1. QUESTIONS

2. Question 1
The physician orders intestinal decompression with
a Cantor tube for a client with an intestinal
obstruction. In order to determine effectiveness of
intestinal decompression the nurse should evaluate
the client to determine if:
A.Fluid and gas have been removed from the
intestine
B.The client has had a bowel movement.
C.The client’s urinary output is adequate
D.The client can sit up without pain.

3. Answer
Answer A:
Intestinal decompression is accomplished with a
Cantor, Harris, or Miller-Abbott tube. These 6-10
foot tubes are passed into the small intestine to
the obstruction. They remove accumulated fluid
and gas, relieving the pressure.

4. Question 2
The client with an intestinal obstruction
continues to have acute pain even though the
nasogastric tube is patent and draining. Which
action by the nurse would be most appropriate?
A.Reassure the client that the nasogastric tube
is functioning.
B.Assess the client for a rigid abdomen
C.Administer an opioid as ordered.
D.Reposition the client on the left side.

5. Answer
Answer B. The client’s pain may be indicative of
peritonitis, and the nurse should assess for signs
and symptoms, such as a rigid abdomen,
elevated temperature, and increasing pain.
Reassuring the client is important, but accurate
assessment of the client is essential. The full
assessment should occur before pain relief
measures are employed. Repositioning the
client to the left side will not resolve the pain.

6. Question 3
A client has advanced cirrhosis of the liver. The client’s spouse
asks the nurse why his abdomen is swollen, making it very
difficult for him to fasten his pants. How should the nurse
respond to provide the most accurate explanation of the
disease process?
A.“He must have been eating too many foods with salt in
them. Salt pulls water with it.”
B.“The swelling in his ankles must have moved up closer to his
heart so the fluid circulates better.”
C.“He must have forgotten to take his daily water pill.”
D.“Blood is not able to flow readily through the liver now, and
the liver cannot make protein to keep fluid inside the blood
vessels.”

7. Answer
Answer D:
Portal hypertension and hypoalbuminemia as a
result of cirrhosis cause a fluid shift into the
peritoneal space causing ascites. Although
diuretics promote the excretion of excess fluid,
occasionally forgetting or omitting a dose will
not yield the ascites found in cirrhosis of the
liver.

8. Question 4
A client with cirrhosis begins to develop ascites.
Spironolactone (Aldactone) is prescribed to
treat the ascites. The nurse should monitor the
client closely for which of the following drug-
related adverse effects?
A.Constipation
B.Hyperkalemia
C.Irregular pulse
D.Dysuria

9. Answer
Answer B:
Spironolactone (Aldactone) is a potassium-
sparing diuretic; therefore, clients should be
monitored closely for hyperkalemia. Other
common adverse effects include abdominal
cramping, diarrhea, dizziness, headache, and
rash.

10. Question 5
Which of the following interventions should the
nurse anticipate incorporating into the client’s
plan of care when hepatic encephalopathy
initially develops?
A.Inserting a NG tube
B.Restricting fluids to 1000 mL/day
C.Administering IV salt-poor albumin
D.Implementing a low-protein diet

11. Answer
Answer D. When hepatic encephalopathy
develops, measures are taken to reduce
ammonia formation. Protein is restricted in the
diet. Fluid restriction and salt-poor albumin are
incorporated into the treatment of ascites, but
not hepatic encephalopathy.

12. Question 6
A client has been admitted to the ED with acute
renal failure. What should the nurse do? Select
all that apply:
A.Take vital signs
B.Establish an IV access site
C.Call the admitting physician for orders.
D.Contact the hemodialysis unit.

13. Answer
Answers A, B, C:
The nurse should assess the vital signs because
the pulse and respirations will be elevated.
Establishing a site for IV therapy will become
important because fluids will be administered IV
in addition to orally. The physician will need to
be contacted for further orders; there is no need
to contact the hemodialysis unit.

14. Question 7
The client with acute renal failure asks the nurse
for a snack. Because the client’s potassium level
is elevated, which of the following snacks is
most appropriate?
A.A gelatin dessert
B.Yogurt
C.An orange
D.Peanuts

15. Answer
Answer A:
Gelatin desserts contain little or no potassium
and can be served to a client on potassium-
restricted diet. Foods high in potassium include
bran and whole grains; most dried, raw, and
frozen fruits and vegetables; most milk and milk
products; chocolate, nuts, raisins, coconut and
strong brewed coffee.

16. Question 8
Which of the following abnormal blood values
would not be improved by dialysis treatment?
A.Elevated serum creatinine level
B.Hyperkalemia
C.Decrease hemoglobin concentration
D.Hypernatremia

17. Answer
Answer C: Dialysis has no effect on anemia.
Because some red blood cells are injured during
the procedure, dialysis aggravates a low
hemoglobin concentration. Dialysis will clear
metabolic waste products from the body and
correct electrolyte imbalances.

18. Question 9
Which of the following symptoms would most
likely indicate that the client has pyelonephritis?
A.Ascites
B.Costovertebral angle (CVA) tenderness
C.Polyuria
D.Nausea and vomiting

19. Answer
Answer B:
Common symptoms of pyelonephritis include
CVA tenderness, burning on urination, urinary
urgency or frequency, chills, fever, and fatigue.
Ascites, polyuria, and nausea and vomiting are
not indicative of pyelonephritis.

20. Question 10
After completion of peritoneal dialysis, the
nurse should expect the client to exhibit which
of the following characteristics?
A.Hematuria
B.Weight loss
C.Hypertension
D.Increased urine output

21. Answer
Answer B:
Weight loss is expected because of the removal
of fluid. The client’s weight before and after
dialysis is one measure of the effectiveness of
treatment. Blood pressure usually decreases
because of the removal of fluid. Hematuria
would not occur after completion of peritoneal
dialysis. Dialysis only minimally affects the
damaged kidneys’ ability to manufacture urine.

22. Question 11
The nurse is doing an admission assessment on
a client with a history of duodenal ulcer. To
determine whether the problem is currently
active, the nurse should assess the client for
which symptom(s) of duodenal ulcer?
A.Weight loss
B.Nausea and vomiting
C.Pain relieved by food intake
D.Pain radiating down the right arm

23. Answer
Answer C: A frequent symptom of duodenal
ulcer is pain that is relieved food intake. These
clients generally describe the pain as a burning,
heavy, sharp, or “hungry” pain that often
localizes in the midepigastric area. The client
with duodenal ulcers usually does not
experience weight loss or nausea and vomiting.
These symptoms are more typical in the client
with a gastric ulcer.

24. Question 12
A client with a peptic ulcer is diagnosed with a Helicobacter pylori
infection. The nurse is teaching the client about the medications
prescribed, including clarithromycin (Biaxin), esomeprazole (Nexium),
and amoxicillin (Amoxil). Which statement by the client indicates the
best understanding of the medication regimen?
A.“My ulcer will heal because these medications will kill the bacteria.”
B.These medications are only taken when I have pain from my ulcer.”
C.“The medications will kill the bacteria and stop the act acid
production.
D.“These medications will coat the ulcer and decrease the acid
production in my stomach.”

25. Answer
Answer C: Triple therapy for Helicobacter pylori
infection usually includes two antibacterial
drugs and a proton pump inhibitor
Clarithromycin and amoxicillin are
antibacterials. Esomeprozole is a proton pump
inhibitor. These medications will kill the bacteria
and decrease acid production.

26. Question 13
The client with chronic renal failure returns to
the nursing unit following a hemodialysis
treatment. On assessment, the nurse notes that
the client’s temperature 100.2 F. Which of the
following is the appropriate nursing action?
A.Monitor the client
B.Notify the physician
C.Elevate the head of the bed
D.Medicate the client for nausea.

27. Answer
Answer A:
The client may have an elevated temperature
following dialysis because the dialysis machine
warms the blood slightly. If the temperature is
elevated excessively and remains elevated,
sepsis would be suspected and a blood sample
would be obtained as prescribed for culture and
sensitivity determinations.

28. Question 14
The nurse is reviewing the record of a client with
a diagnosis of cirrhosis and notes that there is
documentation of the presence of asterixis. How
should the nurse assess for its presence?
A.Dorsiflex the client’s foot.
B.Measure the abdominal girth.
C.Ask the client to extend the arms.
D.Instruct the client to lean forward.

29. Answer
Answer C:
Asterixis is irregular flapping movements of the
fingers and wrists when the hands and arms are
outstretched, with the palms down, wrists bent
up, and fingers spread. Asterixis is the most
common and reliable sign and the hepatic
encephalopathy is developing. Options 1, 2, and
4 are incorrect.

30. Question 15
The client with a gastric ulcer has a prescription
for sucralfate (Carafate), 1 g by mouth 4 times
daily. The nurse schedules the medication for
which times?
A.With meals and at bedtime.
B.Every 6 hours around the clock.
C.One hour after meals and at bed time.
D.One hour before meals and at bedtime.

31. Answer
Answer D: Sucralfate is a gastric protectant. The
medication should be scheduled for
administration 1 hour before meals and at
bedtime. The medication is timed to allow it to
form a protective covering over the ulcer before
food intake stimulates gastric acid production
and mechanical irritation. The other options are
incorrect.

32. Question 16
The nurse is caring for a male client with
cirrhosis. Which assessment findings indicate
that the client has deficient vitamin K absorption
caused by this hepatic disease?
A. Dyspnea and fatigue
B. Ascites and orthopnea
C. Purpura and petechiae
D. Gynecomastia and testicular atrophy
•

33. Answer
Answer C. A hepatic disorder, such as cirrhosis,
may disrupt the liver’s normal use of vitamin K
to produce prothrombin (a clotting factor).
Consequently, the nurse should monitor the
client for signs of bleeding, including purpura
and petechiae. Dyspnea and fatigue suggest
anemia. Ascites and orthopnea are unrelated to
vitamin K absorption. Gynecomastia and
testicular atrophy result from decreased
estrogen metabolism by the diseased liver.

34. Question 17
A female client is admitted for treatment of chronic
kidney disease (CKD). Nurse Juliet knows that this
disorder increases the client’s risk of:
A. Water and sodium retention secondary to a severe
decrease in the glomerular filtration rate.
B. A decreased serum phosphate level secondary to
kidney failure.
C. An increased serum calcium level secondary to
kidney failure.
D. Metabolic alkalosis secondary to retention of
hydrogen ions.

35. Answer
Answer A. A client with CKD is at risk for fluid
imbalance — fluid retention if the kidneys fail to
produce urine. Electrolyte imbalances associated with
this disorder result from the kidneys’ inability to
excrete phosphorus; such imbalances may lead to
hyperphosphatemia with reciprocal hypocalcemia. CKD
may cause metabolic acidosis, not metabolic alkalosis,
secondary to inability of the kidneys to excrete
hydrogen ions.

36. Question 18
A female client with acute renal failure is undergoing
dialysis for the first time. The nurse in charge monitors
the client closely for dialysis equilibrium syndrome, a
complication that is most common during the first few
dialysis sessions. Typically, dialysis equilibrium
syndrome causes:
A. confusion, headache, and seizures.
B. acute bone pain and confusion.
C. weakness, tingling, and cardiac arrhythmias.
D. hypotension, tachycardia, and tachypnea.

37. Answer
Answer A. Dialysis equilibrium syndrome causes
confusion, a decreasing level of consciousness,
headache, and seizures. These findings, which
may last several days, probably result from a
relative excess of interstitial or intracellular
solutes caused by rapid solute removal from the
blood.

38. Question 19
The client who has a history of gout also is
diagnosed with nephrolithiasis and the stones
are determined to be of uric acid type. The
nurse gives the client instructions in which foods
to limit, including:
A. milk
B. liver
C. apples
D. carrots

39. Answer B. The client with uric acid stones should
avoid foods containing high amounts of purines.
This includes limiting or avoiding organ meats
such as liver, brain, heart, kidney, and
sweetbreads. Other foods to avoid include
herring, sardines, anchovies, meat extracts,
consommés, and gravies.

40. Question 20
A client has been diagnosed with urolothiasis in
the right ureter. The nurse would expect the
client to describe the pain (renal colic) as:
A. located in the upper right epigastric area,
radiating to the shoulder or back
B. occurring 2 to 3 hours after meal
C. intermittent in the right upper abdominal
quadrant, radiating to the groin
D. worsening with the ingestion of food

41. Answer
Answer C. Renal colic is generally associated with acute
obstruction of a ureter and resulting ureteral spasm. As the
stone moves along the ureter, the pain can be excruciating,
is intermittent in character, and is located in the flank and
upper abdominal quadrant of the affected side. It is caused
by the spasm of the ureter and anoxia of the ureter wall
from the pressure of the stone. The pain follows the
anterior course of the ureter down to the suprapubic area
and radiates to the external genitalia (groin). Options A, B,
and D describe pain characteristic of gastrointestinal
problems (cholecystitis, duodenal and gastric ulcers,
respectively).