GI for NHI Exam 5

A client has been hospitalized with pancreatitis for 3 days. A nurse checks the client and documents the results below. The nurse realizes that this information is a manifestation of what finding? progress notes:skin warm and dry. color pink with no signs of pallor. BP 1156/84, HR 102/min, RR 22/min. O2 at 2 L/min via nasal cannula. O2 sat 98%. Denies any shortness of breath, bowel sounds present x4 quadrants. patient states he has pain rated at 8 on a pain scale of 0-10, NG tube to low intermittent suction , light green drainage present. NG tube placement verified; pH of 3. Perumbilical area appears discolored and eccymotic. .......F. Johnson LPN

Cullen's sign

A patient with cirrhosis is scheduled for discharge. The LPN/LVN recognizes the need for further teaching if the patient states?

I will limit alcohol intake to two servings per day

The nurse caring for a patient with a possible bowel obstruction would immediately report which of the following?

Increased pain with a rigid, boardlike abdomen

An older adult patient complains that her bowels move only two or three times a week. The most appropriate response by the nurse would be?

That pattern may be normal for you. Tell me about your stool- is it hard or difficult to expel?

The health care provider has prescribed an antibiotic for a patient with peptic ulcer. The patient asks you why this type of medication is being given. The appropriate response is:

This antibiotic will help to rid the stomach of the H. pylori bacteria.

The nurse talking to a community group includes which of the following in her discussion of colorectal cancer?

When you have reached the age of 50, you should have an annual digital rectal exam and a flexible sigmoidoscopy of colonoscopy every 10 years.

A patient recovering from bowel surgery is asking for regular food. The nurse's most appropriate response would be?

When you start passing gas and your bowel is working again, it will be safe to start eating again.

A patient with a newly created sigmoid colostomy asks if the bag will need to be worn constantly. Your best response would be?

Your colostomy is at the level of the lower bowel, so you may be able to have regular daily bowel movements.

When planning care for a patient who has a diagnosis of malnutrition, the nurse would include which of these goals?

a weight gain of 1 to 2 lbs per week

For a client who must undergo colon surgery, the physician order preoperative cleansing enemas and neomycin(Mycifradin). The rationale for using neomycin in this client is to:

decrease the intestinal bacteria count

During the initial assessment, the nurse notes a small painless, dark-colored lesion on the patient's tongue. The patient states that the sore has been in his mouth for several months. Which of the following interventions should be the next priority?

document the findings and notify the health care provider

The nurse is caring for a client who has just undergone a colectomy. To prevent postoperative thrombus formation in the client's legs, which intervention should the nurse perform?

encourage the client to dorsiflex and plantar flex the feet

A patient will manage her cholelithiasis at home using medical interventions. The nurse reinforces which of the following in discharge teaching?

adhere to low fat, low calorie diet

When caring for a patient who has stomatitis, the nurse should give priority to which of these treatment measures?

administer a viscous lidocaine before each meal

While obtaining a client's medication history, the nurse learns that the client takes ranitidine (Zantac) to treat a peptic ulcer. The nurse continues gathering medication history data to evaluate for potential drug interactions. This client should avoid taking a drug from which class of drugs?

antacids

The nurse is caring for a patient with acute pancreatitis. Which nursing assessment should receive the highest priority?

assess cardiovascular status and fluid volume status

The first priority for a nurse admitting a patient with severe diarrhea to an acute medical unit would be to

assess the patient's fluid volume status

The nurse reinforcing teaching for a patient with gastroesophageal reflux disease includes which of the following in the instructions?

avoid lying down for several hours after eating, raise the head of the bed on 6-in. blocks

The patient is receiving enteral feedings of Ensure (240 mL/can) at a rate of 60 mL/hr. The nurse anticipates that each can of the formula will run for ?? hours

4

A client who is scheduled for a colectomy must receive instructions on incision splinting and leg exercises. When is the best time for the nurse to provide teaching?

before the surgical procedure

During insertion of a NG rube, the patient begins to gag. The nurse should?

briefly halt the insertion

A 58-yr old male is admitted with the diagnosis of esophageal cancer with erosion to the middle portion of the esophagus. Which of the following is most important to report immediately?

bright red bleeding from the mouth

A patient is admitted to the nursing unit with a diagnosis of acute pancreatitis. The patient complains of sever pain. Place the following nursing activities to promote patient comfort in order in which the nurse would do them.

Administer prescribed parenteral narcotic analgesic. Insert the ordered nasogastric tube and connect to low intermittent suction. Place an NPO sign over the patient's bed and notify dietary services. Place in a die-lying position with knees flexed and elevate the head of bed 45 degrees. Promote rest by darkening the room and placing a sign on the door to limit visitors.

When a patient is prescribed a low-residue diet, which of the following menu choices indicates an understanding of the diet?

Broiled chicken breast, mashed potatoes, whipped squash, angel food cake

A nurse is caring for a client admitted with suspected upper GI bleeding from esophageal varices. The client begins vomiting bright red blood. Which intervention by the nurse is most appropriate?

call the primary nurse or charge nurse to assist and evaluate the client's condition

A client with pancreatitis has been receiving total parenteral nutrition (TPN)for one week. Which of these measures should a nurse include in the care plan to help determine if TPN is providing adequate nutrition?

monitoring the client's weight every day

A patient diagnosed with cholelithiasis requests medication for pain relief. Which of the following medications is the physician most likely to prescribe?

morphine sulfate- narcotic analgesics are often required for acute pain relief r/t cholelithiasis

A patient returns to his room after an open cholecystectomy. He has a T-tube in place attached to a drainage bag. The nurse would report which of the following assessments to the charge nurse or physician?

patient experiences nausea and vomiting 30 minutes after eating

A patient who was diagnosed with hepatitis A states he was told by the nursing assistant that his disease could be transmitted only through blood contact. The appropriate action by the nurse would be to?

provide the correct information to the patient and the nursing assistant

A client is having a routine check-up at the wellness clinic. Which sign or symptom experienced by a client should a nurse teach is a warning sign of colon cancer?

rectal bleeding

As part of routine screening for colorectal cancer, a client undergoes fecal occult blood testing. Which food should the nurse instruct the client to avoid 48 to 72 hours before the test and throughout the collection period?

red meat, turnips, horseradish

A 45 yr old patient with liver disease is prescribed lactulose (Chronulac)30mL every 6 hours. Recognizing the action of this medication in the treatment of liver disease, the nurse would expect to assess which positive response to the medication?

reduced serum ammonia levels

A patient comes to the walk-in clinic complaining of abdominal pain that started about 2 hours previously. In his assessment, the nurse notes tenderness in the right lower quadrant, and checks for rebound. Rebound tenderness is characterized by?

relief of pain with palpation followed by pain when pressure is released

When developing a teaching plan for a patient who has undergone a partial gastrectomy, which of the following would the nurse include related to preventing dumping syndrome?

resting in a seirecumbent position after eating

A patient is diagnosed with hepatitis B. Which of the following information, if obtained during the admission assessment, would indicate a risk factor?

she is an intravenous drug user

A patient has been admitted with severe diarrhea. The nurse bases his decision on whether to administer the prescribed antidiarrheal medication on the understanding that antidiarrheal medication?

should not be used until the cause of diarrhea has been determined

A client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?

take piroxicam with food or an antacid

A client has a newly created colostomy. After participating in counseling with the nurse and receiving support from his spouse, the client decides to change the colostomy pouch, unaided. Which behavior by the client indicates to the nurse that the client is beginning to accept the change in body image?

the client touches the altered body part

The nurse is teaching a patient with newly diagnosed ulcerative colitis about her prescription for sulfasalazine (Azulfidine). Which of the following does the nurse include in teaching?

use sunscreen while you are taking this drug to prevent sunburns. if you use oral contraceptives, use additional protection while taking this drug

Central or upper body obesity is verified by?

waist circumference 38", to hip cricumference 37", 1 inch or higher identifies central or upper body obesity

The nurse evaluates a 54-yr old patient with cirrhosis for improvement in her ascites. Which of the following assessment findings may indicate improvement?

weight loss of 3lb in the past 72 hours abdominal girth 2cm less than previous measurement