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Test Bank
MULTIPLE CHOICE
1. Which information about an 80-year-old man at the senior center is of most concern to the
nurse?
a. Decreased appetite
b. Unintended weight loss
c. Difficulty chewing food
d. Complaints of indigestion
ANS: B
Unintentional weight loss is not a normal finding and may indicate a problem such as cancer
or depression. Poor appetite, difficulty in chewing, and complaints of indigestion are common
in older patients. These will need to be addressed but are not of as much concern as the weight
loss.
2. A 62- year-old man reports chronic constipation. To promote bowel evacuation, the nurse will
suggest that the patient attempt defecation
a. in the mid-afternoon.
b. after eating breakfast.
c. right after getting up in the morning.
d. immediately before the first daily meal.
ANS: B
The gastrocolic reflex is most active after the first daily meal. Arising in the morning, the
anticipation of eating, and physical exercise do not stimulate these reflexes.
3. When caring for a patient with a history of a total gastrectomy, the nurse will monitor for
a. constipation.
b. dehydration.
c. elevated total serum cholesterol.
d. cobalamin (vitamin B12) deficiency.
ANS: D
The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for
cobalamin (vitamin B12) absorption. Because the stomach absorbs only small amounts of
water and nutrients, the patient is not at higher risk for dehydration, elevated cholesterol, or
constipation.
5. The nurse receives the following information about a 51-year-old woman who is scheduled
for a colonoscopy. Which information should be communicated to the health care provider
before sending the patient for the procedure?
a. The patient has a permanent pacemaker to prevent bradycardia.
b. The patient is worried about discomfort during the examination.
c. The patient has had an allergic reaction to shellfish and iodine in the past.
d. The patient refused to drink the ordered polyethylene glycol (GoLYTELY).
ANS: D
If the patient has had inadequate bowel preparation, the colon cannot be visualized and the
procedure should be rescheduled. Because contrast solution is not used during colonoscopy,
the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance
imaging (MRI), but not to colonoscopy. The nurse should instruct the patient about the
sedation used during the examination to decrease the patients anxiety about discomfort.
6. Which statement to the nurse from a patient with jaundice indicates a need for teaching?
a. I used cough syrup several times a day last week.
b. I take a baby aspirin every day to prevent strokes.
c. I use acetaminophen (Tylenol) every 4 hours for back pain.
d. I need to take an antacid for indigestion several times a week
ANS: C
Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the
patients jaundice. The other patient statements require further assessment by the nurse, but do
not indicate a need for patient education.
8. Which finding by the nurse during abdominal auscultation indicates a need for a focused
abdominal assessment?
a. Loud gurgles
b. High-pitched gurgles
c. Absent bowel sounds
d. Frequent clicking sounds
ANS: C
Absent bowel sounds are abnormal and require further assessment by the nurse. The other
sounds may be heard normally.
9. After assisting with a needle biopsy of the liver at a patients bedside, the nurse should
a. put pressure on the biopsy site using a sandbag.
b. elevate the head of the bed to facilitate breathing.
c. place the patient on the right side with the bed flat.
d. check the patients postbiopsy coagulation studies.
ANS: C
After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site.
Coagulation studies are checked before the biopsy. A sandbag does not exert adequate
pressure to splint the site.
10. A 42-year-old woman is admitted to the outpatient testing area for an ultrasound of the
gallbladder. Which information obtained by the nurse indicates that the ultrasound may need
to be rescheduled?
a. The patient took a laxative the previous evening.
b. The patient had a high-fat meal the previous evening.
c. The patient has a permanent gastrostomy tube in place.
d. The patient ate a low-fat bagel 4 hours ago for breakfast.
ANS: D
Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient
should be NPO for 8 to 12 hours before the test. A high-fat meal the previous evening,
laxative use, or a gastrostomy tube will not affect the results of the study.
11. The nurse is assessing an alert and independent 78-year-old woman for malnutrition risk. The
most appropriate initial question is which of the following?
a.How do you get to the store to buy your food?
b.Can you tell me the food that you ate yesterday?
c.Do you have any difficulty in preparing or eating food?
d.Are you taking any medications that alter your taste for food?
ANS: B
This question is the most open-ended, and will provide the best overall information about the
patients daily intake and risk for poor nutrition. The other questions may be asked, depending
on the patients response to the first question.
12. A 54-year-old man has just arrived in the recovery area after an upper endoscopy. Which
information collected by the nurse is most important to communicate to the health care
provider?
a. The patient is very drowsy.
b. The patient reports a sore throat.
c. The oral temperature is 101.6 F.
d. The apical pulse is 104 beats/minute.
ANS: C
A temperature elevation may indicate that a perforation has occurred. The other assessment
data are normal immediately after the procedure.
13. A 30-year-old man is being admitted to the hospital for elective knee surgery. Which
assessment finding is most important to report to the health care provider?
a. Tympany on percussion of the abdomen
b. Liver edge 3 cm below the costal margin
c. Bowel sounds of 20/minute in each quadrant
d. Aortic pulsations visible in the epigastric area
ANS: B
Normally the lower border of the liver is not palpable below the ribs, so this finding suggests
hepatomegaly. The other findings are within normal range for the physical assessment.
16. While interviewing a 30-year-old man, the nurse learns that the patient has a family history of
familial adenomatous polyposis (FAP). The nurse will plan to assess the patients knowledge
about
a. preventing noninfectious hepatitis.
b. treating inflammatory bowel disease.
c. risk for developing colorectal cancer.
d. using antacids and proton pump inhibitors.
ANS: C
Familial adenomatous polyposis is a genetic condition that greatly increases the risk for
colorectal cancer. Noninfectious hepatitis, use of medications that treat increased gastric pH,
and inflammatory bowel disease are not related to FAP.
17. Which area of the abdomen shown in the accompanying figure will the nurse palpate to assess
for splenomegaly?
a. 1
b. 2
c. 3
d. 4
ANS: B
The spleen is usually not palpable, but when palpated, it is located in left upper quadrant of
abdomen.
OTHER
ANS:
A
The video demonstrates percussion of the right anterior chest and right abdomen to determine
liver height.