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41 Cards in this Set

  • Front
  • Back

To best facilitate an effective breathing pattern, the nurse would place a client with massive ascites in what position?

high-Fowler position

Reviewing a client’s chart, the nurse finds that the client has odynophagia. The nurse questions the client about experience with:

knife-like pain

The morning after admission, a client being treated for gallstones begins to vomit about every 15 minutes and is complaining of abdominal pain. The most appropriate action by the nurse would be to

Prepare to insert a nasogastric (NG) tube

A client who had onset of acute pancreatitis 6 days ago has a respiratory rate of 26 with fine crackles throughout lung fields, and seems a little confused and agitated. The nurse would continue to assess this client for manifestations of

adult respiratory distress syndrome

A nurse is providing discharge instructions for a post-cholecystectomy client. The nurse would view the goals for teaching had been effective when the client states he/she would

notify the physician of jaundice or itching.

A client has undergone radiation therapy to reduce the size of an esophageal tumor. The nurse should be especially vigilant in assessing for

esophageal stenosis

The nurse assesses asterixis while monitoring the blood pressure of a client with viral hepatitis. The nurse would interpret this finding as an indication of

Hepatic encephalopathy

A client experiencing hepatic encephalopathy is receiving lactulose. An irate family member asks, “Why in the world would the doctor give my husband something that gives him diarrhea when he is already so sick?” The nurse’s response would include that the purpose of the lactulose is to

empty the bowel of protein

The nurse recognizes that the individual at highest risk for development of gallstones is

a 60-year old white women being treated for obesity.

The nurse caring for a client with jaundice would assess for other findings frequently associated with this condition, such as

excess pigmentation to the hands

The nurse preparing to discharge a client with acute hepatitis B instructs the client to avoid

acetaminophen and aspirin

A nurse is assessing a client with a history of a duodenal ulcer. Which finding is consistent with the nurse’s knowledge about this condition?

Pain may awaken the client in the middle of the night.

A nurse is serving food trays. From the tray of a client with hepatic encephalopathy, the nurse would remove


The nurse has just finished inserting a nasogastric (NG) tube in a client who has difficulty swallowing. The best measure to test for placement of the tube is

aspirating gastric contents.

A client has returned from an open cholecystectomy. The nurse places the highest priority on which intervention?

coughing and deep breathing

The nurse notes on a client’s chart a report revealing unconjugated hyperbilirubinemia. The nurse explains the presence of unconjugated bilirubin indicates

biliary obstruction is preventing blood flow through the liver.

Ranitidine (Zantac) is prescribed for a client with a gastric ulcer. The statement that best indicates to the nurse that the client understands the action of this drug is

'This drug reduces the acid in my stomach."

A client is taking cortisone. The nurse schedules the medication with food because cortisone can have which effect on gastric mucosa when given on an empty stomach? Cortisone will cause

Susceptibility of the mucosa to injury

Activities the nurse could suggest to a client interested in preventing gallstone formation include which of the following?

Maintain a low-fat diet

A client needs insertion of a long tube for intestinal decompression. The tube that is inappropriate for intestinal decompression is the

Salem-sump or Levin tube

The nurse is working in an area experiencing an outbreak of hepatitis. The manifestations that the nurse would identify as early manifestations of the disease are

epigastric pain and flu-like symptoms

A client with massive ascites had a paracentesis. The site continues to leak through several layers of dressings, despite the nurse holding pressure. Which intervention should the nurse do first?

Obtain urostomy pouch and apply it at the puncure site

The nurse administers alternating doses of two antacids into the NG tube of a client with a duodenal ulcer. The finding that best indicates that this drug regimen has been successful is

Increased gastric pH, mild diarrhea

A client with acute pancreatitis has developed a Cullen’s sign. Which nursing diagnosis takes priority for this client?

Imbalanced fluid volume

A client has ascites and the nursing diagnosis Excess Fluid Volume. The nurse has orders to administer albumin and furosemide (Lasix). Which action by the nurse regarding this order is correct?

Give the albumin first and then give the furosemide.

The nurse planning the care of a client admitted with severe pancreatitis would anticipate the diet order of

NPO with TPN

A nurse explains to a client who recently ate in a fast-food restaurant where several people have developed hepatitis that the incubation period for this type of hepatitis is

2.15 - 30 days

A client with acute pancreatitis has a drop in blood pressure from 142/80 to 105/56 mm Hg at 2 hours after admission. The client has not voided and has become short of breath. The nurse would anticipate that the abnormal laboratory value consistent with these manifestations is


In caring for a client admitted to the hospital for treatment of cirrhosis, the nurse would know that priority interventions revolve around the client’s

Risk for hemorrhage related to bleeding tendencies.

A client returned to the nursing unit after cholecystectomy with common bile duct exploration has bile leaking from around the wound. The most appropriate nursing intervention at this time would be to

assess the client further, asking about pain.

When a client is admitted to the hospital for treatment of acute cholecystitis, the nurse would anticipate that the immediate medical management will be

antibiotic therapy

A client asks the nurse about the prescribed diet after gastric surgery. The nurse clarifies that a high-protein, high-fat, low-carbohydrate, dry diet is the best choice after gastric surgery because this diet

is slow to leave the stomach.

The nurse is caring for a client with chronic atrophic gastritis. When taking an admission history, the nurse would anticipate a history of

pernicious anemia

A client with oral Candidiasis has the nursing diagnosis Acute Pain related to altered oral mucous membrane and ulcerations. To rinse the mouth and provide comfort, the nurse should instruct the client to use:

Saline mouth rinses.

Metoclopramide (Reglan) is prescribed for a client with GERD. The nurse realizes that teaching about this drug has been effective when the client says “I understand metoclopramide

decreases the time food and fluids are in my stomach

In evaluating a client for the presence of gallbladder disease, the nurse would recognize that the client’s statement most suggestive of this problem is

“I have a terrible pain in my stomach; it is so bad I can feel it in my shoulder.”

The nurse should be mindful that the factor in a client’s history most likely to result in esophageal reflux is:

heavy consumption of coffee daily

A client with a history of cholelithiasis presents at the hospital with nausea and vomiting, abdominal pain, and jaundice. The nurse would assess the client for

common bile duct obstruction

The nurse planning to irrigate a nasogastric (NG) tube prepares to use

normal saline

To attempt to alleviate the pain of a client with acute pancreatitis, the nurse would place the client in the

side-lying position with a pillow splinting the abdomen

A client with acute gastritis is admitted to the emergency department for GI bleeding. The nurse would anticipate the client’s history will include

alcohol abuse