1. The male client tells the nurse he has been experiencing “heartburn” at night that awakens him.

Which assessment question should the nurse ask?

a. “How much weight have you gained recently?”
b. “What have you done to alleviate the heartburn?”
c. “Do you consume many milk and dairy products?”
d. “Have you been around anyone with stomach virus?”

Rationale: B. Most clients with GERD have been self medicating with over the counter
medications prior to seeking advice from a health-care provider. It is important to know
what the client has been using to treat the problem.

2. The nurse is preparing a client diagnosed with GERD for discharge following an
esophagogastroduodenoscopy (EGD). Which statement indicates the client understands the discharge
instructions?
a. “I should not eat for at least one (1) day following this procedure.”
b. “I can lie down whenever I want after a meal. It won’t make a difference.”
c. “The stomach content won’t bother my esophagus but it will make me nauseous.”
d. “I should avoid orange juice and eating tomatoes until my esophagus heals”

Rationale: D. orange juice and tomatoes are highly acidic and may become a
contributing factor for an acid reflux. The priority in this situation is to give an ample
amount of time for the esophagus to heal (own rationale since ratio is not included in
the book)

3. The nurse caring for a client diagnosed with GERD. Which nursing interventions should be
implemented?
a. Place the client prone in bed and administer nonsteroidal anti-inflammatory medications
b. Have the client remain upright at all times and walk for 30 minutes three (3) times a
week.
c. Instruct the client to maintain a right lateral side-lying position and take antacids before
meals
d. Elevate the head of the bed (HOB) 30 degrees and discuss lifestyle modifications with the
client.

Rationale: D. The head of the bed should be elevated to allow gravity to help in
preventing reflux. Lifestyle modifications of losing weight, making dietary
modifications, attempting smoking cessation, discontinuing the use of alcohol, and not
stooping or bending at the waist all help to decrease reflux

4. The nurse is administering morning medications at 0 7 3 0 . Which medication should have priority?
a. A proton pump inhibitor
b. A nonnarcotic analgesic
c. A histamine receptor antagonist
d. A mucosal barrier agent

Rationale: D. A mucosal barrier agent must be administered on an empty stomach for

the medication to coat the stomach. (pero letter A nalang isasagot ko huhu)

(A) Proton pump inhibitors can be administered at routine dosing times, usually 0900
or after breakfast.
 (B) Pain medication is important, but a nonnarcotic medication, such as Tylenol, can
be administered after a medication which must be timed.
(C) A histamine receptor antagonist can be administered at routine dosage times.
(D) A MUCOSAL BARRIER AGENT MUST BE ADMINISTERED ON AN EMPTY
STOMACH FOR THE MEDICATION TO COAT THE STOMACH.

5. The charge nurse is making assignments. Staffing includes a registered nurse with five (5) years of
medical-surgical experience, a newly graduated registered nurse, and two (2) unlicensed assistive
personnel (UAP). Which should be assigned to the most experienced nurse?
a. The 39-year-old client diagnosed with lower esophageal dysfunction who is complaining
of pyrosis
b. The 54-year-old client diagnosed with Barrett’s esophagus who is scheduled to have an
endoscopy this morning
c. The 46-year-old client diagnosed with gastroesophageal reflux disease who has wheezes
Assess the client for muscle weakness in all five (5) lobes.
d. The 68 year-old client who is three (3) days postoperative for hiatal hernia and needs to
be ambulated four (4) times today.

Rationale: C. This client is exhibiting symptoms of asthma, a complication of GERD.

This client should be assigned to the most experienced nurse.

6. The nurse is performing an admission assessment on a client diagnosed with GERD. Which signs and
symptoms would indicate GERD?
a. Pyrosis, waterbrash, and flatulence
b. Weight loss, dysarthria, and diarrhea
c. Decreased abdominal fat, proteinuria, and constipation
d. Midepigastric pain, positive H. pylori test, and melena

Rationale: A. Pyrosis is heartburn, water brash is the feeling of saliva secretion as a

result of reflux, and flatulence is gas-all symptoms of GERD.
- Pyrosis - a painful burning sensation in the chest (heartburn)
- Water brash - occurs when a person produces an excessive amount of saliva
that mixes with stomach acids that have risen to the throat.
- Flatulence - utot

7. Which signs and symptoms should the nurse expect to find in a client diagnosed with ulcerative
colitis?
a. Twenty bloody stools a day
b. Oral temperature of 102F
c. Hard rigid abdomen
d. Urinary stress incontinence

Rationale: A. The colon is ulcerated and unable to absorb water, resulting in blooding
diarrhea. 20-30 bloody diarrhea stools is the main common symptom of ulcerative
colitis.

8. The client is diagnosed with inflammatory bowel disease and has serum potassium level of 3.4
mEq/L. Which action should the nurse implement first?
a. Notify the health-care provider (HCP)
b. Assess the client for muscle weakness
c. Request telemetry for the client
 d. Prepare to administer potassium IV

Rationale: B. Muscle weakness may be a sign of hypokalemia; hypokalemia can lead

to cardiac dysrythmias and can be life threatening. Assessment is priority for
potassium level just below normal level, which is 3.5 to 5.5 mEq/L..

9. The client diagnosed with IBD is prescribed total parenteral nutrition (TPN). Which intervention
should the nurse implement?
a. Check the client’s glucose level
b. Administer an oral hypoglycemic
c. Assess the peripheral intravenous site
d. Monitor the client’s oral food intake

Rationale: A. TPN is high in dextrose, which is glucose; therefore, the clients blood
glucose level must be monitored closely

10. The client diagnosed with Crohn’s disease is crying and tells the nurse, “I can’t take it anymore. I
never know when I will get sick and end up here in the hospital.” Which statement is the nurse’s is
the best response?
a. “I understand how frustrating this must be for you”
b. “You must keep thinking about the good things in your life”
c. “I can see you are very upset. I’ll sit down and we can talk”
d. “Are you thinking about doing anything life==ke committing suicide”

Rationale: C. The client is crying and is expressing feelings of powerlessness;

therefore, the nurse should allow the client to talk.

11. The client diagnosed with IBD is prescribed sulfasalazine (Asulfidinc), a sulfonamide antibiotic.
Which statement best describes the rationale for administering this medication?
a. It is administered rectally to help decrease colon inflammation.
b. This medication slows gastrointestinal (GI) motility and reduces diarrhea.
c. This medication kills the bacteria causing the exacerbation.
d. It acts topically on the colon mucosa to decrease inflammation.

Rationale: Asulfidine is poorly absorbed from the gastrointestinal tract and acts topically on
the colonic mucosa to inhibit the inflammatory process

12. The client diagnosed with ulcerative colitis is prescribed a low-residue diet. Which meal selection
indicates the client understands the diet teaching?
a. Grilled hamburger on a wheat bun and fried potatoes.
b. A chicken salad sandwich and lettuce and tomato salad.
c. Roast pork, white rice, and plain custard.
d. Fried fish, whole grain pasta, and fruit salad.

Rationale: A low-residue diet is a low-fiber diet. Products made of refined flour or finely milled grains,
along with roasted, baked, or broiled meats, are recommended

13. Which assessment data supports the client's diagnosis of gastric ulcer to the nurse?
a. Presence of blood in the client's stool for the past month.
 b. Reports of a burning sensation moving like a wave.
c. Sharp pain in the upper abdomen after eating a heavy meal.
d. Complaints of epigastric pain 30 to 60 minutes after ingesting food.

Rationale: The client diagnosed with a gastric ulcer, pain usually occurs 30 to 60 minutes after eating,
but not at night. In contrast,no client with a duodenal ulcer has pain during the night often relieved by
eating food. Pain occurs 1-3 hours after meals.

14. Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer
disease?
a. History of side effects experienced from all medications.
b. Use of nonsteroidal anti-inflammatory drugs (NSAIDS).
c. Any known allergies to drugs and environmental factors.
d. Medical histories of at least three (3) generations.

Rationale: Use of NSAIDs places the client at risk for peptic ulcer and hemorrhage. NSAIDs suppress
the production of prostaglandin in the stomach, which is a protective mechanism to prevent damage
from hydrochloric acid.

15. Which problems should the nurse include in the plan of care for the client diagnosed with peptic ulcer
disease to observe for physiological complications?
a. Alteration in bowel elimination patterns.
b. Knowledge deficit in the causes of ulcers.
c. Inability to cope with changing family roles.
d. Potential for alteration in gastric emptying.

Rationale: Potential for alteration in gastric emptying is caused by edema or scarring associated with
an ulcer, which may cause a feeling of "fullness", vomiting of undigested food or abdominal
distention

16. Which expected outcome should the nurse include for a client diagnosed with peptic ulcer disease?
a. The client's pain is controlled with the use of NSAIDS.
b. The client maintains lifestyle modifications.
c. The client has no signs and symptoms of hemoptysis.
d. The client takes antacids with each meal.

Rationale: Maintaining lifestyle changes such as following an appropriate diet and reducing stress
indicate the client is complying with the medical regimen. Compliance is the goal of treatment to
prevent complications.

17. Which oral medication should the nurse question before administering to the client with peptic ulcer
disease?
a. E-mycin, an antibiotic.
b. Prilosec, a proton pump inhibitor.
 c. Flagyl, an antimicrobial agent.
d. Tylenol, a nonnarcotic analgesic.

Rationale: E-mycin is irritating to stomach, and its use in a client with peptic ulcer disease should be
questioned

18. Which assessment data indicate to the nurse the client's gastric ulcer has perforated?
a. Complaints of sudden, sharp, substernal pain.
b. Rigid, board like abdomen with rebound tenderness.
c. Frequent, clay-colored, liquid stool.
d. Complaints of vague abdominal pain in the right upper quadrant.

Rationale: A rigid, boardlike abdomen with rebound tenderness is the classic sign/symptom of peritonitis,
which is a complication of a perforated gastric ulcer.

19. The occupational health nurse is preparing a presentation to a group of factory workers about
preventing colon cancer. Which information should be included in the presentation?
a. Wear a high-filtration mask when around chemicals.
b. Eat several servings of cruciferous vegetables daily.
c. Take multiple vitamins every day.
d. Do not engage in high-risk sexual behaviors.

Rationale: Cruciferous vegetables, such as broccoli, cauliflower, and cabbage, are high in
fiber. One of the risks for cancer of the colon is a high-fat, low-fiber, and high-protein diet.
The longer the transit time (the time from ingestion of the food to the elimination of the waste
products), the greater the chance of developing cancer of the colon.

20. The 85-year-old male client diagnosed with cancer of the colon asks the nurse, "Why did I get this
cancer?" Which statement is the nurse's best response?
a. "Research shows a lack of fiber in the diet can cause colon cancer."
b. "It is not common to get colon cancer at your age; it is usually in young people."
c. "No one knows why anyone gots cancer, it just happens to certain people."
d. Women usually get colon cancer more often than men but not always."

Rationale: A long history of low-fiber, high-fat, and high-protein diets results in a prolonged transit
time, which allows waste build up in the colon and increases risk. This allows the carcinogenic agents
in the waste products to have a greater exposure to the lumen of the colon.

21. The client who has had an abdominal perineal resection is being discharged. Which discharge
information should the nurse teach?
a. The stoma should be white, blue or purple color
b. Limit ambulation to prevent the pouch from coming off
c. Take pain medication when the pain level is at an “8”
d. Empty the pouch when it is one-third to one-half full
Rationale: Prevent leakage and heaviness
22. The client complains to the nurse of unhappiness with the health-care provider. which intervention
should the nurse implement next?
a. Call the HCP and suggest he or she talk with the client
b. Determine what about the HCP is bothering the client
c. Notify the nursing supervisor to arrange a new HCP to take cover
d. Explain the client cannot request another HCP until after discharge
Rationale: The nurse should determine the client’s concern
23. The nurse is preparing to hang a new bag of TPN. The bag has 1,500 mL of 50% dextrose, 10 mL of
trace elements, 20 mL of multivitamins, 20 mL of potassium chloride, and 500 mL of lipids. The bag is to
infuse over the next 24 hours. At what rate should the nurse set the pump?
a. 0Ml/hr
b. 84.mL/hr
c. 0mL/hr
d. 85mL/hr
Rationale: 1500 + 500 + 20 + 20 = 2,040 mL
2,040 mL/24 hours = 85 mL/hr
24. The nurse writes of a psychosocial problem of “risk for altered sexual functioning related to new
colostomy.” Which intervention should the nurse implement?
a. Tell the client there should be no intimacy for at least three (3) months.
b. Ensure the client and significant other are able to change the ostomy pouch.
c. Demonstrate with charts possible sexual positions for the client to assume.
d. Teach the client to protect the pouch from becoming dislodged during sex.
Rationale: A pouch that becomes dislodged can be embarrassing (?)
25. The client diagnosed with diverticulitis is complaining of severe pain in the left lower quadrant and
has an oral temperature of 100.6F. Which intervention should the nurse implement first?
a. Notify the health-care provider
b. Document the findings in the chart
c. Administer an oral antipyretic
d. Assess the client’s abdomen
Rationale: Determine if it is soft or rigid. Diverticulitis usually produces localized abdominal pain,
tenderness to touch and fever.
26. The client is admitted to the medical unit with a diagnosis of acute diverticulitis. Which healthcare
provider’s order should the nurse question?
a. Insert a nasogastric tube
b. Start an IV with D3W at 125 mL/hr
c. Put the client on a clear liquid diet
d. Place the client on bedrest with bathroom privileges
Rationale: The nurse should question a clear liquid diet because the bowel must be put on total rest,
which means NPO
27. The client is two (2) hours post colonoscopy. Which assessment data warrant intermediate
intervention by the nurse?
a. The client has a soft, nontender abdomen
b. The client has a loose, watery stool
c. The client has hyperactive bowel sounds
d. The client’s pulse is 104 and BP is 98/60
Rationale: Bowel perforation is a potential complication of a colonoscopy. Therefore, signs of
hypotension- decreased BP and increased pulse- warrant immediate intervention from the nurse
28. The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On
assessment, the nurse finds a hard, rigid abdomen and T 102F. Which intervention should the nurse
implement?
a. Notify the healthcare provider
b. Prepare to administer a Fleets enema
c. Administer an antipyretic suppository
d. Continue to monitor the client closely
Rationale: These are signs of peritonitis which is life threatening
29. The client with acute diverticulitis has a nasogastric tube draining green liquid bile. Which
intervention should the nurse implement?
a. Document the findings as normal
b. Assess the client’s bowel sounds
c. Determine the client’s last bowel movement
d. Insert the N/G tube at least two (2) more inches
Rationale: The normal color of gastric drainage is yellow or green due to the presence of bile.
30. The nurse is working in an outpatient clinic. Which client is most likely to hae a diagnosis of
diverticulosis?
a. A 60 year old male with a sedentary lifestyle
b. A 72 year old female with multiple births
c. A 63 year old female with hemorrhoids
d. A 40 year old male with a family history of diverticulosis
Rationale: Hemorrhoids indicate chronic constipation, which is a strong risk factor because the
pressure can lead to outpouchings

31. The client is four (4) hours postoperative open cholecystectomy. Which data warrant immediate
intervention by the nurse?

A. Absent bowel sounds in all four (4) quadrants.

B. The T-tube has 60 mL of green drainage.
C. Urine output of 100 mL in the past three (3) hours.
D. Refusal to turn, deep breath, and cough.
Rationale: Refusing to turn, deep breathe, and cough puts the client at risk for pneumonia. This client
needs immediate intervention to pre- vent complications.

32. The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement
indicates the discharge teaching was effective?

A. "I will take my lipid-lowering medicine at the same time each night."
B. "I may experience some discomfort when I eat a high-fat meal."
C. "I need someone to stay with me for about a week after surgery."
D. "I should not splint my incision when I deep breathe and cough."

Rationale: After removal of the gallbladder, some clients experience abdominal discomfort when
eating fatty foods.

33. The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy.
Which task could the nurse delegate to the unlicensed nursing assistant (UAP)?

A. Check the abdominal dressings for bleeding.

B. Increase the IV fluid if the blood pressure is low.
C. Document the amount of output on the I & O sheet.
D. Listen to the breath sounds in all lobes.

Rationale: This intervention would be appropriate for the nursing assistant to implement. The nurse
cannot delegate teaching, assessing, and evaluating to a nursing assistant. The nurse cannot delegate
any nursing task unless the client is stable and the task does not require judgment.

34. The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which
intervention should the nurse include in the plan of care?

A. Instruct the client to cough forcefully.

B. Encourage early ambulation.
C. Assess for return of a gag reflex.
D. Administer held medications.

Rationale: The endoscopic retrograde cholangiopan- creatogram (ERCP) requires that an anesthetic
spray be used prior to insertion of the endoscope. If medications, food, or fluid is given orally prior to
the return of the gag reflex, the client may aspirate, causing pneumonia that could be fatal.

35. Which assessment data indicate that the client recovering from an open cholecystectomy requires pain
medication?

A. The client's pulse is 65 beats per minute.

B. The client has shallow respirations.
C. The client's bowel sounds are 20 per minute.
D. The client uses a pillow to splint when coughing

Rationale: Clients having abdominal pain frequently have shallow respirations. When assessing
clients for pain, the nurse should discuss pain medication with any client who has shallow
respirations.
36. Which problem is highest priority for the nurse to identify in the client who had an open
cholecystectomy surgery?

A. Alteration in nutrition.
B. Alteration in skin integrity.
C. Alteration in urinary pattern.
D. Alteration in comfort.

Rationale: Acute pain management is the highest priority client problem after surgery because pain
may indicate a life-threatening problem.

37. The client is diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP
inserts and inflates a triple-lumen nasogastric tube (Sengstaken-Blakemore). Which nursing intervention
should the nurse implement for this treatment?

A. Assess the gag reflex every shift.

B. Stay with the client at all times.
C. Administer the laxative lactulose (Chronulac).
D. Monitor the client's ammonia level.

Rationale: While the balloons are inflated, the client must not be left unattended in case they become
dislodged and occlude.

38. The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which
dietary restriction should be implemented by the nurse to address this complication?

A. Restrict sodium intake to 2 g/day.

B. Limit oral fluids to 1,500 mL/day.
C. Decrease the daily fat intake.
D. D. Reduce protein intake to 60 to 80 g/day.

Rationale: A diet high in calories and moderate in fat intake is recommended to promote healing.

39. The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which
action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse?

A. The UAP is assisting the client to take a hot soapy shower.

B. The UAP applies an emollient to the client's legs and back.
C. The UAP puts mittens on both hands of the client.
D. The UAP pats the client's skin dry with a clean towel.

Rationale: Hot water increases pruritus, and soap will cause dry skin, which increases pruritus;
therefore, the nurse should discuss this with the UAP.

40. The client in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse
implement? Select all that apply.

1. Avoid rectal temperatures.

2. Use only a soft toothbrush.
3. Monitor the platelet count.
4. Use small-gauge needles.
 5. Assess for asterixis.
A. 1,2,3
B. 1,2,3,4
C. 2,3,4
D. 3,4,5

Rationale: Vitamin K is responsible for blood clotting. This is an alternate-type question, which
requires the test taker to select all applicable interventions; the test taker should select interventions
addressing bleeding. 1. Vitamin K deficiency causes impaired coagulation; therefore, rectal
thermometers should be avoided to prevent bleeding. 2. Soft-bristle toothbrushes will help prevent
bleeding of the gums.3. Platelet count, PTT/PT, and INR should be monitored to assess coagulation
status. 4. Injections should be avoided, if at all possible, because the client is unable to clot, but if they
are absolutely necessarily, the nurse should use smallgauge needles.

41. Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver
failure secondary to alcoholic cirrhosis?

A. “How many years have you been drinking alcohol?”

B. “Have you completed an advance directive?”
C. “When did you have your last alcoholic drink?”
D. “What foods did you eat at your last meal?”

Rationale: The nurse must know when the client had the last alcoholic drink to be able to
determine when and if the client will experience delirium tremens, the physical withdrawal
from alcohol.

42. The client is diagnosed with end-stage liver failure. The client asks the nurse, “Why is my
doctor decreasing the doses of my medications?” Which statement is the nurse’s best response?

A. “You are worried because your doctor has decreased the dosage.”
B. “You really should ask your doctor. I am sure there is a good reason.”
C. “You may have an overdose of the medication because your liver is damaged.”
D. “The half-life of the medications is altered because the liver is damaged.”

Rationale: This is the main reason the HCP decreases the client's medication dose and is an
explanation appropriate for the client.

43. The client is in the pre-icteric phase of hepatitis. Which signs/symptoms should the nurse
expect the client to exhibit during this phase?

A. Clay-colored stools and jaundice.

B. Normal appetite and pruritus.
C. Being afebrile and left upper quadrant pain.
D. Complaints of fatigue and diarrhea.

Rationale: “Flu-like” symptoms are the first complaints of the client in the pre-icteric phase
of hepatitis, which is the initial phase and may begin abruptly or insidiously.
44. Which type of precaution should the nurse implement to protect from being exposed to any
hepatitis viruses?

A. Airborne Precautions.
B. Standard Precautions.
C. Droplet Precautions.
D. Exposure Precautions.

Rationale: The universal application of standard precautions is the minimum level of

infection control required in the treatment and care of all patients to prevent transmission of
hepatitis B virus (HBV).

45.Which instruction should the nurse discuss with the client who is in the icteric phase of
hepatitis C?

A. Decrease alcohol intake.

B. Encourage rest periods.
C. Eat a large evening meal.
D. Drink diet drinks and juices.

Rationale: Adequate rest is needed for maintaining optimal immune function.

46. The client with hepatitis asks the nurse, “I went to an herbalist who recommended I take milk
thistle. What do you think about the herb?” Which statement is the nurse’s best response?

A. “You are concerned about taking an herb.”

B. “The herb has been used to treat liver disease.”
C. “I would not take anything that is not prescribed.”
D. “Why would you want to take any herbs?”

Rationale: Milk thistle has an active ingredient, silymarin, which has been used to treat liver
disease for more than 2,000 years. It is a powerful oxidant and promotes liver cell growth.

47. The female nurse sticks herself with a contaminated needle. Which action should the nurse
implement first?

A. Notify the infection control nurse.

B. Cleanse the area with soap and water.
C. Request postexposure prophylaxis.
D. Check the hepatitis status of the client.

Rationale: The nurse should first clean the needle stick with soap and water and attempt stick
bleed to help remove any virus injected into the skin.

48. Which statement by the client diagnosed with hepatitis warrants immediate intervention by
the clinic nurse?

A. “I will not drink any type of beer or mixed drink.”

 B. “I will get adequate rest so I don't get exhausted.”
C. “I had a big hearty breakfast this morning.”
D. “I took some cough syrup for this nasty head cold.”

Rationale: D. C is fine because you need more calories for more energy. D needs immediate
intervention because it contains alcohol.

49. The female client came to the clinic complaining of abdominal cramping and at least 10
episodes of diarrhea every day for the last two (2) days, The client just returned from a trip to
Mexico.Which intervention should the nurse implement?

A. Instruct the client to take a cathartic laxative daily.

B. Encourage the client to drink lots of Gatorade.
C. Discuss the need to increase protein in the diet.
D. Explain the client should weigh herself daily.

Rationale: The client probably has traveler’s diarrhea, and oral rehydration is the preferred
choice for replacing fluids lost as a result of diarrhea. An oral glucose electrolyte solution,
such as Gatorade, All-sport, or pedialyte, is recommended.

50. The client is diagnosed with salmonellosis secondary to eating slightly cooked hamburger
meat. Which clinical manifestations should the nurse expect the client to report?

A. Abdominal cramping, nausea, and vomiting.

B. Neuromuscular paralysis and dysphagia.
C. Gross amounts of explosive bloody diarrhea.
D. Frequent “rice water stool” with no fecal odor.

Rationale: Symptoms develop 8 to 48 hours after ingesting the Salmonella bacteria and
include diarrhea, abdominal cramping, nausea, and vomiting, along with low-grade fever,
chills, and weakness.