Chapters 32-35
The nurse id reinforcing teaching on a client about an upcoming colonoscopy procedure. The nurse would include in the instructions that the client will be placed in which position for the procedure?
Left Sim's position
The nurse reinforces postoperative liver biopsy instructions to a client. Which would the nurse tell the client?
Lie on the right side for two hours
The nurse provides teaching for a patient with a peptic ulcer. Which patient statement would the nurse evaluate as indicating understanding of the purpose of histamine 2 (H2)-receptor antagonists?
"H2-receptor antagonists inhibit secretion of gastric acid."
The nurse is to palpate the patient's abdomen during data collection. Which of the following techniques should the nurse use?
Lightly depress the abdomen 0.5 to 1 inch
The nurse participated in a patient's teaching session for care to prevent respiratory complications after a hernia repair. Which statement by the patient would indicate to the nurse that the patient understood the teaching?
"I will deep breathe every hour while awake."
The nurse assisted with inserting a flexible feeding tube into a patient. Which of the following actions should the nurse take to confirm tube placement?
obtain ordered chest x-ray results
The nurse is caring for a client after a Billroth II produce. During review of the postoperative prescriptions, which would the nurse clarify?
Irrigating the NG tube
The nurse is planning a teaching session for a patient with a peptic ulcer. Which of these would the nurse include in the teaching plan as the primary cause of peptic ulcers?
A bacterial infection
The nurse is planning care for a team of patients. To provide patient-centered care safely, for which patients should the nurse use specialized mobility equipment designed for the patient who is obese?
A man with body weight 30% above ideal body weight. A man with body mass index of 31. A woman with waist measurement of 36 inches4. A man with waist measurement of 44 inches
The nurse teaches a patient with cirrhosis functions of the liver. Which of these would the nurse include as functions of the liver?
Amino acid metabolism, Lipid metabolism, Synthesis of plasma proteins. and Phagocytosis by Kupffer cells
The nurse is caring for patient with chronic pancreatitis. While reviewing laboratory data, the nurse would expect an elevation in which serum laboratory value?
Amylase
For which complication does the nurse monitor that can occur following a barium enema?
Barium impaction
Liver Functions
Carbohydrate metabolism .Amino acid metabolism. Lipid metabolism. Synthesis of plasma proteins. Phagocytosis by Kupffer cells. Formation of bilirubin. Storage
Prior to administering medications via a percutaneous endoscopic gastrostomy (P E G) tube, which of these actions does the nurse take?
Check placement, Observe for abdominal distention, Check allergies, and Verify tube length
The nurse is teaching a patient with dumping syndrome about food choices. Which of these foods would the nurse instruct the patient to avoid?
Coffee and glazed doughnut
The nurse is to collect data on a patient who reports diarrhea. What data should the nurse collect?
Consistency of stools, color of stools, frequency of stools, and antibiotic use
A patient is admitted with an order for a nasogastric sump tube. The nurse knows this tube is used for which of the following purposes?
Decompression, irrigation, and lavage
The nurse is caring for a patient who had a barium enema. Which of the following actions should the nurse implement?
Encourage fluids, and provide ordered laxative
The nurse is reinforcing patient teaching. Which of the following foods would the nurse reinforce that the patient with ulcerative colitis is to avoid?
Fresh fruits
The nurse would evaluate the patient as understanding diet teaching for celiac disease if the patient selected which of the following breakfast foods to eat?
Hard-boiled egg, bacon, and blueberries. Scrambled eggs and orange juice. Protein smoothie with carrots and spinach.
Which of these patient's dietary habits does the nurse understand may increase the risk for development of colon cancer?
High-fat, low-fiber intake
The nurse is caring for a patient who is receiving a parenteral nutrition infusion. The nurse performs blood glucose monitoring every 6 hours to detect which complication?
Hyperglycemia
The nurse is contributing to the plan of care for a 78-year-old patient's elimination needs. Which of the following interventions should the nurse recommend to reduce complications due to the aging change of slowed motility?
Increase dietary fiber and increase activity level
The nurse is preparing to perform an abdominal examination. Which step would be taken first?
Inspection
The nurse is caring for a patient with a small-bowel obstruction who is NPO (nothing by mouth) with an orogastric tube on low intermittent suction. Which of the following ongoing data would be a priority for the nurse to monitor and collect?
Intake and output,. Pain level, Temperature, Pulse rate, and Firmness of abdomen or distention
The nurse is caring for a patient with gastritis. Which intervention should the nurse implement for a patient with acute gastritis?
Monitor patient for bloody diarrhea
The nurse is caring for a patient who has a sudden onset of diarrhea with black tarry stools. Which action should the nurse take?
Obtain vital signs
The nurse is caring for a patient after an appendectomy. Which of the following interventions should the nurse include in the patient's plan of care to prevent respiratory complications?
Pain control, Early ambulation, Coughing and deep breathing, and Incentive spirometer
The nurse is planning care for a newly admitted patient with acute pancreatitis. Which patient outcome should receive the highest priority in the plan of care?
Patient expresses satisfaction with pain control
A patient who has just returned from surgery after a total gastrectomy begins to vomit bright red blood. What is the priority action for the nurse to take?
Place patient onto side.
Which of these converting functions does the pancreatic enzyme trypsin have?
Polypeptides to peptides
The nurse is caring for a patient who had an open cholecystectomy 24 hors ago. Which actions should the nurse take to assist the patient to maintain an effective breathing pattern?
Provide analgesics for pain relief, encourage coughing and deep breathing, and assist with splinting during coughing
The nurse is collecting data on a patient admitted with a history of severe diarrhea. Findings include cool, pale skin, and red tongue with furrows. Vitals signs are blood pressure 102/74 mm Hg, pulse 106 beats per minute, respirations 20 breaths per minute, and temperature 99.9°F (37.7°C). Which action should the nurse take now?
Report findings to registered nurse.
The nurse is caring for a 1-day postoperative patient who has a new end colostomy that is a dusky color. Which action is the priority for the nurse to take?
Report this finding to the health care provider now.
The nurse reinforces teaching for a patient after a cholecystectomy who is on a low-fat diet. The nurse will know that the patient understands the diet if which menu items are selected?
Roast chicken, rice, and gelatin dessert
The nurse would evaluate the patient as understanding teaching for gastrointestinal changes that occur with aging if the patient included which of these?
Sweet taste sensation lost, Esophagus motility lessens, and Weaker gag reflex
Aging and the Gastrointestinal System
Tooth enamel harder/more brittle. Tongue atrophy Sweet taste sensation lost. Saliva production decreased 33%. Esophagus motility less, emptying slower. Weaker gag reflex. Decreased motility of stomach. Decreased gastric hydrochloric acid production. Fat absorption slower. Atrophy of large/small intestine. Decreased mucous secretions. Decreased elasticity of rectal wall. Weakness of intestinal wall. Faulty absorption of vitamins B subscript 1 and B subscript 2, calcium, and iron
The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency?
Vitamin B12
The nurse s collecting data for a patient who develops jaundice and dark-colored urine. The nurse recognizes that which of the following is most likely the cause of these clinical manifestations?
bile duct obstruction
The nurse is collecting data for a patient with suspected acute hepatitis A infection. Which clinical manifestations would the nurse expect the patient to report?
headache, flu-like symptoms, and nausea
