197 Nursezone Med-surg Nursing Final Coaching (By Doc Tacs) Part 2 (71 To 100)
Questions and Answers
- 1.
SITUATION: A 56 year old male client was admitted to the Medical-Surgical Ward for Liver Cirrhosis When caring for a patient with esophageal varices, the nurse knows that bleeding in this disorder usually stems from:
- A.
Esophageal perforation
- B.
Pulmonary hypertension
- C.
Portal hypertension
- D.
Peptic ulcers
Correct Answer
C. Portal hypertensionExplanation
Bleeding in esophageal varices usually stems from portal hypertension. Portal hypertension is an increase in blood pressure within the portal vein system, which carries blood from the intestines to the liver. In liver cirrhosis, scar tissue replaces healthy liver tissue, leading to obstruction of blood flow through the liver. This obstruction causes an increase in pressure within the portal vein, leading to the formation of esophageal varices. These varices are dilated blood vessels in the esophagus that are prone to bleeding. Therefore, portal hypertension is the most likely cause of bleeding in this disorder.Rate this question:
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- 2.
SITUATION: A 56 year old male client was admitted to the Medical-Surgical Ward for Liver Cirrhosis The nurse assesses a client with hepatic encephalopathy for apraxia by:
- A.
Assessing the client’s breath for a musty, sweet odor
- B.
Asking the client to draw a simple figure and noting any deterioration
- C.
Reviewing the bilirubin and alkaline phosphate levels
- D.
Asking the client to extend an arm, dorsiflex the wrist, and extend the fingers
Correct Answer
B. Asking the client to draw a simple figure and noting any deteriorationExplanation
The nurse assesses a client with hepatic encephalopathy for apraxia by asking the client to draw a simple figure and noting any deterioration. Apraxia is a neurological condition that affects a person's ability to perform purposeful movements or gestures. In the case of hepatic encephalopathy, which is a condition caused by liver dysfunction, apraxia can occur due to the buildup of toxins in the brain. By asking the client to draw a simple figure, the nurse can assess their ability to plan and execute the task, as well as observe any deterioration in motor skills, which can be indicative of apraxia.Rate this question:
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- 3.
SITUATION: A 56 year old male client was admitted to the Medical-Surgical Ward for Liver Cirrhosis Inadequate nutrition with protein deficiency in a patient with long-standing liver cirrhosis is expected to lead to:
- A.
Tissue anabolism
- B.
Decreased bile in the blood
- C.
Fat accumulation in the liver tissue
- D.
Coagulation of blood in microcirculation
Correct Answer
C. Fat accumulation in the liver tissueExplanation
Inadequate nutrition with protein deficiency in a patient with long-standing liver cirrhosis can lead to fat accumulation in the liver tissue. This is because the liver plays a crucial role in metabolizing fats, and when it is damaged due to cirrhosis, it becomes less efficient at processing and breaking down fats. As a result, fats can build up in the liver, leading to fat accumulation. This can further worsen liver function and contribute to the progression of liver cirrhosis.Rate this question:
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- 4.
SITUATION: A 56 year old male client was admitted to the Medical-Surgical Ward for Liver Cirrhosis A diet that would be most therapeutic in a patient with liver failure is:
- A.
High fat diet
- B.
Low caloric diet
- C.
Low protein diet
- D.
High sodium diet
Correct Answer
C. Low protein dietExplanation
A low protein diet would be most therapeutic in a patient with liver failure. Liver cirrhosis can lead to impaired liver function, including the inability to properly metabolize proteins. A low protein diet helps reduce the workload on the liver and minimize the accumulation of toxic byproducts that result from protein metabolism. This can help alleviate symptoms and slow down the progression of liver failure. Additionally, a low protein diet can also help manage complications such as hepatic encephalopathy, which is associated with high ammonia levels in the blood.Rate this question:
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- 5.
SITUATION: A 56 year old male client was admitted to the Medical-Surgical Ward for Liver Cirrhosis A nurse assessing a patient with portal hypertension should be most watchful of signs and symptoms indicating:
- A.
Liver abscess
- B.
Intestinal obstruction
- C.
Perforation of the duodenum
- D.
Hemorrhage for esophageal varices
Correct Answer
D. Hemorrhage for esophageal varicesExplanation
A nurse assessing a patient with portal hypertension should be most watchful of signs and symptoms indicating hemorrhage from esophageal varices. Portal hypertension is a condition where there is increased pressure in the portal vein, which carries blood from the digestive organs to the liver. This increased pressure can cause the development of varices, which are dilated blood vessels in the esophagus. These varices are prone to bleeding, and if a hemorrhage occurs, it can be life-threatening. Therefore, it is crucial for the nurse to closely monitor the patient for any signs or symptoms of bleeding from esophageal varices.Rate this question:
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- 6.
The nurse recognizes that manifestations of portal hypertension among liver failure patients are mainly due to:
- A.
Infection of the liver
- B.
Fatty degeneration of the liver
- C.
Obstruction of the hepatic circulation
- D.
Obstruction of the cystic and hepatic ducts
Correct Answer
C. Obstruction of the hepatic circulationExplanation
The manifestations of portal hypertension among liver failure patients are mainly due to obstruction of the hepatic circulation. Portal hypertension occurs when there is increased pressure in the portal vein, which carries blood from the digestive organs to the liver. This obstruction can be caused by various factors such as liver cirrhosis, blood clots, or tumors. The increased pressure in the portal vein leads to the development of collateral blood vessels, which can cause symptoms such as varices (enlarged veins), ascites (fluid accumulation in the abdomen), and splenomegaly (enlarged spleen).Rate this question:
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- 7.
The physician orders paracentesis for a client with ascites. Before the procedure, the nurse should instruct the patient to:
- A.
Empty the bladder
- B.
Eat foods low in fat
- C.
Remain NPO for 24 hours
- D.
Assume the supine position
Correct Answer
A. Empty the bladderExplanation
Before undergoing paracentesis, it is important for the client to empty their bladder. This is because the procedure involves the insertion of a needle into the abdomen to remove fluid, which can cause discomfort and pressure on the bladder. By emptying the bladder beforehand, the client can minimize any potential discomfort during the procedure.Rate this question:
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- 8.
The nurse assesses the client with cirrhosis for indications of hepatic coma. One classic sign is:
- A.
Bile-colored stools
- B.
Elevated cholesterol
- C.
Flapping hand tremors
- D.
Depressed muscle reflexes
Correct Answer
C. Flapping hand tremorsExplanation
Flapping hand tremors, also known as asterixis, is a classic sign of hepatic coma in clients with cirrhosis. It is characterized by a sudden, brief, and involuntary jerking movement of the hand when the wrist is extended. This tremor is caused by the buildup of toxins in the bloodstream, which affects the brain's ability to regulate muscle movements. Elevated cholesterol levels, depressed muscle reflexes, and bile-colored stools are not specifically associated with hepatic coma in cirrhosis.Rate this question:
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- 9.
The nurse should assess a client with liver cirrhosis and hepatic coma for:
- A.
Jaundice and icterisia
- B.
Urticaria and clay colored stools
- C.
Hepatic fetor and liver flap
- D.
Hemangioma and bleeding
Correct Answer
C. Hepatic fetor and liver flapExplanation
Hepatic fetor refers to a characteristic breath odor that is often present in individuals with liver disease, including liver cirrhosis. It is caused by the accumulation of toxins in the body that the liver is unable to process and eliminate. Liver flap, also known as asterixis, is a tremor or flapping of the hands that is commonly seen in hepatic encephalopathy, a complication of liver cirrhosis. Assessing for these signs is important as they indicate the severity of the liver disease and the potential for hepatic coma, a life-threatening condition.Rate this question:
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- 10.
Upon examining the laboratory test of a client with hepatic failure, the nurse recognizes which of the following that would indicate neomycin enemas?
- A.
Ammonia level
- B.
White blood cell count
- C.
Culture and sensitivity
- D.
Alanine aminotransferase level
Correct Answer
A. Ammonia levelExplanation
The nurse recognizes that an elevated ammonia level would indicate neomycin enemas in a client with hepatic failure. Neomycin is an antibiotic that is often used to reduce the production of ammonia in the intestines. In hepatic failure, the liver is unable to properly metabolize ammonia, leading to elevated levels in the blood. Neomycin enemas can help reduce the amount of ammonia produced by the bacteria in the intestines, thereby decreasing the ammonia levels in the body. Monitoring the ammonia level is essential in assessing the effectiveness of the neomycin enemas in this client.Rate this question:
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- 11.
The nurse notes signs of severe hemorrhagic pancreatitis that is accurately documented as:
- A.
The presence of a positive fluid wave in the abdominal area
- B.
A yellowish color of the sclera and skin
- C.
Ecchymosis in the flank and around the umbilical area
- D.
Bloody, foul-smelling stools
Correct Answer
C. Ecchymosis in the flank and around the umbilical areaExplanation
The presence of ecchymosis in the flank and around the umbilical area is a sign of severe hemorrhagic pancreatitis. Ecchymosis refers to the discoloration of the skin caused by bleeding under the skin. In severe cases of pancreatitis, bleeding can occur in the abdominal area, leading to the appearance of ecchymosis. This finding is significant because it indicates the presence of internal bleeding, which can be a life-threatening complication of pancreatitis. The other options, such as a positive fluid wave, yellowish color of the sclera and skin, and bloody, foul-smelling stools, may be seen in other conditions or may not specifically indicate severe hemorrhagic pancreatitis.Rate this question:
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- 12.
Acute pancreatitis is best diagnosed by which of the following studies?
- A.
Serum amylase level
- B.
Serum glucose level
- C.
Serum bilirubin level
- D.
White blood cell
Correct Answer
A. Serum amylase levelExplanation
Serum amylase level is the best diagnostic study for acute pancreatitis. This is because elevated levels of serum amylase are typically found in patients with this condition. Serum amylase is an enzyme produced by the pancreas, and its levels increase when there is inflammation or damage to the pancreas. Therefore, measuring serum amylase levels can help in confirming the diagnosis of acute pancreatitis.Rate this question:
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- 13.
A patient was admitted for acute pancreatitis. the nurse will prepare which of the following as the first line treatment, except:
- A.
NGT for decompression
- B.
Strict NPO
- C.
IV fluids for hydration
- D.
Morphine for the severe pain
Correct Answer
D. Morphine for the severe painExplanation
Morphine is not the first line treatment for acute pancreatitis because it can worsen the condition by causing spasm of the sphincter of Oddi, leading to increased pancreatic duct pressure and exacerbating the inflammation. The first line treatment for acute pancreatitis includes NGT for decompression to relieve gastric distention, strict NPO to rest the pancreas and minimize enzyme secretion, and IV fluids for hydration to maintain fluid balance and prevent dehydration.Rate this question:
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- 14.
Orders from the physician included feeding via a nasogastric tube. The best nursing action would be:
- A.
Assess for tube placement by aspirating stomach content
- B.
Place the patient in a left-lying position
- C.
Administer feeding with 50% Dextrose
- D.
Clarify the orders
Correct Answer
D. Clarify the ordersExplanation
The best nursing action would be to clarify the orders because it is important to ensure that the physician's orders are clear and understood before proceeding with any medical intervention. This will help prevent any potential errors or misunderstandings that could harm the patient.Rate this question:
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- 15.
A patient is recovering from an attack of acute pancreatitis. The nasogastric tube has been removed. Which meal is the best choice for lunch?
- A.
Fruit salad and vegetables
- B.
Boiled egg and vegetables
- C.
Cheeseburger and fries
- D.
Tuna salad with pasta
Correct Answer
A. Fruit salad and vegetablesExplanation
Fruit salad and vegetables are the best choice for lunch for a patient recovering from acute pancreatitis because they are low in fat and easy to digest. Acute pancreatitis is often caused by gallstones or heavy alcohol use and is characterized by inflammation of the pancreas. During recovery, it is important to avoid foods that are high in fat, as they can worsen symptoms and put strain on the pancreas. Fruit salad and vegetables provide essential nutrients without adding unnecessary fat to the diet, making them a suitable choice for a patient in recovery.Rate this question:
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- 16.
The objective information most helpful for future monitoring of the condition of a client admitted for hepatic cancer is:
- A.
Diet history
- B.
Bowel sounds
- C.
Present weight
- D.
Pain description
Correct Answer
C. Present weightExplanation
The present weight of a client admitted for hepatic cancer is the most helpful objective information for future monitoring of their condition. Weight loss is a common symptom of hepatic cancer, and monitoring changes in weight can provide important insights into the progression of the disease and the effectiveness of treatment. By regularly measuring and monitoring the client's present weight, healthcare professionals can assess the impact of the cancer on their overall health and make necessary adjustments to their treatment plan.Rate this question:
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- 17.
In assessing the patient with Hepatitis A, the nurse recognizes that the first signs and symptoms of these disease are:
- A.
High fever and vomiting
- B.
Petechiae and hepatomegaly
- C.
Jaundice and dark urine
- D.
Constipation alternating with diarrhea
Correct Answer
A. High fever and vomitingExplanation
The first signs and symptoms of Hepatitis A include high fever and vomiting. This is because Hepatitis A is a viral infection that affects the liver, causing inflammation. The body's immune response to the infection can lead to an increase in body temperature, resulting in a high fever. Vomiting can occur as a result of the body's attempt to rid itself of the virus. These symptoms typically appear within two to six weeks after exposure to the virus.Rate this question:
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- 18.
During the course of treatment of Hepatitis A, the nurse pay particular attention to which of the following test results?
- A.
WBC
- B.
BUN
- C.
Creatinine clearance
- D.
Serum transaminase
Correct Answer
D. Serum transaminaseExplanation
During the course of treatment of Hepatitis A, the nurse pays particular attention to the serum transaminase test results. Serum transaminase levels, specifically alanine aminotransferase (ALT) and aspartate aminotransferase (AST), are elevated in cases of liver damage. Monitoring these levels helps assess the severity of liver inflammation and damage, as well as the effectiveness of the treatment. Therefore, it is crucial for the nurse to closely monitor the serum transaminase levels to ensure appropriate management of the hepatitis A infection.Rate this question:
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- 19.
The nurse is caring for a patient with suspected diverticulitis. The nurse would be most prudent in questioning which of the following diagnostic tests?
- A.
Abdominal ultrasound
- B.
Barium enema
- C.
Complete blood count
- D.
Computed tomography (CT) scan
Correct Answer
B. Barium enemaExplanation
A barium enema is not the most appropriate diagnostic test for suspected diverticulitis. Diverticulitis is an inflammation or infection of small pouches that develop in the lining of the colon, and a barium enema is not the best test to diagnose this condition. Instead, a computed tomography (CT) scan is the preferred diagnostic test for diverticulitis as it can provide detailed images of the colon and identify any inflammation or infection. Additionally, a complete blood count may be useful to assess for signs of infection, and an abdominal ultrasound may be helpful in ruling out other possible causes of abdominal pain.Rate this question:
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- 20.
The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast?
- A.
White bread
- B.
Dried fish
- C.
Fried rice
- D.
Boiled corn
Correct Answer
A. White breadExplanation
The nurse should instruct the patient with celiac disease to avoid white bread for breakfast. Celiac disease is an autoimmune disorder where the consumption of gluten, found in wheat, barley, and rye, triggers an immune response that damages the small intestine. White bread is typically made from wheat flour, which contains gluten. Therefore, it is important for patients with celiac disease to avoid white bread and opt for gluten-free alternatives.Rate this question:
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- 21.
The nurse is teaching about irritable bowel syndrome (IBS). Which of the following would be most important?
- A.
Reinforcing the need for a balance diet
- B.
Encouraging the client to drink 16 ounces of fluid with each meal
- C.
Telling the client to eat a diet low in fiber
- D.
Instructing the client to limit his intake of fruits and vegetables
Correct Answer
A. Reinforcing the need for a balance dietExplanation
A balanced diet is most important for a client with irritable bowel syndrome (IBS) because it can help manage symptoms and promote overall digestive health. A balanced diet includes a variety of foods from different food groups, such as fruits, vegetables, whole grains, lean proteins, and healthy fats. This can help provide essential nutrients, promote regular bowel movements, and prevent exacerbation of symptoms. It is important for the nurse to reinforce the importance of a balanced diet to ensure the client understands the role of nutrition in managing their condition.Rate this question:
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- 22.
In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority?
- A.
Anxiety
- B.
Impaired skin integrity
- C.
Fluid volume deficit
- D.
Nutrition altered, less than body requirements
Correct Answer
C. Fluid volume deficitExplanation
The priority nursing diagnosis for a patient with ulcerative colitis is fluid volume deficit. Ulcerative colitis is a condition characterized by inflammation and ulceration of the colon, which can lead to diarrhea and fluid loss. Fluid volume deficit can result in dehydration and electrolyte imbalances, which can be life-threatening. Therefore, it is crucial for the nurse to address and manage fluid volume deficit as a priority to ensure the patient's overall well-being and prevent complications.Rate this question:
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- 23.
The nurse is caring for a patient with colostomy. The patient asks, “Will I ever be able to swim again?” The nurse’s best response would be:
- A.
Yes, you should be able to swim again, even with the colostomy
- B.
You should avoid immersing the colostomy in water
- C.
No, you should avoid getting the colostomy wet
- D.
Don’t worry about that. You will be able to live just like you did before
Correct Answer
A. Yes, you should be able to swim again, even with the colostomyExplanation
The nurse's best response would be "Yes, you should be able to swim again, even with the colostomy" because it reassures the patient that they can still engage in activities they enjoy, such as swimming, despite having a colostomy. It provides the patient with a sense of hope and normalcy, promoting their overall well-being and quality of life.Rate this question:
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- 24.
The nurse is assisting in the care of a patient who is 2 days post-operative from a hemorrhoidectomy. The nurse would be correct in instructing the patient to:
- A.
Avoid a high-fiber diet
- B.
Continue to use ice packs
- C.
Take a laxative daily to prevent constipation
- D.
Use a sitz bath after each bowel movement
Correct Answer
D. Use a sitz bath after each bowel movementExplanation
After a hemorrhoidectomy, it is important for the patient to use a sitz bath after each bowel movement. This is because a sitz bath helps to soothe the surgical area, reduce swelling, and promote healing. It also helps to keep the area clean and prevent infection. Avoiding a high-fiber diet would not be recommended as it can help prevent constipation. Continuing to use ice packs may provide temporary relief for pain and swelling, but it is not the most appropriate instruction for the patient. Taking a laxative daily to prevent constipation may not be necessary and can lead to dependency on laxatives.Rate this question:
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- 25.
The nurse is assisting in the care of a patient with diverticulosis. Which of the following assessment findings must necessitate an immediate report to the doctor?
- A.
Bowel sounds are present
- B.
Intermittent left-lower quadrant pain
- C.
Constipation alternating with diarrhea
- D.
Hemoglobin 26% and hematocrit 32
Correct Answer
D. Hemoglobin 26% and hematocrit 32Explanation
The assessment findings of hemoglobin 26% and hematocrit 32 indicate that the patient has a low red blood cell count and may be experiencing anemia. This is a significant finding that requires immediate medical attention as it can lead to complications such as fatigue, weakness, and difficulty in carrying oxygen to the body's tissues.Rate this question:
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- 26.
Nurse Remy did her admission assessment. She understands that the pain is characterized as:
- A.
Tenderness that is generalized in the upper epigastric area
- B.
Pain on the left upper quadrant radiating to the left shoulder
- C.
Tenderness and rigidity at the left epigastric area radiating to the back
- D.
Tenderness and rigidity of the upper right abdomen radiating to the midsternal area
Correct Answer
D. Tenderness and rigidity of the upper right abdomen radiating to the midsternal areaExplanation
The correct answer is "Tenderness and rigidity of the upper right abdomen radiating to the midsternal area." This is because the location of the tenderness and rigidity in the upper right abdomen, along with the radiation to the midsternal area, suggests a possible issue with the liver or gallbladder. The other options do not match the given symptoms.Rate this question:
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- 27.
To confirm the diagnosis of cholecystitis, the attending physician ordered the procedure that can detect gallstones as small as 1 to 2 cm and inflammation. Nurse Remy would prepare the client for which specific diagnostic procedure?
- A.
Cholangiography
- B.
Ultrasonography
- C.
Gall bladder series
- D.
Oral cholecystogram
Correct Answer
B. UltrasonographyExplanation
Ultrasonography is a diagnostic procedure that uses high-frequency sound waves to create images of the internal organs. It is commonly used to detect gallstones, as it can identify even small stones as small as 1 to 2 cm. In addition, ultrasonography can also detect signs of inflammation, which is important in confirming the diagnosis of cholecystitis. Therefore, Nurse Remy would prepare the client for ultrasonography to confirm the diagnosis of cholecystitis.Rate this question:
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- 28.
The diagnosis was confirmed as cholecystitis with gallstones. The doctor prepared the client for the removal of his gallbladder. The client asks the nurse “how will this procedure affect my digestion?” The nurse’s most correct response would be:
- A.
“The removal of the gallbladder would significantly interfere only with the digestion of fatty foods”
- B.
“The removal of the gallbladder does not usually interfere with digestion”
- C.
“Your body system will adjust in due time”
- D.
“The removal of the gallbladder usually interferes with digestion but can be remedied by dietary modifications”
Correct Answer
D. “The removal of the gallbladder usually interferes with digestion but can be remedied by dietary modifications”Explanation
The correct answer is "The removal of the gallbladder usually interferes with digestion but can be remedied by dietary modifications". This response is the most correct because it acknowledges that the removal of the gallbladder can affect digestion, but also provides a solution by mentioning that dietary modifications can help alleviate the interference.Rate this question:
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- 29.
Reviewing the laboratory findings of the client, the nurse found which findings are elevated? 1. White blood cell count; 2. Total bilirubin; 3. Alkaline phosphates; 4. Red blood cell count; 5. Cholesterol; 6. Serum amylase
- A.
1, 2, 3
- B.
2, 3, 4
- C.
3, 5, 6
- D.
1, 2, 6
Correct Answer
A. 1, 2, 3 -
- 30.
A t-tube was inserted and the doctor ordered monitoring of the amount, color, consistency and odor of the drainage. Which of the following procedures can the nurse perform without the doctor’s orders?
- A.
Clamping the t-tube
- B.
Aspirating the drainage
- C.
Irrigating the drainage
- D.
Emptying the drainage
Correct Answer
D. Emptying the drainageExplanation
The nurse can empty the drainage from the t-tube without the doctor's orders. This is a routine nursing task that does not require a specific order. Emptying the drainage allows the nurse to monitor the amount, color, consistency, and odor of the drainage, as ordered by the doctor. Clamping the t-tube, aspirating the drainage, and irrigating the drainage, on the other hand, may require specific orders from the doctor as they involve more invasive procedures and potential risks.Rate this question:
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