NUR270 Exam 3 Questions and Answers 100% Guaranteed Success
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NUR270 Exm 3
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NUR270 Exm 3
NUR270 Exam 3 Questions and Answers 100% Guaranteed Success
10. The patient's alpha fetoprotein level is 200 ng/mL. The nurse will evaluate further for the presence of _____ cancer.
a. pancreatic
b. colon
c. liver
d. stomach - Answers ANS: C
Normal levels of alpha fetoprotein are 6 to 20 ng/...
NUR270 Exam 3 Questions and Answers 100% Guaranteed Success
10. The patient's alpha fetoprotein level is 200 ng/mL. The nurse will evaluate further for the presence
of _____ cancer.
a. pancreatic
b. colon
c. liver
d. stomach - Answers ANS: C
Normal levels of alpha fetoprotein are 6 to 20 ng/mL. Elevated values are seen in primary hepatocellular
carcinoma.
14. The nurse is teaching a nursing student how to perform an abdominal assessment. When performing
an abdominal assessment, what examination sequence should the nurse follow?
a. Inspection, auscultation, percussion, and palpation
b. Inspection, auscultation, palpation, and percussion
c. Inspection, percussion, palpation, and auscultation
d. Inspection, palpation, percussion, and auscultation - Answers ANS: A
In order to prevent stimulation of gastrointestinal activity, the order of the assessment is changed to
inspection, auscultation, percussion, and palpation.
5. During auscultation of the patient's abdomen, the nurse hears frequent high-pitched, tinkling sounds.
This is probably evidence of:
a. paralytic ileus.
b. volvulus.
c. normal bowel sounds.
d. peritoneal bleeding. - Answers ANS: C
Normal bowel sounds include high-pitched, gurgling sounds that occur approximately every 5 to 15
seconds or at a rate of 5 to 34 times each minute.
3. Auscultation of the abdomen reveals a bruit over the left renal artery. This is an indication of:
a. normal artery function.
b. adventitious sounds.
,c. a partially obstructed artery.
d. renal hypertension. - Answers ANS: C
Bruits are created by turbulent flow through a partially obstructed artery and are always considered an
abnormal finding.
2. The nurse is unable to hear bowel sounds in any of the four quadrants of the patient's abdomen. This
may indicate the presence of:
a. flatus.
b. an ileus.
c. constipation.
d. an obstruction. - Answers ANS: B
Abnormal findings include the absence of bowel sounds throughout a 5-minute period, extremely soft
and widely separated sounds, and increased sounds with a high-pitched, loud, rushing noise (peristaltic
rush). Absent bowel sounds may occur as a result of inflammation, ileus, electrolyte disturbances, and
ischemia.
16. The patient at risk for gastrointestinal (GI) hemorrhage should be monitored for which of the
following signs and symptoms?
a. Metabolic acidosis and hypovolemia
b. Decreasing hemoglobin and hematocrit
c. Hyperkalemia and hypernatremia
d. Hematemesis and melena - Answers ANS: D
The initial clinical presentation of the patient with acute GI hemorrhage is that of a patient in
hypovolemic shock; the clinical presentation depends on the amount of blood lost. Hematemesis (bright
red or brown, coffee grounds emesis), hematochezia (bright red stools), and melena (black, tarry, or
dark red stools) are the hallmarks of GI hemorrhage.
13. The patient has been admitted to the unit with lower gastrointestinal bleeding secondary to
advanced diverticulitis. What diagnostic test may be done to diagnose this type of lesion?
a. Gastric analysis
b. Barium enema
c. Barium swallow
, d. Gastroscopy - Answers ANS: B
Barium enema or lower GI series is done to diagnose colorectal lesions, diverticulitis, inflammatory
bowel disease, strictures, and fistulas.
19. The best diagnostic test for the determination of upper gastrointestinal bleeding is:
a. barium swallow.
b. colonoscopy.
c. endoscopy.
d. angiography. - Answers ANS: C
Endoscopy is the procedure of choice for the diagnosis of upper GI bleeding
21. A patient is admitted to the unit vomiting blood from an acute upper gastrointestinal hemorrhage. In
planning care for the patient, the nurse gives the highest priority to the goal of:
a. controlling bleeding.
b. protecting the airway.
c. maintaining fluid volume.
d. relieving the patient's anxiety. - Answers ANS: B
Protecting the patient's airway is the highest patient priority. The airway is compromised by vomiting
and aspiration easily occurs. Controlling the bleeding can only occur once the patient's airway is secured
or protected.
24. A patient is admitted to the unit with vomiting and severe abdominal pain. The patient informs the
nurse doing the admission history that he drinks 2 to 3 cocktails every night. Upon inspection, the nurse
notes that the patient's abdomen is rigid and there is a grey-blue discoloration on the patient's flank.
The nurse suspects the patient is exhibiting signs of:
a. pancreatic hemorrhage.
b. acute appendicitis.
c. retroperitoneal hemorrhage.
d. disseminated intravascular coagulation. - Answers ANS: A
The patient is exhibiting signs of pancreatic hemorrhage.
4. Which of the following are clinical manifestations of pancreatitis? (Select all that apply)
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