ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 44 Questions
Question 1 of 5
The nurse is assessing a client of color for jaundice. In which location(s) would the nurse assess for discoloration? Select all that apply.
Correct Answer: A,B,E,F
Rationale: In very dark-skinned clients, the nurse inspects the hard palate, gums, conjunctiva, and surrounding tissues for discoloration. If the skin appears jaundiced, the nurse inspects the sclera if it is yellow.
Question 2 of 5
The nurse is accompanying the client to the diagnostic imaging unit for a magnetic resonance imaging (MRI). Which action by the nurse is most important prior to the test?
Correct Answer: B
Rationale: It is most important that the nurse calculate the drip rate of the intravenous fluids because the client will not be able to have an electrical or mechanical pump operating during the MRI. The MRI electrical charges during the test can affect the pump. It is also important to advise the client of the loud noises and offer support to the client. Water is typically not available in the waiting area prior to testing.
Question 3 of 5
The instructor has just finished teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders. The instructor determines that the teaching was successful when the students identify which structure as possibly being affected?
Correct Answer: C
Rationale: The upper gastrointestinal (GI) tract begins at the mouth and ends at the jejunum.
Therefore, the stomach would be a component of the upper GI tract. The lower GI tract begins at the ileum and ends at the anus. The liver is considered an accessory structure.
Question 4 of 5
The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client?
Correct Answer: B
Rationale: Helicobacter pylori, a bacterium, is believed to be responsible for the majority of peptic ulcers. Blood tests are used to determine whether there are antibodies to H. pylori in the blood. A complete blood count with differential can indicate bleeding and infection associated with a bleeding ulcer. A sigmoidoscopy assesses the lower gastrointestinal tract. Gastric analysis is more common in analyzing gastric fluid in determining problems with the secretory activity of the gastric mucosa.
Question 5 of 5
Which nursing instruction is correct to provide the client following a barium enema?
Correct Answer: B
Rationale: It is important to instruct the client that it is normal to have a white- or clay-colored stool following the barium enema. The client should report the color of the stool to the nurse. A progression of clay-colored stools to brown-colored stools should be noted. The client is prescribed a low-residue diet before the procedure. An increased fluid intake is offered to eliminate the barium from the bowel. The client is encouraged to move the bowel independently.