating to delay gastric emptying, and to
take antispasmodics as prescribed. Identify
A. Sweating and pallor
B. Bradycardia and indigestion Hormonal imbalances may cause delayed
motility, decreased gastric and intestinal
C. Double vision and chest pain
secretions, which delay the digestion and
D. Abdominal cramping and pain transit of food that arrives at the small
bowel.
Incorrect
Option D: Late dumping, also known as
Correct Answer: A. Sweating and pallor postprandial hyperinsulinemic
hypoglycemia, usually occurs 1 to 3 hours
after a high-carbohydrate meal. There is an
Early manifestations of dumping syndrome association with hypoglycemia, but the
occur 5 to 30 minutes after eating. exact mechanism is unknown. It is proposed
Symptoms include vertigo, tachycardia, that the rapid absorption of carbohydrates
syncope, sweating, pallor, palpitations, and exaggerates the glucose-mediated insulin
the desire to lie down. In early dumping, response.
the symptoms usually occur within 10 to 30
24 24. Question 24
minutes after a meal. The rapid transit of
hyperosmolar chyme from the stomach into The nurse is preparing a discharge teaching
the duodenum causes fluid to shift from the plan for the male client who had umbilical
vasculature to the intestinal lumen, leading hernia repair. What should the nurse
to increased volume in the small bowel. include in the plan?

Option B: Bradycardia and indigestion are A. Irrigating the drain

not signs of dumping syndrome. There may
be GI or vasomotor symptoms. GI B. Avoiding coughing
symptoms include nausea, vomiting,
C. Maintaining bed rest
diarrhea, or belching. Vasomotor symptoms
include shock, syncope, near-syncope, D. Restricting pain medication
palpitations, dizziness, desire to lie down, or
Incorrect
diaphoresis.
Correct Answer: B. Avoiding coughing.
Option C: Double vision and chest pain are
not signs of dumping syndrome. GI
hormones such as enteroglucagon,
pancreatic polypeptide, peptide YY, Coughing is avoided following umbilical
vasoactive intestinal polypeptide, glucagon- hernia repair to prevent disruption of tissue
like peptide, and neurotensin have been integrity, which can occur because of the
evident with higher values after meals. location of this surgical procedure. Splint
the stomach by placing a pillow over the
abdomen with firm pressure before
A. Limit oral fluid
coughing or movement to help reduce the
pain. B. Elevate the scrotum

C. Apply heat to the abdomen

Option A: A drain is not used in this surgical D. Remain in a low-fiber diet
procedure, although the client may be
instructed in simple dressing changes. Do Incorrect
not soak in a bathtub until the stitches or
Correct Answer: B. Elevate the scrotum.
staples are removed. A small amount of
drainage from the incision is normal.

Option C: Bed rest is not required following Following inguinal hernia repair, the client
this surgical procedure. The client may should be instructed to elevate the scrotum
slowly increase his activity. He should get and apply ice packs while in bed to decrease
up and walk every hour or so to prevent pain and swelling. The nurse also should
blood clot formation. After recovery, the instruct the client to apply a scrotal support
client may return to work within 2 or 3 when out of bed. In the beginning phases of
days. There should be no lifting anything healing, the body produces extra fluid that
above 10 lbs, climbing, or any strenuous helps with the healing process. This fluid
activities for 4 to 6 weeks. brings nutrients and cells that can help
tissues repair themselves, and appears as
Option D: The client should take analgesics
swelling at the site where there was an
as needed and as prescribed to control
injury to the tissues (similar to swelling after
pain. Most non-opioid analgesics are
a sprained ankle). When this swelling sits in
classified as non-steroidal anti-
one area for a few days, it often turns hard
inflammatory drugs (NSAIDs). They are used
and can feel like a firm lump.
to treat mild pain and inflammation or
combined with narcotics. Narcotics or
opioids are used for severe pain.
Option A: Limiting oral fluids can cause
25 25. Question 25 constipation. Sometimes the swelling is soft
and does not seem to go away after
The nurse is instructing the male client who
surgery. Again, this is most likely due to the
has an inguinal hernia repair how to reduce
body’s normal fluid pooling in the space the
postoperative swelling following the
hernia used to be. If this swelling persists
procedure. What should the nurse tell the
longer than three to six months after
client?
surgery, it should be re-evaluated by the
surgical team to determine if hernia has Rebound tenderness may indicate
recurred. peritonitis. During the physical exam,
pertinent findings include fever and
Option C: Heat will increase swelling. While
abdominal tenderness to palpation which
most swelling after hernia surgery is
usually is diffuse with wall rigidity in more
normal, it can rarely be an indicator of a
septic presentations. Signs of peritonitis
complication, including infection and hernia
must be reported to the physician. It is
recurrence. Swelling after hernia surgery is
important to conduct a thorough exam as
rarely a sign of infection. Since infection
certain thoracic or pelvic pathologies can
from hernia surgery occurs less than 1% of
mimic peritoneal irritation (empyema
the time, swelling is normal the other 99%
causing diaphragmatic irritation and
of the time.
cystitis/pyelonephritis causing peritoneum
Option D: A low-fiber diet can cause adjacent pain).
constipation. Pain or swelling that continues
to worsen after hernia surgery or pain and
swelling accompanied by red discoloration Option A: Because of the blood loss, the
of the skin are signs of infection and require client may be hypotensive. In ulcerative
attention by the surgical team. colitis, bleeding can arise from the lining of
the rectum or large intestine, and this blood
26 26. Question 26
can be visible in the stool. The bleeding
The nurse is caring for a hospitalized female generally comes from the ulcers that have
client with a diagnosis of ulcerative colitis. formed in the lining of the large intestine or
Which finding, if noted on assessment of rectum.
the client, would the nurse report to the
Option B: Bloody diarrhea is expected to
physician?
occur in ulcerative colitis. Ulcerative colitis’s
main symptom is bloody diarrhea, with or
without mucus. Associated symptoms also
A. Hypotension include urgency or tenesmus, abdominal
pain, malaise, weight loss, and fever,
B. Bloody diarrhea
depending on the extent and severity of the
C. Rebound tenderness disease.

D. A hemoglobin level of 12 mg/dL Option D: Because of the blood loss, the

client may be hypotensive and the
Incorrect
hemoglobin level may be lower than
Correct Answer: C. Rebound tenderness normal. Signs of peritonitis must be
reported to the physician. It may also be
necessary to treat the loss of blood that has
happened. If the client developed anemia Option A: Review with the patient and/or
from blood loss, he may need to SO sexual functioning in relation to their
supplement with iron, folic acid, or vitamin own situation. Understanding if nerve
B12, depending on what your health damage has altered normal sexual
provider says. In serious cases of blood loss, functioning helps the patient/SO to
a blood transfusion might be required. understand the need for exploring
alternative methods of satisfaction.
27 27. Question 27
Option C: Provide opportunities for
The nurse is caring for a male client
patient/SO to view and touch stoma, using
postoperatively following the creation of a
the moment to point out positive signs of
colostomy. Which nursing diagnosis should
healing, normal appearance, and so forth.
the nurse include in the plan of care?
Remind the patient that it will take time to
adjust, both physically and emotionally.

A. Sexual dysfunction Option D: Nutrition: less than body

requirements, imbalanced is the more likely
B. Body image, disturbed nursing diagnosis. Recommend patient
increase use of yogurt, buttermilk, and
C. Fear related to poor prognosis
acidophilus preparations. Identify odor-
D. Nutrition: more than body causing foods (e.g., cabbage, fish, beans)
requirements, imbalanced and temporarily restrict them from the diet.
Gradually reintroduce one food at a time.
Incorrect
28 28. Question 28
Correct Answer: B. Body image, disturbed
The nurse is reviewing the record of a
female client with Crohn’s disease. Which
Body image, disturbed relates to loss of stool characteristics should the nurse
bowel control, the presence of a stoma, the expect to note documented in the client’s
release of fecal material onto the abdomen, record?
the passage of flatus, odor, and the need
for an appliance (external pouch).
Encourage the patient/SO to verbalize A. Diarrhea
feelings regarding the ostomy.
B. Chronic constipation
Acknowledge normality of feelings of anger,
depression, and grief over a loss. Discuss C. Constipation alternating with diarrhea
daily “ups and downs” that can occur.
D. Stools constantly oozing from the
rectum
Incorrect formation. Crohn’s disease is also
associated with enterovesical,
Correct Answer: A. Diarrhea
enteroenteral, enterocutaneous and
enterovaginal fistulas.

Crohn’s disease is characterized by non- 29 29. Question 29

bloody diarrhea of usually not more than
The nurse is performing colostomy
four to five stools daily. Over time, the
irrigation on a male client. During the
diarrhea episodes increase in frequency,
irrigation, the client begins to complain of
duration, and severity. In CD, the
abdominal cramps. What is the appropriate
inflammation extends through the entire
nursing action?
thickness of the bowel wall from the
mucosa to the serosa. The disease runs a
relapsing and remitting course. The other
A. Notify the physician
options are not associated with diarrhea.
B. Stop the irrigation temporarily

C. Increase the height of the irrigation

Option B: Patients with flare-ups of Crohn’s
disease typically present with abdominal D. Medicate for pain and resume the
pain (right lower quadrant), irrigation
flatulence/bloating, diarrhea (can include
mucus and blood), fever, weight loss, Incorrect
anemia. In severe cases, perianal abscess,
Correct Answer: B. Stop the irrigation
perianal Crohn’s disease, and cutaneous
temporarily.
fistulas can be seen.

Option C: When the small bowel is involved,

it may present with diarrhea, If cramping occurs during colostomy
malabsorption, weight loss, abdominal pain, irrigation, the irrigation flow is stopped
and anorexia. Enterovesical fistulae may temporarily and the client is allowed to rest.
present with pneumaturia, recurrent Cramping may occur from an infusion that
urinary tract infections, and feculent vaginal is too rapid or is causing too much pressure.
discharge. Have the colostomy patient sit on or near
the toilet for about 15 to 20 minutes so the
Option D: Granuloma formation is very
initial colostomy returns can drain into the
common in Crohn’s disease but their
toilet. (If the patient is on bed rest, allow
absence does not exclude the diagnosis.
the colostomy to drain into the bedpan.)
The ongoing inflammation and scarring lead
to bowel obstruction and stricture
Option A: The physician does not need to
be notified. Unless contraindicated or
To enhance the effectiveness of the
otherwise ordered by the physician, it is
irrigation and fecal returns, the client is
best to establish a routine of daily irrigation
instructed to increase fluid intake and to
in accordance with the patient’s former
take other measures to prevent
bowel habits.
constipation. A colostomy may make the
Option C: Increasing the height of the client more prone to constipation or
irrigation will cause further discomfort. diarrhea. It’s important to get enough fiber
Hold the enema can approximately 12 in the diet and drink plenty of water to
inches above the bed and allow the solution prevent these problems. Some people
to flow in slowly to avoid painful cramps experience a small amount of stool leakage
usually caused by too rapid flow. between irrigations.

Option D: Medicating the client for pain is

not the appropriate action in this situation.
Option B: Abdominal pain or nausea may
If cramping occurs, slow down the flow rate
occur during irrigation, and may mean that
and ask the patient to deep breathe until
water flow is too fast or the water is too
cramps subside. Cramping during irrigation
cold. In six to eight weeks, the bowels will
may indicate that the flow is too fast or the
typically adjust, and bowel movements will
water is too cold.
become regular.
30 30. Question 30
Option C: It is best to perform irrigation at
The nurse is teaching a female client how to the same time each day. The client may
perform a colostomy irrigation. To enhance want to try irrigating at the time of day he
the effectiveness of the irrigation and fecal typically had a bowel movement (before
returns, what measure should the nurse getting the colostomy). Irrigation may be
instruct the client to do? easier after a meal or hot drink.

Option D: Fill the irrigating container with

about 16 to 50 ounces (500 to 1500 mL) of
A. Increase fluid intake
lukewarm water. The water should not be
B. Place heat on the abdomen cold or hot. Ask how much water will be
needed to irrigate. Hang the irrigation
C. Perform the irrigation in the evening container so that it is level with the
shoulder.
D. Reduce the amount of irrigation solution
31 31. Question 31
Incorrect

Correct Answer: A. Increase fluid intake.

For a client in hepatic coma, which outcome potential etiologies (e.g., intracranial
would be the most appropriate? lesions, masses, hemorrhage or stroke;
seizure activity; post-seizure
encephalopathy; intracranial infections; or
A. The client is oriented to time, place, and toxic encephalopathy from other causes).
person.
Option C: Although oral intake may be
B. The client exhibits no ecchymotic areas. related to the level of consciousness, it is
more closely related to anorexia. Triggers of
C. The client increases oral intake to 2,000 hepatic encephalopathy include renal
calories/day. failure, gastrointestinal bleeding (e.g.,
esophageal varices), constipation, infection,
D. The client exhibits increased serum
medication non-compliance, excessive
albumin level.
dietary protein intake, dehydration (e.g.,
Incorrect fluid restriction, diuretics, diarrhea,
vomiting, excessive paracentesis),
Correct Answer: A. The client is oriented to
electrolyte imbalance, consumption of
time, place, and person.
alcohol, or consumption of certain
sedatives, analgesics or diuretics all in the
setting of chronic liver disease.
Hepatic coma is the most advanced stage of
hepatic encephalopathy. As hepatic coma Option D: The serum albumin level reflects
resolves, improvement in the client’s level hepatic synthetic ability, not level of
of consciousness occurs. The client should consciousness. Elevated blood ammonia
be able to express orientation to time, levels are often seen in patients with
place, and person. Throughout the hepatic encephalopathy. It is more useful,
intermediate stages, patients tend to however, to assess the clinical
experience worsening levels of confusion, improvement or deterioration of a patient
lethargy, and personality changes. undergoing treatment rather than monitor
serial arterial blood ammonia
measurements.
Option B: Ecchymotic areas are related to 32 32. Question 32
decreased synthesis of clotting factors. In
order to make a diagnosis of hepatic Jordin is a client with jaundice who is
encephalopathy, there must be confirmed experiencing pruritus. Which nursing
the presence of liver disease (e.g., abnormal intervention would be included in the care
liver function tests, ultrasound or liver plan for the client?
biopsy demonstrating liver disease) or a
portosystemic shunt, and exclusion of other
A. Administering vitamin K subcutaneously develops bleeding problems. Instruct the
client to allow the skin to air dry or gently
B. Applying pressure when giving I.M.
pat the skin dry after bathing. Avoid rubbing
injections
or brisk drying. Rubbing the skin with a
C. Decreasing the client's dietary protein towel can irritate the skin and exacerbate
intake the itch-scratch cycle.

D. Keeping the client's fingernails short and Option C: Decreasing the client’s dietary
smooth intake is appropriate if the client’s ammonia
levels are increased. The patient who
Incorrect scratches the skin to relieve intense itching
may cause open skin lesions with an
Correct Answer: D. Keeping the client’s
increased risk for infection. Characteristic
fingernails short and smooth
patterns associated with scratching include
reddened papules that run together and
become confluent, widespread erythema,
The client with pruritus experiences itching,
and scaling or lichenification.
which may lead to skin breakdown and
possibly infection from scratching. Keeping 33 33. Question 33
his fingernails short and smooth helps
Marie, a 51-year-old woman, is diagnosed
prevent skin breakdown and infection from
with cholecystitis. Which diet, when
scratching. Encourage the patient to adopt
selected by the client, indicates that the
skin care routines to decrease skin
nurse’s teaching has been successful?
irritation. One of the first steps in the
management of pruritus is promoting
healthy skin and healing of skin lesions.
A. 4-6 small meals of low-carbohydrate
foods daily
Option A: Administering vitamin K B. High-fat, high-carbohydrate meals
subcutaneously is important if the client
develops bleeding problems. Instruct the C. Low-fat, high-carbohydrate meals
client to bathe or shower using lukewarm
D. High-fat, low protein meals
water and mild soap or nonsoap cleansers.
Long bathing or showering in hot water Incorrect
causes drying of the skin and can aggravate
Correct Answer: C. Low-fat, high-
itching through vasodilation.
carbohydrate meals
Option B: Applying pressure when giving
I.M. injections is important if the client
Option C: For the client with cholecystitis, vasopressors in the setting of an intensive
fat intake should be reduced. The calories care unit should be considered.
from fat should be substituted with
carbohydrates.
Option B: Hypotension, not hypertension, is
Option A: Reducing carbohydrate intake
associated with septicemia. The Society of
would be contraindicated.
Interventional Radiology (SIR) has published
Options B & D: Any diet high in fat may lead complication rates for PTC and PBD. The
to another attack of cholecystitis. rate of major complications is around 2% to
10%. Major complications include inducing
34 34. Question 34
sepsis, other severe infections (such as an
The hospital administrator had undergone abscess), bile leak/biloma, hemorrhage
percutaneous transhepatic (subcapsular hematoma, pseudoaneurysm),
cholangiography. Which assessment finding pneumothorax, and death.
indicates complication after the operation?
Option C: Tachycardia, not bradycardia, is
most likely to occur. Transgression of blood
vessels during PTC is to be expected.
A. Fever and chills Coagulation usually occurs successfully, and
hemorrhage ceases entirely within 2 to 3
B. Hypertension
days. Bleeding through the catheter can
C. Bradycardia occur if a catheter side hole is left in
communication with a hepatic vessel or if a
D. Nausea and diarrhea
pseudoaneurysm develops.
Incorrect
Option D: Nausea and diarrhea may occur
Correct Answer: A. Fever and chills but are not classic signs of sepsis. If
electrolyte depletion occurs due to high-
output external drainage, then the
electrolytes should be replaced and
Septicemia is a common complication after
considerations should be made on
a percutaneous transhepatic
converting the catheter to internal drainage
cholangiography. Evidence of fever and
as soon as possible.
chills, possibly indicative of septicemia, is
important. Although PTC may be performed 35 35. Question 35
to treat the obstruction that is the cause of
sepsis, PTC itself may also cause sepsis. When planning home care for a client with
Antibiotics, IV fluids, oxygen, and hepatitis A, which preventive measure
should be emphasized to protect the
client’s family?
 close physical contact with an infectious
person. According to the World Health
A. Keeping the client in complete isolation
Organization (WHO), infection rates in
B. Using good sanitation with dishes and developed countries are low.
shared bathrooms
Option D: Avoiding the sharing of needles
C. Avoiding contact with blood-soiled or syringes are precautions needed to
clothing or dressing prevent transmission of hepatitis B.
Globally, the rates of HAV have decreased
D. Forbidding the sharing of needles or due to improvements in public healthcare
syringes policies, sanitation, and education, but
infection rates of other hepatitis viruses
Incorrect
appear to be increasing.
Correct Answer: B. Using good sanitation
36 36. Question 36
with dishes and shared bathrooms.
For Jayvin who is taking antacids, which
instruction would be included in the
Hepatitis A is transmitted through the fecal- teaching plan?
oral route or from contaminated water or
food. Measures to protect the family
include good handwashing, personal A. "Take the antacids with 8 oz of water."
hygiene and sanitation, and the use of
standard precautions. According to the B. "Avoid taking other medications within 2
WHO, the most effective way to prevent hours of this one."
HAV infection is to improve sanitation, food
C. "Continue taking antacids even when
safety, and immunization practices.
pain subsides."

D. "Weigh yourself daily when taking this

Option A: Complete isolation is not medication."
required. No specific treatment is needed
Incorrect
for most patients with acute,
uncomplicated HAV infection beyond Correct Answer: B. “Avoid taking other
supportive care. Complete recovery from medications within 2 hours of this one.”
symptoms may take several weeks to
months.
Antacids neutralize gastric acid and
Option C: HAV is most commonly
decrease the absorption of other
transmitted through the oral-fecal route via
medications. The client should be instructed
exposure to contaminated food, water, or
to avoid taking other medications within 2 Which clinical manifestation would the
hours of the antacid. The antacids act by nurse expect a client diagnosed with acute
neutralizing the acid in the stomach and by cholecystitis to exhibit?
inhibiting pepsin, which is a proteolytic
enzyme. Each of these cationic salts has a
characteristic pharmacological property A. Jaundice, dark urine, and steatorrhea
that determines its clinical use.
B. Acute right lower quadrant (RLQ) pain,
diarrhea, and dehydration
Option A: Water, which dilutes the antacid, C. Ecchymosis petechiae, and coffee-
should not be taken with an antacid. The ground emesis
dose for antacids depends upon the age of
the patient, the purpose of administration D. Nausea, vomiting, and anorexia
(neutralization of acid or off-label use), and
Incorrect
the presence of other comorbidities like
renal or hepatic impairment. Correct Answer: D. Nausea, vomiting, and
anorexia
Option C: A histamine receptor antagonist
should be taken even when the pain
subsides. Calcium salts neutralize gastric
Acute cholecystitis is an acute inflammation
acidity resulting in increased gastric and
of the gallbladder commonly manifested by
duodenal bulb pH; they additionally inhibit
the following: anorexia, nausea, and
the proteolytic activity of pepsin if the pH is
vomiting; biliary colic; tenderness and
greater than 4 and increase lower
rigidity the right upper quadrant (RUQ)
esophageal sphincter tone.
elicited on palpation (e.g., Murphy’s sign);
Option D: Daily weights are indicated if the fever; fat intolerance; and signs and
client is taking a diuretic, not an antacid. symptoms of jaundice.
The average therapeutic dose of antacid is
10 to 15 mL (1 tablespoon or one package
content) of liquid or 1 to 2 tablets 3 to 4 Option A: Jaundice, dark urine, and
times a day. Periodic monitoring of calcium steatorrhea are clinical manifestations of
and phosphorus plasma concentrations is a the icteric phase of hepatitis. Patients in this
suggested practice in patients on chronic phase present with dark-colored urine and
therapy. pale-colored stool. Some patients develop
jaundice and right upper quadrant pain with
37 37. Question 37
liver enlargement.
Option B: Cases of chronic cholecystitis D. Dietary plan of a low-fat diet and
present with progressing right upper increased fluid intake to 2,000 ml/day
quadrant abdominal pain with bloating,
Incorrect
food intolerances (especially greasy and
spicy foods), increased gas, nausea, and Correct Answer: C. Maintenance of nothing-
vomiting. Pain in the mid back or shoulder by-mouth status and insertion of
may also occur. nasogastric (NG) tube with low intermittent
suction
Option C: Ecchymosis, petechiae, and
coffee-ground emesis are clinical
manifestations of esophageal bleeding. The
coffee-ground appearance indicates old With acute pancreatitis, the client is kept on
bleeding. The clinical presentation can vary nothing-by-mouth status to inhibit
but should be well-characterized. pancreatic stimulation and secretion of
Hematemesis is the overt bleeding with pancreatic enzymes. NG intubation with low
vomiting of fresh blood or clots. Melena intermittent suction is used to relieve
refers to dark and tarry-appearing stools nausea and vomiting, decrease painful
with a distinctive smell. The term “coffee- abdominal distention, and remove
grounds” describes gastric aspirate or hydrochloric acid. Prolonged bowel rest by
vomitus that contains dark specks of old nothing per os (NPO) to minimize
blood. pancreatic secretion was an important part
of the therapy for any patient with acute
38 38. Question 38 pancreatitis.
Pierre, who is diagnosed with acute
pancreatitis, is under the care of Nurse
Bryan. Which intervention should the nurse Option A: Vasopressin would be
include in the care plan for the client? appropriate for a client diagnosed with
bleeding esophageal varices. The most
common cause of late death in acute
necrotizing pancreatitis is represented by
A. Administration of vasopressin and
organ failure through infected pancreatic
insertion of a balloon tamponade
necrosis (IPN). Therefore there might be a
B. Preparation for a paracentesis and theoretical benefit from antibiotic
administration of diuretics prophylaxis.

C. Maintenance of nothing-by-mouth Option B: Paracentesis and diuretics would

status and insertion of nasogastric (NG) be appropriate for a client diagnosed with
tube with low intermittent suction portal hypertension and ascites. Fluid
therapy in acute pancreatitis can be seen as
double edge sword with risk of necrosis that breaks down triglycerides into free
through tissue hypoperfusion by using low fatty acids and glycerol. Lipases are present
fluid quantities and liquid sequestration and in pancreatic secretions and are responsible
increased morbidity with too high volumes for fat digestion. There are many different
types of lipases; for example, hepatic
Option D: A low-fat diet and increased fluid
lipases are in the liver, hormone-sensitive
intake would further aggravate pancreatitis.
lipases are in adipocytes, lipoprotein lipase
The concept of nutritional support in AP has
is in the vascular endothelial surface, and
gradually moved towards enteral feeding,
pancreatic lipase in the small intestine.
due to large evidence proving safety and
efficiency. Timing and mode of nutritional
support in acute pancreatitis should be
Option A: Lipase is not involved with the
based on risk prediction of severity.
transport of fatty acids into the brush
39 39. Question 39 border. Lipases are enzymes that play a
crucial role in lipid transport. Hepatic lipase
When teaching a client about pancreatic
plays a crucial role in the formation and
function, the nurse understands that
delivery of low-density lipoprotein(LDL). LDL
pancreatic lipase performs which function?
is formed by the modification of
intermediate density lipoprotein in the
peripheral tissue and liver by hepatic lipase.
A. Transports fatty acids into the brush These LDL particles are taken up, or
border endocytosed, via receptor-mediated
endocytosis by target cell tissue. LDL serves
B. Breaks down fat into fatty acids and
to ultimately transport cholesterol from the
glycerol
liver to peripheral tissue.
C. Triggers cholecystokinin to contract the
Option C: Fat itself triggers cholecystokinin
gallbladder
release. Hormone-sensitive lipase is found
D. Breaks down protein into dipeptides and within fat tissue and is responsible for
amino acids degrading the triglycerides that are stored
within adipocytes. Fat necrosis occurs
Incorrect
enzymatically and non-enzymatically. In
Correct Answer: B. Breaks down fat into acute pancreatitis, saponification of
fatty acids and glycerol. peripancreatic fat occurs. During traumatic
events, such as physical injury in breast
tissue, non-enzymatic fat necrosis takes
place.
Lipase hydrolyses or breaks down fat into
fatty acids and glycerol. Lipase is an enzyme
Option D: Protein breakdown into if not monitored closely and documented,
dipeptides and amino acids is the function could place the client at risk for serious fluid
of trypsin, not lipase. Lipoprotein lipase is and electrolyte imbalances. The most
found on the vascular endothelial surface common adverse effect for any diuretic is
and is responsible for degrading mild hypovolemia, which can lead to
triglycerides that circulating from transient dehydration and increased thirst.
chylomicrons and VLDLs. Pancreatic lipase is When there is an over-treatment with a
found within the small intestine and is diuretic, this could lead to severe
responsible for degrading dietary hypovolemia, causing hypotension,
triglycerides. dizziness, and syncope.

40 40. Question 40

A 52-year-old man was referred to the clinic Option A: Hypokalemia, not hyperkalemia,
due to increased abdominal girth. He is commonly occurs with diuretic therapy.
diagnosed with ascites by the presence of a Hypokalemia and metabolic alkalosis can
fluid thrill and shifting dullness on occur with both loop and thiazide diuretics
percussion. After administering diuretic but are more common with loop diuretics.
therapy, which nursing action would be Loop agents increase distal Na+ delivery at
most effective in ensuring safe care? macula densa and cause volume depletion,
both of which indirectly activate the RAAS
pathway.
A. Measuring serum potassium for
Option B: Because urine output increases, a
hyperkalemia
client should be assessed for hypovolemia,
B. Assessing the client for hypervolemia not hypervolemia. Acid-base disorders
usually accompany the electrolyte
C. Measuring the client's weight weekly derangement due to their close association
with their reabsorption in the renal tubules.
D. Documenting precise intake and output
Metabolic disturbances can lead to
Incorrect derangement of glucose, uric acid, or lipid
levels with certain diuretics and are
Correct Answer: D. Documenting precise
individually discussed.
intake and output.
Option C: Weights are also an accurate
indicator of fluid balance. However, for this
For the client with ascites receiving diuretic client, weights should be obtained daily, not
therapy, careful intake and output weekly. Diuretic treatment calls for careful
measurement are essential for safe diuretic assessment of extracellular fluid volume,
therapy. Diuretics lead to fluid losses, which urine output, electrolyte levels in plasma
and urine, body weight, acid-base status, lactulose, and hence lactulose reaches the
serum glucose, and BP regularly with large bowel unchanged. Lactulose is
particular emphasis on patients with metabolized in the colon by colonic bacteria
cardiovascular, hepatic, renal, or metabolic to monosaccharides, and then to volatile
disorders and in the elderly individuals. fatty acids, hydrogen, and methane.

41 41. Question 41

Which assessment finding indicates that Option B: Watery diarrhea indicates

lactulose is effective in decreasing the overdose. Since its intended use is to soften
ammonia level in the client with hepatic the stool quantity and increase the stool
encephalopathy? amount, its most significant side effect
remains diarrhea. The diarrhea is dose-
dependent and decreases in severity with a
A. Passage of two or three soft stools daily reduction in the dose of lactulose.

B. Evidence of watery diarrhea Option C: Daily deterioration in the client’s

handwriting indicates an increase in the
C. Daily deterioration in the client's ammonia level and worsening of hepatic
handwriting encephalopathy. From a pharmacokinetic
standpoint, lactulose has negligible
D. Appearance of frothy, foul-smelling
systemic absorption. However, like most
stools
laxatives, it has a propensity to bring about
Incorrect large changes in the body’s fluid and
electrolyte status. This activity would
Correct Answer: A. Passage of two or three
require periodic electrolyte monitoring,
soft stools daily.
especially in the elderly and critically ill
population.

Lactulose reduces serum ammonia levels by Option D: Frothy, foul-smelling stools

inducing catharsis, subsequently decreasing indicate steatorrhea, caused by impaired fat
colonic pH and inhibiting fecal flora from digestion. Because lactulose has
producing ammonia from urea. Ammonia is insignificant absorption by the gut and
removed with the stool. Two or three soft undergoes rapid excretion by the kidneys,
stools daily indicate the effectiveness of the its effects remain localized to the gut
drug. Lactulose, also known as 1,4 beta microenvironment.
galactoside-fructose, is a non-absorbable
42 42. Question 42
synthetic disaccharide made up of galactose
and fructose. The human small intestinal Nurse Farrah is providing care for Kristoff
mucosa does not have the enzymes to split who has jaundice. Which statement
indicates that the nurse understands the and hypoalbuminemia are. Itching in
rationale for instituting skin care measures patients with primary biliary cirrhosis may
for the client? be severe in the early stages of the disease
when bile salt concentrations are low but
cease to be a significant symptom when
A. "Jaundice is associated with pressure liver failure and cholestasis is advanced.
ulcer formation."
Option B: Consequently bile salts emerged
B. "Jaundice impairs urea production, as the primary causative agents in pruritus.
which produces pruritus." This was supported by the observation that
feeding bile salts to cholestatic patients
C. "Jaundice produces pruritus due to worsened pruritus, intradermal injection of
impaired bile acid excretion." bile salts in healthy volunteers caused local
itching, and administration of anion
D. "Jaundice leads to decreased tissue
exchange resins to bind luminal bile salts
perfusion and subsequent breakdown."
decreased itching intensity.
Incorrect
Option D: Jaundice itself does not lead to
Correct Answer: C. “Jaundice produces decreased tissue perfusion. Histamine is the
pruritus due to impaired bile acid principal mediator of allergic reactions and
excretion.” is released by mast cells and circulating
basophils. Bile salts, particularly
chenodeoxycholate and deoxycholate,
Jaundice is a symptom characterized by stimulate the release of histamine from
increased bilirubin concentration in the mast cells and plasma histamine
blood. Bile acid excretion is impaired, concentrations are increased in pruritic
increasing the bile acids in the skin and patients.
causing pruritus. Patients with jaundice
43 43. Question 43
often nominate pruritus as their most
troublesome symptom to control and the Which rationale supports explaining the
symptom that has the most negative placement of an esophageal tamponade
influence on their quality of life. The tube in a client who is hemorrhaging?
presence of pruritus can cause severe sleep
deprivation resulting in lassitude, fatigue,
depression, and suicidal ideation A. Allowing the client to help insert the
tube

B. Beginning teaching for home care

Option A: Jaundice is not associated with
pressure ulcer formation. However, edema
 C. Maintaining the client's level of anxiety C. Encouraging daily exercise
and alertness
D. Modifying dietary protein
D. Obtaining cooperation and reducing fear
Incorrect
Incorrect
Correct Answer: B. Counseling to stop
Correct Answer: D. Obtaining cooperation alcohol consumption.
and reducing fear

Chronic pancreatitis typically results from

An esophageal tamponade tube would be repeated episodes of acute pancreatitis.
inserted in critical situations. Typically, the More than half of chronic pancreatitis cases
client is fearful and highly anxious. The are associated with alcoholism. Counseling
nurse, therefore, explains the placement to to stop alcohol consumption would be the
help obtain the client’s cooperation and most helpful for the client. Explore the
reduce his fear. availability of treatment programs and
rehabilitation of chemical dependency if
indicated.
Option A: The client would not be helping
to insert the tube.
Option A: Resume oral intake with clear
Option B: This type of tube is used only
liquids and advance diet slowly to provide a
short-term and is not indicated for home
high-protein, high-carbohydrate diet, when
use. The tube is large and uncomfortable.
indicated. Oral feedings given too early in
Option C: A client’s anxiety should be the course of illness may exacerbate
decreased, not maintained, and depending symptoms. Loss of pancreatic function and
on the degree of hemorrhage, the client reduced insulin production may require the
may not be alert. initiation of a diabetic diet.

44 44. Question 44 Option C: Daily exercise would be helpful

but not the most beneficial intervention.
For Rico who has chronic pancreatitis, Review the importance of initially
which nursing intervention would be most continuing a bland, low-fat diet with
helpful? frequent small feedings and restricted
caffeine, with a gradual resumption of a
normal diet within individual tolerance.
A. Allowing liberalized fluid intake
Option D: Dietary protein modification is
B. Counseling to stop alcohol consumption not necessary for chronic pancreatitis.
Maintain NPO status and gastric suctioning encephalopathy (HE) is a reversible
in the acute phase. Prevents stimulation syndrome observed in patients with
and release of pancreatic enzymes advanced liver dysfunction. The syndrome
(secretin), released when chyme and HCl is characterized by a spectrum of
enter the duodenum. neuropsychiatric abnormalities resulting
from the accumulation of neurotoxic
45 45. Question 45
substances in the bloodstream (and
Mr. Hasakusa is in end-stage liver failure. ultimately in the brain).
Which interventions should the nurse
implement when addressing hepatic
encephalopathy? Select all that apply. Option A: The nurse should monitor the
client’s neurologic status. Symptoms
typically include confusion, personality
A. Assessing the client's neurologic status changes, disorientation, and a depressed
every 2 hours level of consciousness. The earliest stage is
often characterized by an inverted sleep-
B. Monitoring the client's hemoglobin and wake pattern wherein patients are found to
hematocrit levels be sleeping during the day and awake
throughout the night.
C. Evaluating the client's serum ammonia
level Option B: Monitoring the client’s
hemoglobin and hematocrit levels address
D. Monitoring the client's handwriting daily
esophageal bleeding. A diagnosis of HE
E. Preparing to insert an esophageal should involve a thorough evaluation of the
tamponade tube patient’s vital signs and airway followed by
classification of the symptoms according to
F. Making sure the client's fingernails are
the West-Haven Criteria.
short
Option C: The nurse should monitor the
Incorrect
client’s serum ammonia level. Elevated
Correct Answers: A, C, & D blood ammonia levels are often seen in
patients with hepatic encephalopathy. It is
more useful, however, to assess the clinical
improvement or deterioration of a patient
Hepatic encephalopathy results from an
undergoing treatment rather than monitor
increased ammonia level due to the liver’s
serial arterial blood ammonia
inability to convert ammonia to urea, which
measurements.
leads to neurologic dysfunction and
possible brain damage. Hepatic
Option D: The nurse should monitor the Incorrect
client’s handwriting. During the
Correct Answer: B. Applying pressure to
intermediate stages of HE, a characteristic
injection sites.
jerking movement of the limbs is often
observed (e.g., asterixis) when the patient
attempts to hold arms outstretched with
hands bent upward at the wrist. The client with cirrhosis who has altered
clotting is at high risk for hemorrhage.
Option E: Insertion of an esophageal Prolonged application of pressure to
tamponade tube addresses esophageal injection or bleeding sites is important.
bleeding. Treatment for HE involves proper Instruct patient/SO of signs and symptoms
identification and treatment of the that warrant notification of health care
underlying cause. Antibiotics (e.g., provider: increased abdominal girth; rapid
rifaximin) weight loss/gain; increased peripheral
neomycin/paromomycin/metronidazole, or edema; increased dyspnea, fever; blood in
vancomycin) are often given empirically due stool or urine; excess bleeding of any kind;
to the frequency of infection as an jaundice.
underlying cause.

Option F: Keeping fingernails short

addresses jaundice. Protein restriction is Option A: Complete independence may
only of use in patients with acute flare-ups increase the client’s potential for injury,
and is not justified in chronic cases. These because an unsupervised client may injure
patients need nutrition as they have a high himself and bleed excessively. Instruct SO
catabolic rate and severe wasting. to notify health care providers of any
confusion, untidiness, night wandering,
46 46. Question 46 tremors, or personality change. Changes
(reflecting deterioration) may be more
For a client with hepatic cirrhosis who has
apparent to SO, although insidious changes
altered clotting mechanisms, which
may be noted by others with less frequent
intervention would be most important?
contact with the patient.

Option C: Antibiotics are important to

A. Allowing complete independence of promote liver regeneration. However, they
mobility are not most important for a client at high
risk for hemorrhage. Some drugs are
B. Applying pressure to injection sites
hepatotoxic (especially narcotics, sedatives,
C. Administering antibiotics as prescribed and hypnotics). In addition, the damaged
liver has a decreased ability to metabolize
D. Increasing nutritional intake
all drugs, potentiating cumulative effect HE, a characteristic jerking movement of
and/or aggravation of bleeding tendencies. the limbs is often observed (e.g., asterixis)
when the patient attempts to hold arms
Option D: Encourage the patient to eat;
outstretched with hands bent upward at
explain reasons for the types of diet. Feed
the wrist.
the patient if tiring easily, or have SO
assisted the patient. Include the patient in
meal planning to consider his/her
Option A: Malaise is not related to
preferences in food choices. Improved
neurological involvement. Other physical
nutrition and diet are vital to recovery. The
signs may include hyperreflexia, a positive
patient may eat better if the family is
Babinski’s sign, or Parkinsonian symptoms
involved and preferred foods are included
(e.g., rigidity or tremors). Symptoms
as much as possible.
typically include confusion, personality
47 47. Question 47 changes, disorientation, and a depressed
level of consciousness. The earliest stage is
A client with advanced cirrhosis has been
often characterized by an inverted sleep-
diagnosed with hepatic encephalopathy.
wake pattern wherein patients are found to
The nurse expects to assess for:
be sleeping during the day and awake
throughout the night.

A. Malaise Option B: Stomatitis is not related to

neurological involvement. Throughout the
B. Stomatitis intermediate stages, patients tend to
experience worsening levels of confusion,
C. Hand tremors
lethargy, and personality changes. In the
D. Weight loss advanced stages, hepatic encephalopathy
may eventually lead to coma (e.g., hepatic
Incorrect
coma or coma hepaticum) and ultimately to
Correct Answer: C. Hand tremors death.

Option D: These clients typically have

ascites and edema so experience weight
Hepatic encephalopathy results from the gain. In order to make a diagnosis of HE,
accumulation of neurotoxins in the blood, there must be confirmed the presence of
therefore the nurse wants to assess for liver disease (e.g., abnormal liver function
signs of neurological involvement. Flapping tests, ultrasound or liver biopsy
of the hands (asterixis), changes in demonstrating liver disease) or a
mentation, agitation, and confusion are portosystemic shunt, and exclusion of other
common. During the intermediate stages of potential etiologies (e.g., intracranial
lesions, masses, hemorrhage or stroke;
seizure activity; post-seizure
Option A: Range of motion exercises
encephalopathy; intracranial infections; or
preserve joint function but do not prevent
toxic encephalopathy from other causes).
skin breakdown. Encourage and assist the
48 48. Question 48 patient with reposition on a regular
schedule. Assist with active and passive
A client diagnosed with chronic cirrhosis
ROM exercises as appropriate.
who has ascites and pitting peripheral
edema also has hepatic encephalopathy. Option B: Repositioning reduces pressure
Which of the following nursing on edematous tissues to improve
interventions are appropriate to prevent circulation. Exercises enhance circulation
skin breakdown? Select all that apply. and improve and/or maintain joint mobility.
Edematous tissues are more prone to
breakdown and to the formation of
A. Range of motion every 4 hours decubitus. Ascites may stretch the skin to
the point of tearing in severe cirrhosis.
B. Turn and reposition every 2 hours
Option C: Abdominal or foot massage will
C. Abdominal and foot massages every 2 not prevent skin breakdown but must be
hours cleaned carefully to prevent breaks in skin
integrity. Keep linens dry and free of
D. Alternating air pressure mattress
wrinkles. Moisture aggravates pruritus and
E. Sit in chair for 30 minutes each shift increases the risk of skin breakdown.

Incorrect Option D: Use an alternating pressure

mattress, egg-crate mattress, waterbed,
Correct Answers: B & D
sheepskins, as indicated. Reduces dermal
pressure, increases circulation, and
diminishes the risk of tissue ischemia.
Edematous tissue must receive meticulous
care to prevent tissue breakdown. An air Option E: The feet should be kept at the
pressure mattress, careful repositioning can level of the heart or higher so Fowler’s
prevent skin breakdown. Inspect pressure position should not be employed.
points and skin surfaces closely and Recommend elevating lower extremities.
routinely. Gently massage bony Enhances venous return and reduces
prominences or areas of continued stress. edema formation in extremities.
Use of emollient lotions and limiting use of
49 49. Question 49
soap for bathing may help.
Which of the following will the nurse use (neomycin, lactulose) to decrease
include in the care plan for a client serum ammonia levels in the presence of
hospitalized with viral hepatitis? hepatic encephalopathy.

Option C: Encourage intake of fruit juices,

carbonated beverages, and hard candy
A. Increase fluid intake to 3000 ml per day
throughout the day. Monitor dietary intake
B. Adequate bed rest and caloric count. Suggest several small
feedings and offer the “largest” meal at
C. Bland diet breakfast. Large meals are difficult to
manage when a patient is anorexic.
D. Administer antibiotics as ordered
Anorexia may also worsen during the day,
Incorrect making intake of food difficult later in the
day.
Correct Answer: B. Adequate bed rest.
Option D: Establish isolation techniques for
enteric and respiratory infections according
Treatment of hepatitis consists of bed rest to infection guidelines and policy.
during the acute phase to reduce metabolic Encourage or model effective handwashing.
demands on the liver, thus increasing blood Prevents transmission of viral disease to
supply and cell regeneration. Institute bed others. Thorough hand washing is effective
red or chair rest during the toxic state. in preventing virus transmission.
Provide a quiet environment; limit visitors
50 50. Question 50
as needed. Promotes rest and relaxation.
Available energy is used for healing. Activity Spironolactone (Aldactone) is prescribed for
and an upright position are believed to a client with chronic cirrhosis and ascites.
decrease hepatic blood flow, which The nurse should monitor the client for
prevents optimal circulation to the liver which of the following medication-related
cells. side effects?

Option A: Monitor I&O, compare with A. Jaundice

periodic weight. Note enteric losses:
B. Hyperkalemia
vomiting and diarrhea. Diarrhea may be due
to transient flu-like response to viral C. Tachycardia
infection or may represent a more serious
problem of obstructed portal blood flow D. Constipation
with vascular congestion in the GI tract, or it
Incorrect
may be the intended result of medication
Correct Answer: B. Hyperkalemia Option D: Constipation is not an expected
side effect of spironolactone (Aldactone).
Hyperkalemia can be due to spironolactone
This is a potassium-sparing diuretic so alone or a synergistic side effect from
clients should be monitored closely for multiple medications such as beta-blockers,
hyperkalemia. Diarrhea, dizziness, and angiotensin-converting enzyme inhibitors,
headaches are other more common side and angiotensin receptor blockers that
effects. Spironolactone is a medication used clinicians often prescribe to patients for
in the management and treatment of indications such as hypertension or heart
hypertension and heart failure with some failure.
indications aside from cardiovascular
#2
disease. It is in the mineralocorticoid
receptor antagonist class of drugs. 1. Question

During preparation for bowel surgery, a

male client receives an antibiotic to reduce
Option A: Jaundice is not an expected side
intestinal bacteria. Antibiotic therapy may
effect of spironolactone (Aldactone). The
interfere with the synthesis of which
most common non-electrolyte and
vitamin and may lead to
electrolyte adverse effects of
hypoprothrombinemia?
spironolactone are breast complaints and
hyperkalemia, respectively. Men specifically
may experience gynecomastia, loss of
A. Vitamin A
libido, and general feminization; the drug is
a category C pregnancy drug because B. Vitamin D
animal studies showed that the
feminization of male fetuses is a concern. C. Vitamin E

Option C: Tachycardia is not an expected D. Vitamin K

side effect of spironolactone (Aldactone).
Correct
Women can experience menstrual
irregularities. One study mentions the Correct Answer: D. Vitamin K
following additional adverse effects in order
from more to less common: dehydration,
hyponatremia, gastrointestinal problems Intestinal bacteria synthesize such
(nausea, vomiting, diarrhea or anorexia), nutritional substances as vitamin K,
neurological abnormalities (headache, thiamine, riboflavin, vitamin B12, folic acid,
drowsiness, asterixis, confusion, or coma), biotin, and nicotinic acid. Therefore,
and skin rashes. antibiotic therapy may interfere with the
synthesis of these substances, including Option C: Intestinal bacteria don’t
vitamin K. Antibiotics, especially those synthesize vitamin E. Vitamin E or
known as cephalosporins, reduce the tocopherol is a fat-soluble vitamin
absorption of vitamin K in the body. Using functioning as an antioxidant, protecting
them for more than 10 days may lower the cell membrane. As with all fat-soluble
levels of vitamin K because these drugs kill vitamins, transport and absorption require
not only harmful bacteria but also the intact fat digestion mechanisms. Fat
bacteria that make vitamin K. metabolism involves lipases, both lingual
and gastric, bile salts, pancreatic enzymes,
and intestinal absorption.
Option A: Vitamin A is a general term that
2. Question
encompasses various fat-soluble substances
such as retinol, retinyl palmitate, and beta- When evaluating a male client for
carotene. In the liver, retinol is esterified to complications of acute pancreatitis, the
retinyl esters and stored in the stellate cells. nurse would observe for:
In the tissues, both retinol and beta-
carotene are oxidized to retinal and retinoic
acid, which are essential for vision and gene A. Increased intracranial pressure
regulation, respectively. These active
metabolites bind nuclear receptors of the B. Decreased urine output
RAR family to control gene expression.
C. Bradycardia
Option B: Vitamin D is labeled as the
D. Hypertension
“sunshine vitamin,” as it is produced in the
skin on sun exposure. Vitamin D is a Correct
hormone obtained through dietary
Correct Answer: B. Decreased urine output
consumption and skin production.
Ultraviolet B (UVB) radiation, wavelength
(290 to 315 nm) converts 7-
dehydrocholesterol in the skin to Acute pancreatitis can cause decreased
previtamin D. This previtamin D undergoes urine output, which results from the renal
heat isomerization and is converted to failure that sometimes accompanies this
vitamin D. Vitamin D from the skin and diet condition. AKI develops late in the course of
is metabolized in the liver to 25- acute pancreatitis, usually after failure of
hydroxyvitamin D (25 OH D), and 25- other organs. Remarkably, the kidney was
hydroxyvitamin D is useful in assessing the first organ to fail in only 8.9% of
vitamin D status. patients with AKI, and only a minority of
patients develop isolated AKI
 colonoscopy. How should the nurse position
the client for this test initially?
Option A: Intracranial pressure neither
increases nor decreases in a client with
pancreatitis. The causes of increased
A. Lying on the right side with legs straight
intracranial pressure (ICP) can be divided
based on the intracerebral components B. Lying on the left side with knees bent
causing elevated pressures. Generalized
swelling of the brain or cerebral edema C. Prone with the torso elevated
from a variety of causes such as trauma,
D. Bent over with hands touching the floor
ischemia, hyperammonemia, uremic
encephalopathy, and hyponatremia. Correct

Option C: Tachycardia, not bradycardia, Correct Answer: B. Lying on the left side
usually is associated with pulmonary or with knees bent
hypovolemic complications of pancreatitis.
Tachycardia and mild hypotension may
result from hypovolemia from For a colonoscopy, the nurse initially should
sequestration of fluid in the pancreatic bed. position the client on the left side with
About 60% of patients develop low-grade knees bent. Preparation for a colonoscopy
pyrexia from peripancreatic inflammation is the biggest complaint that most patients
without evident infection. have about receiving the procedure, and is
a primary reason for non-compliance to
Option D: Hypotension can be caused by a
screening colonoscopies. The technician or
hypovolemic complication, but
nurse is there to assist with preserving
hypertension usually isn’t related to acute
stability and preventing the patient from
pancreatitis. Release into the systemic
rolling forward or backward. Also, they are
circulation of activated enzymes and
there to help provide counter pressure to
proteases may cause endothelial damage
the abdomen to assist the endoscopist in
leading to extravasation of fluids from the
navigating corners and turns.
vascular space, hypovolemia, hypotension,
increased abdominal pressure, intense
kidney vasoconstriction, hypercoagulability,
and fibrin deposition in the glomeruli. Option A: Placing the client on the right side
with legs straight wouldn’t allow proper
3. Question visualization of the large intestine.
Performing a colonoscopy requires practice
A male client with a recent history of rectal
and is a skill that is difficult to master. While
bleeding is being prepared for a
watching an experienced clinician perform a
colonoscopy may appear simple, the
technique is something that requires time, demonstrates her understanding of
patience, and a lot of practice. Navigating Mallory-Weiss tearing is:
through a cylindrical tube that can flex,
dilate, contract, and move is not an easy
task. A. “Tell me about your husband’s alcohol
usage.”
Option B: Placing the client prone with the
torso elevated wouldn’t allow proper B. “Is your husband being treated for
visualization of the large intestine. The tuberculosis?”
patient should be positioned in the left
lateral decubitus position. Although, some C. “Has your husband recently fallen or
clinicians may prefer the patient on their injured his chest?”
back or right side if circumstances require.
D. “Describe spices and condiments your
The legs being flexed toward the chest help
husband uses on food.”
to relax the puborectalis and
pubococcygeus muscles. This allows for Incorrect
easier entry and traversing past the angle at
Correct Answer: A. “Tell me about your
the sacral prominence.
husband’s alcohol usage.”
Option D: Placing the client bent over with
hands touching the floor wouldn’t allow
proper visualization of the large intestine. A Mallory-Weiss tear is associated with
On the left-sided position, the patient’s legs massive bleeding after a tear occurs in the
should be flexed, and pillows should be mucous membrane at the junction of the
placed around their back, head, and esophagus and stomach. There is a strong
between their knees to help prevent injury relationship between ethanol usage,
to the bony prominence and to help resultant vomiting, and a Mallory-Weiss
maintain position. tear. Mallory-Weiss tears account for an
estimated 1-15% of cases of upper
4. Question
gastrointestinal bleeding. Although the age
A male client with extreme weakness, range varies widely, affected individuals are
pallor, weak peripheral pulses, and generally in middle age (40s-50s), and men
disorientation is admitted to the emergency reportedly have a higher incidence than
department. His wife reports that he has women by a ratio of 2-4:1.
been “spitting up blood.” A Mallory-Weiss
tear is suspected, and the nurse begins
taking the client’s history from the client’s Option B: The bleeding is coming from the
wife. The question by the nurse that stomach, not from the lungs as would be
true in some cases of tuberculosis. The
presence of a hiatal hernia is a predisposing B. Maintain the head of the bed at a 15-
factor and is found in 35-100% of patients degree elevation continuously.
with Mallory-Weiss tears. During retching
C. Check the gastrostomy tube for position
or vomiting, the transmural pressure
every 2 days.
gradient is greater within the hernia than
the rest of the stomach, and it is the D. Maintain the client on bed rest during
location most likely to sustain a tear the feedings.
Option C: A Mallory-Weiss tear doesn’t Incorrect
occur from chest injuries or falls.
Precipitating factors include retching, Correct Answer: A. Change the tube feeding
vomiting, straining, hiccupping, coughing, solutions and tubing at least every 24 hours.
primal scream therapy, blunt abdominal
trauma, and cardiopulmonary resuscitation.
In a few cases, no apparent precipitating Tube feeding solutions and tubing should
factor can be identified. One study reported be changed every 24 hours, or more
that 25% of patients had no identifiable risk frequently if the feeding requires it. Doing
factor. so prevents contamination and bacterial
growth. The feeding bag should be changed
Option D: A Mallory-Weiss tear isn’t
every 24 hours. Food (formula) should not
associated with eating spicy foods. Mallory-
be left in the bag for more than 4 hours. So,
Weiss tears are usually associated with
only put 4 hours (or less) worth of food in
other mucosal lesions. In one study, 83% of
the feeding bag at a time.
patients had additional mucosal
abnormalities potentially contributing to
bleeding or actually causing retching and
Option B: The head of the bed should be
vomiting that would induce these tears.
elevated 30 to 45 degrees continuously to
5. Question prevent aspiration. Lying prone/supine
during feeding increases the risk of
Which of the following nursing
aspiration and therefore where clinically
interventions should the nurse perform for
possible the child should be placed in an
a female client receiving enteral feedings
upright position. If unable to sit up for a
through a gastrostomy tube?
bolus feed or if receiving continuous
feeding, the head of the bed should be
elevated 30-45 degrees during feeding and
A. Change the tube feeding solutions and for at least 30 minutes after the feed to
tubing at least every 24 hours. reduce the risk of aspiration.
Option C: Checking for gastrostomy tube Correct Answer: B. 15 to 30 minutes
placement is performed before initiating
the feedings and every 4 hours during
continuous feedings. Correct placement of Meperidine’s onset of action is 15 to 30
the tube should be confirmed prior to minutes. It peaks between 30 and 60
administration of an enteral feed by minutes and has a duration of action of 2 to
checking the insertion site at the abdominal 4 hours. Meperidine is in the class of
wall and observing the client for abdominal phenylpiperidine as a hydrochloride salt
pain or discomfort. If the nurse is unsure synthetic form of the opioid. Meperidine is
regarding the position of the gastrostomy used for the treatment of moderate to
or jejunostomy tube contact the medical severe pain. It has intramuscular,
team immediately. subcutaneous, intravenous injection, syrup,
and tablet forms.
Option D: Clients may ambulate during
feedings. Tube feeding doesn’t need to
keep the client from most physical
activities. He can run or walk, but the client Option A: Injection should be into large
should talk to a doctor about yoga or other muscle mass, and it is preferable to
exercises that work the abdomen muscles. subcutaneous injection. Using Meperidine
Even swimming is fine if the incision site has for pain control should be considered if no
healed and the water is clean. other options are available, in which case
the duration of medication use should be
6. Question limited to less than 48 hours, and the total
dosage administered should not exceed 600
A male client is recovering from a small
mg in 24 hours.
bowel resection. To relieve pain, the
physician prescribes meperidine (Demerol), Option C: For intravenous (IV) injection,
75 mg I.M. every 4 hours. How soon after inject the dose of 10 mg/ml slowly. The
administration should meperidine onset of injection should be a consideration only
action occur? when an opiate antagonist and the
administration of oxygen and respiratory
monitoring facilities are available. In the
A. 5 to 10 minutes 20th century, it was the drug of choice
amongst the opioids in the management of
B. 15 to 30 minutes
acute pain by most physicians and the
C. 30 to 60 minutes management of some patients with chronic
pain. Meperidine is also being used as an
D. 2 to 4 hours adjunct to preoperative medications to
reduce shivering.
Incorrect
Option D: Meperidine has the same larger, typically raised lesions resulting from
mechanism of action as morphine, which is bleeding within the skin
acting as an agonist to the mu-opioid
receptor. The anti-shivering effect may
involve the stimulation of k-opioid Option A: Dyspnea and fatigue suggest
receptors. anemia. When patients with severe anemia
develop a high output state, cardiac failure
7. Question
can ensue causing them to have shortness
The nurse is caring for a male client with of breath from cardiac causes as well.
cirrhosis. Which assessment findings Diseases in other organs, such as the
indicate that the client has deficient vitamin kidneys and the liver, may cause dyspnea by
K absorption caused by this hepatic a combination of the interactions discussed.
disease?
Option B: Ascites and orthopnea are
unrelated to vitamin K absorption. Patients
with malignant ascites can have symptoms
A. Dyspnea and fatigue
related to malignancy, which may include
B. Ascites and orthopnea weight loss. On the other hand, patients
with ascites due to heart failure may report
C. Purpura and petechiae dyspnea, orthopnea, and peripheral edema,
and those with chylous ascites report
D. Gynecomastia and testicular atrophy
diarrhea, steatorrhea, malnutrition, edema,
Incorrect nausea, enlarged lymph nodes, early
satiety, fevers, and night sweats.
Correct Answer: C. Purpura and petechiae
Option D: Gynecomastia and testicular
atrophy result from decreased estrogen
A hepatic disorder, such as cirrhosis, may metabolism by the diseased liver.
disrupt the liver’s normal use of vitamin K Gynecomastia is most commonly caused by
to produce prothrombin (a clotting factor). an imbalance between the hormones
Consequently, the nurse should monitor the estrogen and testosterone. Estrogen
client for signs of bleeding, including controls female traits, including breast
purpura and petechiae. Petechiae and growth. Testosterone controls male traits,
purpura result from a wide variety of such as muscle mass and body hair.
underlying disorders and may occur at any
8. Question
age. Petechiae are small (1–3 mm), red,
non-blanching macular lesions caused by Which condition is most likely to have a
intradermal capillary bleeding. Purpura are nursing diagnosis of fluid volume deficit?
 record of I&O, noting output less than
intake, increased urine specific gravity.
A. Appendicitis
Option D: A client with a gastric ulcer may
B. Pancreatitis
be at risk for deficient fluid volume. The
C. Cholecystitis erosion of an ulcer through the gastric or
duodenal mucosal layer may cause GI
D. Gastric ulcer bleeding. The client may develop anemia. If
bleeding is brisk, changes in vital signs and
Incorrect
physical symptoms of hypovolemia may
Correct Answer: B. Pancreatitis develop rapidly.

9. Question

Hypovolemic shock from fluid shifts is a While a female client is being prepared for
major factor in acute pancreatitis. The other discharge, the nasogastric (NG) feeding
conditions are less likely to exhibit fluid tube becomes clogged. To remedy this
volume deficit. Early fluid therapy is the problem and teach the client’s family how
cornerstone of treatment and is universally to deal with it at home, what should the
recommended; however, there is a lack of nurse do?
consensus regarding the type, rate, amount,
and endpoints of fluid replacement. The
basic goal of fluid depletion should be to A. Irrigate the tube with warm water.
prevent or minimize the systemic response
to inflammatory markers. B. Advance the tube into the intestine.

C. Apply intermittent suction to the tube.

Option A: A client with appendicitis may be D. Withdraw the obstruction with a 30-ml
at risk for deficient fluid volume. The syringe.
peritoneum reacts to irritation and infection
Incorrect
by producing large amounts of intestinal
fluid, possibly reducing the circulating blood Correct Answer: A. Irrigate the tube with
volume, resulting in dehydration and warm water.
relative electrolyte imbalances.

Option C: A client with cholecystitis may be

The American Society for Parenteral and
at risk for deficient fluid volume. Prolonged
Enteral Nutrition (ASPEN) recommends
vomiting, gastric aspiration, and restricted
warm water as the best initial choice for
oral intake can lead to deficits in sodium,
trying to unclog a feeding tube. First, attach
potassium, and chloride. Maintain accurate
a 30- or 60-mL piston syringe to the feeding 10. Question
tube and pull back the plunger to help
A male client with pancreatitis complains of
dislodge the clog. Next, fill the flush syringe
pain. The nurse expects the physician to
with warm water, reattach it to the tube,
prescribe meperidine (Demerol) instead of
and attempt a flush.
morphine to relieve pain because:

Option B: Advancing the NG tube is

A. Meperidine provides a better, more
inappropriate because the tube is designed
prolonged analgesic effect.
to stay in the stomach and isn’t long
enough to reach the intestines. If there is B. Morphine may cause spasms of Oddi’s
still continued resistance, gently move the sphincter.
syringe plunger back and forth to help
loosen the clog. Then, clamp the tube to C. Meperidine is less addictive than
allow the warm water to penetrate the clog morphine.
for up to 20 minutes.
D. Morphine may cause hepatic
Option C: Applying intermittent suction or dysfunction.
using a syringe for aspiration is unlikely to
Incorrect
dislodge the material clogging the tube but
may create excess pressure.If the patient’s Correct Answer: B. Morphine may cause
feeding tube becomes clogged, attempt to spasms of Oddi’s sphincter.
unclog it before replacing it, which is both
costly and uncomfortable for the patient.
The belief that carbonated beverages or For a client with pancreatitis, the physician
cranberry juice will unclog a feeding tube is will probably avoid prescribing morphine
a persistent nursing myth. In fact, these because this drug may trigger spasms of the
beverages have an acidic pH that can sphincter of Oddi (a sphincter at the end of
worsen the occlusion by causing proteins in the pancreatic duct), causing irritation of
the EN formula to precipitate within the the pancreas. Morphine showed an
tube. excitatory effect on the sphincter of Oddi,
and might be a cause of Oddi’s sphincter
Option D: Intermittent suction may even
dysfunction(SOD). SO may function as a
collapse the tube. Consistently flushing
peristaltic pump to actively expel fluid from
feeding tubes with water as scheduled
the sphincter segment into the duodenum.
during EN therapy and medication
administration is the best way to minimize
the risk of occlusions.
Option A: Meperidine has a somewhat C. Chronic low self-esteem
shorter duration of action than morphine.
D. Deficient knowledge
Morphine is the standard opium-based
analgesic with well-known analgesic effects Incorrect
and side effects. Meperidine (pethidine) is
another opioid, but the use of meperidine is Correct Answer: C. Chronic low self-esteem
not very popular in countries such as the
USA and Canada, however, it is still used in
Iran for pain management in the ED. Young women with chronic low self-esteem
— are at the highest risk for anorexia
Option C: The two drugs are equally
nervosa because they perceive being thin as
addictive. Meperidine appeared to be safer
a way to improve their self-confidence.
with a lower risk of addiction when
Anorexia nervosa is an illness of starvation,
compared to other opioids and because of
brought on by severe disturbance of body
the anticholinergic effects associated with
image and a morbid fear of obesity. People
less biliary spasm or renal colic.
with anorexia nervosa attempt to maintain
Option D: Morphine isn’t associated with a weight that’s far below normal for their
hepatic dysfunction. Respiratory depression age and height.
is among the more serious adverse
reactions with opiate use that is especially
important to monitor in the postoperative Option A: Hopelessness is an inappropriate
patient population. Other reported side nursing diagnosis because clients with
effects include lightheadedness, sedation, anorexia nervosa seldom feel hopeless;
and dizziness. instead, they use food to control their
desire to be thin and hope that restricting
11. Question
food intake will achieve this goal. Feelings
Mandy, an adolescent girl is admitted to an of personal ineffectiveness, low self-
acute care facility with severe malnutrition. esteem, and perfectionism are often part of
After a thorough examination, the physician the problem.
diagnoses anorexia nervosa. When
Option B: Major physical and psychological
developing the plan of care for this client,
changes in adolescence can contribute to
the nurse is most likely to include which
the development of eating disorders.
nursing diagnosis?
Feelings of powerlessness and loss of
control of feelings (in particular sexual
sensations) lead to an unconscious desire to
A. Hopelessness desexualize self. The patient often believes
that these fears can be overcome by taking
B. Powerlessness
control of bodily appearance, development, be inserted into the openings of the body
and function. such as the mouth or anus. An upper GI
series, or barium study, usually isn’t the
Option D: Anorexia nervosa doesn’t result
diagnostic method of choice, especially in a
from a knowledge deficit, such as one
client with acute active bleeding who’s
regarding good nutrition. The patient sees
vomiting and unstable.
herself as weak-willed, even though part of
a person may feel a sense of power and
control (dieting, weight loss). The patient
Option B: An upper GI series is also less
feels helpless to change and requires
accurate than endoscopy. Although an
assistance to problem-solve methods of
upper GI series might confirm the presence
control in life situations.
of a lesion, it wouldn’t necessarily reveal
12. Question whether the lesion is bleeding. An upper
gastrointestinal series (UGI) is a
Which diagnostic test would be used first to
radiographic (X-ray) examination of the
evaluate a client with upper GI bleeding?
upper gastrointestinal (GI) tract. The
esophagus, stomach, and duodenum (first
part of the small intestine) are made visible
A. Endoscopy on X-ray film by a liquid suspension. This
liquid suspension may be barium or a
B. Upper GI series
water-soluble contrast.
C. Hemoglobin (Hb) levels and hematocrit
Option C: Hb levels and HCT, which indicate
(HCT)
loss of blood volume, aren’t always reliable
D. Arteriography indicators of GI bleeding because a
decrease in these values may not be seen
Incorrect
for several hours. Upper GI bleeding is
Correct Answer: A. Endoscopy sometimes fatal, and the European Society
of Gastrointestinal Endoscopy recommends
maintaining Hb levels between 7.0–9.0 g/dl
using blood transfusion in order to reduce
Endoscopy permits direct evaluation of the
mortality.
upper GI tract and can detect 90% of
bleeding lesions. Endoscopy is the insertion Option D: Arteriography is an invasive study
of a long, thin tube directly into the body to associated with life-threatening
observe an internal organ or tissue in detail. complications and wouldn’t be used for an
It can also be used to carry out other tasks initial evaluation. An arteriogram is an
including imaging and minor surgery. imaging test that uses x-rays and a special
Endoscopes are minimally invasive and can dye to see inside the arteries. It can be used
to view arteries in the heart, brain, kidney,
and other parts of the body.
Option B: Hepatitis B can be transmitted by
13. Question I.V. drug use. In the United States,
estimates are about 2.2 million people have
A female client who has just been
chronic hepatitis B virus infection. It is
diagnosed with hepatitis A asks, “How could
transmitted parenterally and sexually when
I have gotten this disease?” What is the
individuals come in contact with mucous
nurse’s best response?
membranes or body fluids of infected
individuals.

A. “You may have eaten contaminated Option C: Hepatitis B can be transmitted by

restaurant food.” blood transfusion. Transfusion of blood and
blood products, injection drug use with
B. “You could have gotten it by using I.V. shared needles, needlesticks, or wounds
drugs.” caused by other instruments in healthcare
workers and hemodialysis are all examples
C. “You must have received an infected
of parenteral and percutaneous exposures,
blood transfusion.”
but parenteral mode remains the dominant
D. “You probably got it by engaging in mode of transmission both globally and in
unprotected sex.” the United States.

Incorrect Option D: Hepatitis C can be transmitted by

unprotected sex. Transmission can be
Correct Answer: A. “You may have eaten
parenteral, perinatal, and sexual, with the
contaminated restaurant food.”
most common mode being the sharing of
contaminated needles among IV drug users.
Also, other high-risk groups include people
Hepatitis A virus typically is transmitted by who require frequent blood transfusions
the oral-fecal route — commonly by and organ transplantation of organs from
consuming food contaminated by infected infected donors.
food handlers. The hepatitis A virus (HAV) is
a common infectious etiology of acute 14. Question
hepatitis worldwide. HAV is most commonly
When preparing a male client, age 51, for
transmitted through the oral-fecal route via
surgery to treat appendicitis, the nurse
exposure to contaminated food, water, or
formulates a nursing diagnosis of Risk for
close physical contact with an infectious
infection related to inflammation,
person. The virus isn’t transmitted by the
perforation, and surgery. What is the
I.V. route, blood transfusions, or
unprotected sex.
rationale for choosing this nursing Option A: Inflammation and bacterial
diagnosis? growth follow, and swelling continues to
raise pressure within the appendix,
resulting in gangrene and rupture. The
A. Obstruction of the appendix may pathophysiology of appendicitis likely stems
increase venous drainage and cause the from obstruction of the appendiceal orifice.
appendix to rupture. This results in inflammation, localized
ischemia, perforation, and the development
B. Obstruction of the appendix reduces of a contained abscess or frank perforation
arterial flow, leading to ischemia, with resultant peritonitis.
inflammation, and rupture of the appendix.
Option C: Geriatric, not middle-aged, clients
C. The appendix may develop gangrene and are especially susceptible to appendix
rupture, especially in a middle-aged client. rupture. Appendicitis occurs most often
between the ages of 5 and 45 with a mean
D. Infection of the appendix diminishes
age of 28. The incidence is approximately
necrotic arterial blood flow and increases
233/100,000 people. Males have a slightly
venous drainage.
higher predisposition of developing acute
Incorrect appendicitis compared to females, with a
lifetime incidence of 8.6% for men and 6.7
Correct Answer: B. Obstruction of the
% for women.
appendix reduces arterial flow, leading to
ischemia, inflammation, and rupture of the Option D: When an obstruction is the cause
appendix. of appendicitis, it leads to an increase in
intraluminal and intramural pressure,
resulting in small vessel occlusion and
A client with appendicitis is at risk for lymphatic stasis. Once obstructed, the
infection related to inflammation, appendix fills with mucus and becomes
perforation, and surgery because distended, and as lymphatic and vascular
obstruction of the appendix causes mucus compromise advances, the wall of the
fluid to build up, increasing pressure in the appendix becomes ischemic and necrotic.
appendix and compressing venous outflow
15. Question
drainage. The pressure continues to rise
with venous obstruction; arterial blood flow A female client with hepatitis C develops
then decreases, leading to ischemia from liver failure and GI hemorrhage. The blood
lack of perfusion. products that would most likely bring about
hemostasis in the client are:
A. Whole blood and albumin. are dysfunctional, due to medications or
other acquired or inherited lesions.
B. Platelets and packed red blood cells.
Option C: The indications for whole blood
C. Fresh frozen plasma and whole blood.
and blood component transfusion consist of
D. Cryoprecipitate and fresh frozen plasma. increasing hemoglobin and oxygenation of
tissues, maintaining adequate blood volume
Incorrect to avoid ischemia and hypovolemic shock,
and to reconstitute platelets, coagulation
Correct Answer: D. Cryoprecipitate and
factors, and other plasma proteins to a
fresh frozen plasma.
functional status.

16. Question
The liver is vital in the synthesis of clotting
To prevent gastroesophageal reflux in a
factors, so when it’s diseased or
male client with a hiatal hernia, the nurse
dysfunctional, as in hepatitis C, bleeding
should provide which of the following
occurs. Treatment consists of administering
discharge instructions?
blood products that aid clotting. These
include fresh frozen plasma containing
fibrinogen and cryoprecipitate, which have
most of the clotting factors. A. “Lie down after meals to promote
digestion.”

B. “Avoid coffee and alcoholic beverages.”

Option A: Although administering whole
blood, albumin, and packed cells will C. “Take antacids with meals.”
contribute to hemostasis, those products
D. “Limit fluid intake with meals.”
aren’t specifically used to treat hemostasis.
Whole blood is often divided into Incorrect
component parts for ease of storage and
Correct Answer: B. “Avoid coffee and
administration. These typically include Red
alcoholic beverages.”
Blood Cells (RBC), Platelets (thrombocytes),
and Plasma.

Option B: Platelets are helpful, but the best To prevent reflux of stomach acid into the
answer is cryoprecipitate and fresh frozen esophagus, the nurse should advise the
plasma. Platelets are typically given when client to avoid foods and beverages that
patients have a low platelet count increase stomach acids, such as coffee and
(thrombocytopenia) or have platelets that alcohol. Instruct the patient regarding
avoidance of alcohol, smoking, and
caffeinated beverages. These increase acid A. Administering pain medication
production and may cause esophageal
B. Obtaining a blood sample for laboratory
spasms.
studies

C. Preparing to insert a nasogastric (NG)

Option A: The nurse also should teach the tube
client to avoid lying down after meals,
D. Administering I.V. fluids
which can aggravate reflux. Instruct to
remain in an upright position at least 2 Incorrect
hours after meals; avoiding eating 3 hours
before bedtime. This helps control reflux Correct Answer: D. Administering I.V. fluids.
and causes less irritation from reflux action
into the esophagus.
I.V. infusions containing normal saline
Option C: The nurse also should teach the
solution and potassium should be given first
client to take antacids after eating. Instruct
to maintain fluid and electrolyte balance.
the patient in medications, effects, side
Maintenance of bowel rest requires
effects, and to report to the physician if
alternative fluid replacement to correct
symptoms persist despite medication
losses and anemia. Fluids containing sodium
treatment. Promotes knowledge, facilitates
may be restricted in presence of regional
compliance with treatment, and allows for
enteritis.
prompt identification of potential need for
changes in medication regimen to prevent
complications.
Option A: Pain medication often is withheld
Option D: The client need not limit fluid until the obstruction is diagnosed because
intake with meals as long as the fluids analgesics can decrease intestinal motility.
aren’t gastric irritants. Instruct the patient Provide comfort measures (back rub,
to avoid highly seasoned food, acidic juices, reposition) and diversional activities.
alcoholic drinks, bedtime snacks, and foods Promotes relaxation, refocuses attention,
high in fat. These can reduce the lower and may enhance coping abilities.
esophageal sphincter pressure.
Option B: A blood sample is then obtained
17. Question for laboratory studies to aid in the diagnosis
of bowel obstruction and guide treatment.
The nurse caring for a client with small
Blood studies usually include a complete
bowel obstruction would plan to implement
blood count, serum electrolyte levels, and
which nursing intervention first?
blood urea nitrogen level.
Option C: For the client’s comfort and to Dysphagia isn’t associated with rectal
assist in bowel decompression, the nurse tenesmus, duodenal inflammation, or
should prepare to insert an NG tube next. abnormal gastric structures.
Resume or advance diet as indicated (clear
liquids progressing to bland, low residue;
then high-protein, high-calorie, caffeine- Option A: Rectal tenesmus can happen for
free, non-spicy, and low-fiber as indicated). several reasons. The most common is colon
inflammation, either from a noninfectious
18. Question
or infectious cause. Inflammatory bowel
A female client with dysphagia is being disease (IBD) is one cause of colon
prepared for discharge. Which outcome inflammation. IBD is an umbrella term for
indicates that the client is ready for several long-term conditions involving
discharge? chronic inflammation of the gut.

Option C: The most common cause of

duodenitis is infection by Helicobacter
A. The client doesn’t exhibit rectal
pylori (H. pylori) bacteria. Another common
tenesmus.
cause is the long-term use of NSAIDs (such
B. The client is free from esophagitis and as aspirin and ibuprofen). Celiac disease, an
achalasia. allergy to gluten, causes a particular type of
inflammation in the duodenum along with
C. The client reports diminished duodenal other changes.
inflammation.
Option D: Dysphagia means difficulty
D. The client has normal gastric structures. swallowing. For this diagnosis, it is critical
that related symptoms be associated with
Incorrect
the act of swallowing a liquid or solid bolus.
Correct Answer: B. The client is free from When unassociated with swallowing, the
esophagitis and achalasia. sensation of fullness in the upper
esophagus suggests globus hystericus,
which is distinct from dysphagia.
Dysphagia may be the reason why a client
19. Question
with esophagitis or achalasia seeks
treatment. Dysphagia is common in patients A male client undergoes total gastrectomy.
with erosive esophagitis but is not a reliable Several hours after surgery, the nurse notes
clinical predictor of severe erosive that the client’s nasogastric (NG) tube has
esophagitis. Dysphagia resolved with PPI stopped draining. How should the nurse
therapy in most cases, but persistent respond?
dysphagia may indicate failed healing.
 facilitates a better surgical field and reduces
complications such as nausea, vomiting,
A. Notify the physician.
aspiration, and anastomotic leakage caused
B. Reposition the tube. by postoperative ileus.

C. Irrigate the tube. Option D: Increasing the level of suction

may cause trauma to GI mucosa or the
D. Increase the suction level. suture line. The reason to perform such
activity may be either therapeutic, as in
Incorrect
patients with distention and vomiting from
Correct Answer: A. Notify the physician bowel obstruction, diagnostic, as in the case
of gastrointestinal bleeding or peptic ulcer
disease, or prophylactic, as in patients
An NG tube that fails to drain during the having major abdominal surgery.
postoperative period should be reported to
20. Question
the physician immediately. It may be
clogged, which could increase pressure on What laboratory finding is the primary
the suture site because fluid isn’t draining diagnostic indicator for pancreatitis?
adequately. Nasogastric decompression has
been routinely used in most abdominal
operations to prevent the consequences of A. Elevated blood urea nitrogen (BUN)
postoperative ileus.
B. Elevated serum lipase

C. Elevated aspartate aminotransferase

Option B: Repositioning an NG tube in a (AST)
client who has undergone gastric surgery
can disrupt the anastomosis. Routine use of D. Increased lactate dehydrogenase (LD)
nasogastric tubes after abdominal
Incorrect
operations is intended to hasten the return
of bowel function, prevent pulmonary Correct Answer: B. Elevated serum lipase
complications, diminish the risk of
anastomotic leakage, increase patient
comfort and shorten hospital stay. Elevation of serum lipase is the most
reliable indicator of pancreatitis because
Option C: Irrigating an NG tube in a client
this enzyme is produced solely by the
who has undergone gastric surgery can
pancreas. Serum lipase typically increases
disrupt the anastomosis. Most surgeons
3–6 hours after the onset of acute
traditionally continue to use nasogastric
pancreatitis and usually peaks at 24 hours.
decompression, believing that its use
Unlike amylase, there is significant A male client with cholelithiasis has a
reabsorption of lipase in the renal tubules gallstone lodged in the common bile duct.
so the serum concentrations remain When assessing this client, the nurse
elevated for 8–14 days. expects to note:

Option A: A client’s BUN is typically A. Yellow sclera

elevated in relation to renal dysfunction. A
B. Light amber urine
BUN test is done to see how well the
kidneys are working. If the kidneys are not C. Circumoral pallor
able to remove urea from the blood
normally, the BUN level rises. Heart failure, D. Black, tarry stools
dehydration, or a diet high in protein can
Incorrect
also make the BUN level higher. Liver
disease or damage can lower the BUN level. Correct Answer: A. Yellow sclera

Option C: A client’s AST is typically elevated

in relation to liver dysfunction. The elevated
Yellow sclera may be the first sign of
AST-to-ALT ratio in alcoholic liver disease
jaundice, which occurs when the common
results in part from the depletion of vitamin
bile duct is obstructed. Jaundice can be a
B6 (pyridoxine) in chronic alcoholics. ALT
sign of a common bile duct obstruction
and AST both use pyridoxine as a coenzyme,
from an entrapped gallstone. In the
but the synthesis of ALT is more strongly
presence of jaundice and abdominal pain,
inhibited by pyridoxine deficiency than is
often, a procedure is an indication to go and
the synthesis of AST.
retrieve the stone to prevent further
Option D: A client’s LD is typically elevated sequelae.
in relation to damaged cardiac muscle.
Usually, LDH isoenzyme levels increase 24–
72 hours following myocardial infarction Option B: Urine normally is light amber.
and reach a peak concentration in 3–4 days. Usually, patients with symptoms from
Glycogen phosphorylase BB is released into gallstones present with right upper
circulation 2–4 h after onset of cardiac abdominal pain after eating greasy or spicy
ischemia and returns to baseline levels 1–2 foods. There is often nausea and vomiting.
days after acute myocardial infarction, Pain can also be present in the epigastric
making it an early marker. area that radiates to the right scapula or
mid-back.
21. Question
Option C: Circumoral pallor doesn’t occur in Risk factors for peptic (gastric and
common bile duct obstruction; it is a sign of duodenal) ulcers include alcohol abuse,
hypoxia, respectively. The classic physical smoking, and stress. Peptic ulcer disease
exam finding is a positive Murphy’s sign, (PUD) has various causes; however,
where the pain is elicited on deep palpation Helicobacter pylori-associated PUD and
to the right upper quadrant underneath the NSAID-associated PUD account for the
rib cage upon deep inspiration. majority of the disease etiology.

Option D: Black, tarry stools don’t occur in

common bile duct obstruction; they are
Option A: A sedentary lifestyle isn’t a risk
signs of GI bleeding. Progression of this
factor for peptic ulcers. PUD is a global
condition is indicated by neurologic changes
problem with a lifetime risk of development
and hypotension (Reynold’s pentad). Other
ranging from 5% to 10%. Overall, there is a
sequelae are acute pancreatitis with
decrease in the incidence of PUD worldwide
symptoms of midepigastric pain and
due to improved hygienic and sanitary
intractable vomiting.
conditions combined with effective
22. Question treatment and judicious use of NSAIDs.

Nurse Hannah is teaching a group of Option B: A history of hemorrhoids isn’t a

middle-aged men about peptic ulcers. risk factor for peptic ulcers. Gastric and
When discussing risk factors for peptic duodenal ulcers can be differentiated from
ulcers, the nurse should mention: the timing of their symptoms in relation to
meals. Nocturnal pain is common with
duodenal ulcers. Those with gastric outlet
A. A sedentary lifestyle and smoking. obstruction commonly report a history of
abdomen bloating and or fullness.
B. A history of hemorrhoids and smoking.
Option C: Chronic renal failure, not acute
C. Alcohol abuse and a history of acute renal failure, is associated with duodenal
renal failure. ulcers. The prognosis of PUD is excellent
after the underlying cause is successfully
D. Alcohol abuse and smoking.
treated. Recurrence of the ulcer may be
Incorrect prevented by maintaining good hygiene and
avoiding alcohol, smoking, and NSAIDs.
Correct Answer: D. Alcohol abuse and
smoking. 23. Question

While palpating a female client’s right

upper quadrant (RUQ), the nurse would
expect to find which of the following long. Normally, the appendix sits in the
structures? lower right abdomen.

Option C: The spleen is located in the left

upper quadrant. The spleen is a fist-sized
A. Sigmoid colon
organ in the upper left side of the
B. Appendix abdomen, next to the stomach and behind
the left ribs. It’s an important part of the
C. Spleen immune system, but one can survive
without it.
D. Liver
24. Question
Incorrect
A male client has undergone a colon
Correct Answer: D. Liver
resection. While turning him, wound
dehiscence with evisceration occurs. The
nurse’s first response is to:
The RUQ contains the liver, gallbladder,
duodenum, head of the pancreas, hepatic
flexure of the colon, portions of the
A. Call the physician.
ascending and transverse colon, and a
portion of the right kidney. Begin palpation B. Place saline-soaked sterile dressings on
over the right lower quadrant, near the the wound.
anterior iliac spine. Palpate for the liver
with one or two hands palm down moving C. Take blood pressure and pulse.
upward 2-3 cm at a time towards the lower
D. Pull the dehiscence closed.
costal margin.
Incorrect

Correct Answer: B. Place saline-soaked

Option A: The sigmoid colon is located in
sterile dressings on the wound.
the left lower quadrant. The 40cm long
sigmoid colon is located in the left lower
quadrant of the abdomen, extending from
The nurse should first place saline-soaked
the left iliac fossa to the level of the S3
sterile dressings on the open wound to
vertebra.
prevent tissue drying and possible infection.
Option B: The appendix is located in the Ask the client to bend the knees to reduce
right lower quadrant. The appendix sits at abdominal tension. Note the color of the
the junction of the small intestine and large tissue before it is covered. Then, cover the
intestine. It’s a thin tube about four inches moistened dressings with a sterile drape.
 C. Anticoagulant drugs

Option A: After placing saline-soaked sterile D. Antihypertensive drugs

dressings, the nurse should call the
Incorrect
physician. The bed should be lowered until
it is flat or not higher than 20 degrees. Correct Answer: B. Anticholinergic drugs
Dehiscence occurs when an incisional
wound separates after surgery; evisceration
occurs when an internal bodily organ
Paregoric has an additive effect of
protrudes through the incision. Dehiscence
constipation when used with anticholinergic
and evisceration can be a life-threatening
drugs. The opiate anhydrous morphine,
emergency.
which is contained in paregoric, can
Option C: Take the client’s vital signs and decrease motility more than loperamide or
SPO2 while notifying the physician. Check the combination of diphenoxylate and
every 15 minutes and assess for signs of atropine can. Antiarrhythmics,
shock. The nurse may also start a patent IV anticoagulants, and antihypertensives
line with 0.9% sodium chloride solution for aren’t known to interact with paregoric.
surgery.

Option D: The dehiscence needs to be

Option A: Of the Class III antiarrhythmics,
surgically closed, so the nurse should never
amiodarone is involved in a significant
try to close it. Be prepared to insert a
number of interactions since it is a potent
nasogastric tube if ordered, to decompress
inhibitor of several cytochrome P450
the stomach. Keep the dressings wet and
enzymes. It can significantly impair the
check the wound frequently, using a new
metabolism of digoxin, theophylline and
pair of sterile gloves each time.
warfarin. Dosages of digoxin and warfarin
25. Question should empirically be decreased by one-half
when amiodarone therapy is added.
The nurse is monitoring a female client
receiving paregoric to treat diarrhea for Option C: The anticoagulant effect of
drug interactions. Which drugs can produce warfarin is inhibited by drugs like
additive constipation when given with an barbiturates, rifampin, azathioprine, and
opium preparation? carbamazepine, which increase its
clearance by inducing hepatic metabolism.
Azathioprine also reduces the anticoagulant
effect of warfarin, presumably through a
A. Antiarrhythmic drugs
potentiating effect on hepatic clearance.
B. Anticholinergic drugs
Option D: Nonsteroidal anti-inflammatory avoid fluid loss through ileostomy drainage,
drugs (NSAIDs) can induce an increase in the nurse should instruct the client to
blood pressure (BP) and may potentially increase fluid intake. Monitor I&O. Note
reduce the efficacy of several number, character, and amount of stools;
antihypertensive drugs. Probably the main estimate insensible fluid losses
mechanism of action is inhibition of (diaphoresis). Measure urine specific
prostaglandin (PG) synthesis since NSAIDs gravity; observe for oliguria. Provides
have a higher propensity to increase BP as information about overall fluid balance,
the regulation of BP (and renal function) is renal function, and bowel disease control,
more PG-dependent and to interact with as well as guidelines for fluid replacement.
drugs (diuretics, beta-blockers, and ACE
inhibitors) that may act through the
increase of PG formation. Option B: The nurse should teach the client
to wear a collection appliance at all times
26. Question
because ileostomy drainage is incontinent.
A male client is recovering from an Resume or advance diet as indicated (clear
ileostomy that was performed to treat liquids progressing to bland, low residue;
inflammatory bowel disease. During then high-protein, high-calorie, caffeine-
discharge teaching, the nurse should stress free, non-spicy, and low-fiber as indicated).
the importance of:
Option C: The nurse should teach the client
to avoid high-fiber foods because they may
irritate the intestines. Avoid or limit foods
A. Increasing fluid intake to prevent
that might cause or exacerbate abdominal
dehydration.
cramping, flatulence (milk products, foods
B. Wearing an appliance pouch only at high in fiber or fat, alcohol, caffeinated
bedtime. beverages, chocolate, peppermint,
tomatoes, orange juice).
C. Consuming a low-protein, high-fiber diet.
Option D: The nurse should teach the client
D. Taking only enteric-coated medications. to avoid enteric-coated medications
because the body can’t absorb them after
Incorrect
an ileostomy. Allows the intestinal tract to
Correct Answer: A. Increasing fluid intake to readjust to the digestive process. Protein is
prevent dehydration. necessary for tissue healing integrity. Low
bulk decreases peristaltic response to
meals.
Because stool forms in the large intestine,
27. Question
an ileostomy typically drain liquid waste. To
The nurse is caring for a female client with been achieved and should not be delayed
active upper GI bleeding. What is the by more than 24 hours.
appropriate diet for this client during the
Option B: Skim milk shouldn’t be given
first 24 hours after admission?
because it increases gastric acid production,
which could prolong bleeding. Further
research found that ingesting milk increases
A. Regular diet
the production of stomach acid, which can
B. Skim milk worsen gastritis symptoms. Any relief
gastritis sufferers experience after drinking
C. Nothing by mouth a glass of milk is likely to be temporary;
within a half-hour, symptoms are usually
D. Clear liquids
worse, not better.
Incorrect
Option D: A liquid diet is the first diet
Correct Answer: C. Nothing by mouth offered after bleeding and shock are
controlled. They can be fed with clear
liquids soon after endoscopy. Clear liquids
Shock and bleeding must be controlled provide the advantage that if the patient
before oral intake, so the client should starts to bleed again, sedation and
receive nothing by mouth. When the anesthesia can be given within two hours
bleeding is controlled, the diet is gradually after the last ingestion
increased, starting with ice chips and then
28. Question
clear liquids. In patients hospitalized for
acute upper gastrointestinal bleeding due A male client has just been diagnosed with
to an ulcer with high risk of rebleeding or hepatitis A. On assessment, the nurse
with variceal bleeding, it is recommended expects to note:
to wait at least 48 h after endoscopic
therapy before initiating oral or enteral
feeding. A. Severe abdominal pain radiating to the
shoulder.

B. Anorexia, nausea, and vomiting.

Option A: A regular diet is incorrect. Proton
pump inhibitors (PPIs) are beneficial for C. Eructation and constipation.
both ulcer and non-ulcer diseases as they
reduce the risk of re-bleeding by clot D. Abdominal ascites.
stabilization. Endoscopy should only be
Incorrect
performed after hemodynamic stability has
Correct Answer: B. Anorexia, nausea, and cavity. It is the most common complication
vomiting. of cirrhosis and occurs in about 50% of
patients with decompensated cirrhosis in 10
years. The development of ascites denotes
Hallmark signs and symptoms of hepatitis A the transition from compensated to
include anorexia, nausea, vomiting, fatigue, decompensated cirrhosis.
and weakness. Acute hepatitis usually
29. Question
presents as a self-limited illness;
development of fulminant hepatitis is rare. A female client with viral hepatitis A is being
Typical symptoms of acute infection include treated in an acute care facility. Because
nausea, vomiting, abdominal pain, fatigue, the client requires enteric precautions, the
malaise, poor appetite, and fever; nurse should:
management is with supportive care.

A. Place the client in a private room.

Option A: Abdominal pain may occur but
B. Wear a mask when handling the client’s
doesn’t radiate to the shoulder.
bedpan.
Extrahepatic manifestations rarely occur
but may include pancreatitis, rash, acute C. Wash the hands after touching the
kidney injury with interstitial nephritis or client.
glomerulonephritis, pneumonitis,
pericarditis, hemolysis, and acute D. Wear a gown when providing personal
cholecystitis. care for the client.

Option C: Eructation and constipation are Incorrect

common in gallbladder disease, not
Correct Answer: C. Wash the hands after
hepatitis A. Patients may develop dark urine
touching the client.
and pale stools within a week, followed by
jaundice, icteric (yellow-tinted) sclera, and
pruritus. Patients usually have elevated
To maintain enteric precautions, the nurse
levels of serum alanine aminotransferase,
must wash the hands after touching the
aspartate aminotransferase, bilirubin,
client or potentially contaminated articles
alkaline phosphatase, and lambda-glutamyl
and before caring for another client. Enteric
transpeptidase.
precautions are taken to prevent infections
Option D: Abdominal ascites is a sign of that are transmitted primarily by direct or
advanced hepatic disease, not an early sign indirect contact with fecal material. They’re
of hepatitis A. Ascites is the pathologic indicated for patients with known or
accumulation of fluid within the peritoneal
suspected infectious diarrhea or Incorrect
gastroenteritis.
Correct Answer: C. Eating contaminated
shellfish.

Option A: A private room is warranted only

if the client has poor hygiene — for
Hepatitis A can be caused by consuming
instance, if the client is unlikely to wash the
contaminated water, milk, or food —
hands after touching infective material or is
especially shellfish from contaminated
likely to share contaminated articles with
water. The most common mode of
other clients.
transmission of hepatitis A is via the fecal-
Option B: For enteric precautions, the nurse oral route from contact with food, water, or
need not wear a mask. While taking care of objects contaminated by fecal matter from
the client, the nurse may wear gloves and a an infected individual. It is more commonly
gown if she might have contact with body encountered in developing countries where
fluids (stool, urine, saliva). A sign on the due to poverty and lack of sanitation, there
door to the client’s room reminds staff to is a higher chance of fecal-oral spread.
wear a gown and gloves when inside the
room. Staff will wash their hands before
entering and leaving the client’s room. Option A: Hepatitis B is caused by blood and
sexual contact with an infected person.
Option D: For enteric precautions, the nurse
Transfusion of blood and blood products,
must wear a gown only if soiling from fecal
injection drug use with shared needles,
matter is likely. Wash hands before entering
needlesticks, or wounds caused by other
and before leaving the client’s room. Make
instruments in healthcare workers and
sure to use soap and water when leaving
hemodialysis are all examples of parenteral
the room. Be sure other visitors do this too.
and percutaneous exposures, but
30. Question parenteral mode remains the dominant
mode of transmission both globally and in
Which of the following factors can cause
the United States.
hepatitis A?
Option B: Hepatitis C is usually caused by
contact with infected blood, including
A. Contact with infected blood. receiving blood transfusions. Transmission
can be parenteral, perinatal, and sexual,
B. Blood transfusions with infected blood. with the most common mode being the
sharing of contaminated needles among IV
C. Eating contaminated shellfish.
drug users. Also, other high-risk groups
D. Sexual contact with an infected person. include people who require frequent blood
transfusions and organ transplantation of and distorting auscultatory sounds. The
organs from infected donors. diaphragm of the stethoscope should be
placed on the right side of the umbilicus to
Option D: Hepatitis B and C can be caused
listen to the bowel sounds, and their rate
by sexual contact with an infected person.
should be calculated after listening for at
Intravenous drug users, men who have sex
least two minutes. Normal bowel sounds
with men, healthcare workers with
are low-pitched and gurgling, and the rate is
exposure to infected body fluids, patients
normally 2-5/min.
who require frequent and multiple blood
transfusions, people who have multiple
sexual partners, prisoners, partners of
Option A: Begin with the general inspection
hepatitis B virus carriers, and persons born
of the patient and then proceed to the
in endemic areas are all at high risk for
abdominal area. This should be performed
hepatitis B virus infection.
at the foot end of the bed. The general
31. Question inspection can give multiple clues regarding
the diagnosis of the patient, for example,
The correct sequence for abdominal
yellowish discoloration of the skin
assessment is:
(jaundice) indicates a possible hepatic
abnormality.

A. Inspection, percussion, palpation, Option C: There are three stages of

auscultation. palpation that include superficial or light
palpation, deep palpation, and organ
B. Inspection, auscultation, palpation, palpation and should be performed in the
percussion. same order. Maneuvers specific to certain
diseases are also a part of abdominal
C. Inspection, palpation, auscultation,
palpation. The examiner should begin with
percussion.
superficial or light palpation from the area
D. Inspection, percussion, auscultation, furthest from the point of maximal pain and
palpation. move systematically through the nine
regions of the abdomen.
Incorrect
Option D: A proper technique of percussion
Correct Answer: B. Inspection, auscultation,
is necessary to gain maximum information
palpation, percussion.
regarding the abdominal pathology. While
percussing, it is important to appreciate
tympany over air-filled structures such as
Auscultation is done before palpation to the stomach and dullness to percussion
avoid stimulating peristaltic movements which may be present due to an underlying
mass or organomegaly (for example, antibiotic sensitivity, number of organs
hepatomegaly or splenomegaly). affected, and patient age. The more factors
that match SIRS, the higher the mortality.
32. Question
Option B: The high mortality of patients
Peritonitis can occur as a complication of:
with multiple organ failure provided a focus
for the problems that ultimately led to
death for many patients in the intensive
A. Septicemia care unit. The frequency of infection, sepsis,
or inflammation in producing multiple
B. Multiple organ failure
organ failure led to clinical trials of so-called
C. Hypovolemic shock magic bullets for the treatment of patients
with sepsis.
D. Peptic ulcer disease
Option C: Patients with volume depletion
Incorrect
may complain of thirst, muscle cramps,
Correct Answer: D. Peptic ulcer disease and/or orthostatic hypotension. Severe
hypovolemic shock can result in mesenteric
and coronary ischemia that can cause
abdominal or chest pain. Agitation,
Perforation is a life-threatening
lethargy, or confusion may result from brain
complication of peptic ulcer disease and can
malperfusion.
result in peritonitis. Since the peritoneum
completely covers the stomach, perforation 33. Question
of the wall creates a communication
between the gastric lumen and the A patient has become very depressed
peritoneal cavity. If the perforation occurs postoperatively after receiving a colostomy
acutely, there is no time for an for GI cancer. He does not participate in his
inflammatory reaction to wall off the colostomy care or looks at the stoma. An
perforation, and the gastric content is free appropriate nursing diagnosis for this
to enter the general peritoneal cavity, situation is:
causing chemical peritonitis.

A. Ineffective Individual Coping

Option A: Septic shock is a serious illness
B. Knowledge Deficit
and despite all the advances in medicine, it
still carries high mortality which can exceed C. Impaired Adjustment
40%. Mortality does depend on many
D. Anxiety
factors including the type of organism,
Incorrect model. Helps reinforce teaching (shared
experiences) and facilitates acceptance of
Correct Answer: A. Ineffective Individual
change as the patient realizes “life does go
Coping
on” and can be relatively normal.

34. Question
The patient is dealing with a disturbance in
Patients with esophageal varices would
self-concept and difficulty coping with the
reveal the following assessment:
newly established stoma. Encourage the
patient/SO to verbalize feelings regarding
the ostomy. Acknowledge normality of
A. Increased blood pressure
feelings of anger, depression and grief over
a loss. Discuss daily “ups and downs” that B. Increased heart rate
can occur.
C. Decreased respiratory rate

D. Increased urinary output

Option B: Provide opportunities for
patient/SO to view and touch stoma, using Incorrect
the moment to point out positive signs of
Correct Answer: B. Increased heart rate
healing, normal appearance, and so forth.
Remind the patient that it will take time to
adjust, both physically and emotionally.
Tachycardia is an early sign of
Option C: Although integration of stoma compensation for patients with esophageal
into body image can take months or even varices. Since the portal venous system has
years, looking at the stoma and hearing no valves, resistance at any level between
comments (made in a normal, matter-of- the splanchnic vessels and the right side of
fact manner) can help the patient with this the heart results in retrograde flow and
acceptance. Touching stoma reassures elevated pressure. The collaterals slowly
patient/SO that it is not fragile and that enlarge and connect the systemic
slight movements of stoma actually reflect circulation to the portal venous system.
normal peristalsis.

Option D: Maintain a positive approach

Option A: Esophageal varices are a direct
during care activities, avoiding expressions
result of high blood pressure in the portal
of disdain or revulsion. Do not take angry
vein. This condition is called portal
expressions of the patient and SO
hypertension. It causes blood to build up in
personally. A person who is living with an
nearby blood vessels, including those in
ostomy can be a good support system/role
your esophagus. Veins begin to dilate and Vasopressin is the drug of choice when
swell as a result of increased blood flow. sclerotherapy is contraindicated. Vasoactive
drugs stop bleeding in most patients, and
Option C: The respiratory rate is not
emergency sclerotherapy may carry risks to
decreased in esophageal varices.
the patient and is more demanding on the
Esophageal varices are the major
healthcare system. Sclerotherapy did not
complication of portal hypertension. It is
appear to be superior to vasoactive drugs in
detected in about 50% of cirrhosis patients,
terms of control of bleeding, the number of
and approximately 5–15% of cirrhosis
transfusions, 42?day rebleeding and
patients show newly formed varices or
mortality, or rebleeding and mortality
worsening of varices each year.
before other elective treatments.
Option D: Effective resuscitation, accurate
diagnosis, and early treatment are key to
reducing mortality in variceal bleeding. The Option A: Neomycin is used in preventing
aims are not only to stop bleeding as soon encephalopathy when blood is broken
as possible but also to prevent early re- down. Neomycin belongs to a group of
bleeding. Early rebleeding, as with peptic antibiotics known as aminoglycosides. Like
ulcer disease, is significantly associated with others in the aminoglycoside family,
worsening mortality. neomycin works by inhibiting bacterial
protein synthesis leading to its bactericidal
35. Question
effect. This group of medications is
The nurse would anticipate using which particularly effective in killing gram-
medication if sclerotherapy has not been negative organisms allowing for good
used? coverage of enteric organisms.

Option B: Propranolol may or may not be

used to decrease cardiac output and
A. Neomycin hepatic venous pressure. Propranolol can
be used to ameliorate the sympathetic
B. Propranolol
response in angina, tachyarrhythmias,
C. Vasopressin prevention of acute ischemic attacks,
migraine prophylaxis, and restless leg
D. Cimetidine
syndrome. Propranolol can be used in
Incorrect almost all cases if the desired result is to
slow contractility and decrease a patient’s
Correct Answer: C. Vasopressin heart rate.

Option D: Cimetidine is a drug with the

indication of peptic ulcer disease,
gastroesophageal reflux disease, and for Option B: A pericardiectomy is a procedure
dermatological conditions including warts, done on the sac around the heart. A
urticaria, mastocytosis, and erythropoietic surgeon cuts away this sac or a large part of
protoporphyria. This medication is an H2 this sac. This allows the heart to move
receptor antagonist. freely. Pericardiectomy is most often
needed in people with chronic constrictive
36. Question
pericarditis. It’s not usually an option for
The nurse must be alert for complications people who have had a single instance of
with Sengstaken-Blakemore intubation pericarditis. With chronic constrictive
including: pericarditis, the pericardium has become
stiff and thick. This is due to repeated
scarring. This scarring constricts the heart’s
movement.
A. Pulmonary obstruction
Option C: A pulmonary embolism is a blood
B. Pericardiectomy syndrome
clot that occurs in the lungs. It can damage
C. Pulmonary embolization part of the lung due to restricted blood
flow, decrease oxygen levels in the blood,
D. Cor pulmonale
and affect other organs as well. Large or
Incorrect multiple blood clots can be fatal. The
blockage can be life-threatening.
Correct Answer: A. Pulmonary obstruction.
Option D: Cor pulmonale is a condition that
most commonly arises out of complications
from high blood pressure in the pulmonary
Rupture or deflation of the balloon could
arteries (pulmonary hypertension). It’s also
result in upper airway obstruction.
known as right-sided heart failure because
Esophageal rupture is a well-known but
it occurs within the right ventricle of the
rarely reported fatal complication of the
heart.
management of bleeding esophageal
varices with the Sengstaken-Blakemore (SB) 37. Question
tube. The most common complications of
esophageal balloon therapy for varices Peptic ulcer disease may be caused by
include aspiration, esophageal perforation, which of the following?
and pressure necrosis of the mucosa. The
other choices are not related to the tube.
A. Helicobacter pylori

B. Clostridium difficile
C. Candida albicans And in the case of certain infections, like
thrush, it can create white patches.
D. Staphylococcus aureus
Option D: Staphylococcus aureus is the
Incorrect
most dangerous of all of the many common
Correct Answer: A. Helicobacter pylori staphylococcal bacteria. These Gram-
positive, sphere-shaped (coccal) bacteria
often cause skin infections but can cause
pneumonia, heart valve infections, and
Helicobacter pylori is considered to be the
bone infections.
major cause of ulcer formation. Peptic ulcer
disease (PUD) has various causes; however, 38. Question
Helicobacter pylori-associated PUD and
NSAID-associated PUD account for the Pain control with peptic ulcer disease
majority of the disease etiology. H. pylorus includes all of the following except:
is a gram-negative bacillus that is found
within the gastric epithelial cells. This
bacterium is responsible for 90% of A. Promoting physical and emotional rest.
duodenal ulcers and 70% to 90% of gastric
B. Identifying stressful situations.
ulcers. Other choices are not related to
ulcer formation. C. Eating meals when desired.

D. Administering medications that decrease

gastric acidity.
Option B: Clostridium difficile is a gram-
positive bacterium that is the cause most Incorrect
implicated in antibiotic-associated diarrhea.
The emergence of a newer hypervirulent Correct Answer: C. Eating meals when
strain North American pulsed-field gel desired.
electrophoresis type 1 (NAP1) has been
attributed to the increase in incidence and
severity of C. difficile infections (CDI) over Meals should be regularly spaced in a
the last decade. relaxed environment. Instruct the client
that meals should be eaten at regularly
Option C: Candida albicans is the most
spaced intervals in a relaxed setting. An
prevalent cause of fungal infections in
irregular schedule of meals may interfere
people. Its species name, Albicans, comes
with the regular administration of
from the Latin word for “white.” The yeast
medications.
appears white when cultured on a plate.
Option A: Encourage the use of Correct Answer: A. Vitamin C
nonpharmacological pain relief measures
such as distraction, guided imagery.
Massage, or music therapy. Non- Vitamin C and refrigeration of foods inhibit
pharmacological relaxation techniques will nitroso carcinogen. Humans are exposed to
decrease the production of gastric acid, a wide range of nitrogen-containing
which in turn will reduce pain. compounds and nitrosating agents, such as
nitrite, nitrate, and nitrogen oxides (NOx),
Option B: Acknowledge awareness of the
that can react in vivo to form potentially
client’s anxiety. Acknowledgement of the
carcinogenic N-nitroso compounds (NOCs),
client’s feelings validates the feelings and
as well as several carcinogenic C-nitro(so) or
communicates the acceptance of those
reactive diazo compounds.
feelings. Open communication enables the
client to develop a trusting relationship that
aids in reducing anxiety and stress.
Option B: Ascorbic acid, alpha-tocopherol,
Option D: Antacids buffer gastric acid and phenolic compounds, and fruit, vegetable
prevent the formation of peptin. This and plant extracts inhibit NOC formation by
mechanism of action promotes the healing destroying nitrosating agents. Fresh fruits
of the ulcer. Antibiotics treat the and vegetables (sources of nitrosation
Helicobacter pylori infection and promote inhibitors) exert a protective effect against
healing of the ulcer. As the ulcer heals, the various epithelial cancers.
client experiences less pain. H2 receptor
antagonists block the secretion of gastric Option C: Although vitamin C has been
acid. known to stimulate immune function,
inhibit nitrosamine formation, and block the
39. Question metabolic activation of carcinogens, its
cancer-preventive effects may be
Nitrosocarcinogen production can be
associated mainly with its protective effects
inhibited with the intake of:
against oxidative stress.

Option D: Vitamin C, not fiber, is considered

A. Vitamin C to be one of the most prevalent
antioxidative components of fruit and
B. Vitamin E
vegetables, and it could exert
C. Carbohydrates chemopreventive effects without apparent
toxicity at doses higher than the current
D. Fiber recommended dietary allowance of 60
mg/d. It has also been used as a dietary
Incorrect
supplement intended to prevent oxidative
stress-mediated chronic diseases such as GI tract such as gastroparesis, anorexia,
cancer, cardiovascular disease, vomiting, early satiety, intestinal
hypertension, stroke, and enteropathy, diarrhea, constipation, or fecal
neurodegenerative disorder. incontinence.

40. Question Option C: Addison disease is an acquired

primary adrenal insufficiency. A primary
The nurse can expect a 60-year old patient
adrenal insufficiency is termed Addison
with ischemic bowel to report a history of:
disease when an autoimmune process
causes the condition. It is a rare but
potentially life-threatening emergency
A. Diabetes mellitus condition. It results from bilateral adrenal
cortex destruction leading to decreased
B. Asthma
adrenocortical hormones, which may
C. Addison's Disease include cortisol, aldosterone, and
androgens.
D. Cancer of the bowel
Option D: Approximately 5% of patients
Incorrect
with ischemic colitis have an obstructing
Correct Answer: A. Diabetes mellitus lesion, usually in the distal colon. Half of
these patients have colon cancer while the
remainder has strictures caused by
disorders such as diverticulitis, radiation,
Ischemic bowel occurs in patients over 50
and previous surgery.
with a history of diabetes mellitus. Diabetes
mellitus is the most common endocrine 41. Question
disorder affecting multiple organs including
the gastrointestinal (GI) tract where During the initial assessment of a patient
manifestations and/or complications relate post-endoscopy, the nurse notes absent
to disordered gut motility possibly as a bowel sounds, tachycardia, and abdominal
result of autonomic neuropathy. distention. The nurse would anticipate:

Option B: Asthma is not related to an A. Ischemic bowel

ischemic bowel. An increased prevalence of
B. Peritonitis
GI symptoms or complications has been
documented in diabetic patients compared C. Hypovolemic shock
with nondiabetic control subjects including
D. Perforated bowel
symptoms from both the upper and lower
Incorrect action decreases, leading to bowel
obstruction. Large amounts of fluid from
Correct Answer: D. Perforated bowel
the intravascular space move into the
peritoneal cavity, causing hypovolemia and
hemoconcentration.
Invasive diagnostic testing can cause
perforated bowel. Perforation is widely 42. Question
recognized as one of the most serious
Which of the following tests can be useful
complications of endoscopy of the lower
as a diagnostic and therapeutic tool in the
gastrointestinal tract. The risk of
biliary system?
perforation ranges from 0.027% to 0.088%
for flexible sigmoidoscopy, from 0.016% to
0.2% for diagnostic colonoscopy, and up to
A. Ultrasonography
5% for therapeutic endoscopy.
B. MRI

C. Endoscopic retrograde
Option A: Ischemic bowel is usually not
cholangiopancreatography (ERCP)
related. As the volume of both diagnostic
and therapeutic endoscopic procedures D. Computed tomography scan (CT scan)
increases, the absolute number of
perforations will undoubtedly increase even Incorrect
with a relatively constant perforation rate.
Correct Answer: C. Endoscopic retrograde
Option B: Peritonitis can be a complication cholangiopancreatography (ERCP)
after initial perforation. The risk factors
contributing to perforation are well
established in the literature. They include ERCP permits direct visualization of the
patient-related factors such as advanced pancreatic and common bile ducts. Its
age, female sex, diverticular disease, therapeutic value is in retrieving gallstones
previous abdominal surgery, and colonic from the distal and common bile ducts and
stricture in addition to therapeutic dilating strictures. Endoscopic retrograde
procedures such as endoscopic resection cholangiopancreatography (ERCP) is a
and dilation. combined endoscopic and fluoroscopic
procedure in which an endoscope is
Option C: Hypovolemic shock can occur if
advanced into the second part of the
peritonitis is allowed to continue. If the
duodenum, thus allowing other tools to be
peritoneum is weakened or injured,
passed into the biliary and pancreatic ducts
inflammation and infection can spread
via the major duodenal papilla.
through the peritoneal cavity. Peristaltic
 superimposition of images, which provides
a tremendous advantage over plain films.
Option A: Ultrasonography aids in the
diagnosis of cholecystitis, gallstones, 43. Question
pancreatitis, and metastatic disease. It also
To inhibit pancreatic secretions, which
identifies edema, inflammation, and fatty or
pharmacologic agent would you anticipate
fibrotic infiltrates or calcifications. A
administering to a patient with acute
procedure that uses high-energy sound
pancreatitis?
waves to look at tissues and organs inside
the body. The sound waves make echoes
that form pictures of the tissues and organs
on a computer screen (sonogram). A. Nitroglycerin
Ultrasonography may be used to help
B. Somatostatin
diagnose diseases, such as cancer.
C. Pancrelipase
Option B: MRI detects hepatic neoplasms,
cysts, abscesses, and hematomas. Magnetic D. Pepcid
resonance imaging ( MRI ) uses a large
Incorrect
magnet and radio waves to look at organs
and structures inside the body. Health care Correct Answer: B. Somatostatin
professionals use MRI scans to diagnose a
variety of conditions, from torn ligaments to
tumors. MRIs are very useful for examining Somatostatin, a treatment for acute
the brain and spinal cord. pancreatitis, inhibits the release of
Option D: A CT Scan can be done without a pancreatic enzymes. Somatostatin produces
contrast medium. It can detect tumors, predominantly neuroendocrine inhibitory
cysts, pseudocysts, abscesses, hematomas, effects across multiple systems. It is known
and obstructions of the liver, biliary tract to inhibit GI, endocrine, exocrine,
and pancreas. The CT scan is essentially an pancreatic, and pituitary secretions, as well
X-ray study, where a series of rays are as modify neurotransmission and memory
rotated around a specified body part, and formation in the CNS.
computer-generated cross-sectional images
are produced. The advantage of these
tomographic images compared to Option A: Nitroglycerin is a vasodilator and
conventional X-rays is that they contain does not affect pancreatic secretions.
detailed information of a specified area in Nitroglycerin is a vasodilatory drug used
cross-section, eliminating the primarily to provide relief from anginal
chest pain. It is currently FDA approved for
the acute relief of an attack or acute B. Respiratory alkalosis
prophylaxis of angina pectoris secondary to
C. Metabolic acidosis
coronary artery disease.
D. Metabolic alkalosis
Option C: Pancrelipase is an enzyme that
aids in the digestion and absorption of fats Incorrect
and proteins. Pancrelipase refers to a class
of medications designed to treat Correct Answer: A. Respiratory acidosis
malabsorption and abdominal pain
secondary to exocrine pancreatic
insufficiency. These agents serve as A pH of 7.35 indicates acidosis, as does an
exogenous versions of digestive hormones acidic CO2 and bicarbonate. The primary
and enzymes required for normal digestion disturbance of elevated arterial PCO2 is the
and are ingested with meals to improve decreased ratio of arterial bicarbonate to
digestion, absorption, and abdominal pain arterial PCO2, which leads to a lowering of
frequently seen in chronic pancreatitis and the pH. In the presence of alveolar
exocrine pancreatic insufficiency. hypoventilation, 2 features commonly are
seen are respiratory acidosis and
Option D: Pepcid is an H2 blocker and is
hypercapnia. To compensate for the
used to decrease gastric motility. H2
disturbance in the balance between carbon
receptor blockers, or H2 receptor
dioxide and bicarbonate (HCO3-), the
antagonists (H2RAs), are a class of gastric
kidneys begin to excrete more acid in the
acid-suppressing agents frequently used in
forms of hydrogen and ammonium and
various gastric conditions. They are FDA-
reabsorb more base in the form of
approved for short-term use in treating
bicarbonate. See also: 8-Step Guide to ABG
uncomplicated gastroesophageal reflux
Analysis: Tic-Tac-Toe Method
disease (GERD), gastric or duodenal ulcers,
gastric hypersecretion, and mild to
infrequent heartburn or indigestion.
Option B: Respiratory alkalosis is 1 of the 4
44. Question basic classifications of blood pH imbalances.
Normal human physiological pH is 7.35 to
Your patient’s ABG reveals an acidic pH, an
7.45. A decrease in pH below this range is
acidic CO2, and a normal bicarbonate level.
acidosis, an increase above this range is
Which of the following indicates this acid-
alkalosis. Respiratory alkalosis is by
base disturbance?
definition a disease state where the body’s
pH is elevated to greater than 7.45
secondary to some respiratory or
A. Respiratory acidosis pulmonary process.
Option C: Determining the type of D. Low-Fowler's position
metabolic acidosis can help clinicians
Incorrect
narrow down the cause of the disturbance.
Acidemia refers to a pH less than the Correct Answer: A. Knee-chest position
normal range of 7.35 to 7.45. In addition,
metabolic acidosis requires a bicarbonate
value less than 24 mEq/L. Further
Flexion of the trunk lessens the pain and
classification of metabolic acidosis is based
decreases restlessness. Promote position of
on the presence or absence of an anion gap,
comfort on one side with knees flexed,
or concentration of unmeasured serum
sitting up, and leaning forward. Reduces
anions.
abdominal pressure and tension, providing
Option D: HCO3 functions as an alkalotic some measure of comfort and pain relief.
substance. CO2 functions as an acidic Other positions do not decrease the pain.
substance. Therefore, increases in HCO3 or
decreases in CO2 will make blood more
alkalotic. The opposite is also true where Option B: The Semi-Fowler’s position is a
decreases in HCO3 or an increase in CO2 position in which a patient, typically in a
will make blood more acidic. CO2 levels are hospital or nursing home is positioned on
physiologically regulated by the pulmonary their back with the head and trunk raised to
system through respiration, whereas the between 15 and 45 degrees, although 30
HCO3 levels are regulated through the renal degrees is the most frequently used bed
system with reabsorption rates. Therefore, angle.
metabolic alkalosis is an increase in serum
Option C: The word “lateral” means “to the
HCO3.
side,” while “recumbent” means “lying
45. Question down.” In the right or left lateral recumbent
position, the individual is lying on their right
A clinical manifestation of acute
or left side. This position makes it easier to
pancreatitis is epigastric pain. Your nursing
access a patient’s side.
intervention to facilitate relief of pain would
place the patient in a: Option D: Supine position often increases
pain. The Semi-Fowler’s position is often
used for purposes similar to those of the
A. Knee-chest position regular Fowler’s position, including feeding
and lung expansion, cardiac or respiratory
B. Semi-Fowler's position conditions, and for patients with a
nasogastric tube.
C. Recumbent position
46. Question
What assessment finding of a patient with with Cullen’s sign (periumbilical
acute pancreatitis would indicate a bluish ecchymosis).
discoloration around the umbilicus?
Option B: Homan’s sign is called pain
elicited by the dorsiflexion of the foot and
suggests deep vein thrombosis. Homan’s
A. Grey-Turner's sign
sign test also called dorsiflexion sign test is
B. Homan's sign a physical examination procedure that is
used to test for deep vein thrombosis
C. Rovsing's sign (DVT). A positive Homan’s sign in the
presence of other clinical signs may be a
D. Cullen's sign
quick indicator of DVT. Clinical evaluation
Incorrect alone cannot be relied on for patient
management, but when carefully
Correct Answer: D. Cullen’s sign
performed, it remains useful in determining
the need for additional testing (like D-dimer
test, ultrasonography, multidetector helical
Cullen’s sign is associated with pancreatitis computed axial tomography (CT), and
when a hemorrhage is suspected. Cullen’s pulmonary angiography).
sign is described as superficial edema with
bruising in the subcutaneous fatty tissue Option C: Rovsing’s sign is associated with
around the periumbilical region. It is also appendicitis when pain is felt with pressure
known as periumbilical ecchymosis. It is at McBurney’s point. Rovsing’s sign is a
most often recognized as a result of clinical finding that is indicative of acute
hemorrhagic pancreatitis. The sign can take appendicitis (the inflammation and possible
2–3 days before appearance and may be infection of the appendix). A positive
used as a clinical sign to help the diagnosis Rovsing’s sign is characterized by right
of acute pancreatitis. lower abdominal pain upon palpation of the
left side of the lower abdomen

47. Question
Option A: Grey-Turner’s sign is ecchymosis
in the flank area suggesting retroperitoneal A patient with severe cirrhosis of the liver
bleed. Grey Turner’s sign is an uncommon develops hepatorenal syndrome. Which of
subcutaneous manifestation of intra- the following nursing assessment data
abdominal pathology that manifests as would support this?
ecchymosis or discoloration of the flanks.
Classically it correlates with severe acute
necrotizing pancreatitis, often in association A. Oliguria and azotemia
B. Metabolic alkalosis The systemic drop in circulating pressure
triggers the carotid and aortic arch
C. Decreased urinary concentration
baroreceptors to activate three separate
D. Weight gain of less than 1 lb per week compensatory mechanisms. These include
the renin-angiotensin-aldosterone system,
Incorrect vasopressin release, and activation of the
sympathetic nervous system (SNS).
Correct Answer: A. Oliguria and azotemia
Option D: With renal insufficiency,
significant weight gain is expected due to
Hepatorenal syndrome is a functional fluid retention. The progression of cirrhosis
disorder resulting from a redistribution of causes a fall in cardiac output and a fall in
renal blood flow. Oliguria and azotemia systemic vascular resistance in a cycle that
occur abruptly as a result of this induces further renal vasoconstriction. This
complication. Confusion due to hepatic leads to further renal hypoperfusion,
encephalopathy is likely the last and most worsened by renal vasoconstriction with
severe stage of liver disease as a result of the endpoint of renal failure.
the liver failing to break down toxic
48. Question
metabolites. Most importantly these
patients notice they urinate less frequently Which phase of hepatitis would the nurse
in smaller and smaller volumes as they incur strict precautionary measures at?
become oliguric.

A. Icteric
Option B: Excess organic acids are not being
excreted by the damaged kidneys, resulting B. Non-icteric
in an elevated concentration of hydrogen
C. Post-icteric
ions; decreased pH occurs, causing
metabolic acidosis. Cirrhosis and portal D. Pre-icteric
hypertension can trigger the
Incorrect
neurohormonal cascade which leads to the
development of HRS. This, in turn, causes Correct Answer: D. Pre-icteric
the production and release of vasodilators
and cytokines like nitric oxide and
prostaglandins which cause splanchnic and
Pre-icteric is the infective phase and
systemic vasodilation.
precautionary measures should be strictly
Option C: Concentration of the urine is enforced. However, most patients are not
increased with decreased renal function. always diagnosed during this phase.
Nonspecific symptoms occur; they include spontaneously 4 to 8 weeks after symptom
profound anorexia, malaise, nausea and onset.
vomiting, a newly developed distaste for
49. Question
cigarettes (in smokers), and often fever or
right upper quadrant abdominal pain. You are caring for Rona, a 35-year-old
Urticaria and arthralgias occasionally occur, female in a hepatic coma. Which evaluation
especially in HBV infection. criteria would be the most appropriate?

Option A: During the icteric phase, A. The patient demonstrates an increase in

precautionary measures should already be the level of consciousness.
in place. After 3 to 10 days, the urine
darkens, followed by jaundice. Systemic B. The patient exhibits improved skin
symptoms often regress, and patients feel integrity.
better despite worsening jaundice. The liver
C. The patient experiences no evident signs
is usually enlarged and tender, but the edge
of bleeding.
of the liver remains soft and smooth. Mild
splenomegaly occurs in 15 to 20% of D. The patient verbalizes decreased
patients. Jaundice usually peaks within 1 to episodes of pain.
2 weeks.
Incorrect
Option B: There is no non-icteric phase.
Correct Answer: A. The patient
Some manifestations of acute hepatitis are
demonstrates an increase in the level of
virus-specific, but in general, acute infection
consciousness.
tends to develop in predictable phases.
Acute viral hepatitis is a common,
worldwide disease that has different
causes; each type shares clinical, Increased level of consciousness indicates
biochemical, and morphologic features. The resolving of a comatose state. Ongoing
term acute viral hepatitis often refers to assessment of behavior and mental status is
infection of the liver by one of the hepatitis important because of the fluctuating nature
viruses. of impending hepatic coma. Other options
are important evaluations but do not
Option C: During the post-icteric phase, evaluate a patient in a hepatic coma who is
precautionary measures should already be responding to external stimuli.
in place. During this 2- to 4-week period,
jaundice fades. Appetite usually returns
after the first week of symptoms. Acute
viral hepatitis usually resolves
Option B: Inspect pressure points and skin Incorrect
surfaces closely and routinely. Gently
Correct Answer: B. Risk for Rejection
massage bony prominences or areas of
continued stress. Use of emollient lotions
and limiting the use of soap for bathing may
help. Keep linens dry and free of wrinkles. Risk for rejection is always a possibility,
especially during the 4th to 10th day
Option C: Closely assess for signs and postoperatively. LT patients are at risk for
symptoms of GI bleeding: check all several complications. The primary care NP
secretions for frank or occult blood. should be aware of these complications and
Observe color and consistency of stools, NG needs to know when referral back to a
drainage, or vomitus. The esophagus and transplant center or hepatologist is
rectum are the most usual sources of appropriate. The most serious issues are
bleeding because of their mucosal fragility problems with the vasculature of the liver,
and alterations in hemostasis associated biliary issues, rejection, and infection. Lab
with cirrhosis. abnormalities—specifically elevation in
alkaline phosphatase, alanine
Option D: Use small needles for injections.
aminotransferase (ALT), and serum bilirubin
Apply pressure to small bleeding and
levels—are usually the first indication of a
venipuncture sites for longer than usual.
problem in one or more of these areas.
Minimizes damage to tissues, reducing risk
of bleeding and hematoma. Encourage the
use of soft toothbrush, electric razor,
avoiding straining for stool, vigorous nose Option A: Post-transplant acute kidney
blowing, and so forth. injury (AKI) has been reported to occur in 9-
78% of cases with 10% progressing to end-
50. Question stage renal failure. Early identification of
potential AKI is crucial to improving patient
What is the primary nursing diagnosis for a
outcomes as evidence shows that even
4th to 10th-day postoperative liver
small increases in serum creatinine are
transplant patient?
associated with a decline in overall
mortality.

A. Excess Fluid Volume Option C: Patients are also at risk for

specific opportunistic infections in the early
B. Risk for Rejection
postoperative period. Herpes simplex virus
C. Impaired Skin Integrity (HSV) reactivation disease is the most
common opportunistic viral infection and
D. Decreased Cardiac Output can quickly progress to disseminated multi-
organ infection and failure.
Option D: In the first month postoperatively
patients are most likely to develop
infections related to the surgical procedure
and hospitalization, such as bacterial and
fungal wound infections, urinary tract
infections, bloodstream infections,
pneumonia, and Clostridium difficile colitis.