GI NCLEX review e12 upper/lower GI

50. The nurse instructs the client on health maintenance activities to help control symptoms from a hiatal hernia. Which statement would indicate that the client has understood the instructions? 1. "I will avoid lying down after a meal." 2. "I can still enjoy my potato chips and cola at bedtime." 3. "I wish I did not have to give up swimming." 4. "If I wear a girdle, I will have more support for my stomach."

50. 1. A client with a hiatal hernia should avoid the recumbent position immediately after meals to minimize gastric reflux. Bedtime snacks, as well as high-fat foods and carbonated beverages, should be avoided. Excessive vigorous exercise also should be avoided, especially after meals, but there is no reason why the client must give up swimming. Wearing tight, constrictive clothing such as a girdle can increase intra-abdominal pressure and thus lead to reflux of gastric juices.

11. When planning diet teaching for the client with a colostomy, the nurse should develop a plan that emphasizes which dietary instruction? 1. Foods containing roughage should not be eaten. 2. Liquids are best limited to prevent diarrhea. 3. Clients should experiment to find the diet that is best for them. 4. A high-fiber diet will produce a regular passage of stool.

11. 3. It is best to adjust the diet of a client with a colostomy in a manner that suits the client rather than trying special diets. Severe restriction of roughage is not recommended. The client is encouraged to drink 2 to 3 L of fluid per day. A high-fiber diet may produce loose stools.

12. What is an expected outcome for a client during the first 2 weeks who is recovering from an abdominal-perineal resection with a colostomy? The client will: 1. maintain a fluid intake of 3,000 mL/day. 2. eliminate fiber from the diet. 3. limit physical activity to light exercise. 4. accept that sexual activity will be diminished.

12. 1. An expected outcome is that the client will maintain a fluid intake of 3,000 mL/day unless contraindicated. There is no need to eliminate fiber from the diet; the client can eat whatever foods are desired, avoiding those that are bothersome. Physical activity does not need to be limited to light exercise. The client can resume normal activities as tolerated, usually within 6 to 8 weeks. The client's sexual activity may be affected, but it does not need to be diminished.

12. The nurse is caring for a client who has had a gastroscopy. Which findings indicate that the client is developing a complication related to the procedure? Select all that apply. 1. The client has a sore throat. 2. The client has a temperature of 100°F (37.8°C). 3. The client appears drowsy following the procedure. 4. The client has epigastric pain. 5. The client experiences hematemesis.

12. 2,4,5. Following a gastroscopy, the nurse should monitor the client for complications, which include perforation and the potential for aspiration. An elevated temperature, epigastric pain, or the vomiting of blood (hematemesis) are all indications of a possible perforation and should be reported promptly. A sore throat is a common occurrence following a gastroscopy. Clients are usually sedated to decrease anxiety, and the nurse would anticipate that the client will be drowsy following the procedure.

13. A client with colon cancer has developed ascites. The nurse should conduct a focused assessment for which signs and symptoms? Select all that apply. 1. respiratory distress 2. bleeding 3. fluid and electrolyte imbalance 4. weight gain 5. infection

13. 1,3. Ascites limits the movement of the diaphragm leading to respiratory distress. Fluid shift from the intravascular space precipitates fluid and electrolyte imbalances. Weight gain is not a direct consequence of ascites, but weight loss may result in decreased albumin levels. Decreased albumin in the intravascular space results in decreased oncotic pressure, precipitating movement of fluid out of space. A client with ascites is not at increased risk for infection unless a peritoneal tap is done to remove fluid. The risk of bleeding is a result of alterations in liver enzymes affecting coagulation.

13. A client admitted to the hospital with peptic ulcer disease tells the nurse about having black, tarry stools. The nurse should: 1. encourage the client to increase fluid intake. 2. advise the client to avoid iron-rich foods. 3. place the client on contact precautions. 4. report the finding to the healthcare provider (HCP).

13. 4. Black, tarry stools are an important warning sign of bleeding in peptic ulcer disease. Digested blood in the stool causes it to be black; the odor of the stool is very offensive. The nurse should instruct the client to report the incidence of black stools promptly to the HCP. Increasing fluids or avoiding iron-rich foods will not change the stool color or consistency if the stools contain digested blood. Until other information is available, it is not necessary to initiate contact precautions.

15. A client with a peptic ulcer reports epigastric pain that frequently causes the client to wake up during the night. The nurse should instruct the client to do which activities? Select all that apply. 1. Obtain adequate rest to reduce stimulation. 2. Eat small, frequent meals throughout the day. 3. Take all medications on time as prescribed. 4. Sit up for 1 hour when awakened at night. 5. Stay away from crowded areas.

15. 1,2,3,4. The nurse should encourage the client to reduce stimulation that may enhance gastric secretion. The nurse can also advise the client to utilize health practices that will prevent recurrences of ulcer pain, such as avoiding fatigue and elimination of smoking. Eating small, frequent meals helps to prevent gastric distention if not actively bleeding and decreases distention and release of gastrin. Medications should be administered promptly to maintain optimum levels. After awakening during the night, the client should eat a small snack and return to bed, keeping the head of the bed elevated for an hour after eating. It is not necessary to stay away from crowded areas.

15. Two days following a colon resection, an elderly client shows new onset of confusion. When contacting the healthcare provider (HCP), the nurse should make which recommendation? 1. "Do you want a CT scan to rule out stroke?" 2. "May we have a prescription for restraining this client?" 3. "Shall I collect and send a urine sample for culture and sensitivity?" 4. "Would you like a stat potassium level done?"

15. 3. Sending a urine sample for culture and sensitivity is most warranted. An older adult often has confusion when experiencing a bladder infection. While stroke is always a concern, particularly in the older adult, the presenting information most supports a bladder infection and perhaps early-onset urosepsis. Restraining the client may be needed at some point in time, but finding the cause of the client's new onset of confusion has greatest priority. Potassium is usually related to cardiac rhythm irritability rather than confusion.

16. A client with peptic ulcer disease reports being nauseated most of the day and now feeling light-headed and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? Select all that apply. 1. administering an antacid hourly until nausea subsides 2. monitoring the client's vital signs 3. notifying the healthcare provider (HCP) of the client's symptoms 4. initiating oxygen therapy 5. reassessing the client in an hour

16. 2,3. The symptoms of nausea and dizziness in a client with peptic ulcer disease may be indicative of hemorrhage and should not be ignored. The appropriate nursing actions at this time are for the nurse to monitor the client's vital signs and notify the HCP of the client's symptoms. To administer an antacid hourly or to wait 1 hour to reassess the client would be inappropriate; prompt intervention is essential in a client who is potentially experiencing a gastrointestinal hemorrhage. The nurse would notify the HCP of assessment findings and then initiate oxygen therapy if prescribed by the HCP.

17. The nurse is teaching a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the diet should include: 1. bland foods. 2. high-protein foods. 3. any foods that are tolerated. 4. a glass of milk with each meal.

17. 3. Diet therapy for ulcer disease is a controversial issue. There is no scientific evidence that diet therapy promotes healing. Most clients are instructed to follow a diet that they can tolerate. There is no need for the client to ingest only a bland or high-protein diet. Milk may be included in the diet, but it is not recommended in excessive amounts.

18. The nurse instructs the client who has had a hemorrhoidectomy not to use sitz baths until at least 12 hours postoperatively to avoid inducing which complication? 1. hemorrhage 2. rectal spasm 3. urine retention 4. constipation

18. 1. Applying heat during the immediate postoperative period may cause hemorrhage at the surgical site. Moist heat may relieve rectal spasms after bowel movements. Urine retention caused by reflex spasm may also be relieved by moist heat. Increasing fiber and fluid in the diet can help prevent constipation.

18. A client diagnosed with peptic ulcer disease (PUD) has an H. pylori infection. The client is following a 2-week drug regimen that includes clarithromycin along with omeprazole and amoxicillin. The nurse should instruct the client to: 1. alternate the use of the drugs. 2. take the drugs at different times during the day. 3. discontinue all drugs if nausea occurs. 4. take the drugs for the entire 2-week period.

18. 4. The use of the triple-therapy approach to the H. pylori infection has proved effective; therefore, the nurse advises the client to take the drugs as prescribed for the duration of the prescription. The nurse instructs the client to avoid alternating the use of the drugs and to take all medication at the same time, three times a day unless otherwise noted by the healthcare provider (HCP) . Drugs have very few side effects; however, the nurse instructs the client to continue taking medications and contact the HCP if adverse effects occur.

2. A client refuses to look at or care for her colostomy. Which statement by the nurse would be most appropriate? 1. "It has been 4 days since your surgery, and you will soon be discharged. You have to learn to care for your colostomy before you leave the hospital." 2. "I think we will need to teach your husband to care for your colostomy if you are not going to be able to do it." 3. "I understand how you are feeling. It is important for you to feel attractive, and you think having a colostomy changes your attractiveness." 4. "I can see that you are upset. Would you like to share your concerns with me?"

2. 4. It is important for the nurse to recognize that individuals go through a grieving process when adjusting to a colostomy. The nurse should be accepting and provide the client with opportunities to share her concerns and feelings when she is ready. Lecturing the client about the need to learn how to care for the colostomy is not productive nor is attempting to shame her into caring for the colostomy by implying her husband will have to provide the care if she does not. It is not possible for the nurse to understand what the client is feeling.

21. A client has been taking aluminum hydroxide 30 mL six times per day at home to treat a peptic ulcer. The client has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that the most likely cause of the client's constipation is because the client: 1. has not been including enough fiber in the diet. 2. needs to increase the daily exercise. 3. is experiencing an adverse effect of the aluminum hydroxide. 4. has developed a gastrointestinal obstruction.

21. 3. It is most likely that the client is experiencing an adverse effect of the antacid. Antacids with aluminum salt products, such as aluminum hydroxide, form insoluble salts in the body. These precipitate and accumulate in the intestines, causing constipation. Increasing dietary fiber intake or daily exercise may be a beneficial lifestyle change for the client but is not likely to relieve the constipation caused by the aluminum hydroxide. Constipation, in isolation from other symptoms, is not a sign of a bowel obstruction.

22. A client is taking an antacid for treatment of a peptic ulcer. Which statement best indicates that the client understands how to correctly take the antacid? 1. "I should take my antacid before I take my other medications." 2. "I need to decrease my intake of fluids so that I do not dilute the effects of my antacid." 3. "My antacid will be most effective if I take it whenever I experience stomach pains." 4. "It is best for me to take my antacid 1 to 3 hours after meals."

22. 4. Antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an antacid is taken on an empty stomach, the duration of the drug's action is greatly decreased. Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the therapeutic action of the drug. Antacids should be administered about 2 hours after other medications to decrease the chance of drug interactions. It is not necessary to decrease fluid intake when taking antacids. If antacids are taken more frequently than recommended, the likelihood of developing adverse effects increases. Therefore, the client should not take antacids as often as desired to control pain.

23. Which is an expected outcome for a client with peptic ulcer disease? The client will: 1. demonstrate appropriate use of analgesics to control pain. 2. explain the rationale for eliminating alcohol from the diet. 3. verbalize the importance of monitoring hemoglobin and hematocrit every 3 months. 4. eliminate engaging in contact sports.

23. 2. Alcohol is a gastric irritant that should be eliminated from the intake of the client with peptic ulcer disease. Analgesics are not used to control ulcer pain; many analgesics are gastric irritants. The client's hemoglobin and hematocrit typically do not need to be monitored every 3 months, unless gastrointestinal bleeding is suspected. The client can maintain an active lifestyle and does not need to eliminate contact sports as long as they are not stress inducing.

23. Which goal for the client's care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis? 1. promoting self-care and independence 2. managing diarrhea 3. maintaining adequate nutrition 4. promoting rest and comfort

23. 2. Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and decreasing the frequency of stools is the first goal of treatment. The other goals are ongoing and will be best achieved by halting the exacerbation. The client may receive antidiarrheal agents, antispasmodic agents, bulk hydrophilic agents, or anti-inflammatory drugs.

24. The nurse should assess the client who is being admitted to the hospital with upper GI bleeding for which finding? Select all that apply. 1. dry, flushed skin 2. decreased urine output 3. tachycardia 4. widening pulse pressure 5. rapid respirations 6. thirst

24. 2,3,5,6. The client who is experiencing upper GI bleeding is at risk for developing hypovolemic shock from blood loss. Therefore, the signs and symptoms the nurse should expect to find are those related to hypovolemia, including decreased urine output, tachycardia, rapid respirations, and thirst. The client's skin would be cool and clammy, not dry, and flushed. The client would also be likely to develop hypotension, which would lead to a narrowing pulse pressure, not a widening pulse pressure.

24. The client with ulcerative colitis is to be on bed rest with bathroom privileges. When evaluating the effectiveness of this level of activity, the nurse should determine if the client has: 1. conserved energy. 2. reduced intestinal peristalsis. 3. obtained needed rest. 4. minimized stress.

24. 2. Although modified bed rest does help conserve energy and promotes comfort, its primary purpose in this case is to help reduce the hypermotility of the colon. Remaining on bed rest does not by itself reduce stress, and if the client is having stress, the nurse can plan with the client to use strategies that will help the client manage the stress.

25. A client with cancer of the stomach had a total gastrectomy 2 days earlier. Which indicates the client is ready to try a liquid diet? The client: 1. is hungry. 2. has not requested pain medication for 8 hours. 3. has frequent bowel sounds. 4. has had a bowel movement.

25. 3. The client can begin eating with a liquid diet when bowel sounds return, usually in 2 to 3 days. The client may be hungry but cannot have oral fluids or foods until intestinal motility has been established. The client may continue to have postoperative pain for several days; because receiving a liquid diet does not depend on the client being pain free, the nurse can continue to offer pain medication. The client does not have to experience a bowel movement to receive fluids and food.

26. A client who has ulcerative colitis says to the nurse, "I cannot take this anymore; I am constantly in pain, and I cannot leave my room because I need to stay by the toilet. I do not know how to deal with this." Based on these comments, the nurse should determine the client is experiencing: 1. extreme fatigue. 2. disturbed thought. 3. a sense of isolation. 4. difficulty coping.

26. 4. It is not uncommon for clients with ulcerative colitis to become apprehensive and have difficulty coping with the frequency of stools and the presence of abdominal cramping. During these acute exacerbations, clients need emotional support and encouragement to verbalize their feelings about their chronic health concerns and assistance in developing effective coping methods. The client has not expressed feelings of fatigue or isolation or demonstrated disturbed thought processes.

26. Within 6 hours following a subtotal gastrectomy, the drainage from the client's NG tube is bright red. The nurse should first: 1. clamp the NG tube. 2. remove the existing NG tube. 3. irrigate the NG tube with iced saline. 4. chart the finding in the client's medical record.

26. 4. NG drainage is expected to be bright red during the first 12 hours after surgery and then darken within 24 hours. The nurse notes the color of the drainage on the medical record and then monitors the change of color of the drainage throughout the immediate postoperative period. To prevent stress on the suture line, NG suction is applied and patency of the tube maintained. Removal of the NG tube may traumatize the surgical site. The NG tube is irrigated only if the healthcare provider (HCP) prescribes irrigation because there is danger of injury to the suture line; saline at room temperature is usually prescribed.

27. A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. The nurse should tell the client: 1. "Ulcerative colitis can be cured by the use of steroids." 2. "Steroids are used in severe flare-ups because they can decrease the incidence of bleeding." 3. "Long-term use of steroids will prolong periods of remission." 4. "The side effects of steroids outweigh their benefits to clients with ulcerative colitis."

27. 2. Steroids are effective in management of the acute symptoms of ulcerative colitis. Steroids do not cure ulcerative colitis, which is a chronic disease. Long-term use is not effective in prolonging the remission and is not advocated. Clients should be assessed carefully for side effects related to steroid therapy, but the benefits of short-term steroid therapy usually outweigh the potential adverse effects.

28. A client who has ulcerative colitis has persistent diarrhea and has lost 12 lb (5.5 kg) since the exacerbation of the disease. Which approach will be most effective in helping the client meet nutritional needs? 1. continuous enteral feedings 2. following a high-calorie, high-protein diet 3. total parenteral nutrition (TPN) 4. eating six small meals a day

28. 3. Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the bowel. To maintain the client's nutritional status, the client will be started on TPN. Enteral feedings or dividing the diet into six small meals does not allow the bowel to rest. A high-calorie, high-protein diet will worsen the client's symptoms.

29. A client with ulcerative colitis is to take sulfasalazine. Which instructions should the nurse give the client about taking this medication at home? Select all that apply. 1. Drink enough fluids to maintain a urine output of at least 1,200 to 1,500 mL/day. 2. Discontinue therapy if symptoms of acute intolerance develop, and notify the healthcare provider (HCP). 3. Stop taking the medication if the urine turns orange-yellow. 4. Avoid activities that require alertness. 5. If dose is missed, skip and continue with the next dose.

29. 1,2,4. Sulfasalazine may cause dizziness, and the nurse should caution the client to avoid driving or other activities that require alertness until response to medication is known. If symptoms of acute intolerance (cramping, acute abdominal pain, bloody diarrhea, fever, headache, rash) occur, the client should discontinue therapy and notify the HCP immediately. Fluid intake should be sufficient to maintain a urine output of at least 1,200 to 1,500 mL daily to prevent crystalluria and stone formation. The nurse can also inform the client that this medication may cause orange-yellow discoloration of urine and skin, which is not significant and does not require the client to stop taking the medication. The nurse should instruct the client to take missed doses as soon as remembered unless it is almost time for the next dose.

29. After a subtotal gastrectomy, the drainage in the nasogastric tube is expected to be what color for about 12 to 24 hours after surgery? 1. dark brown 2. bile green 3. bright red 4. cloudy white

29. 1. About 12 to 24 hours after a subtotal gastrectomy, gastric drainage is normally brown, which indicates digested blood. Bile green or cloudy white drainage is not expected during the first 12 to 24 hours after a subtotal gastrectomy. Drainage during the first 6 to 12 hours contains some bright red blood, but large amounts of blood or excessive bloody drainage should be reported to the healthcare provider (HCP) promptly.

31. A client who is recovering from gastric surgery is receiving IV fluids to be infused at 100 mL/h. The IV tubing delivers 15 gtt/mL. The nurse should infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/h? Record your answer using a whole number. ___________ gtt/min.

31. 25 gtt/min. To administer IV fluids at 100 mL/h using tubing that has a drip factor of 15 gtt/mL, the nurse should use the following formula: 100 mL/60 minutes × 15 gtts/1 mL = 25 gtt/min.

32. Following a gastrectomy, the nurse should place the client in which position? 1. prone 2. supine 3. low Fowler's 4. right or left Sims

32. 3. A client who has had abdominal surgery is best placed in a low Fowler's position postoperatively. This positioning relaxes abdominal muscles and provides for maximum respiratory and cardiovascular function. The prone, supine, or Sims position would not be tolerated by a client who has had abdominal surgery, nor do those positions support respiratory or cardiovascular functioning.

32. A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for: 1. hyperalbuminemia. 2. thrombocytopenia. 3. hypokalemia. 4. hypercalcemia.

32. 3. Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.

33. A client with Crohn's disease has concentrated urine; decreased urinary output; dry skin with decreased turgor; hypotension; and weak, thready pulses. What should the nurse do first? 1. Encourage the client to drink at least 1,000 mL/day. 2. Provide parenteral rehydration therapy as prescribed. 3. Turn and reposition every 2 hours. 4. Monitor vital signs every shift.

33. 2. Initially, the extracellular fluid (ECF) volume with isotonic IV fluids should be administered until adequate circulating blood volume and renal perfusion are achieved. Vital signs should be monitored as parenteral and oral rehydration are achieved. Oral fluid intake should be >1,000 mL/day. Turning and repositioning the client at regular intervals aid in the prevention of skin breakdown, but it is first necessary to rehydrate this client.

34. Which is a priority focus of care for a client experiencing an exacerbation of Crohn's disease? 1. encouraging regular ambulation 2. promoting bowel rest 3. maintaining current weight 4. decreasing episodes of rectal bleeding

34. 2. A priority goal of care during an acute exacerbation of Crohn's disease is to promote bowel rest. This is accomplished through decreasing activity, encouraging rest, and initially placing client on nothing-by-mouth status while maintaining nutritional needs parenterally. Regular ambulation is important, but the priority is bowel rest. The client will probably lose some weight during the acute phase of the illness. Diarrhea is nonbloody in Crohn's disease, and episodes of rectal bleeding are not expected.

34. A client who is recovering from a subtotal gastrectomy experiences dumping syndrome. The client asks the nurse, "When will I be able to eat three meals a day again like I used to?" Which response by the nurse is most appropriate? 1. "Eating six meals a day is time-consuming, isn't it?" 2. "You will have to eat six small meals a day for the rest of your life." 3. "You will be able to tolerate three meals a day before you are discharged." 4. "Most clients can resume their normal meal patterns in about 6 to 12 months."

34. 4. The symptoms related to dumping syndrome that occur after a gastrectomy usually disappear by 6 to 12 months after surgery. Most clients can begin to resume normal meal patterns after signs of the dumping syndrome have stopped. Acknowledging that eating six meals a day is time-consuming does not address the client's question and makes an assumption about the client's concerns. It is not necessarily true that a six-meal-a-day dietary pattern will be required for the rest of the client's life. Clients will not be able to eat three meals a day before hospital discharge.

35. A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for which signs and symptoms? Select all that apply. 1. projectile vomiting 2. significant abdominal distention 3. copious diarrhea 4. rapid onset of dehydration 5. increased bowel sounds

35. 1,4,5. Signs and symptoms of intestinal obstructions in the small intestine may include projectile vomiting and rapidly developing dehydration and electrolyte imbalances. The client will also have increased bowel sounds, usually high pitched and tinkling. The client would not normally have diarrhea and would have minimal abdominal distention. Pain is intermittent, being relieved by vomiting. Intestinal obstructions in the large intestine usually evolve slowly and produce persistent pain, and vomiting is less common. Clients with a large intestine obstruction may develop obstipation and significant abdominal distention.

35. After surgery for gastric cancer, a client is scheduled to undergo radiation therapy. The nurse should include which information in the teaching plan? 1. nutritional intake 2. management of alopecia 3. exercise and activity levels 4. access to community resources

35. 1. Clients who have had gastric surgery are prone to postoperative complications, such as dumping syndrome and postprandial hypoglycemia, which can affect nutritional intake. Vitamin absorption can also be an issue, depending on the extent of the gastric surgery. Radiation therapy to the upper gastrointestinal area also can affect nutritional intake by causing anorexia, nausea, and esophagitis. The client would not be expected to develop alopecia. Exercise and activity levels as well as access to community resources are important teaching areas, but nutritional intake is a priority need.

36. A client is admitted with a bowel obstruction. The client has nausea, vomiting, and crampy abdominal pain. The healthcare provider (HCP) has written the following prescriptions: for the client to be up ad lib, have narcotics for pain, have a nasogastric tube inserted if needed, and for IV, Ringer's lactate and hyperalimentation fluids. What should the nurse do in order of priority from first to last? All options must be used. 1. Assist with ambulation to promote peristalsis. 2. Insert a nasogastric tube. 3. Administer IV Ringer's lactate. 4. Start an infusion of hyperalimentation fluids.

36. 1,3,2,4. The nurse should first help the client ambulate to try to induce peristalsis; this may be effective and require the least amount of invasive procedures. Next, the nurse should initiate IV fluid therapy to correct fluid and electrolyte imbalances (sodium and potassium) with Ringer's lactate to correct interstitial fluid deficit. Nasogastric (NG) decompression of the GI tract to reduce gastric secretions and nasointestinal tubes may also be used as necessary. Lastly, hyperalimentation can be used to correct protein deficiency from chronic obstruction, paralytic ileus, or infection.

36. One month following a subtotal gastrectomy for cancer, the nurse is evaluating the nursing care goal related to improved nutrition. What indicates that the client has attained the goal? The client has: 1. regained weight loss. 2. resumed normal dietary intake of three meals a day. 3. controlled nausea and vomiting through regular use of antiemetics. 4. achieved adequate nutritional status through oral or parenteral feedings.

36. 4. An appropriate expected outcome is for the client to achieve optimal nutritional status through the use of oral feedings or total parenteral nutrition (TPN). TPN may be used to supplement oral intake, or it may be used alone if the client cannot tolerate oral feedings. The client would not be expected to regain lost weight within 1 month after surgery or to tolerate a normal dietary intake of three meals a day. Nausea and vomiting would not be considered an expected outcome of gastric surgery, and regular use of antiemetics would not be anticipated.

37. The healthcare provider (HCP) prescribes intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression, the nurse should evaluate the client to determine if: 1. intestinal fluid and gas have been removed. 2. the client has had a bowel movement. 3. the client's urinary output is adequate. 4. the client can sit up without pain.

37. 1. Intestinal decompression is accomplished with a Cantor, Harris, or Miller-Abbott tube. These 6- to 10-foot (180- to 300-cm) tubes are passed into the small intestine to the obstruction. They remove accumulated fluid and gas, relieving the pressure. The client will not have an adequate bowel movement until the obstruction is removed. The pressure from the distended intestine should not obstruct urinary output. While the client may be able to more easily sit up, and the pain caused by the intestinal pressure will be less, these are not the primary indicators for successful intestinal decompression.

38. The client is scheduled to have an upper gastrointestinal tract series of x-rays. Following the x-rays, the nurse should instruct the client to: 1. take a laxative. 2. follow a clear liquid diet. 3. administer an enema. 4. take an antiemetic.

38. 1. The client should take a laxative after an upper gastrointestinal series to stimulate a bowel movement. This examination involves the administration of barium, which must be promptly eliminated from the body because it may harden and cause an obstruction. A clear liquid diet would have no effect on stimulating removal of the barium. The client should not have nausea, and an antiemetic would not be necessary; additionally, the antiemetic will decrease peristalsis and increase the likelihood of eliminating the barium. An enema would be ineffective because the barium is too high in the gastrointestinal tract.

38. After insertion of a nasoenteric tube, the nurse should place the client in which position? 1. supine 2. right side-lying 3. semi-Fowler's 4. upright in a bedside chair

38. 2. The client is placed in a right side-lying position to facilitate movement of the mercury-weighted tube through the pyloric sphincter. After the tube is in the intestine, the client is turned from side to side or encouraged to ambulate to facilitate tube movement through the intestinal loops. Placing the client in the supine or semi-Fowler's position or having the client sitting out of bed in a chair will not facilitate tube progression.

39. What should the nurse tell the client who is preparing for insertion of a nasoduodenal tube? Select all that apply. 1. The nose and throat will be numbed with a viscous anesthetic. 2. The tube will be placed at the bedside. 3. X-rays with the use of a contrast dye will be used to verify placement. 4. The client will be closely monitored for 30 minutes following the procedure. 5. The tube will be taped to the nose.

39. 1,3,4,5. A nasoduodenal tube is used primarily for feeding. The tube is inserted in endoscopy or radiology. Prior to insertion of the tube, the client's nose and throat will be numbed with a viscous anesthetic such as lidocaine. The tube placement is verified by contrast x-rays, and the client is observed for 30 minutes after the insertion to be sure the client does not have an allergic reaction, puncture to the lung, or bleeding. The tube is taped to the nose.

39. A client who has been diagnosed with gastroesophageal reflux disease (GERD) has heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which item from the diet? 1. lean beef 2. air-popped popcorn 3. hot chocolate 4. raw vegetables

39. 3. With GERD, eating substances that decrease lower esophageal sphincter pressure causes heartburn. A decrease in the lower esophageal sphincter pressure allows gastric contents to reflux into the lower end of the esophagus. Foods that can cause a decrease in esophageal sphincter pressure include fatty foods, chocolate, caffeinated beverages, peppermint, and alcohol. A diet high in protein and low in fat is recommended for clients with GERD. Lean beef, popcorn, and raw vegetables would be acceptable.

4. A client had a colon resection yesterday. The client's hemoglobin was 14.1 g/dL yesterday and today it is 7.2 g/dL. The client's oxygen saturation is 87%. After reviewing the chart (see chart) and notifying the healthcare provider (HCP), the nurse should first: Chart: 100mL NS q 8hr @ 125gtts/hr VS q 4hr Morphine sulfae 10mg IV q 4hr PRN NPO O2 2-4L/min per mask 1. Take the vital signs every hour. 2. Increase the saline infusion to 150 gtts/h. 3. Administer oxygen at 2 L/min. 4. Determine when last pain medication was administered.

4. 3. This client has decreased oxygen saturation and also decreased hemoglobin, which puts the client at great risk for cardiac ischemia. The nurse should start the oxygen as prescribed. The nurse can take the vital signs more frequently once the oxygen flow has been started. It is not appropriate to increase the rate of the intravenous infusion, and it would be necessary to request a prescription to do so. After starting the oxygen, the nurse can ask the client about the current pain level.

40. The client with an intestinal obstruction continues to have acute pain even though the nasoenteric tube is patent and draining. The nurse should first: 1. reassure the client that the nasoenteric tube is functioning. 2. assess the client for signs of peritonitis. 3. administer an opioid as prescribed. 4. reposition the client on the left side.

40. 2. The client's pain may be indicative of peritonitis, and the nurse should assess for signs and symptoms, such as a rigid abdomen, elevated temperature, and increasing pain. Reassuring the client is important, but accurate assessment of the client is essential. The full assessment should occur before pain relief measures are employed. Repositioning the client to the left side will not resolve the pain.

40. The client with gastroesophageal reflux disease (GERD) has a chronic cough. This symptom may indicate: 1. development of laryngeal cancer. 2. irritation of the esophagus. 3. esophageal scar tissue formation. 4. aspiration of gastric contents.

40. 4. Clients with GERD can develop pulmonary symptoms, such as coughing, wheezing, and dyspnea, that are caused by the aspiration of gastric contents. GERD does not predispose the client to the development of laryngeal cancer. Irritation of the esophagus and esophageal scar tissue formation can develop as a result of GERD. However, GERD is more likely to cause painful and difficult swallowing.

41. Before abdominal surgery for an intestinal obstruction, the nurse monitors the client's urine output and finds that the total output for the past 2 hours was 35 mL. The nurse then assesses the client's total intake and output over the last 24 hours and notes 2,000 mL of IV fluid for intake, 500 mL of drainage from the nasogastric tube, and 700 mL of urine for a total output of 1,200 mL. These findings indicate: 1. decreased renal function. 2. the nasogastric tube is not draining well. 3. extension of the obstruction. 4. inadequate fluid replacement.

41. 4. Considering that there is usually 1 L of insensible fluid loss, this client's output exceeds his intake (intake, 2,000 mL; output, 2,200 mL), indicating deficient fluid volume. The kidneys are concentrating urine in response to low circulating volume, as evidenced by a urine output of <30 mL/h. This indicates that increased fluid replacement is needed. Decreasing urine output can be a sign of decreased renal function, but the data provided suggest that the client is dehydrated. Pain does not affect urine output. There are no data to suggest that the obstruction has worsened.

42. The nurse is developing a care management plan with a client who has been diagnosed with gastroesophageal reflux disease (GERD). What should the nurse instruct the client to do? Select all that apply. 1. Avoid a diet high in fatty foods. 2. Avoid beverages that contain caffeine. 3. Eat three meals a day, with the largest meal being at dinner in the evening. 4. Avoid all alcoholic beverages. 5. Lie down after consuming each meal for 30 minutes. 6. Use over-the-counter (OTC) antisecretory agents rather than prescriptions.

42. 1,2,4. No specific diet is necessary, but foods that cause reflux are avoided, including fatty foods (which decrease the rate of gastric emptying) and foods that decrease lower esophageal sphincter (LES) pressure such as chocolate, peppermint, coffee, and tea. The client should also avoid alcohol. The client should not lie down for 3 to 4 hours after eating. Antisecretory agents decrease the secretion of hydrochloric acid (HCl) by the stomach; some are available in both OTC and prescription formulations, but the OTC preparations have lower drug dosages compared with prescription drugs. Cimetidine, ranitidine, famotidine, and nizatidine are available in both formulations.

43. Which dietary measures would be useful in preventing esophageal reflux? 1. eating small, frequent meals 2. increasing fluid intake 3. avoiding air swallowing with meals 4. adding a bedtime snack to the dietary plan

43. 1. Esophageal reflux worsens when the stomach is overdistended with food. Therefore, an important measure is to eat small, frequent meals. Fluid intake should be decreased during meals to reduce abdominal distention. Avoiding air swallowing does not prevent esophageal reflux. Food intake in the evening should be strictly limited to reduce the incidence of nighttime reflux, so bedtime snacks are not recommended.

44. The nurse is obtaining a health history from a client who has a sliding hiatal hernia associated with reflux. The nurse should ask the client about the presence of which symptom? 1. heartburn 2. jaundice 3. anorexia 4. stomatitis

44. 1. Heartburn, the most common symptom of a sliding hiatal hernia, results from reflux of gastric secretions into the esophagus. Regurgitation of gastric contents and dysphagia are other common symptoms. Jaundice, which results from a high concentration of bilirubin in the blood, is not associated with hiatal hernia. Anorexia is not a typical symptom of hiatal hernia. Stomatitis is inflammation of the mouth.

45. Which risk factor would most likely contribute to the development of a hiatal hernia? 1. having a sedentary desk job 2. being 5 feet, 3 inches tall (160 cm) and weighing 190 lb (86.2 kg) 3. using laxatives frequently 4. being 40 years old

45. 2. Any factor that increases intra-abdominal pressure, such as obesity, can contribute to the development of hiatal hernia. Other factors include abdominal straining, frequent heavy lifting, and pregnancy. Hiatal hernia is also associated with older age and occurs in women more frequently than in men. Having a sedentary desk job, using laxatives frequently, or being 40 years old is not likely to be a contributing factor in development of a hiatal hernia.

46. Which nursing interventions would most likely promote self-care behaviors in the client with a hiatal hernia? 1. Introduce the client to other people who are successfully managing their care. 2. Include the client's daughter in the teaching so that she can help implement the plan. 3. Ask the client to identify other situations in which the client changed healthcare habits. 4. Provide reassurance that the client will be able to implement all aspects of the plan successfully.

46. 3. Self-responsibility is the key to individual health maintenance. Using examples of situations in which the client has demonstrated self-responsibility can be reinforcing and supporting. The client has ultimate responsibility for personal health habits. Meeting other people who are managing their care and involving family members can be helpful, but individual motivation is more important. Reassurance can be helpful but is less important than individualization of care.

47. The client has been taking magnesium hydroxide (milk of magnesia) to control hiatal hernia symptoms. The nurse should assess the client for which condition most commonly associated with the ongoing use of magnesium-based antacids? 1. anorexia 2. weight gain 3. diarrhea 4. constipation

47. 3. The magnesium salts in magnesium hydroxide are related to those found in laxatives and may cause diarrhea. Aluminum salt products can cause constipation. Many clients find that a combination product is required to maintain normal bowel elimination. The use of magnesium hydroxide does not cause anorexia or weight gain.

48. Which lifestyle modification should the nurse encourage the client with a hiatal hernia to include in activities of daily living? 1. daily aerobic exercise 2. eliminating smoking and alcohol use 3. balancing activity and rest 4. avoiding high-stress situations

48. 2. Smoking and alcohol use both reduce esophageal sphincter tone and can result in reflux. They therefore should be avoided by clients with hiatal hernia. Daily aerobic exercise, balancing activity and rest, and avoiding high-stress situations may increase the client's general health and well-being, but they are not directly associated with hiatal hernia.

49. In developing a teaching plan for the client with a hiatal hernia, the nurse's assessment of which work-related factors would be most useful? 1. number and length of breaks 2. body mechanics used in lifting 3. temperature in the work area 4. cleaning solvents used

49. 2. Bending, especially after eating, can cause gastroesophageal reflux. Lifting heavy objects increases intra-abdominal pressure. Assessing the client's lifting techniques enables the nurse to evaluate the client's knowledge of factors contributing to hiatal hernia and how to prevent complications. Number and length of breaks, temperature in the work area, and cleaning solvents used are not directly related to treatment of hiatal hernia.

5. A client with colon cancer is having a barium enema. The nurse should instruct the client to take which type of medication after the procedure is completed? 1. laxative 2. anticholinergic 3. antacid 4. demulcent

5. 1. After a barium enema, a laxative is ordinarily prescribed. This is done to promote elimination of the barium. Retained barium predisposes the client to constipation and fecal impaction. Anticholinergic drugs decrease gastrointestinal motility. Antacids decrease gastric acid secretion. Demulcents soothe mucous membranes of the gastrointestinal tract and are used to treat diarrhea.

51. The nurse should instruct the client to avoid which drug while taking metoclopramide hydrochloride? 1. antacids 2. antihypertensives 3. anticoagulants 4. alcohol

51. 4. Metoclopramide hydrochloride can cause sedation. Alcohol and other central nervous system depressants add to this sedation. A client who is taking this drug should be cautioned to avoid driving or performing other hazardous activities for a few hours after taking the drug. Clients may take antacids, antihypertensives, and anticoagulants while on metoclopramide.

52. A client is taking cimetidine to treat a hiatal hernia. The nurse should evaluate the client to determine that the drug has been effective in preventing which health problem? 1. esophageal reflux 2. dysphagia 3. esophagitis 4. ulcer formation

52. 3. Cimetidine is a histamine receptor antagonist that decreases the quantity of gastric secretions. It may be used in hiatal hernia therapy to prevent or treat the esophagitis and heartburn associated with reflux. Cimetidine is not used to prevent reflux, dysphagia, or ulcer development.

53. The client asks the nurse if surgery is needed to correct a hiatal hernia. Which reply by the nurse would be most accurate? 1. "Surgery is usually required, although medical treatment is attempted first." 2. "Hiatal hernia symptoms can usually be successfully managed with diet modifications, medications, and lifestyle changes." 3. "Surgery is not performed for this type of hernia." 4. "A minor surgical procedure to reduce the size of the diaphragmatic opening will probably be planned."

53. 2. Most clients can be treated successfully with a combination of diet restrictions, medications, weight control, and lifestyle modifications. Surgery to correct a hiatal hernia, which commonly produces complications, is performed only when medical therapy fails to control the symptoms.

54. A client has returned from surgery during which the jaws were wired as treatment for a fractured mandible. The client is in stable condition. The nurse is instructing the unlicensed assistive personnel (UAP) on how to properly position the client. Which instructions about positioning would be appropriate for the nurse to give the UAP? 1. Keep the client in a side-lying position with the head slightly elevated. 2. Do not reposition the client without the assistance of a registered nurse (RN). 3. The client can assume any position that is comfortable. 4. Keep the client's head elevated on two pillows at all times.

54. 1. Immediately after surgery, the client should be placed on the side with the head slightly elevated. This position helps facilitate removal of secretions and decreases the likelihood of aspiration should vomiting occur. An RN does not need to be present to reposition the client, unless the client's condition warrants the presence of the nurse. Although it is important to elevate the head, there is no need to keep the client's head elevated on two pillows unless that position is comfortable for the client.

55. The nurse has been assigned to provide care for four clients. In what order, from first to last, should the nurse assess these clients? All options must be used. 1. a client awaiting surgery for a hiatal hernia repair at 1100 2. a client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests 3. a client with peptic ulcer disease experiencing a sudden onset of acute stomach pain 4. a client who is requesting pain medication 2 days after surgery to repair a fractured jaw

55. 3,4,2,1. The client with peptic ulcer disease who is experiencing a sudden onset of acute stomach pain should be assessed first by the nurse. The sudden onset of stomach pain could be indicative of a perforated ulcer, which would require immediate medical attention. It is also important for the nurse to thoroughly assess the nature of the client's pain. The client with the fractured jaw is experiencing pain and should be assessed next. The nurse should then assess the client who is NPO for tests to ensure NPO status and comfort. Last, the nurse can assess the client before surgery.

56. The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8°F (38.8°C). The nurse should: 1. promptly assess the client for potential perforation. 2. tell the assistant to change thermometers and retake the temperature. 3. plan to give the client acetaminophen to lower the temperature. 4. ask the UAP to bathe the client with tepid water.

56. 1. A sudden spike in temperature following an endoscopic procedure may indicate perforation of the GI tract. The nurse should promptly conduct a further assessment of the client, looking for further indicators of perforation, such as a sudden onset of acute upper abdominal pain; a rigid, board-like abdomen; and developing signs of shock. Telling the assistant to change thermometers is not an appropriate action and only further delays the appropriate action of assessing the client. The nurse would not administer acetaminophen without further assessment of the client or without a healthcare provider's (HCP's) prescription; a suspected perforation would require that the client be placed on nothing-by-mouth status. Asking the assistant to bathe the client before any assessment by the nurse is inappropriate.

57. Which hospitalized client is at risk to develop parotitis? 1. a 50-year-old client with nausea and vomiting who is on nothing-by-mouth status 2. a 75-year-old client with diabetes who has ill-fitting dentures 3. an 80-year-old client who has poor oral hygiene and is dehydrated 4. a 65-year-old client with lung cancer who has a feeding tube in place

57. 3. Parotitis is inflammation of the parotid gland. Although any of the clients listed could develop parotitis, given the data provided, the one most likely to develop parotitis is the elderly client who is dehydrated with poor oral hygiene. Any client who experiences poor oral hygiene is at risk for developing parotitis. To help prevent parotitis, it is essential for the nurse to ensure the client receives oral hygiene at regular intervals and has an adequate fluid intake.

58. The nurse instructs the unlicensed assistive personnel (UAP) on how to provide oral hygiene for clients who cannot perform this task for themselves. Which technique should the nurse ask the UAP to incorporate into the client's daily care? 1. Assess the oral cavity each time mouth care is given and record observations. 2. Use a soft toothbrush to brush the client's teeth after each meal. 3. Swab the client's tongue, gums, and lips with a soft foam applicator every 2 hours. 4. Rinse the client's mouth with mouthwash several times a day.

58. 2. A soft toothbrush should be used to brush the client's teeth after every meal and more often as needed. Mechanical cleaning is necessary to maintain oral health, stimulate gingiva, and remove plaque. Assessing the oral cavity and recording observations are the responsibilities of the nurse, not of the UAP . Swabbing with a safe foam applicator does not provide enough friction to clean the mouth. Mouthwash can be a drying irritant and is not recommended for frequent use.

59. The nurse is developing standards of care for a client with gastroesophageal reflux disease and wants to review current evidence for practice. Which resource will provide the most helpful information? 1. a review in the Cochrane Library 2. a literature search in a database, such as the Cumulative Index to Nursing and Allied Health Literature (CINAHL) 3. an online nursing textbook 4. the policy and procedure manual at the healthcare agency

59. 1. The Cochrane Library provides systematic reviews of healthcare interventions and will provide the best resource for evidence for nursing care. The CINAHL offers key word searches to published articles in nursing and allied health literature, but not reviews. A nursing textbook has information about nursing care, which may include evidence-based practices, but textbooks may not have the most up-to-date information. While the policy and procedure manual may be based on evidence-based practices, the most current practices will be found in evidence-based reviews of literature.

6. A client has a nasogastric tube inserted at the time of abdominal-perineal resection with permanent colostomy for colon cancer. This tube will most likely be removed when the client demonstrates: 1. absence of nausea and vomiting. 2. passage of mucus from the rectum. 3. passage of flatus and feces from the colostomy. 4. absence of stomach drainage for 24 hours.

6. 3. A sign indicating that a client's colostomy is open and ready to function is passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed to start taking fluids and food orally. Absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not yet returned.

60. The nurse in the intensive care unit is giving a report to the nurse in the postsurgical unit about a client who had a gastrectomy. The most effective way to assure essential information about the client is reported is to: 1. give the report face to face with both nurses in a quiet room. 2. audiotape the report for future reference and documentation. 3. use a checklist with information individualized for the client. 4. document essential transfer information in the client's electronic health record.

60. 3. Using a checklist assures that all key information is reported; the checklist can then serve as a record to which nurses can refer later. Giving a verbal report leaves room for error in memory; using an audiotape or an electronic health record requires nurses to spend unnecessary time retrieving information.

61. A nurse is delegating activities to unlicensed assistive personnel (UAP). Which activities can be appropriately delegated? Select all that apply. 1. Assist client with oral care prior to breakfast. 2. Ask about location, quality, and radiation of pain. 3. Observe and document effect of medication after given by the nurse. 4. Measure and record intake and output throughout the shift. 5. Determine if client is oriented to person, place, and time and report to nurse. 6. Change a simple dry dressing on a client's coccyx while bathing.

61. 1,4. Though still responsible for follow-up to make sure oral care is completed and accurate intake and output is ongoing, these are appropriate tasks to delegate to UAP . Evaluating level of consciousness (orientation), pain, and the effect of medications given by the nurse requires nursing judgment and should not be delegated to UAP. While UAP often assist clients with bathing, dressing changes are not delegated to UAP as the wound should be assessed by a nurse while changing the dressing.

64. When a client has an acute attack of diverticulitis, the nurse should first: 1. prepare the client for a colonoscopy. 2. encourage the client to eat a high-fiber diet. 3. assess the client for signs of peritonitis. 4. encourage the client to drink a glass of water every 2 hours.

64. 3. The nurse should first assess the client for signs of peritonitis. Complications of diverticulitis include perforation with peritonitis, abscess, and fistula formation; bowel obstruction; ureteral obstruction; and bleeding. A computed tomography (CT) scan with oral contrast is the test of choice for diverticulitis. A client with acute diverticulitis does not receive a barium enema or colonoscopy because of the possibility of peritonitis and perforation. With acute diverticulitis, the goal of treatment is to allow the colon to rest and inflammation to subside. The client is kept on NPO status; parenteral fluid therapy is provided.

65. A barium enema is not prescribed as a diagnostic test for a client with diverticulitis because a barium enema: 1. can perforate an intestinal abscess. 2. would greatly increase the client's pain. 3. is of minimal diagnostic value in diverticulitis. 4. is too lengthy a procedure for the client to tolerate.

65. 1. Barium enemas and colonoscopies are contraindicated in clients with acute diverticulitis because they can lead to perforation of the colon and peritonitis. A barium enema may be prescribed after the client has been treated with antibiotic therapy and the inflammation has subsided. A barium enema is diagnostic in diverticulitis. A barium enema could increase the client's pain; however, that is not a reason for excluding this test. The client may be able to tolerate the procedure, but the concern is the potential for perforation of the intestine.

66. The nurse should teach the client with diverticulitis to integrate which measure into a daily routine at home? 1. using enemas to relieve constipation 2. decreasing fluid intake to increase the formed consistency of the stool 3. eating a high-fiber diet when symptomatic with diverticulitis 4. refraining from straining and lifting activities

66. 4. Clients with diverticular disease should refrain from any activities, such as lifting, straining, or coughing, that increase intra-abdominal pressure and may precipitate an attack. Enemas are contraindicated because they increase intestinal pressure. Fluid intake should be increased, rather than decreased, to promote soft, formed stools. A low-fiber diet is used when inflammation is present.

14. A client with peptic ulcer disease is taking ranitidine. What is the expected outcome of this drug? 1. heal the ulcer 2. protect the ulcer surface from acids 3. reduce acid concentration 4. limit gastric acid secretion

14. 4. Histamine-2 (H2) receptor antagonists, such as ranitidine, reduce gastric acid secretion. Antisecretories, or proton pump inhibitors, such as omeprazole, help ulcers heal quickly in 4 to 8 weeks. Cytoprotective drugs, such as sucralfate, protect the ulcer surface against acid, bile, and pepsin. Antacids reduce acid concentration and help reduce symptoms.

72. Postoperative nursing care for a client after an appendectomy should include: 1. administering sitz baths four times a day. 2. noting the first bowel movement after surgery. 3. limiting the client's activity to bathroom privileges. 4. measuring abdominal girth every 2 hours.

72. 2. Noting the client's first bowel movement after surgery is important because this indicates that normal peristalsis has returned. Sitz baths are used after rectal surgery, not appendectomy. Ambulation is started the day of surgery and is not confined to bathroom privileges. The abdomen should be auscultated for bowel sounds and palpated for softness, but there is no need to measure the girth every 2 hours.

73. A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to: 1. provide access for wound irrigation. 2. promote drainage of wound exudates. 3. minimize development of scar tissue. 4. decrease postoperative discomfort.

73. 2. Drains are inserted postoperatively in appendectomies when an abscess was present or the appendix was perforated. The purpose is to promote drainage of exudate from the wound and facilitate healing. A drain is not used for irrigation of the wound. The drain will not minimize scar tissue development or decrease postoperative discomfort.

Skipped illeostomy and TPN - Q42 - 62

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Skipped inguinal hernia Q74 - 76

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69. A client with diverticulitis has developed peritonitis following diverticular rupture. When assessing the client, what should the nurse do? Select all that apply. 1. Percuss the abdomen to note tympany. 2. Percuss the liver to note lack of dullness. 3. Monitor the vital signs for fever. 4. Assess presence of excessive thirst. 5. Auscultate bowel sounds to note frequency.

69. 1,2,3,5. Percussion will show resonance and tympany indicating paralytic ileus. Lack of liver dullness may indicate free air in the abdomen. The client with peritonitis will have fever, tachypnea, and tachycardia. The abdomen becomes rigid with rebound tenderness, and there will be absent bowel sounds. The client will not demonstrate excessive thirst but may have anorexia, nausea, and vomiting as peristalsis decreases.

77. A client has anemia resulting from bleeding from ulcerative colitis and is to receive two units of packed red blood cells (PRBCs). The client is receiving an infusion of total parenteral nutrition (TPN). In preparing to administer the PRBCs, what should the nurse do to ensure client comfort and safety? 1. Discontinue the TPN infusion. 2. Start an IV infusion of normal saline. 3. Administer PRBCs in the same IV as the TPN. 4. Wait until the TPN infusion is completed, and use the same IV line to infuse the PRBCs.

77. 2. The nurse administers the PRBCs using a separate infusion line and appropriate tubing, with normal saline as the priming solution. It is not necessary to discontinue the TPN infusion or wait until the TPN infusion is completed.

10. Which skin preparation would be best to apply around the client's colostomy? 1. adhesive skin barrier 2. petroleum jelly 3. cornstarch 4. antiseptic cream

10. 1. An adhesive skin barrier is effective for protecting the skin around a colostomy to keep the skin healthy and prevent skin irritation from stoma drainage. Petroleum jelly, cornstarch, and antiseptic creams do not protect the skin adequately and may prevent an adequate seal between the skin and the colostomy bag.

19. The nurse teaches the client who has had rectal surgery the proper timing for a cleansing sitz baths. The client has understood the teaching when the client states that it is most important to take a sitz bath: 1. first thing each morning. 2. as needed for discomfort. 3. after a bowel movement. 4. at bedtime.

19. 3. Adequate cleaning of the anal area is difficult but essential. After rectal surgery, sitz baths assist in this process, so the client should take a sitz bath after a bowel movement. Other times are dictated by client comfort.

1. Which guideline reflects the current American and Canadian Cancer Societies' recommendations for screening for colon cancer in individuals who are not at high risk? 1. Annual digital rectal examination should begin at age 40. 2. Annual fecal testing for occult blood should begin at age 50. 3. Individuals should obtain a baseline barium enema at age 40. 4. Individuals should obtain a baseline colonoscopy at age 45.

1. 2. Annual fecal testing for occult blood should begin at age 50. Annual digital rectal examinations are recommended in men beginning at age 50 to screen for prostate cancer. Baseline barium enemas or colonoscopies are recommended at age 50. Baseline barium enemas and colonoscopies are not performed on individuals in their 40s unless they experience signs or symptoms that indicate the need for such diagnostic testing or are considered to be at high risk.

16. The nurse is caring for a 70-year-old male client after a colectomy. The client has received chemotherapy prior to surgery and has hypertension and diabetes mellitus. Which factors put this client at risk for sepsis? Select all that apply. 1. age 2. abdominal surgery 3. gender 4. diabetes mellitus 5. weight

16. 1,2,4. Known risk factors for sepsis include age (<1 year and >65 years old), chronic illness, and invasive procedures. Immunosuppression and malnourishment are also risk factors. There is no correlation between gender or age and risk for sepsis. Nurses must be aware of risk factors and monitor clients at risk closely for any signs of sepsis.

19. A client with peptic ulcer disease (PUD) is admitted to the hospital for a gastric resection. The client reports a sudden sharp pain in the midepigastric area that radiates to the shoulder. The nurse should first: 1. establish an IV line. 2. administer pain medication. 3. notify the surgeon. 4. call for a stat ECG.

19. 3. The sharp, sudden midepigastric pain indicates the client may have a perforated ulcer. The nurse notifies the surgeon and may then obtain prescriptions for pain medication and IV fluids. It is not necessary to first obtain an ECG because the pain from ulcer perforation is different from that of chest pain that may indicate coronary artery syndrome (crushing pain radiating to the jaw).

33. To reduce the risk of dumping syndrome, the nurse should teach the client to: 1. sit upright for 30 minutes after meals. 2. drink liquids with meals, avoiding caffeine. 3. avoid milk and other dairy products. 4. decrease the carbohydrate content of meals.

33. 4. Carbohydrates are restricted, but protein, including meat and dairy products, is recommended because it is digested more slowly. Lying down for 30 minutes after a meal is encouraged to slow movement of the food bolus. Fluids are restricted to reduce the bulk of food. There is no need to avoid caffeine.

20. A client has been placed on long-term sulfasalazine therapy for treatment of ulcerative colitis. The nurse should encourage the client to eat which foods to help avoid the nutrient deficiencies that may develop as a result of this medication? 1. citrus fruits 2. green, leafy vegetables 3. eggs 4. milk products

20. 2. In long-term sulfasalazine therapy, the client may develop folic acid deficiency. The client can take folic acid supplements, but the nurse should also encourage the client to increase the intake of folic acid in the client's diet. Green, leafy vegetables are a good source of folic acid. Citrus fruits, eggs, and milk products are not good sources of folic acid.

22. A client who is experiencing an exacerbation of ulcerative colitis is receiving IV fluids that are to be infused at 125 mL/h. The IV tubing delivers 15 gtt/mL. How quickly should the nurse infuse the fluids in drops per minute to infuse the fluids at the prescribed rate? Record your answer using a whole number. gtt/min.

22. 31 gtt/min. To administer IV fluids at 125 mL/h using tubing that has a drip factor of 15 gtt/mL, the nurse should use the formula:

28. Since the diagnosis of stomach cancer, the client has been having trouble sleeping and is frequently preoccupied with thoughts about how life will change. The client says, "I wish my life could stay the same." Based on this information, the nurse should understand that the client: 1. is having difficulty coping. 2. has a sleep disorder. 3. is grieving. 4. is anxious.

28. 3. The information presented indicates the client is grieving about the changes that will occur as a result of the diagnosis of gastric cancer. The information does not indicate the client is having difficulty coping or experiencing insomnia. The client is not demonstrating signs of anxiety.

3. The nurse should teach clients about which potential risk factor for the development of colon cancer? 1. chronic constipation 2. long-term use of laxatives 3. history of smoking 4. history of inflammatory bowel disease

3. 4. A history of inflammatory bowel disease is a risk factor for colon cancer. Other risk factors include age (older than 40 years), history of familial polyposis, colorectal polyps, and high-fat or low-fiber diet.

30. The nurse has a prescription to administer sulfasalazine 2 g. The medication is available in 500-mg tablets. How many tablets should the nurse administer? tablets.

30. 4 tablets. To administer 2 g sulfasalazine, the nurse will need to administer four tablets.

31. Which diet would be most appropriate for the client with ulcerative colitis? 1. high-calorie, low-protein 2. high-protein, low-residue 3. low-fat, high-fiber. 4. low-sodium, high-carbohydrate

31. 2. Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid excess roughage. There is no need for clients with ulcerative colitis to follow low-sodium diets.

37. Which instruction should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease (GERD)? 1. Limit caffeine intake to two cups of coffee per day. 2. Do not lie down for 2 hours after eating. 3. Follow a low-protein diet. 4. Take medications with milk to decrease irritation.

37. 2. The nurse should instruct the client to not lie down for about 2 hours after eating to prevent reflux. Caffeinated beverages decrease pressure in the lower esophageal sphincter, and milk increases gastric acid secretion, so these beverages should be avoided. The client is encouraged to follow a high-protein, low-fat diet and avoid foods that are irritating.

68. A client with diverticular disease is receiving psyllium hydrophilic mucilloid. The drug has been effective when the client: 1. passes stool without cramping. 2. does not have diarrhea. 3. has firm, well-formed stool. 4. does not expel gas.

68. 1. Diverticular disease is treated with a high-fiber diet and bulk laxatives such as psyllium hydrophilic mucilloid. Fiber decreases the intraluminal pressure and makes it easier for stool to pass through the colon. Bulk laxatives do not manage diarrhea or relieve gas formation. The stool should remain soft and easy to expel.

17. A 36-year-old female client has been diagnosed with hemorrhoids. Which factor in the client's history would most likely be a primary cause of her hemorrhoids? 1. her age 2. three vaginal delivery pregnancies 3. her job as a schoolteacher 4. varicosities in her legs

17. 2. Hemorrhoids are associated with prolonged sitting or standing, portal hypertension, chronic constipation, and prolonged increased intra-abdominal pressure, as associated with pregnancy and the strain of vaginal childbirth. Her job as a schoolteacher does not require prolonged sitting or standing. Age and leg varicosities are not related to the development of hemorrhoids.

14. A client has 4,000 mL removed via paracentesis. When the nurse weighs the client after the procedure, how many kilograms is an expected weight loss? Record your answer in whole numbers. kg.

14. 4 kg. A liter of water weighs 1 kg. Therefore, the client should have a weight of 4 kilograms less than preprocedure weight.

63. Following the acute stage of diverticulosis, which foods should the nurse encourage a client to incorporate into the diet? Select all that apply. 1. bran cereal 2. broccoli 3. tomato juice 4. navy beans 5. cheese

63. 1,2,4. Clients with diverticulosis are encouraged to follow a high-fiber diet. Bran, broccoli, and navy beans are foods high in fiber. Tomato juice and cheese are low-residue foods.

41. Bethanechol has been prescribed for a client with gastroesophageal reflux disease (GERD). The nurse should assess the client for which adverse effect? 1. constipation 2. urinary urgency 3. hypertension 4. dry oral mucosa

41. 2. Bethanechol, a cholinergic drug, may be used in GERD to increase lower esophageal sphincter pressure and facilitate gastric emptying. Cholinergic adverse effects may include urinary urgency, diarrhea, abdominal cramping, hypotension, and increased salivation. To avoid these adverse effects, the client should be closely monitored to establish the minimum effective dose.

70. A nurse is providing wound care to a client 1 day following an appendectomy. A drain was inserted into the incisional site during surgery. When providing wound care, the nurse should: 1. remove the dressing and leave the incision open to air. 2. remove the drain if wound drainage is minimal. 3. gently irrigate the drain to remove exudate. 4. clean the area around the drain moving away from the drain.

70. 4. The nurse should gently clean the area around the drain by moving in a circular motion away from the drain. Doing so prevents the introduction of microorganisms to the wound and drain site. The incision cannot be left open to air as long as the drain is intact. The nurse should note the amount and character of wound drainage, but the surgeon will determine when the drain should be removed. Surgical wound drains are not irrigated.

84. On the 2nd day following an abdominal-perineal resection, the nurse notes that the wound edges are not approximated and one-half of the incision has torn apart. What should the nurse do first? 1. Flush the wound with sterile water. 2. Apply an abdominal binder. 3. Cover the wound with a sterile dressing moistened with normal saline. 4. Apply strips of tape.

84. 3. When dehiscence occurs, the nurse should immediately cover the wound with a sterile dressing moistened with normal saline. If the dehiscence is extensive, the incision must be resutured in surgery. Later, after the sutures are removed, additional support may be provided to the incision by applying strips of tape as directed by institutional policy or by the surgeon. An abdominal binder may also be utilized for additional support.

71. An adult with appendicitis has severe abdominal pain. Which action will be the most effective to assist the client to manage pain prior to surgery? 1. Place the client in semi-Fowler's position with the knees to the chest. 2. Apply moist heat to the abdomen. 3. Teach client to massage the painful area. 4. Provide distraction with music.

71. 1. Appendicitis typically begins with periumbilical pain followed by anorexia, nausea, and vomiting. The pain is persistent and continuous, eventually shifting to the right lower quadrant and localizing at McBurney point (located halfway between the umbilicus and the right iliac crest). To relieve pain prior to surgery, the nurse assists the client to a comfortable position with the knees drawn to the chest and the head of the bed slightly elevated. The nurse may also administer analgesics and ice packs, if prescribed; heat is avoided as heat may precipitate rupture of the appendix. The abdomen is not palpated or massaged more than necessary to avoid increasing the pain. Distraction with music may be helpful, but positioning, using ice packs, and analgesics are most effective.

78. The nurse is assigning clients for the evening shift. Which clients are appropriate for the nurse to assign to a licensed practical/vocational nurse (LPN/VN) to provide client care? Select all that apply. 1. a client with Crohn's disease who is receiving total parenteral nutrition (TPN) 2. a client who had inguinal hernia repair surgery 3 hours ago; vital signs are stable 3. a client with an intestinal obstruction who needs a Cantor tube inserted 4. a client with diverticulitis who needs teaching about take home medications 5. a client who is experiencing an exacerbation of ulcerative colitis

78. 2,5. The nurse should consider client needs and scope of practice when assigning staff to provide care. The client who is recovering from inguinal hernia repair surgery and the client who is experiencing an exacerbation of ulcerative colitis are appropriate clients to assign to an LPN/VN as the care they require falls within the scope of practice for an LPN or a VN. It is not within the scope of practice for the LPN/VN to administer TPN, insert nasoenteric tubes, or provide client teaching related to medications.

79. When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistive personnel (UAP)? Select all that apply. 1. assessing the client's bowel sounds 2. providing skin care following bowel movements 3. evaluating the client's response to antidiarrheal medications 4. maintaining intake and output records 5. obtaining the client's weight

79. 2,4,5. The nurse can delegate the following basic care activities to the UAP : providing skin care following bowel movements, maintaining intake and output records, and obtaining the client's weight. Assessing the client's bowel sounds and evaluating the client's response to medication are registered nurse (RN) activities that cannot be delegated.

80. The nurse is caring for a client 1 day after having a colectomy. The client is lethargic and difficult to arouse; the temperature is 101.5°F (38.6°C), blood pressure is 92/36 mm Hg (MAP 55), and heart rate is 114 bpm with SpO2 of 88% on oxygen at 2 L/min/nasal cannula (previously 94%). A saline lock has been established and is patent. Which prescription should the nurse implement first? 1. Obtain stat portable chest x-ray. 2. Administer vancomycin intravenously. 3. Draw blood cultures. 4. Insert an indwelling urinary catheter.

80. 3. This client has signs and symptoms of severe sepsis. Blood cultures should be drawn prior to administering the antibiotic (vancomycin); and the antibiotics should be administered within the first 45 minutes after recognition of these signs in order to try to prevent septic shock. Obtaining a chest x-ray and inserting a urinary catheter to accurately measure intake and output are also important actions but are not first priority for this client.

81. The nurse is taking care of a client with Clostridium difficile (C. difficile). To prevent the spread of infection, what should the nurse do? Select all that apply. 1. Wear a particulate respirator. 2. Wear sterile gloves when providing care. 3. Cleanse hands with alcohol-based hand sanitizer. 4. Wash hands with soap and water. 5. Wear a protective gown when in the client's room.

81. 4,5. Clostridium difficile is an organism that has developed very resistant and highly morbid strains. Universal precautions, most importantly handwashing, wearing personal protective gear, and modest use of antibiotics, are critical actions for stopping the spread. C. difficile is not spread via the respiratory tract; therefore, a mask is not needed. Alcohol-based hand sanitizers do not kill the spores of C. difficile; soap and water must be used. Sterile gloves are not needed to provide care; clean gloves may be worn.

82. The nurse discovers that a client's TPN solution was running at an incorrect rate and is now 2 hours behind schedule. Which action is most appropriate for the nurse to take to correct the problem? 1. Readjust the solution to infuse the desired amount. 2. Continue the infusion at the current rate, but run the next bottle at an increased rate. 3. Double the infusion rate for 2 hours. 4. Notify the healthcare provider (HCP).

82. 4. When TPN fluids are infused too rapidly or too slowly, the HCP should be notified. TPN solutions must be carefully and accurately infused. Rate adjustments should not be made without a written prescription from the HCP. Significant alterations in rate (10% increase or decrease) can result in fluctuations of blood glucose levels. Speeding up the solution can result in too much glucose entering the system.

83. The nurse is to administer ampicillin 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client's medication box, which is located inside of the client's room. The dosage of the medication is not labeled, but the nurse recognizes the color and shape of the capsule. The nurse should next: 1. administer the medication to maintain blood levels of the drug. 2. ask another registered nurse (RN) to verify that the capsule is ampicillin. 3. contact the pharmacy to bring a properly labeled medication. 4. notify the unit manager to report the problem.

83. 3. The nurse should contact the pharmacy directly and request that a properly labeled medication be provided. The nurse should not administer any drug that is not properly labeled, even if the nurse or another nurse recognizes the medication. It is not necessary to notify the unit manager at this point because the client needs to receive the antibiotic as soon as possible.

85. A client has received numerous different antibiotics and now is experiencing diarrhea. The healthcare provider (HCP) has prescribed a transmission-based precaution. The nurse should institute: 1. airborne precautions. 2. contact precautions. 3. droplet precautions. 4. needlestick precautions.

85. 2. Airborne precautions are required for clients with presumed or proven pulmonary tuberculosis (TB), chickenpox, or other airborne pathogens. Contact precautions are used for organisms that are spread by skin-to-skin contact, such as antibiotic-resistant organisms or Clostridium difficile. Droplet precautions are used for organisms such as influenza or meningococcus that can be transmitted by close respiratory or mucous membrane contact with respiratory secretions. The most important aspect of reducing the risk of bloodborne infection is avoidance of percutaneous injury. Extreme care is essential when needles, scalpels, and other sharp objects are handled.

86. The healthcare provider (HCP) has prescribed ciprofloxacin for a client who takes warfarin. What should the nurse instruct the client to do? Select all that apply. 1. Split the tablets and stir them in food. 2. Avoid exposure to sunlight. 3. Eliminate caffeine from the diet. 4. Report unusual bleeding. 5. Increase fluid intake to 3,000 mL/day.

86. 2,4. A black box warning for ciprofloxacin is that ciprofloxacin may increase the anticoagulant effects of warfarin. The nurse should instruct the client to report increased bleeding and to monitor the prothrombin time (PT) and the international normalized ratio (INR) closely. Although there is a drug-food interaction and taking ciprofloxacin may increase the stimulatory effect of caffeine, the client does not need to eliminate caffeine, but should report signs of stimulant effect. Ciprofloxacin may cause photosensitivity reactions; the nurse must advise the client to avoid excessive sunlight or artificial ultraviolet light during therapy. Clients must be advised not to crush, split, or chew the extended-release tablets. It is not necessary to increase the amount of fluids.

10. A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, board-like abdomen. After obtaining the client's vital signs, what should the nurse do next? 1. Administer pain medication as prescribed. 2. Raise the head of the bed. 3. Prepare to insert a nasogastric tube. 4. Notify the healthcare provider (HCP).

10. 4. The client is experiencing a perforation of the ulcer, and the nurse should notify the HCP immediately. The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in board-like abdominal rigidity, usually with extreme pain. Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation. Administering pain medication is not the first action, although the nurse later should institute measures to relieve pain. Elevating the head of the bed will not minimize the perforation. A nasogastric tube may be used following surgery.

20. A client is to take one daily dose of ranitidine at home to treat a peptic ulcer. The client understands proper drug administration of ranitidine when the client will take the drug: 1. before meals. 2. with meals. 3. at bedtime. 4. when pain occurs.

20. 3. Ranitidine blocks secretion of hydrochloric acid. Clients who take only one daily dose of ranitidine are usually advised to take it at bedtime to inhibit nocturnal secretion of acid. Clients who take the drug twice a day are advised to take it in the morning and at bedtime. It is not necessary to take the drug before meals. The client should take the drug regularly, not just when pain occurs.

21. A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which factor is of greatest significance in causing an exacerbation of ulcerative colitis? 1. a demanding and stressful job 2. changing to a modified vegetarian diet 3. beginning a weight-training program 4. walking 2 miles (3.2 km) every day

21. 1. Stressful and emotional events have been clearly linked to exacerbations of ulcerative colitis, although their role in the etiology of the disease has been disproved. A modified vegetarian diet or an exercise program is an unlikely cause of the exacerbation.

27. A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to undergo a subtotal gastrectomy (Billroth II procedure). During preoperative teaching, the nurse is reinforcing information about the surgical procedure. The nurse should instruct the client that the procedure will result in: 1. enlargement of the pyloric sphincter. 2. anastomosis of the gastric stump to the jejunum. 3. removal of the duodenum. 4. repositioning of the vagus nerve.

27. 2. A Billroth II procedure bypasses the duodenum and connects the gastric stump directly to the jejunum. The pyloric sphincter is removed, along with some of the stomach fundus.

30. Following a subtotal gastrectomy, a client has a nasogastric (NG) tube connected to low suction. The nurse should: 1. irrigate the tube with 30 mL of sterile water every hour, if needed. 2. reposition the tube if it is not draining well. 3. monitor the client for nausea, vomiting, and abdominal distention. 4. change to high suction if the drainage is sluggish on low suction.

30. 3. Nausea, vomiting, or abdominal distention indicates that gas and secretions are accumulating within the gastric pouch due to impaired peristalsis or edema at the operative site and may indicate that the drainage system is not working properly. Saline is used to irrigate NG tubes. Hypotonic solutions such as water increase electrolyte loss. In addition, a healthcare provider's (HCP) prescription is needed to irrigate the NG tube because this procedure could disrupt the suture line. After gastric surgery, only the surgeon repositions the NG tube because of the danger of rupturing or dislodging the suture line. The amount of suction varies with the type of tube used and is prescribed by the HCP. High suction may create too much tension on the gastric suture line.

9. While changing the client's colostomy bag and dressing, the nurse determines that the client is ready to participate in self-care when the client: 1. asks if the healthcare provider (HCP) will change the dressing soon. 2. asks about the supplies used during the dressing change. 3. talks about the news on the television. 4. is upset about the way the night nurse changed the dressing.

9. 2. A client who displays interest in the procedure and asks about supplies used for dressings may be ready to participate in self-care. Inquiring about when the HCP will change the dressing does not indicate the client's readiness to change the dressing. Discussing news events and discussing a dressing change are behaviors that avoid the subject of the colostomy.

11. When obtaining a nursing history from a client with a suspected gastric ulcer, which signs and symptoms should the nurse assess? Select all that apply. 1. epigastric pain at night 2. relief of epigastric pain after eating 3. vomiting 4. weight loss 5. melena

11. 3,4,5. Vomiting and weight loss are common with gastric ulcers. The client may also have blood in the stools (melena) from gastric bleeding. Clients with a gastric ulcer are most likely to have a burning epigastric pain that occurs about 1 hour after eating. Eating frequently aggravates the pain. Clients with duodenal ulcers are more likely to have pain that occurs during the night and is frequently relieved by eating.

25. A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication? 1. heart failure 2. deep vein thrombosis 3. hypokalemia 4. hypocalcemia

25. 3. Excessive diarrhea causes significant depletion of the body's stores of sodium and potassium as well as fluid. The client should be closely monitored for hypokalemia and hyponatremia. Ulcerative colitis does not place the client at risk for heart failure, deep vein thrombosis, or hypocalcemia.

67. After instructing a client with diverticulosis about appropriate self-care activities, which comment by the client indicates effective teaching? Select all that apply. 1. "With careful attention to my diet, my diverticulosis can be cured." 2. "Using a cathartic laxative weekly is okay to control bowel movements." 3. "I should follow a diet that is high in fiber." 4. "It is important for me to drink at least 2,000 mL of fluid every day." 5. "I should exercise regularly."

67. 3,4,5. Clients who have diverticulosis should be instructed to maintain a diet high in fiber and, unless contraindicated, should increase their fluid intake to a minimum of 2,000 mL/day. Participating in a regular exercise program is also strongly encouraged. Diverticulosis can be controlled with treatment but cannot be cured. Clients should be instructed to avoid the regular use of cathartic laxatives. Bulk laxatives and stool softeners may be helpful to maintain regularity and decrease straining.

7. The client with colon cancer has an abdominal-perineal resection with a colostomy. To promote hygiene following surgery, what should the nurse do? 1. Maintain the client in a semi-Fowler's position. 2. Assist the client with warm sitz baths. 3. Administer 30 mL of milk of magnesia to stimulate peristalsis. 4. Remove the ostomy pouch as needed so the stoma can be assessed.

7. 2. Appropriate nursing interventions after an abdominal-perineal resection with a colostomy include assisting the client with warm sitz baths three to four times a day to clean the perineal incision. The client will be more comfortable assuming a side-lying position because of the perineal incision. It would be inappropriate to administer milk of magnesia to stimulate colostomy activity. Stool passage will begin as peristalsis returns. It is not necessary or desirable to change the ostomy pouch daily to assess the stoma. The ostomy pouch should be transparent to allow easy observation of the stoma and drainage.

8. The nurse assesses the client's stoma during the initial postoperative period. What observation should the nurse report to the healthcare provider (HCP) immediately? 1. The stoma is slightly edematous. 2. The stoma is dark red to purple. 3. The stoma oozes a small amount of blood. 4. The stoma does not expel stool.

8. 2. A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing of blood are normal in the early postoperative period. The colostomy would typically not begin functioning until 2 to 4 days after surgery.