Medsurg II: CH 7 GI Disorders

The client with a new colostomy is being discharged. Which statement made by the client indicates the need for further teaching? 1. "If I notice any skin breakdown, I will call the HCP." 2. "I should drink only liquids until the colostomy starts to work." 3. "I should not take a tub bath until the HCP okays it." 4. "I should not drive or lift more than five (5) pounds."

1. If the tissue around the stoma becomes excoriated, the client will be unable to pouch the stoma adequately, resulting in discomfort and leakage. The client understands the teaching. 2. The client should be on a regular diet, and the colostomy will have been working for several days prior to discharge. The client's statement indicates the need for further teaching. 3. Until the incision is completely healed, the client should not sit in bath water because of the potential contamination of the wound by the bath water. The client understands the teaching. 4. The client has had major surgery and should limit lifting to minimal weight. The client understands the teaching.

Which data should the nurse expect to assess in the client who had an upper gastrointestinal (UGI) series? 1. Chalky white stools. 2. Increased heart rate. 3. A firm hard abdomen. 4. Hyperactive bowel sounds.

Ans 1 1. A UGI series requires the client to swallow barium, which passes through the intestines, making the stools a chalky white color. 2. Increased heart rate is abnormal data and would be cause for further assessment. 3. A firm, hard abdomen is not expected from the UGI series. 4. Hyperactive bowel sounds is not an expected sequela of a UGI series.

The client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement? 1. Apply a heating pad to the abdomen for 15 to 20 minutes. 2. Administer morphine sulfate intravenously after diluting with saline. 3. Contact the surgeon for an order to x-ray the right shoulder. 4. Apply a sling to the right arm, which was injured during surgery.

Ans 1 1. A heating pad should be applied for 15 to 20 minutes to assist the migration of the CO2 used to insufflate the abdomen. Shoulder pain is an expected occurrence. 2. Morphine sulfate does not affect the etiology of the pain. 3. The surgeon would not order an x-ray for this condition. 4. There is no indication an injury occurred during surgery. A sling would not benefit the migration of the CO2. Shoulder pain is expected.

The 85-year-old male client diagnosed with cancer of the colon asks the nurse, "Why did I get this cancer?" Which statement is the nurse's best response? 1. "Research shows a lack of fiber in the diet can cause colon cancer." 2. "It is not common to get colon cancer at your age; it is usually in young people." 3. "No one knows why anyone gets cancer, it just happens to certain people." 4. "Women usually get colon cancer more often than men but not always."

Ans 1 1. A long history of low-fiber, high-fat, and high-protein diets results in a prolonged transit time. This allows the carcinogenic agents in the waste products to have a greater exposure to the lumen of the colon. 2. The older the client, the greater the risk of developing cancer of the colon. 3. Risk factors for cancer of the colon include increasing age; family history of colon cancer or polyps; history of IBD; genital or breast cancer; and eating a high-fat, high-protein, low-fiber diet. 4. Males have a slightly higher incidence of colon cancers than do females.

The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse? 1. The UAP is assisting the client to take a hot soapy shower. 2. The UAP applies an emollient to the client's legs and back. 3. The UAP puts mittens on both hands of the client. 4. The UAP pats the client's skin dry with a clean towel.

Ans 1 1. Hot water increases pruritus, and soap will cause dry skin, which increases pruritus; therefore, the nurse should discuss this with the UAP. 2. Applying emollient lotion will help prevent dry skin, which will help decrease pruritus; therefore, this would not require any intervention by the nurse. 3. Mittens will help prevent the client from scratching the skin and causing skin break-down. This would not require intervention by the nurse. 4. The skin should be patted dry, not rubbed, because rubbing the skin will cause increased irritation. This action does not require intervention by the nurse.

The nurse writes the problem "imbalanced nutrition: less than body requirements" for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care? 1. Provide a high-calorie intake diet. 2. Discuss total parenteral nutrition (TPN). 3. Instruct the client to decrease salt intake. 4. Encourage the client to increase water intake.

Ans 1 1. Sufficient energy is required for healing. Adequate carbohydrate intake can spare protein. The client should eat approximately 16 carbohydrate kilocalories for each kilogram of ideal body weight daily. 2. TPN is not routinely prescribed for the client with hepatitis; the client must lose a large of amount of weight and be unable to eat any-thing for TPN to be ordered. 3. Salt intake does not affect the healing of the liver. 4. Water intake does not affect healing of the liver, and the client should not drink so much water as to decrease caloric food intake.

The public health nurse is teaching day-care workers. Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? 1. Hepatitis A. 2. Hepatitis B. 3. Hepatitis C. 4. Hepatitis D.

Ans 1 1. The hepatitis A virus is in the stool of infected people and takes up to two (2) weeks before symptoms develop. 2. Hepatitis B virus is spread through contact with infected blood and body fluids. 3. Hepatitis C virus is transmitted through infected blood and body fluids. 4. Hepatitis D virus only causes infection in people who are also infected with hepatitis B or C.

The charge nurse is monitoring client laboratory values. Which value is expected in the client with cholecystitis who has chronic inflammation? 1. An elevated white blood cell count. 2. A decreased lactate dehydrogenase. 3. An elevated alkaline phosphatase. 4. A decreased direct bilirubin level.

Ans 1 1. The white blood cell count should be elevated in clients with chronic inflammation. 2. A decreased lactate dehydrogenase (LDH) indicates liver abnormalities. 3. An elevated alkaline phosphatase indicates liver abnormalities. 4. A decreased bilirubin indicates an obstructive process.

The nurse caring for a client one (1) day postoperative sigmoid resection notes a moderate amount of dark reddish brown drainage on the midline abdominal incision. Which intervention should the nurse implement first? 1. Mark the drainage on the dressing with the time and date. 2. Change the dressing immediately using sterile technique. 3. Notify the health-care provider immediately. 4. Reinforce the dressing with a sterile gauze pad.

Ans 1 1. The nurse should mark the drainage on the dressing to determine if active bleeding is occurring, because dark reddish-brown drainage indicates old blood. This al-lows the nurse to assess what is actually happening. 2. Surgical dressings are initially changed by the surgeon; the nurse should not remove the dressing until the surgeon orders the dressing change to be done by the nurse. 3. The nurse should assess the situation before notifying the HCP. 4. The nurse may need to reinforce the dressing if the dressing becomes saturated, but this would be after a thorough assessment is completed.

The public health nurse is discussing hepatitis B with a group in the community. Which health promotion activities should the nurse discuss with the group? Select all that apply. 1. Do not share needles or equipment. 2. Use barrier protection during sex. 3. Get the hepatitis B vaccine. 4. Obtain immune globulin injections. 5. Avoid any type of hepatotoxic medications.

Ans 1,2,3 1. Hepatitis B can be transmitted by sharing any type of needles, especially those used by drug abusers. 2. Hepatitis B can be transmitted through sexual activity; therefore, the nurse should recommend abstinence, mutual monogamy, or barrier protection. 3. Three doses of hepatitis B vaccine provide immunity in 90% of healthy adults. 4. Immune globulin injections are administered as postexposure prophylaxis (after being ex-posed to hepatitis B), but encouraging these injections is not a health promotion activity. 5. Hepatotoxic medications should be avoided in clients who have hepatitis or who have had hepatitis. The health-care provider prescribes medications, and the layperson does not know which medications are hepatotoxic.

The client in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse implement? Select all that apply. 1. Avoid rectal temperatures. 2. Use only a soft toothbrush. 3. Monitor the platelet count. 4. Use small-gauge needles. 5. Assess for asterixis.

Ans 1,2,3,4 1. Vitamin K deficiency causes impaired coagulation; therefore, rectal thermometers should be avoided to prevent bleeding. 2. Soft-bristle toothbrushes will help prevent bleeding of the gums. 3. Platelet count, partial thromboplastin time/prothrombin time (PTT/PT), and international normalized ratio (INR) should be monitored to assess coagulation status. 4. Injections should be avoided, if at all possible, because the client is unable to clot, but if they are absolutely necessary, the nurse should use small-gauge needles. 5. Asterixis is a flapping tremor of the hands when the arms are extended and indicates an elevated ammonia level not associated with vitamin K deficiency.

Which signs and symptoms should the nurse report to the health-care provider for the client recovering from an open cholecystectomy? Select all that apply. 1. Clay-colored stools. 2. Yellow-tinted sclera. 3. Amber-colored urine. 4. Wound approximated. 5. Abdominal pain.

Ans 1,2,5 1. Clay-colored stools are caused by recurring stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome. 2. Yellow-tinted sclera and skin indicate residual effects of stricture of the common bile duct, which is a sign of post- cholecystectomy syndrome. 3. Amber-colored urine is a normal finding for a client recovering from an open cholecystectom, so this does not warrant intervention by the nurse. 4. An approximated wound indicates the incision is intact and does not warrant intervention by the nurse. 5. Abdominal pain indicates a residual effect of a stricture of the common bile duct, inflammation, or calculi, which is a sign of post-cholecystectomy syndrome.

The nurse is planning the care of a client who has had an abdominal-perineal resection for cancer of the colon. Which interventions should the nurse implement? Select all that apply. 1. Provide meticulous skin care to stoma. 2. Assess the flank incision. 3. Maintain the indwelling catheter. 4. Irrigate the JP drains every shift. 5. Position the client semirecumbent.

Ans 1,3,5 1. Colostomy stomas are openings through the abdominal wall into the colon, through which feces exit the body. Feces can be irritating to the abdominal skin, so careful and thorough skin care is needed. 2. There are midline and perineal incisions, not flank incisions. 3. Because of the perineal wound, the client will have an indwelling catheter to keep urine out of the incision. 4. Jackson Pratt drains are emptied every shift, but they are not irrigated. 5. The client should not sit upright because this causes pressure on the perineum.

The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching is effective? 1. "I will take my lipid-lowering medicine at the same time each night." 2. "I may experience some discomfort when I eat a high-fat meal." 3. "I need someone to stay with me for about a week after surgery." 4. "I should not splint my incision when I deep breathe and cough."

Ans 2 1 This surgery does not require lipid-lowering medications, but eating high-fat meals may cause discomfort. 2. After removal of the gallbladder, some clients experience abdominal discomfort when eating fatty foods. 3. Laparoscopic cholecystectomy surgeries are performed in day surgery, and clients usually do not need assistance for a week. 4. Using a pillow to splint the abdomen provides support for the incision and should be continued after discharge.

Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? 1. Airborne Precautions. 2. Standard Precautions. 3. Droplet Precautions. 4. Exposure Precautions.

Ans 2 1. Airborne Precautions are required for transmission occurring by dissemination of either airborne droplet nuclei or dust particles containing the infectious agent. 2. Standard Precautions apply to blood, all body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood. 3. Droplet transmission involves contact of the conjunctivae of the eyes or mucous membranes of the nose or mouth with large-particle droplets generated during coughing, sneezing, talking, or suctioning. 4. Exposure Precautions is not a designated isolation category.

The occupational health nurse is preparing a presentation to a group of factory workers about preventing colon cancer. Which information should be included in the presentation? 1. Wear a high-filtration mask when around chemicals. 2. Eat several servings of cruciferous vegetables daily. 3. Take a multiple vitamin every day. 4. Do not engage in high-risk sexual behaviors.

Ans 2 1. Some cancers have a higher risk of development when the client is occupationally ex-posed to chemicals, but cancer of the colon is not one of them. 2. Cruciferous vegetables, such as broccoli, cauliflower, and cabbage, are high in fiber. One of the risks for cancer of the colon is a high-fat, low-fiber, and high-protein diet. The longer the transit time (the time from ingestion of the food to the elimination of the waste products), the greater the chance of developing cancer of the colon. 3. A multiple vitamin may improve immune system function, but it does not prevent colon cancer. 4. High-risk sexual behavior places the client at risk for sexually transmitted diseases. A history of multiple sexual partners and initial sexual experience at an early age does increase the risk for the development of cancer of the cervix in females.

Which instruction should the nurse discuss with the client who is in the icteric phase of hepatitis C? 1. Decrease alcohol intake. 2. Encourage rest periods. 3. Eat a large evening meal. 4. Drink diet drinks and juices.

Ans 2 1. The client must avoid alcohol altogether, not decrease intake, to prevent further liver dam-age and promote healing. 2. Adequate rest is needed for maintaining optimal immune function. 3. Clients are more often anorexic and nauseated in the afternoon and evening; therefore, the main meal should be in the morning. 4. Diet drinks and juices provide few calories, and the client needs an increased-calorie diet for healing.

The female nurse sticks herself with a contaminated needle. Which action should the nurse implement first? 1. Notify the infection control nurse. 2. Cleanse the area with soap and water. 3. Request postexposure prophylaxis. 4. Check the hepatitis status of the client.

Ans 2 1. The nurse must notify the infection control nurse as soon as possible so treatment can start if needed, but this is not the first intervention. 2. The nurse should first clean the needle stick with soap and water and attempt stick bleed to help remove any virus injected into the skin. 3. Postexposure prophylaxis may be needed, but this is not the first action. 4. The infection control/employee health nurse will check the status of the client whom the needle was used on before the nurse stuck herself.

The client complains to the nurse of unhappiness with the health-care provider. Which intervention should the nurse implement next? 1. Call the HCP and suggest he or she talk with the client. 2. Determine what about the HCP is bothering the client. 3. Notify the nursing supervisor to arrange a new HCP to take over. 4. Explain the client cannot request another HCP until after discharge.

Ans 2 1. The nurse should first assess the situation prior to informing the HCP of the client's concerns and then allow the HCP and client to discuss the situation. 2. The nurse should determine what is concerning the client. It could be a misunderstanding or a real situation where the client's care is unsafe or inadequate. 3. If a new HCP is to be arranged, it is the HCP's responsibility to arrange for another HCP to assume responsibility for the care of the client. 4. The choice of HCP is ultimately the client's. If the HCP cannot arrange for another HCP, the client may be discharged and obtain a new health-care provider.

The client diagnosed with liver problems asks the nurse, "Why are my stools claycolored?" On which scientific rationale should the nurse base the response? 1. There is an increase in serum ammonia level. 2. The liver is unable to excrete bilirubin. 3. The liver is unable to metabolize fatty foods. 4. A damaged liver cannot detoxify vitamins.

Ans 2 1. The serum ammonia level is increased in liver failure, but it is not the cause of clay-colored stools. 2. Bilirubin, the by-product of red blood cell destruction, is metabolized in the liver and excreted via the feces, which causes the feces to be brown in color. If the liver is damaged, the bilirubin is excreted via the urine and skin. 3. The liver excretes bile into the gallbladder and the body uses the bile to digest fat, but it does not affect the feces. 4. Vitamin deficiency, resulting from the liver's inability to detoxify vitamins, may cause steatorrhea, but it does not cause clay-colored stool.

The nurse identifies the client problem "excess fluid volume" for the client in liver failure. Which short-term goal would be most appropriate for this problem? 1. The client will not gain more than two (2) kg a day. 2. The client will have no increase in abdominal girth. 3. The client's vital signs will remain within normal limits. 4. The client will receive a low-sodium diet.

Ans 2 1. Two (2) kg is more than four (4) pounds, which indicates severe fluid retention and is not an appropriate goal. 2. Excess fluid volume could be secondary to portal hypertension. Therefore, no increase in abdominal girth would be an appropriate short-term goal, indicating no excess of fluid volume. 3. Vital signs are appropriate to monitor, but they do not yield specific information about fluid volume status. 4. Having the client receive a low-sodium diet does not ensure the client will comply with the diet. The short-term goal must evaluate if the fluid volume is within normal limits.

The client is admitted with end-stage liver failure and is prescribed the laxative lactulose (Chronulac). Which statement indicates the client needs more teaching concerning this medication? 1. "I should have two to three soft stools a day." 2. "I must check my ammonia level daily." 3. "If I have diarrhea, I will call my doctor." 4. "I should check my stool for any blood."

Ans 2 1. Two to three soft stools a day indicates the medication is effective. 2. There is no instrument used at home to test daily ammonia levels. The ammonia level is a serum level requiring venipuncture and laboratory diagnostic equipment. 3. Diarrhea indicates an overdosage of the medication, possibly requiring the dosage to be decreased. The HCP needs to make this change in dosage, so the client understands the teaching. 4. The client should check the stool for bright-red blood as well as dark, tarry stool.

Which assessment data indicate to the nurse the client recovering from an open cholecystectomy may require pain medication? 1. The client's pulse is 65 beats per minute. 2. The client has shallow respirations. 3. The client's bowel sounds are 20 per minute. 4. The client uses a pillow to splint when coughing.

Ans 2 1. An increased pulse is expected in the client who is in acute pain. 2. An open cholecystectomy requires a large incision under the diaphragm. Deep breathing places pressure on the diaphragm and the incision, causing pain. Shallow respirations indicate inadequate pain control, and the nurse should intervene. 3. Twenty bowel sounds a minute is normal data and does not require further action. 4. Splinting the abdomen allows the client to in-crease the strength of the cough by increasing comfort and does not indicate a need for pain medication.

The nurse is caring for clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society's recommendations for the early detection of colon cancer? 1. Beginning at age 60, a digital rectal examination should be done yearly. 2. After reaching middle age, a yearly fecal occult blood test should be done. 3. Have a colonoscopy at age 50 and then once every five (5) to 10 years. 4. A flexible sigmoidoscopy should be done yearly after age 40.

Ans 3 1. A digital rectal examination is done to detect prostate cancer and should be started at age 40 years. 2. "Middle age" is a relative term; specific ages are used for recommendation. 3. The American Cancer Society recommends a colonoscopy at age 50 and every five (5) to 10 years thereafter, and a flexible sigmoidoscopy and a barium enema every five (5) years. 4. A flexible sigmoidoscopy should be done at five (5)-year intervals between the colonoscopy.

The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care? 1. Instruct the client to cough forcefully. 2. Encourage early ambulation. 3. Assess for return of a gag reflex. 4. Administer held medications.

Ans 3 1. Asking the client to cough forcefully may irritate the client's throat. 2. Early ambulation does not enhance safety because the client will be sedated. 3. The ERCP requires an anesthetic spray be used prior to insertion of the endoscope. If medications, food, or fluid are given orally prior to the return of the gag reflex, the client may aspirate. 4. Medications are not administered until the gag reflex has returned.

The nurse is admitting a client to a medical floor with a diagnosis of adenocarcinoma of the rectosigmoid colon. Which assessment data support this diagnosis? 1. The client reports up to 20 bloody stools per day. 2. The client has a feeling of fullness after a heavy meal. 3. The client has diarrhea alternating with constipation. 4. The client complains of right lower quadrant pain.

Ans 3 1. Frequent bloody stools are a symptom of inflammatory bowel disease (IBD). IBD is a risk factor for cancer of the colon, but the symptoms are different when the colon becomes cancerous. 2. Most people have a feeling of fullness after a heavy meal; this does not indicate cancer. 3. The most common symptom of colon cancer is a change in bowel habits, specifically diarrhea alternating with constipation. 4. Lower right quadrant pain with rebound tenderness would indicate appendicitis. TEST-

Which gastrointestinal assessment data should the nurse expect to find when assessing the client in end-stage liver failure? 1. Hypoalbuminemia and muscle wasting. 2. Oligomenorrhea and decreased body hair. 3. Clay-colored stools and hemorrhoids. 4. Dyspnea and caput medusae.

Ans 3 1. Hypoalbuminemia (decreased albumin) and muscle wasting are metabolic effects, not gastrointestinal effects. 2. Oligomenorrhea is no menses, which is a reproductive effect, and decreased body hair is an integumentary effect. 3. Clay-colored stools and hemorrhoids are gastrointestinal effects of liver failure. 4. Dyspnea is a respiratory effect, and caput medusae (dilated veins around the umbilicus) is an integumentary effect, although it is on the abdomen.

Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis? 1. "How many years have you been drinking alcohol?" 2. "Have you completed an advance directive?" 3. "When did you have your last alcoholic drink?" 4. "What foods did you eat at your last meal?"

Ans 3 1. It really doesn't matter how long the client has been drinking alcohol. The diagnosis of alcoholic cirrhosis indicates the client has probably been drinking for many years. 2. An advance directive is important for the client who is terminally ill, but it is not the priority question. 3. The nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol. 4. This is not a typical question asked by the nurse unless the client is malnourished, which is not information provided in the stem.

The client has had a liver biopsy. Which postprocedure intervention should the nurse implement? 1. Instruct the client to void immediately. 2. Keep the client NPO for eight (8) hours. 3. Place the client on the right side. 4. Monitor BUN and creatinine level.

Ans 3 1. The client should empty the bladder immediately prior to the liver biopsy, not after the procedure. 2. Foods and fluids are usually withheld two (2) hours after the biopsy, after which the client can resume the usual diet. 3. Direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure. 4. Blood urea nitrogen (BUN) and creatinine levels are monitored for kidney function, not liver function, and the renal system is not affected with the liver biopsy.

The client presents with a complete blockage of the large intestine from a tumor. Which health-care provider's order would the nurse question? 1. Obtain consent for a colonoscopy and biopsy. 2. Start an IV of 0.9% saline at 125 mL/hr. 3. Administer 3 liters of GoLYTELY. 4. Give tap water enemas until it is clear.

Ans 3 1. The client will need to have diagnostic tests, so this is an appropriate intervention. 2. The client who has an intestinal blockage will need to be hydrated. 3. This client has an intestinal blockage from a solid tumor blocking the colon. Although the client needs to be cleaned out for the colonoscopy, GoLYTELY could cause severe cramping without a reasonable benefit to the client and could cause a medical emergency. 4. Tap water enemas until clear would be instilling water from below the tumor to try to rid the colon of any feces. The client can expel this water.

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Draw the serum liver function test. 2. Evaluate the client's intake and output. 3. Perform the bedside glucometer check. 4. Help the ward clerk transcribe orders.

Ans 3 1. The laboratory technician draws serum blood studies, not the UAP. 2. The UAP can obtain the intake and out-put, but the nurse must evaluate the data to determine if the results are normal for the client's disease process or condition. 3. The UAP can perform a bedside glucometer check, but the nurse must evaluate the result and determine any action needed. 4. The ward clerk has specific training that allows the transcribing of health-care provider orders.

The client diagnosed with end-stage renal failure and ascites is scheduled for a paracentesis. Which client teaching should the nurse discuss with the client? 1. Explain the procedure will be done in the operating room. 2. Instruct the client a Foley catheter will have to be inserted. 3. Tell the client vital signs will be taken frequently after the procedure. 4. Provide instructions on holding the breath when the HCP inserts the catheter.

Ans 3 1. The procedure is done in the client's room, with the client seated either on the side of the bed or in a chair. 2. The client should empty the bladder prior to the procedure to avoid bladder puncture, but there is no need for an indwelling catheter to be inserted. 3. The client is at risk for hypovolemia; therefore, vital signs will be assessed frequently to monitor for signs of hemorrhaging. 4. The client does not have to hold the breath when the catheter is inserted into the peritoneum; this is done when obtaining a liver biopsy.

The nurse assesses a large amount of red drainage on the dressing of a client who is six (6) hours postoperative open cholecystectomy. Which intervention should the nurse implement? 1. Measure the abdominal girth. 2. Palpate the lower abdomen for a mass. 3. Turn client onto side to assess for further drainage. 4. Remove the dressing to determine the source.

Ans 3 1. Measuring the abdominal girth helps further assess internal bleeding, not external bleeding. 2. Palpating the lower abdomen assesses the bladder, not bleeding. 3. Turning the client to the side to assess the amount of drainage and possible bleeding is important prior to contacting the surgeon. 4. The first dressing change is usually done by the surgeon; the nurse can reinforce the dressing.

The client is diagnosed with end-stage liver failure. The client asks the nurse, "Why is my doctor decreasing the doses of my medications?" Which statement is the nurse's best response? 1. "You are worried because your doctor has decreased the dosage." 2. "You really should ask your doctor. I am sure there is a good reason." 3. "You may have an overdose of the medications because your liver is damaged." 4. "The half-life of the medications is altered because the liver is damaged."

Ans 3 1. This is a therapeutic response and is used to encourage the client to verbalize feelings but does not provide factual information. 2. This is passing the buck; the nurse should be able to answer this question. 3. This is the main reason the HCP decreases the client's medication dose and is an explanation appropriate for the client. 4. This is the medical explanation as to why the medication dose is decreased, but it should not be used to explain to a layperson.

The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Check the abdominal dressings for bleeding. 2. Increase the IV fluid if the blood pressure is low. 3. Ambulate the client to the bathroom. 4. Auscultate the breath sounds in all lobes

Ans 3 1. This is assessment and cannot be delegated. 2. This intervention would require nursing judgment, and increasing IV fluid is medication administration; neither task can be delegated. 3. A day surgery client can be ambulated to the bathroom, so this task can be delegated to the UAP. 4. This would require assessment and cannot be delegated.

The client is four (4) hours postoperative open cholecystectomy. Which data warrant immediate intervention by the nurse? 1. Absent bowel sounds in all four (4) quadrants. 2. The T-tube has 60 mL of green drainage. 3. Urine output of 100 mL in the past three (3) hours. 4. Refusal to turn, deep breathe, and cough.

Ans 4 1. After abdominal surgery, it is not uncommon for bowel sounds to be absent. 2. This is a normal amount and color of drainage. 3. The minimum urine output is 30 mL/hr. 4. Refusing to turn, deep breathe, and cough places the client at risk for pneumonia. This client needs immediate intervention to prevent complications.

The school nurse is discussing methods to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the most important to teach the high school teachers? 1. Do not allow students to eat or drink after each other. 2. Drink bottled water as much as possible. 3. Encourage protected sexual activity. 4. Sing the happy birthday song while washing hands.

Ans 4 1. Eating after each other should be discour-aged, but it is not the most important intervention. 2. Only bottled water should be consumed in third world countries, but this precaution is not necessary in American high schools. 3. Hepatitis B and C, not hepatitis A, are trans-mitted by sexual activity. 4. Hepatitis A is transmitted via the fecal-oral route. Good hand washing helps to prevent its spread. Singing the happy birthday song takes approximately 30 seconds, which is how long an individual should wash his or her hands.

The nurse writes a psychosocial problem of "risk for altered sexual functioning related to new colostomy." Which intervention should the nurse implement? 1. Tell the client there should be no intimacy for at least three (3) months. 2. Ensure the client and significant other are able to change the ostomy pouch. 3. Demonstrate with charts possible sexual positions for the client to assume. 4. Teach the client to protect the pouch from becoming dislodged during sex.

Ans 4 1. Intimacy involves more than sexual inter-course. The client can be sexually active whenever the wounds are healed sufficiently to not cause pain. 2. This is an appropriate nursing intervention for home care, but it has nothing to do with sexual activity. 3. The nurse is not a sexual counselor who would have these types of charts. The nurse should address sexuality with the client but would not be considered an expert capable of explaining the advantages and disadvantages of sexual positioning. 4. A pouch that becomes dislodged during the sexual act would cause embarrassment for the client, whose body image has already been dealt a blow.

The client who has had an abdominal perineal resection is being discharged. Which discharge information should the nurse teach? 1. The stoma should be a white, blue, or purple color. 2. Limit ambulation to prevent the pouch from coming off. 3. Take pain medication when the pain level is at an "8." 4. Empty the pouch when it is one-third to one-half full.

Ans 4 1. The stoma should be light to a medium pink, the color of the intestines. A blue or purple color indicates a lack of circulation to the stoma and is a medical emergency. 2. The stoma should be pouched securely for the client to be able to participate in normal daily activities. The client should be encouraged to ambulate to aid in recovery. 3. Pain medication should be taken before the pain level reaches a "5." Delaying taking medication will delay the onset of pain relief and the client will not receive full benefit from the medication. 4. The pouch should be emptied when it is one-third to one-half full to prevent the contents from becoming too heavy for the seal to hold and to prevent leakage from occurring.

Which problem is highest priority for the nurse to identify in the client who had an open cholecystectomy surgery? 1. Alteration in nutrition. 2. Alteration in skin integrity. 3. Alteration in urinary pattern. 4. Alteration in comfort.

Ans 4 1. Alteration in nutrition may be an appropriate client problem, but it is not priority. 2. Alteration in skin integrity may be an appropriate client problem but is not priority. 3. Alteration in urinary elimination may be an appropriate client problem but is not priority. 4. Acute pain management is the highest priority client problem after surgery because pain may indicate a life-threatening problem.

The client is in the preicteric phase of hepatitis. Which signs/symptoms should the nurse expect the client to exhibit during this phase? 1. Clay-colored stools and jaundice. 2. Normal appetite and pruritus. 3. Being afebrile and left upper quadrant pain. 4. Complaints of fatigue and diarrhea

Ans 4 1. Clay-colored stools and jaundice occur in the icteric phase of hepatitis. 2. Normal appetite and itching occur in the icteric phase of hepatitis. 3. Fever subsides in the icteric phase, and the pain is in the right upper quadrant. 4. "Flu-like" symptoms are the first com-plaints of the client in the preicteric phase of hepatitis, which is the initial phase and may begin abruptly or insidiously.

The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication? 1. Restrict sodium intake to 2 g/day. 2. Limit oral fluids to 1,500 mL/day. 3. Decrease the daily fat intake. 4. Reduce protein intake to 60 to 80 g/day.

Ans 4 1. Sodium is restricted to reduce ascites and generalized edema, not for hepatic encephalopathy. 2. Fluids are calculated based on di-uretic therapy, urine output, and serum electrolyte values; fluids do not affect hepatic encephalopathy. 3. A diet high in calories and moderate in fat intake is recommended to promote healing. 4. Ammonia is a by-product of protein metabolism and contributes to hepatic encephalopathy. Reducing protein intake should decrease ammonia levels.

Which statement by the client diagnosed with hepatitis warrants immediate intervention by the clinic nurse? 1. "I will not drink any type of beer or mixed drink." 2. "I will get adequate rest so I don't get exhausted." 3. "I had a big hearty breakfast this morning." 4. "I took some cough syrup for this nasty head cold."

Ans 4 1. The client should avoid alcohol to prevent further liver damage and promote healing. 2. Rest is needed for healing of the liver and to promote optimum immune function. 3. Clients with hepatitis need increased caloric intake, so this is a good statement. 4. The client needs to understand some types of cough syrup have alcohol and all alcohol must be avoided to prevent further injury to the liver; therefore, this statement requires intervention.

Which outcome should the nurse identify for the client scheduled to have a cholecystectomy? 1. Decreased pain management. 2. Ambulate first day postoperative. 3. No break in skin integrity. 4. Knowledge of postoperative care.

Ans 4 1. The expected outcome is pain control for both preoperative and postoperative care. 2. Postoperative care includes ambulation. 3. Prevention of an additional impaired skin integrity is a desired postoperative out-come. The incision would be a break in skin integrity. 4. This would be an expected outcome for the client scheduled for surgery. This indicates preoperative teaching has been effective.

The nurse is preparing to hang a new bag of total parental nutrition for a client with an abdominal perineal resection. The bag has 1,500 mL of 50% dextrose, 10 mL of trace elements, 20 mL of multivitamins, 20 mL of potassium chloride, and 500 mL of lipids. The bag is to infuse over the next 24 hours. At what rate should the nurse set the pump?

85 mL/hr. First determine the total amount to be infused over 24 hours: 1500 + 500 + 20 + 20 = 2,040 mL over 24 hours. Then, determine the rate per hour:2,040 ÷ 24 = 85 mL/hr.