ATI MED SURG UPDATED PRACTICE QUESTIONS AND ANSWER FOR
NURSING COMPLETE A+ GUIDE.LATEST 2023.
1. A nurse is collecting data from a client who has peptic ulcer disease. Which of the
following finding is a manifestation of gastrointestinal perforation?
A. Hyperactive bowel sounds
B. Severe upper abdominal pain
C. Report of epigastric fullness
D. Bradycardia
Answer: Severe upper abdominal pain.
Rationale:
Sudden, severe abdominal pain that radiates to the shoulder is a manifestation of
gastrointestinal perforation.
2. A nurse is reinforcing dietary teaching with a client who tells the nurse she would like to
reduce her solid fat intake and increase oil intake in her diet. Which of the following
instructions should the nurse include in her teaching?
A. Replace tub margarine with stick margarine
B. Use safflower oil instead of butter when baking
C. Consume 2% or whole milk
D. Choose ground beef that is at least 80% lean meat
Answer: Use safflower oil instead of butter when baking
Rationale:
The client should replace butter with safflower oil when baking to decrease solid fats and
increase oil intake.
3. A nurse is administering a tap water enema to a client. The client reports cramping as the
nurse instills the irrigating solution. Which of the following actions should the nurse take to
relieve the client’s discomfort?
A. Lower the height of the solution container
B. Encourage the client to bear down
C. Allow the client to expel some fluid before continuing
D. Stop the enema and document that the client did not tolerate the procedure
Answer: Lower the height of the solution container
Rationale:
If nausea or cramping occurs, the nurse should slow the flow of water, leaving the tube in
place. The nurse should then raise the solution container when the cramping has passed.
4. A nurse is reinforcing teaching with a client how has Cron’s Disease and is experiencing
frequent cramping and diarrhea. Which of the following statements should the nurse include
in the teaching?
A. Increase your caloric intake by eating foods high in protein
B. Include fresh fruits and vegetables at each meal
C. Maintain your weight by eating high fat foods
D. Drink whole milk to ensure adequate calcium intake
Answer: Increase your caloric intake by eating foods high in protein
Rationale:
Clients who have Crohn's disease are at risk for malnutrition; therefore, they should eat a
diet high in protein to help maintain their weight and promote healing and recovery.
5. A nurse is reinforcing teaching with a client that reports having constipation. Which of the
following should the nurse discuss as causes of constipation? (Select all that apply)
A. Excessive laxative use
B. Ignoring the urge to defecate
C. Inadequate fluid intake
D. Increased fiber in the diet
E. Increased activity
Answer: Excessive laxative use.
Rationale:
Chronic use of laxatives causes the large intestine to lose muscle tone and become less
responsive to stimulation by laxatives. Ignoring the urge to defecate. Anything that prevents
the client from responding to the urge to defecate and disrupts regular habits can cause
possible alterations in bowel habits, such as constipation. Inadequate fluidintake. Reduced
fluid intake slows the passage of food through the intestine and can result in hardening of
stool.
6. A nurse is reinforcing teaching for a client who has a duodenal ulcer and a new
prescriptions for sucralfate. The client asks the nurse how sucralfate works. Which of the
following statements should the nurse take?
A. This medication prevents gastric acid secretion in the stomach
B. This medication neutralizes gastric acid after it is secreted
C. This medication kills the bacteria which causes ulcers
D. This medication adheres to the ulcer and protects it from gastric acid
Answer: This medication adheres to the ulcer and protects it from gastric acid
Rationale:
Sucralfate creates a protective coating over the ulcer that lasts about 6 hrs.
7. A charge nurse is reinforcing teaching with a newly licensed nurse about the common link
between ulcerative colitis and Crohn’s disease. Which of the following statements by the
newly licensed nurse indicates an understanding of the teaching?
A. Both illnesses are inflammatory in nature
B. Both illnesses begin in the rectum
C. Both illnesses manifest fistula formation
D. Both illnesses result in malabsorption of nutrients
Answer: Both illnesses are inflammatory in nature
Rationale:
The nurse should reinforce that there are many linking components between ulcerative
colitis and Crohn's disease, one of them being the inflammatory nature of the illnesses.
Other similarities include a genetic component, the chronicity of the illnesses, and the
predominant manifestation of both diseases is diarrhea.
8. A nurse is reinforcing teaching about a high-fiber diet with a client who has constipation.
Which of the following statement indicates the client understands the best choice for a highfiber diet?
A. One medium apple would be a good snack option
B. I will select a ½ cup of sweet potatoes for my starch
C. My breakfast is ½ cup of bran cereal
D. I should choose 1 ounce of almonds when I am hungry midday
Answer: My breakfast is ½ cup of bran cereal
Rationale:
The client who selects ½ cup of bran cereal is selecting the best source of fiber. A ½ cup of
bran cereal contains 8. 8 g per serving of fiber; therefore, it is the best food choice for the
client.
9. A nurse is reinforcing teaching with a client who has GERD. Which of the following
statements should the nurse include in the teaching?
A. Elevate the head of the bed by 18 inches
B. Avoid snacking between meals
C. Use a straw to consume liquids
D. Avoid wearing constricting clothing
Answer: Avoid wearing constricting clothing
Rationale:
The nurse should instruct the client to wear clothing that is comfortably fitting and not
restrictive around the middle of the body. This increases the abdominal pressure and reflux.
10. A nurse is assessing a client who has advanced cirrhosis. Which of the following
manifestation should the nurse expect to find?
A. Spider angioma
B. Dark colored stools
C. Weak pulse
D. Increase body hair
Answer: Spider angioma
Rationale:
The nurse should expect to find spider angioma, which indicates portal hypertension, on the
client who has advanced cirrhosis.
11. A nurse is collecting data from a client in the health clinic who is reporting epigastric
pain. Which of the following statements made by the client should the nurse identify as
being consistent with peptic ulcer disease?
A. The pain is worse after I eat a meal high in fat
B. My pain is relieved by having a bowel movement
C. I feel so much better after eating
D. The pain radiates down to my lower back
Answer: I feel so much better after eating
Rationale:
A client who has peptic ulcer disease usually experiences pain when the stomach is empty, 2
to 3 hr after meals or in the middle of the night. It is usually relieved by eating.
12. A nurse is contributing to the plan of care of a client who has had a stroke. The client is
experiencing severe dysphagia with chocking and coughing while eating. Which of the
following nutritional therapies should the nurse expect to include in the plan of care?
A. NPO until dysphagia subsides
B. Supplements via NG tube
C. Initiation of total parenteral nutrition
D. Mechanical soft diet
Answer: Supplements via NG tube
Rationale:
Delivering supplements via an NG tube provides enteral nutrition for clients who are at risk
for aspiration caused by a diminished gag reflex or difficulty swallowing.
13. A nurse is collecting data from an infant who has gastroesophageal reflux.
Which of the following findings should the nurse expect? (Select all that apply)
A. Vomiting
B. Weight loss
C. Rigid abdomen
D. Wheezing
E. Pallor
Answer: Vomiting.
Rationale:
Vomiting is a finding associated with gastroesophageal reflux. Weight loss. Weight loss is a
finding associated with gastroesophageal reflux. Wheezing. Wheezing is a finding
associated with gastroesophageal reflux.
14. A nurse is contributing to a plan of care for a client who has Hepatitis B. Which of the
following should the nurse include in the plan?
A. Administer antibiotics
B. Provide a high-fat diet
C. Use disposable plates and utensils
D. Limit activity
Answer: Limit activity
Rationale:
The nurse should recognize that the client who has hepatitis experience fatigue and
weakness. It is necessary to limit activity for this client to promote immune function and
recovery for the client who has Hepatitis B.
15. A nurse is collecting data from a client who has obstruction and inflammation of the
common bile duct due to cholelithiasis. Which of the finding is expected for this condition?
A. Fatty stools
B. Straw-colored urine
C. Tenderness in the left upper abdomen
D. Ecchymosis of the extremities
Answer: Fatty stools
Rationale:
An expected client finding is fatty stools due to biliary obstruction, causing a lack of bile for
the absorption of fats in the intestines
16. A nurse is assisting with the implementation of a bowel training program for a client. For
the program to be effective, te nurse should take the client to the bathroom at which of the
following times?
A. When the client has the urge to defecate
B. Every 2 hr while the patient is awake
C. Immediately before meals
D. After the client feels abdominal cramping
Answer: When the client has the urge to defecate
Rationale:
When implementing a bowel training program, the nurse should take the client to the
bathroom when the client reports the urge to defecate. Failure to heed the call to defecate can
lead to overdistention of the rectum with hardening of the stool and constipation.
17. A nurse is caring for a client who requires a clear liquid diet. Which of the following
foods should the nurse allow the client to have?
A. Grape juice
B. Lemon sherbet
C. Skim milk
D. Carrot juice
Answer: Grape juice
Rationale:
A clear liquid diet includes foods that are fluids and clear at body and room temperatures.
This includes apple and grape juices, broth, black coffee, and plain gelatin.
18. A nurse is reinforcing discharge teaching with a client who has a new diagnosis of
GERD. Which of the following foods should the nurse include in the list of foods the client
should avoid?
A. Non-fat milk
B. Chocolate
C. Apples
D. Oatmeal
Answer: Chocolate
Rationale:
The client should avoid foods that reduce pressure on the lower esophageal sphincter. These
include fatty and fried foods, chocolate, caffeine, alcohol, and carbonated drinks.
19. A nurse is contributing to the plan of care for a client who is postoperative following a
gastrectomy and has a double-lumen nasogastric (NG) tube. Which of the following
interventions should the nurse include in the plan?
A. Irrigate the blue pigtail port with sterile saline.
B. Verify tube placement by injecting air into the larger lumen.
C. .Avoid replacing the NG tube if it is accidentally dislodged.
D. Avoid the nares when providing hygiene care.
Answer: Avoid replacing the NG tube if it is accidentally dislodged.
Rationale:
The nurse providing care for the client who has an NG tube following a gastrectomy must be
careful to avoid dislodging or moving the NG tube, as this can disrupt the sutures between
the esophagus and the jejunum. If the NG tube is dislodged, the provider should be notified.
20. A nurse is caring for a newly admitted adolescent who has anorexia nervosa. Which of
the following findings should the nurse expect?
A. Diarrhea
B. Hypertension
C. Tachycardia
D. Lanugo
Answer: Lanugo
Rationale:
Lanugo is a finding associated with anorexia nervosa.
21. A nurse is reinforcing teaching about dietary recommendations for a client who has a
hiatal hernia. Which of the following client statements indicate understanding of the
teaching? (Select all that apply)
A. "I will lie down for one half hour after meals."
B. "I will consume less caffeine and spicy foods."
C. "I will sleep with the head of my bed elevated."
D. "I will try not to gain weight."
E. "I will drink less fluid."
Answer: “I will consume less caffeine and spicy foods.”
Rationale:
These foods and beverages can worsen the symptoms of a hiatal hernia. “I will sleep with
the head of my bed elevated.” The client should raise the head of the bed on blocks to avoid
lying flat when sleeping. “I will try not to gain weight.” Obesity raises intra-abdominal
pressure and makes the hernia worse.
22. A nurse is administering a cleansing enema for a client how has constipation. Which of
the following actions should the nurse take?
A. Keep the container of solution at a level that is comfortable for the client.
B. Hold the container of solution 30 cm (12 in) above the anus.
C. Hold the container of solution level with the upper hip.
D. Slowly lower the container of solution 61 cm (24 in) below the anus.
Answer: Hold the container of solution 30 cm (12 in) above the anus.
Rationale:
Holding the container of solution 30 to 49 cm (12 to 18 in) above the anus generates enough
force for the fluid to reach far enough into the colon to cleanse it well
23. A nurse is caring for an older adult client who has dysphagia and left-sided weakness
following a stroke. Which of the following actions should the nurse take?
A. Instruct the client to tilt her head back when she swallows.
B. Place food on the left side of the client's mouth.
C. Add thickener to fluids
D. Serve food at room temperature.
Answer: Add thickener to fluids
Rationale:
The nurse should thicken fluids to make them easier to swallow and prevent aspiration.
24. A nurse is reinforcing teaching to a client about how to perform fecal occult blood testing
for a screening of colorectal cancer Which of the following statements by the client indicates
a need for further teaching?
A. "I will continue my low-dose aspirin therapy regimen."
B. "I will refrain from eating raw fruits and vegetables."
C. "I will avoid steak and other red meats."
D. "I will urinate before I collect a stool specimen."
Answer: "I will continue my low-dose aspirin therapy regimen."
Rationale:
NSAIDs and aspirin interfere with this testing. This statement indicates a need for further
teaching.
25. A nurse is caring for a toddler who has intussusception. Which of the following
manifestations should the nurse expect?
A. Drooling
B. Increased appetite
C. Jaundice
D. Mucus in stools
Answer: Mucus in stools
Rationale:
Stools with mucus and blood are manifestations of intussusception
26. A nurse is collecting data from a client who has squamous cell carcinoma of the lower
lip. Which of the following is an expected finding?
A. A scaly papule
B. An ulcerated lesion that is bleeding and painful
C. A nodule that resembles a blackberry
D. A lesion that resembles a large freckle
Answer: An ulcerated lesion that is bleeding and painful
Rationale:
As a squamous cell carcinoma grows it can have an ulcerated center and be painful.
27. A client who is scheduled for a barium swallow asks a nurse why a laxative necessary
following the procedure. Which of the following responses should the nurse make?
A. "The medication has been prescribed by your provider."
B. “It helps eliminate the barium."
C. "It is the protocol at this facility."
D. "The medication will make your stool turn white."
Answer: “It helps eliminate the barium."
Rationale:
The nurse's statement that the laxative will help eliminate the barium is a therapeutic
response because it provides the client with the reason for prescribing the laxative.
28. A nurse is planning to assign obtaining the vital signs of postoperative clients to an
assistive personnel (AP). Which of the following clients should the nurse assign to the AP?
A. A client who is 3 hr postoperative following a thyroidectomy
B. A client who is 3 hr postoperative following an abdominal hysterectomy
C. A client who is 3 days postoperative following gastric bypass surgery
D. A client who is 3 days postoperative following a craniotomy
Answer: A client who is 3 days postoperative following gastric bypass surgery
Rationale:
The nurse should identify the client who is 3 days postoperative following gastric bypass
surgery is stable; therefore, the nurse can assign obtaining these vital signs to an AP
29. A nurse is reinforcing teaching with a client who has cancer about foods that prevent
protein energy malnutrition. Which of the following foods should the nurse include in the
teaching? (Select all that apply)
A. Cottage cheese
B. Milkshake
C. Tuna fish
D. Strawberries and bananas
E. Egg and ham omelet
Answer: Cottage cheese
Rationale:
Cottage cheese is a good source of protein. Milkshakes are a good source of protein. Tuna
fish is a good source of protein. Egg and ham omelet is correct. An egg and ham omelet is a
good source of protein.
30. A nurse is reviewing medications for a client who has been diagnosed with a small bowel
obstruction. The nurse should withhold senna prescribed orally based on understanding of
which of the following?
A. Laxatives are contraindicated in clients who have a small bowel obstruction.
B. Bulk-forming laxatives such as psyllium should be substituted for this client.
C. The prescribed medication should be administered via NG route rather than the oral route
for this client.
D. An osmotic laxative, such as magnesium citrate, should be substituted in this client.
Answer: Laxatives are contraindicated in clients who have a small bowel obstruction.
Rationale:
Senna is a stimulant laxative and, like other laxatives, is contraindicated in clients who have
fecal impaction, bowel obstruction, and acute abdominal surgery to prevent perforation.
Because the bowel does not allow for any passage of stool with a complete small bowel
obstruction, laxatives will cause increased abdominal cramping and discomfort and might
cause perforation of the bowel.
31. A nurse is reinforcing teaching with an older adult who is on bed rest about foods high in
dietary fiber. Which of the following food items should the nurse indicate is the best source
of fiber?
A. Pears with skin
B. Mashed potatoes
C. Celery
D. Canned pineapple
Answer: Pears with skin
Rationale:
The nurse should encourage a client who is on bed rest to eat pears with skin because they
are an excellent source of dietary fiber. An older adult client on bed rest has a high risk of
constipation and increasing dietary fiber through the addition of high-fiber foods, such as
pears with skin, promotes bowel regularity.
32. A nurse is contributing to the plan of care for a client who has cirrhosis and ascites.
Which of the following interventions should the nurse recommend for inclusion in the plan
of care?
A. Decrease the client's fluid intake.
B. Increase the client's saturated fat intake.
C. Increase the client's sodium intake.
D. Decrease the client's carbohydrate intake.
Answer: Decrease the client’s fluid intake
Rationale:
The nurse should restrict fluids for a client who has cirrhosis and ascites due to the client's
risk for increased fluid retention.
33. The nurse is caring for a client on the third day following abdominal surgery and
assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus.
These findings indicate the client is experiencing which of the following postoperative
complications?
A. Health care-associated Clostridium difficile
B. Fecal impaction
C. Paralytic ileus
D. Incisional infection
Answer: Paralytic ileus
Rationale:
A paralytic ileus in the postoperative client is indicated by the absence of bowel sounds,
abdominal distention, and the client passing no stool or flatus. It is often caused by bowel
handling during surgery and opioid analgesic use.
34. A nurse is reinforcing teaching with a client who has cholelithiasis and is scheduled for
an endoscopic retrograde cholangiopancreatography. Which of the following statements
made by the client indicates an understanding of the teaching?
A. "They are going to examine my gallbladder and ducts."
B. "Soon those shock waves will get rid of my gallstones."
C. "I'll have an endoscope put down my throat so they can see my gallbladder."
D. "They'll put medication into my gallbladder to dissolve the stones."
Answer: "I'll have an endoscope put down my throat so they can see my gallbladder."
Rationale:
For an endoscopic retrograde cholangiopancreatography, the provider passes a flexible fiber
optic endoscope through the client’s esophagus to visualize gastrointestinal structures.
35. A nurse is collecting data from a client and observes multiple aphthous ulcers in the
client’s oral cavity. The nurse should use which of the following terms when documenting
this finding?
A. Stomatitis
B. Otorrhea
C. Halitosis
D. Candidiasis
Answer: Stomatitis
Rationale:
Stomatitis is an inflammatory disorder of the mouth.
36. A nurse is reinforcing teaching to a client who has peptic ulcer disease and is starting
therapy with sucralfate. Which of the following instructions should the nurse include in the
teaching?
A. Take the medication with an antacid.
B. Take the medication 1 hr before meals.
C. Store the medication in the refrigerator.
D. Take as needed for pain relief.
Answer: Take the medication 1 hr before meals.
Rationale:
The nurse should instruct the client to take sucralfate on an empty stomach, 1 hr before
meals, and at bedtime for maximum effectiveness
37. A nurse is assisting with the plan of care for a client who had an upper endoscopy 1 hr
ago. The nurse should place the priority on monitoring which of the following?
A. Sore throat
B. Abdominal bloating
C. Gag reflex
D. Belching
Answer: Gag reflex
Rationale:
The greatest risk to this client is aspiration immediately after an upper endoscopy; therefore,
monitoring gag reflex is the priority action.
38. The nurse is collecting data from a client who has diverticular disease. The nurse should
expect the client to report abdominal pain in which of the following locations?
A. Lower left quadrant
B. Upper left quadrant
C. Lower right quadrant
D. Upper right quadrant
Answer: Lower left quadrant
Rationale:
The nurse should expect the client to report abdominal pain in the lower left quadrant of the
abdomen. The disease is usually found in the sigmoid colon.
39. A nurse is reinforcing teaching with a client who has stomatitis. Which of the following
statements by the client indicates a need for further teaching?
A. "I will drink liquids through a straw."
B. "I will season foods with dried spices before cooking."
C. "I will rinse my mouth with baking soda and water every 2 hours."
D. "I will eat frozen bananas as a snack."
Answer: "I will season foods with dried spices before cooking."
Rationale:
The client should avoid spices, acidic foods, and salty foods because they can cause
additional irritation to the oral mucosa.
40. A nurse is collecting data from a client who has GERD and reports having heartburn
every night. Which of the following actions should the nurse identify as a contributing factor
to the client’s heartburn?
A. Sleeping on a large wedge-style pillow
B. Drinking orange juice regularly
C. Consuming low-fat meats
D. Eating dinner early in the evening
Answer: Drinking orange juice regularly
Rationale:
Spicy and acidic foods, such as orange juice, irritate inflamed esophageal tissue and decrease
the pressure of the lower esophageal sphincter, causing heartburn.
41. A nurse is assisting with menu selections for a client who has recovered from the acute
phase of diverticulitis. Which of the following foods should the nurse recommend?
A. A poached egg with sliced tomatoes
B. Ham sandwich on white bread
C. Roast chicken with white rice
D. Bean soup with steamed broccoli
Answer: Bean soup with steamed broccoli
Rationale:
A client who has diverticulitis should follow a high-fiber, high-residue diet and should avoid
foods that have small seeds or husks. Chicken and broccoli are good sources of fiber.
42. A nurse is collecting data from a client who is African American has cholecystitis. Which
of the following areas should the nurse inspect to monitor for the presence of jaundice?
A. Peri-umbilical area
B. Hard palate
C. Webbed areas of the fingers
D. Nail beds
Answer: Hard palate
Rationale:
The presence of jaundice in individuals who have dark skin is best evaluated by inspecting
the hard palate of the mouth, the buccal mucosa, the palms of the hands, the soles of the feet,
and the sclera.
43. A nurse is reinforcing discharge with a client who has acute gastritis. Which of the
following instructions should the nurse include in the teaching?
A. Limit drinking milk.
B. Take NSAIDs for pain.
C. Consume a glucose-electrolyte solution.
D. Treat nausea with gingko biloba.
Answer: Consume a glucose-electrolyte solution
Rationale:
The nurse should reinforce that hydration and electrolyte balance are important
considerations for the client who has gastritis. Sipping a glucose-electrolyte solution, even if
the client is nauseated, is usually tolerated and can prevent dehydration and electrolyte
imbalances caused by anorexia and vomiting associated with gastritis.
44. A nurse is planning care for a client who has severe diarrhea. Which of the following
actions is the nurse’s priority?
A. Introduce a regular diet.
B. Rehydrate.
C. Maintain fluid therapy.
D. Assess fluid balance.
Answer: Assess fluid balance
Rationale:
The first action the nurse should take is to assess fluid balance to determine severity of the
dehydration.
45. A school-aged child is an emergency department has a 2-day history of nausea and
vomiting and reports severe right lower quadrant pain. A nurse is preparing the child for an
appendectomy. Which of the following statements should the nurse find most concerning?
A. "I am scared and I want to go home."
B. "I am hungry and thirsty."
C. "I'm tired and want to take a nap."
D. "My belly doesn't hurt anymore."
Answer: "My belly doesn't hurt anymore."
Rationale:
Sudden relief of pain can be an early indication of appendix rupture, which is a surgical
emergency. Because the greatest risk to the client is peritonitis secondary to a ruptured
appendix, this statement is the most concerning
46. A nurse is caring for a client who has a gastrointestinal (GI)bleed. Which os the
following is the priority for the nurse to report to the provider?
A. Urine output of 50 mL in 2 hr
B. BUN 21 mg/dL
C. Positive fecal occult blood test
D. 75 mL coffee ground emesis
Answer: Urine output of 50 mL in 2 hr
Rationale:
The greatest risk to the client is complications related to hypovolemia from the GI bleed.
The nurse should notify the provider of urine output less than 30 mL/hr. This may indicate
poor blood flow to the kidneys, possibly resulting from hypovolemia. If left untreated, this
can cause acute kidney injury (AKI).
47. A nurse is contributing to the plan of care for a client who has an intestinal obstruction
and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which
of the following interventions should the nurse include in the plan of care?
A. Measure abdominal girth daily.
B. Use sterile water to irrigate the nasogastric tube.
C. Maintain the client in Fowler's position.
D. Moisten the client's lips with lemon-glycerin swabs.
Answer: Maintain the client in Fowler’s position
Rationale:
The nurse should place the client in Fowler’s position to reduce pressure on the diaphragm
and to promote function of the naso gastric tube.
48. A nurse on an inpatient unit is caring for a newly admitted client who has anorexia
nervosa. Which of the following actions should the nurse take? (Select al that apply)
A. Give the client a weight gain goal of 4 to 5 lb per week.
B. Monitor the client's weight daily after first voiding.
C. Encourage the client to keep a diary of daily food intake.
D. Stay with the client during meals and for 1 hr afterward.
E. Offer specific privileges for sustained weight gain.
Answer: Monitor the client’s weight daily after first voiding.
Rationale:
Daily weighing makes it difficult for the client to hide weight loss. The nurse should weigh
the client daily after his first void in the morning. Encourage the client to keep a diary of
daily food intake. A food diary provides the client the opportunity to see a realistic picture of
their food intake on a daily basis. Stay with the client during meals andfor 1 hr afterward.
The nurse should offer support and encouragement at mealtimes, but also monitor the
client’s behavior to prevent purging following food ingestion. Offer specific privileges for
sustained weight gain. Positive reinforcement includes rewards for improvements in eating
behaviors and is an appropriate strategy for clients who have eating disorders
49. A nurse is caring for a client who requires an NG tube. After inserting the tube, the nurse
tests the pH of the client’s aspirate. Which of the following pH levels should the nurse
identify as an indication of correct placement of the tube?
A. 7.0
B. 6.0
C. 4.0
D. 8.0
Answer: 4.0
Rationale:
This is an acidic pH, which indicates gastric drainage, the tube is likely to be in the stomach.
50. A nurse is caring for a client who is receiving enteral tube feedings of a diluted formula.
Which of the following complications of enteral tube feeding should the nurse identify as a
reason to administer diluted feeding to clients?
A. Electrolyte imbalances
B. Diarrhea
C. Constipation
D. Delayed gastric emptying
Answer: Diarrhea
Rationale:
Diarrhea requires diluting the formula to replace lost water, reducing the rate of delivery, or
administering an isotonic enteral formula
51. A provider prescribes a sublingual mediation for a client who has an NG tube in place.
Which of the following actions should the nurse take?
A. Request a prescription for an oral formulation of the medication.
B. Administer the crushed medication through the NG tube.
C. Dissolve the medication in water and give it through the NG tube.
D. Administer the medication under the client's tongue.
Answer: Administer the medication under the client's tongue.
Rationale:
The nurse should administer the sublingual medication under the client’s tongue. Sublingual
preparations work via direct absorption into the bloodstream. Swallowing it exposes it to
gastric juices, which can inactivate it
52. A nurse is reinforcing teaching with a client who has constipation about a high-fiber diet.
Which of the following foods should be included sources of fiber? (Select all that apply)
A. Kidney beans
B. Strawberries
C. Peanut butter
D. Whole wheat bread
E. Lean turkey
Answer: Kidney beans, strawberries, whole wheat bread, and lean turkey
Rationale:
Rich in both soluble and insoluble fiber, aiding in digestion and bowel regularity.
53. A nurse is reinforcing discharge teaching with a client who is postoperative for a
traditional cholecystectomy and has a T-tube in place. Which of the following instructions
should the nurse include in the teaching?
A. "Wear tight fitting clothes."
B. "Empty the drainage bag at the same time each day."
C. "Secure the tubing to your clothing."
D. "Take baths instead of showers."
Answer: "Empty the drainage bag at the same time each day."
Rationale:
The nurse should instruct the client to empty the drainage bag at the same time each day to
monitor the amount of drainage in a 24hr period.
54. A nurse in a clinic is caring for a client who has alcohol use disorder. The client reports
frequent bruising and nosebleeds. Which of the following conditions should the nurse
suspect?
A. Cholecystitis
B. Hepatitis A
C. Diabetes mellitus
D. Cirrhosis
Answer: Cirrhosis
Rationale:
Excessive alcohol use can cause liver cirrhosis leading to impaired bleeding time. The nurse
should check the client for other findings such as clay-colored stools, anorexia, and weight
loss.
55. A nurse is reviewing the plan of care for a client experiencing an acute exacerbation of
ulcerative colitis. Which of the following treatments should the nurse expect to administer?
A. Aspirin
B. A bowel cathartic medication.
C. Docusate
D. A corticosteroid medication
Answer: A corticosteroid medication.
Rationale:
The nurse should expect to administer a corticosteroid medication to reduce inflammation
during an acute episode of ulcerative colitis. The nurse should monitor the client’s weight
daily while taking a corticosteroid.
56. A nurse is reinforcing teaching about cimetidine with a client who has peptic ulcer
disease.
Which of the following information about the nurse include in the teaching?
A. Wait at least 1 hr after taking the medication before taking an antacid.
B. Expect breast tenderness while taking this medication.
C. Take this medication on an empty stomach.
D. Take ibuprofen for occasional aches and pains.
Answer: Wait at least 1 hr after taking the medication before taking an antacid.
Rationale:
The nurse should instruct the client to wait at least 1 hr after taking cimetidine before taking
an antacid. These medications can decrease absorption of the medication
57. A nurse is collecting data from a client who has a gastric ulcer. Which of the following
should the nurse identify as a priority finding and notify the provider?
A. Weight loss of 2 lb (0. 91 kg) from baseline
B. Reports being thirsty
C. Dyspepsia
D. Abdominal pain radiating to the shoulder
Answer: Abdominal pain radiating to the shoulder
Rationale:
The nurse should identify that reports of abdominal pain radiating to the shoulder is an
indication of perforation of the gastric ulcer into the peritoneal space. The perforation is
characterized by the radiating pain that increases in intensity and a rigid, board-like
abdomen. The client might show manifestations of shock as well. This finding should be
reported to the provider, as it indicates a medical emergency.
58. A nurse is reinforcing teaching with a client who has a duodenal ulcer and a new
prescription for cimetidine. Which of the following instructions should the nurse include?
A. "Take an antacid 30 min prior to taking cimetidine to minimize stomach upset."
B. "Avoid taking the medication at bedtime."
C. "You will need to continue taking this medication for up to 6 weeks."
D. "Drinking grapefruit juice while taking cimetidine can lead to lead to toxicity."
Answer: "You will need to continue taking this medication for up to 6 weeks."
Rationale:
To heal a duodenal ulcer, the client should take the medication for 4 to 6 weeks.
59. A nurse is reinforcing teaching with a client who reports right shoulder pain following a
laparoscopic cholecystectomy. Which of the following statements should the nurse make?
A. "The pain results from lying in one position too long during surgery."
B. "The pain occurs as a residual pain from cholecystitis."
C. "The pain will dissipate if you ambulate frequently."
D. "The pain is caused from the nitrous dioxide injected into the abdomen."
Answer: "The pain will dissipate if you ambulate frequently."
Rationale:
The client who has right shoulder pain following the procedure should ambulate as soon and
as much as possible to dissipate the carbon dioxide gas that was injected into the abdominal
cavity to visualize and access the abdominal structure. The carbon dioxide causes referred
pain in the clavicle and shoulder area.
60. A nurse is contributing to the plan of care for a client who has cirrhosis of the liver.
Which of the following interventions should the nurse include in the plan? (Select all that
apply)
A. Implement fall precautions.
B. Obtain a weekly weight.
C. Initiate a low sodium diet.
D. Measure abdominal girth daily.
E. Administer enemas to manage constipation.
Answer: Implement fall precautions.
Rationale:
The client who has cirrhosis of the liver has an increased risk of changes in mental status and
confusion due to increased levels of serum ammonia and hepatic encephalopathy, which
place the client at increased risk for falls.
Initiate a low sodium diet. The client who has cirrhosis also has impaired salt and fluid
regulation leading to fluid overload. Regulating sodium intake by placing the client on a low
sodium diet will assist in minimizing water retention. Measure abdominal girth daily. The
client who has cirrhosis develops fluid retention that manifests as ascites in the abdomen.
Measuring abdominal girth daily is one measure the nurse can use to monitor fluid status.
61. A nurse is collecting data for a client who has malnutrition resulting from a chronic
illness. Which of the following manifestations should the nurse expect to find?
A. Non-palpable spleen
B. Slightly moist skin
C. Presence of surface papillae on tongue
D. Depigmented hair
Answer: Depigmented hair
Rationale:
The client who is malnourished due to chronic disease is most likely to have depigmented
hair. Other indications of malnutrition include hair that is stringy, dull, brittle, dry, thin,
sparse, and easily plucked
62. A nurse is collecting a health history from a client. Which of the following client data
should the nurse identify as a risk factor for contracting hepatitis C?
A. Eating raw shellfish
B. Presence of multiple tattoos
C. Working in a childcare center
D. Recent travel to a second world country
Answer: Presence of multiple tattoos
Rationale:
The nurse should recognize that hepatitis C virus is spread through blood and contaminated
needles. If unsanitary tattoo equipment was used for placement of the tattoos, the client
could have been exposed to the virus.
63. A nurse is administering an enteral feeding through a client’s NG tube. Which of the
following actions should the nurse take?
A. Keep the formula cold until instillation.
B. Withhold the feeding if the residual volume is 150 mL.
C. Cleanse the top of the can of formula with an alcohol wipe.
D. Flush the tube with 30 mL of sterile water before the feeding.
Answer: Cleanse the top of the can of formula with an alcohol wipe.
Rationale:
Surface bacteria and dust can contaminate the top of formula cans, so the nurse should
disinfect them before opening them and introducing contaminants into the formula. They
should air-dry before opening to avoid introducing alcohol into the formula.
64. A nurse is reinforcing dietary instructions with a client who has episodes of biliary colic
from chronic cholecystitis. Which of the following diets should the nurse reinforce in the
teaching plan?
A. A high protein diet
B. A high fiber diet
C. A low fat diet
D. A low sodium diet
Answer: A low fat diet
Rationale:
The nurse should instruct the client to consume a low-fat diet to decrease episodes of biliary
colic. Clients who have chronic cholecystitis can experience pain and flatulence after
consuming fatty foods.
65. A nurse is collecting data on a client who has acute pancreatitis. Which of the following
factors should the nurse anticipate in the client’s history?
A. Gallstones
B. GERD
C. Shock
D. Diabetes mellitus
Answer: Gallstones
Rationale:
The nurse should identify the presence of gallstones as a causative factor in the development
of acute pancreatitis. This occurs because a stone blocks the outflow of pancreatic enzymes
and bile from the gall bladder and into the duodenum resulting in autodigestion and
inflammation of the pancreas. An additional causative factor is excessive use of alcohol.
66. A nurse is reinforcing teaching with a community group about the prevention of viral
hepatitis. Which of the following information should the nurse include in the teaching?
A. Wear a mask when in crowded places.
B. Avoid washing fresh vegetables to prevent the removal of nutrients.
C. Thoroughly cook foods prepared with tap water.
D. Limit time spent around individuals who have a productive cough.
Answer: Thoroughly cook foods prepared with tap water
Rationale:
Water can be contaminated with hepatitis A. Therefore, the nurse should remind the group to
prepare foods with purified water.
67. A nurse is planning care for a client who has anorexia and has manifestations of
malnutrition. When reviewing the client’s laboratory values which of the following test
results should the nurse expect to be low?
A. D-dimer
B. Troponin
C. Creatinine
D. Albumin
Answer: Albumin
Rationale:
A low albumin level indicates malnutrition, as well as renal disease, infection, severe burns,
and liver dysfunction
68. A nurse is caring for a client who has cirrhosis. When delivering the client’s lunch tray,
which of the following food selection requires intervention by the nurse?
A. medium baked potato
B. 1 cup of sliced cucumbers in vinegar
C. 1 slice of ham on whole wheat bread
D. 1 240 mL (8 oz) milkshake
Answer: 1 slice of ham on whole wheat bread
Rationale:
Ham is high in sodium and can increase fluid retention, leading to edema. Clients who have
cirrhosis are prone to edema as the osmotic pressures change due to a decrease in plasma
albumin.
69. A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the
following findings should the nurse identify as a risk factor for this condition?
A. History of bulimia
B. History of ibuprofen use
C. Drinks green tea
D. Consumes spicy foods 5 to 8 times weekly
Answer: History of ibuprofen use
Rationale:
The nurse should identify long-term NSAID use as a risk factor for peptic ulcer disease.
Aspirin and glucocorticoids can also induce peptic ulcers.
70. A nurse is caring for a client who has liver cirrhosis with ascites and bleeding esophageal
varices. Which of the following laboratory findings indicates that the client’s gastrointestinal
(GI) tract is digesting and absorbing blood?
A. Elevated BUN
B. Elevated HbA1c
C. Decreased chloride
D. Decreased bilirubin
Answer: Elevated BUN
Rationale:
The nurse should identify that as the body digests blood, BUN rises. An elevated BUN is an
indication of GI bleeding.
71. A nurse in a provider’s office is caring for a client who has a gastric ulcer caused by
Helicobacter pylori. The nurse should anticipate that in addition to ranitidine and sucralfate,
the provider will prescribe which of the following?
A. Filgrastim
B. Mexiletine
C. Desmopressin
D. Clarithromycin
Answer: Clarithromycin
Rationale:
Treatment for a gastric ulcer caused by H. pylori includes a combination of medications,
such as antibiotics, antisecretory agents (H2 receptor antagonists and proton pump
inhibitors), mucosal protectants and antacids.
72. A nurse is contributing to the plan of care of a client who has a small bowel obstruction.
Which of the following interventions should the nurse include?
A. Measure abdominal girth daily.
B. Provide bulk-forming agent.
C. Elevate the head of the bed.
D. Monitor intake and output every 8 hr.
Answer: Elevate the head of the bed
Rationale:
The nurse should elevate the head of the bed to relieve pressure on the diaphragm and ease
breathing in the client who has a bowel obstruction.
73. A nurse is caring for a client who has hepatitis A. The client asks the nurse how he might
have contacted the virus. Before responding, which of the following questions should the
nurse first ask the client?
A. "Have you eaten any shellfish lately?"
B. "Did you have a blood transfusion recently?"
C. "Have you traveled to a third world country in the past two months?"
D. "Do you take any recreational drugs?
Answer: “Have you eaten any shellfish lately?"
Rationale:
Hepatitis A is transmitted by the oral-fecal route and can by contracted by consuming
shellfish which was in contaminated water.
74. When providing care for a client who has facial fractures, the nurse notices a strong
mouth odor. Which of the following terms should the nurse use to document this finding?
A. Stomatitis
B. Gingivitis
C. Halitosis
D. Pyorrhea
Answer: Halitosis
Rationale:
Halitosis is a strong mouth odor or a persistent bad taste in the mouth.
75. A nurse is reinforcing teaching a client who is scheduled for a barium swallow to
evaluate dysphagia. Which of the following statements should indicate to the nurse that the
client understands the instructions?
A. "I will expect a warm feeling when the dye is injected."
B. "I will drink plenty of fluids after the test."
C. "I will maintain a clear liquid diet 24 hours before the test."
D. "I will expect my stool to be black after this procedure."
Answer: "I will drink plenty of fluids after the test."
Rationale:
The client should drink plenty of fluids after the barium swallow to promote elimination of
the barium and prevent constipation.
76. A nurse is preparing a client who has advanced cirrhosis for an abdominal paracentesis.
Which of the actions should the nurse take?
A. Instruct the client to empty his bladder.
B. Place the client on his back.
C. Assure the client that the procedure is painless.
D. Have the client increase fluid intake after the procedure.
Answer: Instruct the client to empty his bladder
Rationale:
The nurse should instruct the client to empty his bladder to reduce the risk of bladder
damage.
77. A nurse is caring for a client who has a prescription for a stool guaiac test. The client
asks the nurse about the purpose of the test. The nurse should respond by stating that the
stool guaiac is testing for which of the following findings in the client’s feces?
A. Bacteria
B. Parasites
C. Blood
D. Fat
Answer: Blood
Rationale:
A guaiac (fecal occult blood) test detects microscopic amounts of blood in the stool and is a
screening tool for colorectal cancer
