Nokea
The nurse is reviewing the results of a Hemoccult test with the client. Which question(s) asked by the nurse is important in screening for the potential of a false-positive result? Select all that apply.
- A. Do you take an iron supplement on a daily basis?
- B. Does your diet include a moderate amount of vitamin C?
- C. Are you prescribed regular strength aspirin daily?
- D. Can you tell me the amount of alcohol that you drink on an average week?
- E. When was the last time that you included red meat in your diet?
Correct Answer: C,D,E
Rationale: When obtaining a positive Hemoccult test, the client needs to be screened for a false-positive test result. Substances that may cause a false-positive include red meat, aspirin, and excessive alcohol. Screening for the frequency and amount of these are important. False-negative results are screened in individuals who ingest ascorbic acid and iron supplements.
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The nurse is assessing a client of color for jaundice. In which location(s) would the nurse assess for discoloration? Select all that apply.
- A. The sclera
- B. The gums
- C. The hands
- D. The nails
- E. The hard palate
- F. The conjunctiva
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.
The nurse is scheduling gastrointestinal (GI) diagnostic testing for a client. Which GI test should be scheduled first?
- A. Radiography of the gallbladder
- B. Barium enema
- C. Small bowel series
- D. Barium swallow
Correct Answer: A
Rationale: Radiography of the gallbladder should be performed before the other GI exams listed in which barium is used because residual barium tends to obscure the images of the gallbladder and its duct.
The nurse is providing care to a client who has had a percutaneous liver biopsy. For what would the nurse monitor the client?
- A. Signs and symptoms of bleeding
- B. Return of the gag reflex
- C. Passage of stool
- D. Intake and output
Correct Answer: A
Rationale: A major complication after a liver biopsy is bleeding, so it would be important for the nurse to monitor the client for signs and symptoms of bleeding. Return of the gag reflex would be important for the client who had an esophagogastroduodenoscopy to prevent aspiration. Monitoring the passage of stool would be important for a client who had a barium enema or colonoscopy. Monitoring intake and output is a general measure indicated for any client. It is not specific to a liver biopsy.
The nurse is preparing to measure the client's abdominal girth as part of the physical examination. At which location would the nurse most likely measure?
- A. In the right upper quadrant
- B. At the umbilicus
- C. At the lower border of the liver
- D. Just below the last rib
Correct Answer: B
Rationale: Measurement of abdominal girth is done at the widest point, which is usually the umbilicus. The right upper quadrant, lower border of the liver, or just below the last rib would be inappropriate sites for abdominal girth measurement.
The nurse is caring for a client following gastrointestinal diagnostic testing. The client verbalizes feeling shame due to having frequent gas. Which nursing suggestion is best?
- A. Having gas following the procedure is normal. Expel the gas to decrease discomfort.
- B. Do not be ashamed. Everyone has gas following the procedure.
- C. The nursing staff is used to having clients with gas due to the procedure completed.
- D. Nurses anticipate that client will have gas following the procedure and provide privacy.
Correct Answer: A
Rationale: The nurse is correct to tell the client that this experience is normal and encourage the client to release the gas to decrease pain and discomfort. Providing information relieving the embarrassment and stating the benefit of the action is most helpful.