MEDS, GI, INCLEX QUESTIONS
1. A CLIENT W/BLEEDING ESOPHAGEAL VARICES IS BEING TREATED W/ A DOUBLE BALLOON
TAMPON AIDE, 4 HOURS AFTER THE GASTRIC AND ESOPHAGEAL BALOON HAVE BEEN
INFLATED, THE NURSE NOTES THAT THE CLIENT HAS BECOME INCREASINGLY AGITATED AND
RESPIRATIONS ARE 36 AND SHALLOW THE IMMEDIATE NURSING ACTION IS:
A.
B.
C.
D.
RAISE HEAD OF BED TO HIGH FOWLERS POSITION
DECREASE PRESSURE IN ESOPHAGEAL BALLOON
USE SCISSORS TO CUT TUBING IN FRONT OF NOSE GUARD OR SPONGE
ADVANCE THE TUBE FURTHER IN CLIENT’S NOSE
ANSWER IS C
2. A CLIENT IS ADMITTED W/ A DX OF HEPATITIS A. IT IS MOST IMPORTANT FOR THE NURSE TO
MAINTAIN WHICH MEASURES IN THE CLIENT’S PLAN OF CARE
A. A LOW PROTEIN HIGH FAT DIET
B. PATENTCY OF T-TUBE
C. STRICT BEDREST
D. STANDARD PRECAUTIONS
ANSWER IS D
3. A CLIENT IS ADMITTED W/ A DX OF CHOLECSITITIS AND IS SCHEDULED FOR AN ENDOSCOPICE
RETROGRADE CHOLANGIOPANCREATIC PANCREATOMOY (ERCP)
WHEN CLIENT RETURNS TO CLINICAL UNIT AFTER PROCEDURE WHAT IS APPROPRIATE
NURSING MEASURE.
A. PUSH FLUIDS FOR FIRST 12 HRS
B. INSPECT PRESSURE FOR SIGNS OF BLEEDING
C. MAINTAIN NPO STATUS UNTIL GAG REFLUX RETURNS
D. KEEP HEAD OF BEAD FLAT FOR 4 HOURS.
ANSWER IS C
4. WHEN A CLIENT RETURNS TO NURSING UNIT AFTER BEING AT PT FOR 1HR,THE NURSE NOTES
THAT THE INFUSION PUMP FOR THE CLIENTS TPN HAS BEEN TURNED OFF THE CLIENT TELLS
THE NURSE THAT THE BATTERY WENT DEAD A WHILE AGO. AFTER RESTARTING THE INFUSION
PUMP, THE NURSE WATCHES THE CLIENT CAREFULLY FOR THE DEVELOPMENT OF
A. HYPERTENSION AND CRACKLES
B. EXCESSIVE THIRST AND URINATION
C. SHAKINESS AND DIAPHORESIS
D. FEVER AND CHILLS
ANSWER IS C
5. THE NURSE TEACHES A CLIENT W/A NEW DX OF PUD. WHICH STAEMENT MADE BY THE CLIENT
INDICATES TO THE NURSE THAT THE CLIENT UNDERSTANDS THE DIET MODIFICATIONS THAT
ARE MOST IMPT FOR THIS DISEASE.
A. I WILL ELIMINATE MILK AND MILK PRODUCTS FROM MY DIET
B. I WILL EAT 5 SMALL MEALS A DAY CONSISTING OF SOFT BLAND FOODS
C. I WILL ELIMINATE FRUITS AND RAW VEGETABLES FROM MY DIET
D. I WILL AVOID FOODS THAT PRODUCE DISCOMFORT FOR ME
D IS THE ANSWER
6. A CLIENT IS SCHEDULED TO UNDERGO A LIVER BIOPSY FOR SUSPECTED MALIGNANCY WHICH
DIAGNOSTIC STUDY MUST THE NURSE MONITOR PRIOR TO THE EXAMINATION TO PREVENT
THE MAJOR COMPLICATION FOLLOWING A LIVER BX.
A. PROTHROMBIN TIME (PT)
B. ASPIRATE AMINOTRANSFERASE
C. SERUM ALBUMIN
D. H & H
ANSWER IS A
7. A CLIENT ARRIVES IN THE ER WITH AN ICE PICK PROTRUDING FROM THE LLQ AT THIS TIME
THE BEST NURSING ACTION IS TO
A. IMMEDIATELY REMOVE OBJECT AND APPLY FIRM PRESSURE TO WOUND
B. ESTABLISH A LARGE BORE IV AND THEN REMOVE OBJECT
C. LEAVE OBJECT IN PLACE UNTIL CLIENT IS IN OR
D. OBTAIN RESULTS OF STAT ABD XR AND THEN REMOVE OBJECT
ANSWER IS C
8. AN ARTERIAL BLOOD GAS (ABG) IS OBTAINED ON ADMISSION FOR A CLIENT W/FOOD
POSIONING CLIENT REPORTS HOURLY EMESIS FOR THE PAST 24 HRS THE RESULTS OF THE
BLOOD GAS PH 7.52 PCO2 44 P02 98 0XYGEN SAT 99 PER CENT AND BICARBONATE HCO3 IS 32.
THE NURSE RELAIZES THAT THE ABG IS IN:
A. RESPIRATORY ALKALOSIS
B. METABOLIC ACIDOSIS
C. METABOLIC ALKADOSIS
D. RESPIRATORY ACIDOSIS
ANSWER IS C
9. A COMMUNITY HEALTH NURSE IS PLANNING AN EDUCATIONAL PROGRAM TO PREVENT THE
TRANSMISSION OF HEP A IN COMMUNITY WHERE THE VIRUS IS BECOMING ENDEMIC. IN
PREPARING THE MATERIAL THE NURSE REALIZE THE POPULATION GROUP MOST LIKELY TO
BECOME INFECTED W/ HEP A VIRUS IS
A. MIDDLE AGED MEN
B. CHILDREN AND YOUNG ADULTS
C. OLDER ADULTS
D. INFANTS AND PREGNANT WOMEN
ANSWER IS B
10. WHEN CARING FOR A CLIENT ADMITTED W/VOMITING, THE NURSE SHOULD FIRST
A. PERFORM ABD ASSESSMENT
B. OBTAIN CLIENTS HX OF DRUG AND ALCHOL ABUSE
C. ADMINISTER DRY CRACKERS OR TOAST
D. PREPARE TO GIVE AN ANTI-EMIC
ANSWER IS A
11. A CLIENT HAS RETURNED TO THE UNIT FOLLOWING A LAPAROSCOPIC CHOLECYSTECOMY
AND COMPLAINS OF SEVERE PAIN IN LET SHOULDER WHEN THE CLIENT WHO IS ALERT AND
HAS STABLE VITAL SIGNS ASKS ABOUT CAUSE OF PAIN, THE NURSES MOST APPROPRIATE
RESPONSE IS BASED ON THE KNOWLEDE THAT THE CLIENTS PAIN IS DUE TO
A CO2 INSTILLED INTO ABD TO BETTER VISUALIZE ABD STRUCTURES
B. HAS RESULTED FROM LYING IN ONE OR MORE POSITIONG TOO LONG ON THE OR TABLE
C. IS RELATED TO THE CLIENT’S HX OF ARTHRITIS AND SHOULD SUBSIDE IN 2-3 DAYS
D. MAY BE INDICATIVE OF A PERITONEAL TEAR AND REQUIRES FURTHER INVESTIGATION.
ANSWER IS A
12. A CLIENT WITH A LONG HX OF LAENNEC’S CIRRHOSIS IS ADMITTED TO HOSPITAL
W/MANIFESTATIONS OF HEPATIC ENCEPHALOPATHY. WHEN QUESTIONED TO CLIENT INSISTS
NO DROPS OF LIQUOR IN 4 YEARS THE NURSE ANTICIPATES WHICH DIAGNOSTIC TESTS WILL
BE ORDERED TO CHECK THE POSS. OF ALCHOL ABUSE
A. ALKALNE PHOSPHATASE
B. ALANINE AMINOTRANSFERASE
C. 5’ NUCLEOTIDASE
D. GAMMA-GLUTAMYLTRANSFERACE
CORRECT ANSWER IS D
13. THE NURSE IS ASKED BY THE DR TO POSITION THE CLIENT FOR A PROCTOSIGMOIDOSCOPY.
WHICH POSITION DOES NURSE PLACE CLIENT IN FOR PROCEDURE
A SUPINE
B. LEFT LATERAL
C SIMS POSITION
D LITHOTOMY POSITION
ANSWER IS B
14. A CLIENT W/DIVERTICULOSIS DEVELOPS AN EPISODE OF ACUTE INFLAMMATION AND IS
OREDERD TO BE NPO UNTIL INFORMATION ABATES. WHEN THE CLIENT RESUMES THE DIET,
THE NURSE WILL REINFORCE DIETARY HABITS THAT INCLUDE FOODS
A. LOW IN CALORIES
B. HIGH IN VITAMIN C
C. HIGH IN FIBER
D. LOW IN FAT
ANSWER IS C
15, WHILE AWAITING LIVER TRANSPLANT SURGERY, A CLIENT IS PLACED ON A LOW BACTERIA DIET
IN COMBINATION W/ AN ORAL SELECTIVE BOWEL DECOMTAMATION SOLUTION THE NURSE WILL
REMOVE WHICH FOOD INADVERTENTLY PLACED ON THE CLIENT’S TRAY
A. CARBONATED COLA
B. HARD BOILED EGGS
C FRESH GRAPES
D. MASHED POTATOES
C. FRESH GRAPES
16.THE NURSE IS CARING FOR AN UNCONSIOUS CLIENT RECOVERING FROM A SEVERE CLOSED HEAD
INJURY FOLLOWING PLACEMENT OF A PEG TUBE OR FEEDINGS THE NURSE GIVES HIGHEST PRIORITY
TO WHICH ACTION
E. ASPIRATE THE TUBE PRIOR TO EACH FEE AND DISCARD ANY RESIDUAL MATERIAL
F. CLEANSE THE SKIN AROUND THE PEG SITE EACH SITE AND CHECK SITE FOR BREAK
DOWN
G. FLUSH PEG W/WATER BEFORE AND AFTER EACH FEEDING
H. POSITION CLIENT IN HIGH FOWLER’S DURING FEEDINGS AND FOR 30 MINUTES AFTER
FEEDINGS
D IS ANSWER
17.A CLIENT IS ADMITTED AND BEING TREATED FOR ACUTE PANCREATITIS AFTER TREATMENT
BEGINS THE NURSE ANTICIPATES THAT WHICH SERUM LABORATORY VALUE WILL RETURN TO
NORMAL WITHIN 72 HOURS
I. LIPASE
J. ALDOLASE
K. LACTIC DEHYDROGENASE
L. AMYLASE
ANSWER IS D
18 AN ESOPHAGOGASTRODUODENOSCOPY (EGD) HAS BEEN ORDERED FOR A CLIENT THE NURSE
REALIZES THAT THIS PROCEDURE CAN BE USED TO
A. COLON POLYPS
B. SCLEROSE ESOPHAGEAL VARICES
C. DETERMINE PRESENCE OF FREE AIR IN ABDOMEN
D. EVALAUTE ILEUM
ANSWER IS B
.
19. THE NURSE IS PREPARING A COMMUNITY EDUCATION PROGRAM ON HEP B, WHICH
STATEMENT WOULD BE INCLUDED IN THE NURSES DISCUSSION
A. HEP B IMMUNIZATIONS GIVEN TO INFANTS AND CHILDREN
B. HEP B VACCINATIONS IS RECOMMENDED FOR THOSE TRAVELING ESPECIALLY MILITARY
PERSONNEL
C. HEP B CAN BE PREVENTED BY GOOD PERSONAL HYGEINE HABITS AND PROPER SANITATION
D. HEP B IS ACQUIRED BY EATING FRUITS, VEGS, SHELLFISH, OR OTHER FOOD THAT BECAME
CONTAMINATED DURING HANDLING
ANSWER IS A
20. A CLIENT IS RECEIVING A TUBE FEEDING VIA CONTINUOUS ENTERAL PUMP AT 75 ML PER HR
WHEN THE NURSE ASSESSES THE CLIENT AT 8 AM WHICH NURSING OBSERAVATION WOULD
REQUIRE INTERVENTION TO MAINTAIN CLIENT’S SAFETY
A. THE DISPOSABLE FEEDING BAG IS DATED 10AM FROM PREVIOUS DAY AND CONTAINS 200 ML
OF FEEDING
B. A PITCHER OF WATER AND A PLASTIC CUP ON SITTING ON CLIENTS OVERBED TABLE WITHIN
REACH
C. THE CLIENT IS LYING ON RT SIDE W/ A VISIBLE DEPENDENT LOOP IN THE FEEDING TUBE
D. THE HEAD OF BED IS ELEVATED 20 DEGREES
D IS CORRECT ANSWER
21. THE NURSE KNOWS THAT THE DISCHARGE TEACHING FOR A CLIENT W/; HEP A VIRUS IS
SUCCESSFUL WHEN THE CLIENT STATES
A. I WILL NEVER EAT AT A RESTAURANT SALAD BAR AGAIN
B. I SURE AM GOING TO MISS MY MOTHER S SOUTHERN FRIED CHICKEN
C. I ALWAYS DONATED BLOOD IN PAST, BUT CAN’T ANYMORE
D. I HOPE I CAN GET MY MONEY BACK FROM THE TRAVEL AGENT FOR THE CRUISE WE ARE
PLANNING
ANSWER IS C
22. WHEN A CLIENT IS IS DIAGNOSED WITH A FULMINANT HEPATIC FAILURE THE NURSE IS
AWARE THAT THE CLIENT WILL MOST LIKELY BE PREPARED FOR A
A. TRANS-JUGULAR INTRAHEPATIC PORTO=SYSTEMIC SHUNT
B. PORTA-CAVAL ANASTOMOSIS
C. LIVER TRANSPLANT
D. RT LIVER LOBECTOMY
ANSWER IS C
23, A CLIENT ADMITTED W/ A BOWEL OBSTRUCTION DEVELOPS SEVERE ABD PAIN. WHAT
ASSESSMENT FINDINGS WOULD INDICATE TO NURSE THAT POSSIBLE BOWEL PERFORATION HAS
OCCURRED
A. ELEVATED BP
B. RIGID ABD
C. EMESIS OF UNDIGESTED FOOD
D. BOWEL SOUNDS OF INCREASED INFREQUENCY AND PITCH
ANSWER IS B
24.THE NURSE EXPECTS THE CLIENT IN EARLY STAGES OF HEP A TO REPORT WHICH
MAIFESTATIONS MOST OFTEN
A. DARK URINE
B. PALE FECES
C. ANOREXIA
D. JAUNDICE
ANSWER IS C
25.THE NURSE IS COMPLETING AN ADMISSION HX AND ASSESSEMENT ON A CLIENT ADMITTED W/
EXACABERATION OF CHRONIC PANCREATITIS . IN SEARCHING FOR POSSIBLE CAUSE FOR THIS
CONDITION WHICH ASPECT OF CLIENTS SHOULD NURSE INVESTIGATE FULLY
A. HIGH CALORIE DIET
B. ALOCHOL USAGE
C. PRIOR GI ILLNESS
D. TOBACCO USE
ANSWER IS B
26.A CLIENT HAS A SPLEENECTOMY FOLLOWING AN MVA THE CLIENT CARE MEASURE THAT THE
NURSE SHOULD GIVE PRIMARY CONSIDERATION FOLLOWING A SPLEENECTOMY IS
A. EARLY AMBLUATION
B. MONITIORING FOR FEVER
C. OBSERVING FOR HEMMORAGE
D. PROMOTING LUNG AERATION
CORRECT ANSWER IS D
27. THE MOST THERAPEUTIC DIET FOR A CLIENT W/ HEPATIC CIRRHOSIS IS
A. LOW CARB./HIGH FAT W/ ADDITIONAL VITAMINS
B. HIGH PROTEIN , LOW CARB, LOW FAT
C. HIGH SODIUM,. MODERATE FAT, LOW PROTEIN
D. LOW SODIUM, PROT TO TOLERANCE, ADDITIONAL VITAMINS
ANSWER IS D
28. 3 DAYS AFTER A GASTROPLASTY FOR OBESITY THE NURSE ASSESSES THAT THE CLIENTS BOWEL
SOUNDS HAVE RETURNED WHICH FOOD SELECTION WOULD BE APPROPRIATE TO AN INITIAL
FEEDING
A. A 1 OUNCE SERVING OF
A. APPLE JUICE
B. VANILLA PUDDING
C. DIET GINGERALE
D. WATER
ANSWER IS D
29. THE SPOUSE OF A CLIENT RECENTLY DX W/ COLON CA QUESTIONS THE NURSE IN REGARD TO THE
CARCINOEMBYRONIC ANTIGEN BLOOD TEST APPROPORIATE INFO FROM THE NURSE WOULD
INCLUDE
A. TEST CAN BE USED AS A METHOD OF DETECTING CA IN OTHERWISE HEALTHY INDIVIDUALS
B. THE CEA TEST IS MOST OFTEN USED FOR FOLLOW-UP OF CLIENTS TREATED FOR COLON CA
C EVEN AFTER SUCCESSFUL TREATMENT , BLOOD LEVELS OF CEA WILL REMAIN ELEVATED
D. THE CEA BLOOD TEST IS CONCLUSIVE FOR DETECTING THE PRESENCE OF MALIGNANT CELLS
ANSWER IS B
30. A CLIENT W/ SEVERE GERD IS TO UNDERGO ESOPHAGOSCOPY THE CLIENT ASKS THE NURSE
WHY PROCEDURE IS NEEDED. IN TEACHING THE CLIENT, THE NURSE EXPLAINS THAT THE
TEST IS USEFUL IN
A. DETERMINING HOW WELL THE LOWER ESOPHAGUS WORKS
B. ESOPHAGOSCOPY LOOKS TO SEE IF YOU HAVE CA
C. THE PROCEDURE IS NEEDED TO MEASURE THE PRESENCE OF ACID IN ESOPHAGUS
D. DISCUSS PROCEDURE WITH PHYSICIAN
ANSWER IS A