Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A patient has been scheduled for a urea breath test in one month's time. What nursing diagnosis most likely prompted this diagnostic test?
A. Imbalanced Nutrition: Less Than Body Requirements Related to Enzyme Deficiency
The urea breath test is typically used to diagnose Helicobacter pylori (H. pylori) infection in the stomach. H. pylori can lead to gastritis and ulcers, which can interfere with nutrient absorption and contribute to imbalanced nutrition.
B. Impaired Dentition Related to Gingivitis
Impaired dentition related to gingivitis is not directly related to the need for a urea breath test. This diagnosis pertains to dental health, not gastric health.
C. Diarrhea Related to Clostridium Difficile Infection
Diarrhea related to Clostridium difficile infection is not directly related to the need for a urea breath test. This diagnosis pertains to a bacterial infection in the colon, not H. pylori infection in the stomach.
D. Risk For Impaired Skin Integrity Related to Peptic Ulcers
Risk for impaired skin integrity related to peptic ulcers is also not directly related to the need for a urea breath test. This diagnosis pertains to potential skin breakdown due to ulcers, not the assessment of H. pylori infection.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 6. Take the full exam now
Full Explanation
Choice A reason:
The urea breath test is typically used to diagnose Helicobacter pylori (H. pylori) infection in the stomach. H. pylori can lead to gastritis and ulcers, which can interfere with nutrient absorption and contribute to imbalanced nutrition.
Choice B reason:
Impaired dentition related to gingivitis is not directly related to the need for a urea breath test. This diagnosis pertains to dental health, not gastric health.
Choice C reason:
Diarrhea related to Clostridium difficile infection is not directly related to the need for a urea
breath test. This diagnosis pertains to a bacterial infection in the colon, not H. pylori infection in the stomach.
Choice D reason:
Risk for impaired skin integrity related to peptic ulcers is also not directly related to the need for a urea breath test. This diagnosis pertains to potential skin breakdown due to ulcers, not the
assessment of H. pylori infection.
Similar Questions
A nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure.
Which of the following assessments is the nurse's priority?
A. Level of consciousness
While assessing the client's level of consciousness is important, it is not the priority after an EGD procedure. Ensuring the client's airway and protective reflexes is more crucial.
B. Gag reflex
This is the correct answer. After an EGD, the client may have residual effects from sedation. Assessing the gag reflex helps ensure that the client's airway is protected.
C. Nausea
Nausea is a common side effect after an EGD, but it is not the priority assessment. Ensuring the client's airway and safety come first.
D. Pain
Assessing pain is important for the client's comfort, but it is not the priority assessment after an EGD. Ensuring the client's airway and protective reflexes is more crucial.
Full Explanation
Choice A reason:
While assessing the client's level of consciousness is important, it is not the priority after an EGD procedure. Ensuring the client's airway and protective reflexes is more crucial.
Choice B reason:
This is the correct answer. After an EGD, the client may have residual effects from sedation. Assessing the gag reflex helps ensure that the client's airway is protected.
Choice C reason:
Nausea is a common side effect after an EGD, but it is not the priority assessment. Ensuring the client's airway and safety come first.
Choice D reason:
Assessing pain is important for the client's comfort, but it is not the priority assessment after an EGD. Ensuring the client's airway and protective reflexes is more crucial.
A patient who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the patient's condition is now stable. For the next several hours, the nurse caring for this
patient should assess for what signs and symptoms of recurrence?
A. Sudden thirst, unrelieved by oral fluid administration
Sudden thirst, unrelieved by oral fluid administration, may indicate dehydration, but it is not specific to a recurrence of upper GI bleeding.
B. Tachycardia, hypotension, and tachypnea
This is the correct answer. Tachycardia (rapid heart rate), hypotension (low blood pressure), and tachypnea (rapid breathing) are signs of potential recurrence of upper GI bleeding and should be closely monitored.
C. Diaphoresis and sudden onset of abdominal pain
Diaphoresis (excessive sweating) and sudden onset of abdominal pain could be indicative of various conditions, but they are not specific to a recurrence of upper GI bleeding.
D. Tarry, foul-smelling stools
Tarry, foul-smelling stools (melena) are indicative of upper GI bleeding. However, in this scenario, the bleeding has been controlled, so this is not an expected sign of recurrence.
Full Explanation
Choice A reason:
Sudden thirst, unrelieved by oral fluid administration, may indicate dehydration, but it is not specific to a recurrence of upper GI bleeding.
Choice B reason:
This is the correct answer. Tachycardia (rapid heart rate), hypotension (low blood pressure), and tachypnea (rapid breathing) are signs of potential recurrence of upper GI bleeding and should be closely monitored.
Choice C reason:
Diaphoresis (excessive sweating) and sudden onset of abdominal pain could be indicative of various conditions, but they are not specific to a recurrence of upper GI bleeding.
Choice D reason:
Tarry, foul-smelling stools (melena) are indicative of upper GI bleeding. However, in this scenario, the bleeding has been controlled, so this is not an expected sign of recurrence.
A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?
A. Dinner roll
A dinner roll is a generally well-tolerated food option and is unlikely to exacerbate gallbladder inflammation.
B. Tapioca pudding
Tapioca pudding is a soft and easily digestible food, which is suitable for a patient with acute gallbladder inflammation.
C. Mashed potatoes
Mashed potatoes are typically considered a bland and easily digestible food, suitable for a patient with gallbladder inflammation.
D. Fried chicken
Fried chicken is high in fat, which can trigger gallbladder symptoms and exacerbate inflammation. Therefore, it is not an appropriate choice for a patient with acute gallbladder inflammation. The nurse should question this item on the tray.
Full Explanation
Choice A reason:
A dinner roll is a generally well-tolerated food option and is unlikely to exacerbate gallbladder inflammation.
Choice B reason:
Tapioca pudding is a soft and easily digestible food, which is suitable for a patient with acute gallbladder inflammation.
Choice C reason:
Mashed potatoes are typically considered a bland and easily digestible food, suitable for a patient with gallbladder inflammation.
Choice D reason:
Fried chicken is high in fat, which can trigger gallbladder symptoms and exacerbate
inflammation. Therefore, it is not an appropriate choice for a patient with acute gallbladder inflammation. The nurse should question this item on the tray.