NCLEX Gastric Questions

The nurse is caring for an older client. The nurse should anticipate that medication dosages will be further adjusted if the client has dysfunction of which organ? 1.Liver 2.Stomach 3.Pancreas 4.Gallbladder

1 Rationale:An important function of the liver is to break down medications and other toxic substances. The older client with liver disease is at increased risk for toxic medication effects and should be monitored carefully for adverse effects. Diseases of the stomach, pancreas, and gallbladder are a lesser concern for prolonged medication effects.

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? 1.Sweating and pallor 2.Bradycardia and indigestion 3.Double vision and chest pain 4.Abdominal cramping and pain

1 Rationale:Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

The nurse is teaching the postgastrectomy client about measures to prevent dumping syndrome. Which statement by the client indicates a need for further teaching? 1."I need to lie down after eating." 2."I need to drink liquids with meals." 3."I need to avoid concentrated sweets." 4."I need to eat small meals 6 times daily."

2 Rationale:The client with dumping syndrome should avoid drinking liquids with meals. The client should be placed on a high-protein, moderate-fat, high-calorie diet and should lie down after eating. The client should avoid concentrated sweets, and frequent small meals are encouraged.

A client seen in the ambulatory care clinic has ascites and slight jaundice. The nurse should assess the client for a history of chronic use of which medication? 1.Ibuprofen 2.Ranitidine 3.Acetaminophen 4.Acetylsalicylic acid

3 Rationale:Acetaminophen is a potentially hepatotoxic medication. Use of this medication and other hepatotoxic agents should be investigated whenever a client presents with signs and symptoms compatible with liver disease (i.e., ascites and jaundice). Hepatotoxicity is not an adverse effect of the medications identified in the remaining options.

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1.Dorsiflex the client's foot. 2.Measure the abdominal girth. 3.Ask the client to extend the arms. 4.Instruct the client to lean forward.

3 Rationale:Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect.

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding? 1.Waves of loud gurgles auscultated in all 4 quadrants 2.Low-pitched swishing auscultated in 1 or 2 quadrants 3.Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants 4.Very high-pitched, loud rushes auscultated especially in 1 or 2 quadrants

1 Rationale:Although frequency and intensity of bowel sounds vary depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with nausea and vomiting. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds. Bowel sounds are very high-pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment data would alert the nurse to this occurrence? 1.Inability to pass flatus 2.Loss of anal sphincter control 3.Severe, constant pain with rapid onset 4.Firm, nontender mass palpable at the lower right costal margin

1 Rationale:An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of anal sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. A firm, palpable mass at the right costal margin describes the physical finding of liver enlargement, which is usually associated with cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, this is not a sign of paralytic ileus or intestinal obstruction.

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1.This is a normal, expected event. 2.The client is experiencing early signs of ischemic bowel. 3.The client should not have the nasogastric tube removed. 4.This indicates inadequate preoperative bowel preparation.

1 Rationale:As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect interpretations.

The nurse cares for a client following a Roux-en-Y gastric bypass surgery. Which nursing intervention is appropriate? 1.Encourage the client to ambulate. 2.Position the client on the left side. 3.Frequently irrigate the nasogastric tube (NG) with 30 mL saline. 4.Discourage the use of the patient-controlled analgesia (PCA) machine.

1 Rationale:Bariatric clients are at risk for developing deep vein thrombosis and atelectasis. It is important to encourage ambulation to promote both venous return in the legs and lung expansion. Therefore, the correct option is 1. Option 2 is incorrect, as positioning on the left side is not indicated and positioning on the right side would be more appropriate to facilitate gastric emptying. Option 3 is incorrect, as the stomach after a Roux-en-Y procedure is very small and often holds only 30 mL, so frequent irrigation with 30 mL could lead to disruption of the anastomosis or staple line. Option 4 is incorrect because clients who have gastric bypass surgery are often in a considerable amount of pain and it is important for their pain to be controlled so that they are able to do the activities required, such as coughing and deep breathing and ambulation, to prevent complications.

A client is admitted to the hospital with acute viral hepatitis. Which sign or symptom should the nurse expect to note based on this diagnosis? 1.Fatigue 2.Pale urine 3.Weight gain 4.Spider angiomas

1 Rationale:Common manifestations of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider angiomas-small, dilated blood vessels-are commonly seen in cirrhosis of the liver.

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? 1."I should increase the fiber in my diet." 2."I will need to avoid caffeinated beverages." 3."I'm going to learn some stress reduction techniques." 4."I can have exacerbations and remissions with Crohn's disease."

1 Rationale:Crohn's disease is an inflammatory disease that can occur anywhere in the gastrointestinal tract but most often affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses. It is characterized by exacerbations and remissions. If stress increases the symptoms of the disease, the client is taught stress management techniques and may require additional counseling. The client is taught to avoid gastrointestinal stimulants containing caffeine and to follow a high-calorie and high-protein diet. A low-fiber diet may be prescribed, especially during periods of exacerbation.

Diphenoxylate hydrochloride with atropine sulfate is prescribed for a client with ulcerative colitis. The nurse should monitor the client for which therapeutic effect of this medication? 1.Decreased diarrhea 2.Decreased cramping 3.Improved intestinal tone 4.Elimination of peristalsis

1 Rationale:Diphenoxylate hydrochloride with atropine sulfate is an antidiarrheal product that decreases the frequency of defecation, usually by reducing the volume of liquid in the stools. The remaining options are not associated therapeutic effects of this medication.

A client who has a gastrostomy tube for feeding refuses to participate in the plan of care, will not make eye contact, and does not speak to the family or visitors. The nurse interprets that the client is using which coping mechanism? 1.Distancing 2.Self-control 3.Problem solving 4.Accepting responsibility

1 Rationale:Distancing is an unwillingness or inability to discuss events. Self-control is demonstrated by stoicism and hiding feelings. Problem solving involves making plans and verbalizing what will be done. Accepting responsibility places the responsibility for a situation on oneself.

A client has been advanced to a solid diet after undergoing a subtotal gastrectomy. What is the appropriate nursing intervention in preventing dumping syndrome? 1. Remove fluids from the meal tray. 2. Give the client 2 large meals per day. 3. Ask the client to sit up for 1 hour after eating. 4. Provide concentrated, high-carbohydrate foods.

1 Rationale:Factors to minimize dumping syndrome after gastric surgery include having the client lie down for at least 30 minutes after eating; giving small, frequent meals; having the client maintain a low-Fowler's position while eating, if possible; avoiding liquids with meals; and avoiding high-carbohydrate food sources. Antispasmodic medications also are prescribed as needed to delay gastric emptying

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? 1.Malaise 2.Dark stools 3.Weight gain 4.Left upper quadrant discomfort

1 Rationale:Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.

The nurse is reviewing the results of serum laboratory studies for a client admitted for suspected hepatitis. Which laboratory finding is most associated with hepatitis, requiring the nurse to contact the primary health care provider? 1.Elevated serum bilirubin level 2.Below normal hemoglobin concentration 3.Elevated blood urea nitrogen (BUN) level 4.Elevated erythrocyte sedimentation rate (ESR)

1 Rationale:Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and ESR. However, ESR is a nonspecific test that indicates the presence of inflammation somewhere in the body. The hemoglobin concentration is unrelated to this diagnosis. An elevated BUN level may indicate renal dysfunction.

The nurse is reviewing the record of a client admitted to the nursing unit and notes that the client has a history of Laënnec's cirrhosis. Which question related to the client's history would be most important to ask? 1."Do you abuse alcohol?" 2."Do you have any known cardiac disease?" 3."Does your type of employment cause you to have exposure to chemicals?" 4."Have you ever been told that you have had obstruction to your biliary ducts?"

1 Rationale:Laënnec's cirrhosis results from long-term alcohol abuse; therefore, the question inquiring about alcohol abuse is most appropriate. Cardiac cirrhosis most commonly is caused by long-term right-sided heart failure. Exposure to hepatotoxins, chemicals, or infections or a metabolic disorder can cause postnecrotic cirrhosis. Biliary cirrhosis results from a decrease in bile flow and is most commonly caused by long-term obstruction of bile ducts.

A Penrose drain is in place on the first postoperative day in a client who has undergone a cholecystectomy procedure. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate? 1.Change the dressing. 2.Continue to monitor the drainage. 3.Notify the primary health care provider (PHCP). 4.Use a pen to circle the amount of drainage on the dressing.

1 Rationale:Serosanguinous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is usually removed within 48 hours. A sterile dressing covers the site and should be changed if wet to prevent infection and skin excoriation. Although the nurse would continue to monitor the drainage, the most appropriate intervention is to change the dressing. The PHCP does not need to be notified.

A client with viral hepatitis states, "I am so yellow." What is the most appropriate nursing action? 1.Assist the client in expressing feelings. 2.Restrict visitors until the jaundice subsides. 3.Perform most of the activities of daily living for the client. 4.Provide information to the client only when he or she requests it.

1 Rationale:The client should be supported to explore feelings about the disease process and altered appearance so that appropriate interventions can be planned. Restricting visitors would reinforce the client's negative self-esteem. To assist the client in adapting to changes in appearance, it is important for the nurse to encourage participation in self-care to foster independence and self-esteem. The client should be encouraged to ask questions to clarify misconceptions, to learn ways to prevent the spread of hepatitis, to reduce fear, and to make appropriate decisions.

The nurse is reviewing the primary health care provider's prescriptions written for a client admitted to the hospital with acute pancreatitis. Which prescription requires follow-up by the nurse? 1.Full liquid diet 2.Morphine sulfate for pain 3.Nasogastric tube insertion 4.An anticholinergic medication

1 Rationale:The client with acute pancreatitis is placed on NPO (nothing by mouth) status to decrease the activity of the pancreas, which occurs with oral intake. Pain management for acute pancreatitis typically begins with the administration of opioids by patient-controlled analgesia. Medications such as morphine or hydromorphone are typically used. Nasogastric tube insertion is done to provide suction of secretions and administer medications as necessary.

A client with chronic pancreatitis needs information on dietary modification to manage the health problem. Which item in the diet should the nurse teach the client to limit? 1.Fat 2.Protein 3.Carbohydrate 4.Water-soluble vitamins

1 Rationale:The client with chronic pancreatitis should limit fat in the diet and also take in small meals, which will reduce the amount of carbohydrates and protein that the client must digest at any one time. The client does not need to limit water-soluble vitamins in the diet.

The nurse is providing dietary instructions to a client hospitalized for pancreatitis. Which food should the nurse instruct the client to avoid? 1.Chili 2.Bagel 3.Lentil soup 4.Watermelon

1 Rationale:The client with pancreatitis needs to avoid alcohol, coffee and tea, spicy foods, and heavy meals, which stimulate pancreatic secretions, producing attacks of pancreatitis. The client is instructed in the benefit of eating small, frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates.

The nurse is caring for a client with biliary obstruction. The nurse interprets that obstruction of which passage is related to the client's condition? 1.Cystic duct 2.Liver canaliculi 3.Common bile duct 4.Right hepatic duct

1 Rationale:The gallbladder receives bile from the liver through the cystic duct. The liver collects bile in the canaliculi, from which bile flows into the right and left hepatic ducts and then into the common hepatic duct. From there, the bile can be transported for storage in the gallbladder through the cystic duct, or it can flow directly into the duodenum by way of the common bile duct.

The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which assessment question would most specifically elicit information regarding the pain that is associated with acute pancreatitis? 1."Does the pain in your stomach radiate to your back?" 2."Does the pain in your lower abdomen radiate to your hip?" 3."Does the pain in your lower abdomen radiate to your groin?" 4."Does the pain in your stomach radiate to your lower middle abdomen?"

1 Rationale:The pain that is associated with acute pancreatitis is often severe, is located in the epigastric region, and radiates to the back. The remaining options are incorrect because they are not specific for the pain experienced by the client with pancreatitis.

A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? Select all that apply. 1.Orthopnea and dyspnea 2.Petechiae and ecchymosis 3.Inguinal or umbilical hernia 4.Poor body posture and balance 5.Abdominal distention and tenderness

1235 Rationale:Excess fluid volume, related to the accumulation of fluid in the peritoneal cavity and dependent areas of the body, can occur in the client with cirrhosis. Ascites can cause physical problems because of the overdistended abdomen and resultant pressure on internal organs and vessels. These problems include respiratory difficulty, petechiae and ecchymosis, development of hernias, and abdominal distention and tenderness. Poor body posture and balance are unrelated to increased abdominal pressure.

The ambulatory care nurse is providing instructions to a client who is scheduled for a small bowel biopsy. What should the nurse tell the client? 1.Clear liquids only are allowed on the day of the test. 2.A signed informed consent form will need to be obtained. 3.A tube will be inserted through the rectum to obtain the tissue sample. 4.A full liquid diet will need to be maintained for 48 hours after the procedure.

2 Rationale:A signed informed consent form is required for this procedure. The client is instructed to maintain a clear liquid diet for 24 to 48 hours before the biopsy and to withhold all food and fluids after the evening meal before the day of the scheduled biopsy. A small bowel biopsy involves removal of a tissue specimen from the small intestine for examination and aids in the diagnosis of diseases of the small intestine. A small biopsy tube is passed through the client's mouth and is monitored fluoroscopically until it reaches the desired location in the jejunum. A normal diet may be resumed after the procedure as soon as the gag reflex returns.

A home care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home care management instructions to the client. Which client statement indicates a need for further instruction? 1."I will obtain adequate rest." 2."I will take acetaminophen if I get a headache." 3."I should monitor my weight on a regular basis." 4."I need to include sufficient amounts of carbohydrates in my diet."

2 Rationale:Acetaminophen is avoided because it can cause fatal liver damage in the client with cirrhosis. Adequate rest and nutrition are important. The client's weight should be monitored on a regular basis. The diet should supply sufficient carbohydrates with a total daily calorie intake of 2000 to 3000.

The nurse is teaching an older client about measures to prevent constipation. Which statement by the client indicates a need for further teaching? 1."I walk 1 to 2 miles every day." 2."I need to decrease fiber in my diet." 3."I have a bowel movement every other day." 4."I drink 6 to 8 glasses of water every day."

2 Rationale:An older client has an increased tendency to experience constipation because of decreased stomach-emptying time and a lowered basal metabolic rate. Adequate dietary fiber is an important factor in aiding bowel function. Dietary fiber increases fecal weight and water content and accelerates the transit of fecal mass through the gastrointestinal tract. The retention of water by the fiber has the ability to soften stools and promote regularity. Fluid intake and exercise also facilitate bowel elimination.

The nurse is caring for a client prescribed enteral feeding via a newly inserted nasogastric (NG) tube. Before initiating the enteral feeding, the nurse should perform which action first? 1.Warm the feeding to 103º F (39.4º C). 2.Confirm NG placement by x-ray study. 3.Make sure the continuous enteral feeding tubing is primed. 4.Position the head of the client's bed to 30 degrees or greater.

2 Rationale:Before initiating enteral feedings via a newly inserted NG tube, the placement of the tube is confirmed by x-ray. If the tube is not in the stomach, the client is at risk for aspiration. Formulas are administered at room temperature, not at 103º F. To prevent aspiration while administering a tube feeding, the nurse should place the client in an upright sitting position or elevate the head of the bed at least 30 degrees. Although an important action, it is not the priority. Priming the enteral feeding tube is important prior to initiating the feedings; however, it is not the priority action.

The nurse is caring for a client who had a subtotal gastrectomy. The nurse should assess the client for which signs and symptoms of dumping syndrome? 1.Diarrhea, chills, and hiccups 2.Weakness, diaphoresis, and diarrhea 3.Fever, constipation, and rectal bleeding 4.Abdominal pain, elevated temperature, and weakness

2 Rationale:Dumping syndrome occurs after gastric surgery because food is not held long enough in the stomach and is "dumped" into the small intestine as a hypertonic mass. This causes fluid to shift into the intestines, causing cardiovascular and gastrointestinal symptoms. Signs and symptoms typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea.

The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the primary health care provider? 1.Stoma is beefy red and shiny 2.Purple discoloration of the stoma 3.Skin excoriation around the stoma 4.Semi-formed stool noted in the ostomy pouch

2 Rationale:Ischemia of the stoma would be associated with a dusky or bluish or purple color. A beefy red and shiny stoma is normal and expected. Skin excoriation needs to be addressed and treated but does not require as immediate attention as purple discoloration of the stoma. Semi-formed stool is a normal finding.

Lactulose is prescribed for a hospitalized client with a diagnosis of hepatic encephalopathy. Which assessment finding indicates that the client is responding to this medication therapy as anticipated? 1.Vomiting occurs. 2.The fecal pH is acidic. 3.The client experiences diarrhea. 4.The client is able to tolerate a full diet.

2 Rationale:Lactulose is an osmotic laxative used to decrease ammonia levels, which are elevated in hepatic encephalopathy. The desired effect is 2 or 3 soft stools per day with an acid fecal pH. Lactulose creates an acid environment in the bowel, resulting in a fall of the colon's pH from 7 to 5. This causes ammonia to leave the circulatory system and move into the colon for excretion. Diarrhea may indicate excessive administration of the medication. Vomiting and ability to tolerate a full diet do not determine that a desired effect has occurred.

A client is admitted to the hospital with a diagnosis of acute pancreatitis. Which would the nurse expect the client to report about the pain? 1.Eating helps to decrease the pain. 2.The pain usually increases after vomiting. 3.The pain is mostly around the umbilicus and comes and goes. 4.The pain increases when the client sits up and bends forward.

2 Rationale:Pain with acute pancreatitis usually increases after vomiting because of an increase in intraductal pressure caused by retching, which leads to further obstruction of the outflow of pancreatic secretions. The pain is a steady and intense epigastric pain that radiates to the client's back and flank. The pain may lessen when the client sits up or bends forward. Eating exacerbates the pain by stimulating the secretion of enzymes.

The nurse is assisting a primary health care provider (PHCP) with the insertion of a Miller-Abbott tube. The nurse understands that the procedure places the client at risk for aspiration and should therefore implement which action to decrease this risk? 1.Insert the tube with the balloon inflated. 2.Place the client in a semi-Fowler's to high-Fowler's position. 3.Instruct the client to cough when the tube reaches the nasal pharynx. 4.Instruct the client to perform a Valsalva maneuver if the impulse to gag and vomit occurs.

2 Rationale:The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine, as in correcting a bowel obstruction. Initial insertion of the tube is an PHCP responsibility. The tube is inserted with the balloon deflated in a manner similar to the proper procedure for inserting a nasogastric tube. The client is usually given water to drink to facilitate passage of the tube through the nasopharynx and esophagus. A semi-Fowler's to high-Fowler's position decreases the risk of aspiration if vomiting occurs. A Valsalva maneuver is not helpful and is not used if the impulse to gag occurs.

A client with appendicitis is scheduled for an appendectomy. The nurse providing preoperative teaching for the client describes the location of the appendix by stating that it is attached to which part of the gastrointestinal (GI) system? 1.Ileum 2.Cecum 3.Rectum 4.Jejunum

2 Rationale:The appendix, sometimes referred to as the vermiform appendix, is attached to the apex of the cecum. The other locations listed are incorrect.

A client is readmitted to the hospital with dehydration after surgery for creation of an ileostomy. The nurse assesses that the client has lost 3 lb of weight, has poor skin turgor, and has concentrated urine. The nurse interprets the client's clinical picture as correlating most closely with recent intake of which medication, which is contraindicated for the ileostomy client? 1.Folate 2.Biscodyl 3.Ferrous sulfate 4.Cyanocobalamin

2 Rationale:The client with an ileostomy is prone to dehydration because of the location of the ostomy in the gastrointestinal tract and should not take laxatives. Laxatives will compound the potential risk for the client. These clients are at risk for deficiencies of folate, iron, and cyanocobalamin and should receive them as supplements if necessary.

The nurse is providing dietary instructions to a client with a diagnosis of irritable bowel syndrome. The nurse determines that education was effective if the client states the need to avoid which food? 1.Rice 2.Corn 3.Broiled chicken 4.Cream of wheat

2 Rationale:The client with irritable bowel should take in a diet that consists of 30 to 40 g of fiber daily because dietary fiber will help produce bulky, soft stools and establish regular bowel habits. The client should also drink 8 to 10 glasses of fluid daily and chew food slowly to promote normal bowel function. Foods that are irritating to the intestines need to be avoided. Corn is high in fiber but can be very irritating to the intestines and should be avoided. The food items in the other options are acceptable to eat.

A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? 1.Call the surgeon to report the problem. 2.Reposition the NG tube to the proper location. 3.Check the suction device to make sure it is working. 4.Irrigate the NG tube with saline to remove the obstruction.

3 Rationale:After gastric surgery, the client will have an NG tube in place until bowel function returns. It is important for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse must ensure that the NG tube is attached to suction at the level prescribed and that the suction device is working correctly. The tip of the NG tube may be placed near the suture line. Because of this possibility, the nurse should never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned, the nurse should call the surgeon, who would do this repositioning under fluoroscopy.

The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels? 1.Evaluating for asterixis 2.Inspecting for petechiae 3.Palpating for peripheral edema 4.Evaluating for decreased level of consciousness

3 Rationale:Albumin is responsible for maintaining the osmolality of the blood. When there is a low albumin level, there is decreased osmotic pressure, which in turn can lead to peripheral edema. The remaining options are incorrect and are not associated with a low albumin level

A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain. Appendicitis is suspected, and appropriate laboratory tests are performed. The emergency department nurse reviews the test results and notes that the client's white blood cell (WBC) count is elevated. The nurse also reviews the prescriptions from the primary health care provider (PHCP). The nurse should contact the PHCP to question which prescription if noted in the client's record? 1.Maintain a semi-Fowler's position. 2.Maintain on NPO (nothing by mouth) status. 3.Apply a heating pad to the lower abdomen for comfort. 4.Initiate an intravenous (IV) line with the administration of IV fluids.

3 Rationale:Appendicitis should be suspected in a client with an elevated WBC count who is complaining of acute right lower quadrant abdominal pain. A semi-Fowler's position is maintained for comfort. The client would be on NPO status and given IV fluids in preparation for possible surgery. Heat should never be applied to the abdomen because this may increase circulation to the appendix, potentially leading to increased inflammation and perforation.

The nurse is caring for a client postoperatively after creation of a colostomy. What is an appropriate potential client problem? 1.Fear 2.Sexual dysfunction 3.Disturbed body image 4.Imbalanced nutrition: more than body requirements

3 Rationale:Disturbed body image for a client who is postoperative after creation of a colostomy relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). There are no data in the question to support sexual dysfunction or fear. Imbalanced nutrition: less (not more) than body requirements is the more likely client problem.

The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? 1.Ambulate following a meal. 2.Eat high-carbohydrate foods. 3.Limit the fluids taken with meals. 4.Sit in a high-Fowler's position during meals.

3 Rationale:Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a gastrojejunostomy (Billroth II procedure). Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low-Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed.

The nurse is caring for a client with altered protein metabolism as a result of liver dysfunction. Which finding should the nurse expect to note when reviewing the client's laboratory results? 1.Increased lactase level 2.Decreased albumin level 3.Increased ammonia level 4.Decreased lactic acid level

3 Rationale:During deamination of proteins in the liver, the amino group splits from the carbon-containing compound, which results in formation of ammonia and a carbon residue. The liver then converts the toxic ammonia substance into urea, which can be excreted by the kidneys. Clients with liver dysfunction may have high serum ammonia levels as a result. The remaining options are incorrect.

A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, "I'm not sure I can avoid alcohol." What is the most appropriate nursing response? 1."I don't believe that." 2."Everything will be all right." 3."I'm not sure that I understand. Would you please explain?" 4."I think you should talk more with the primary health care provider about this."

3 Rationale:Explaining what is vague or clarifying the meaning of what has been said increases understanding for both the client and the nurse. Refusing to consider the client's ideas may cause the client to discontinue interaction with the nurse for fear of further rejection. False reassurance devalues the client's feelings. Placing the client's feelings on hold by referring him or her to the primary health care provider for further information is a block to communication.

The nurse is caring for a client admitted with severe weight loss due to dieting. Based on the data provided, which condition should the nurse suspect is occurring in this client? 1.Lactic acidosis 2.Glycogenolysis 3.Gluconeogenesis 4.Glucose metabolism

3 Rationale:Gluconeogenesis is the production of glucose for energy from protein and fat stores in the body. This can occur with extreme dieting and also with diabetes mellitus. Glycogenolysis is the production of glucose from glycogen stores in the liver. Lactic acidosis occurs with excess production of lactic acid resulting from anaerobic metabolism. The body normally burns glucose for energy.

The medication history of a client with peptic ulcer disease reveals intermittent use of several medications. The nurse would teach the client that which of these medications are not a part of the treatment plan because of its irritating effects on the lining of the gastrointestinal tract? 1.Nizatidine 2.Sucralfate 3.Ibuprofen 4.Omeprazole

3 Rationale:Ibuprofen is a nonsteroidal anti-inflammatory drug that typically is irritating to the lining of the gastrointestinal tract and should be avoided by clients with a history of peptic ulcer disease. The other medications listed are frequently used to treat peptic ulcer disease. Nizatidine is an H2-receptor antagonist that reduces the secretion of gastric acid. Sucralfate coats the surface of an ulcer to promote healing. Omeprazole is a proton pump inhibitor that blocks transport of hydrogen ions into the lumen of the gastrointestinal tract.

The nurse checks the gastric residual of an unconscious client receiving nasogastric tube feedings continuously at 50 mL/hr. The nurse notes that the residual is 250 mL at 0800 and 300 mL at 0900. The nurse determines that the client is experiencing which complication? 1.Air in the stomach 2.Too slow an infusion rate 3.Delayed gastric emptying 4.Early signs of peptic ulcer

3 Rationale:If the gastric residual is greater than 200 mL for 2 consecutive hours, the client may be experiencing delayed gastric emptying. If this occurs, the feeding is stopped, and the primary health care provider should be notified. The nurse should assess whether abdominal girth is enlarged and should auscultate bowel sounds to rule out intestinal obstruction. Some clients benefit from administration of metoclopramide to stimulate gastric emptying. Air in the stomach would be accompanied by abdominal distention and increased abdominal girth. The infusion rate cannot be too slow if the client is not tolerating the rate. Early peptic ulcer could be detected by a Hematest-positive gastric aspirate. In addition, agency procedures should be followed regarding gastric residuals.

During a home care visit, an adult client complains of chronic constipation. What should the nurse tell the client to do? 1. Increase potassium in the diet. 2. Include rice and bananas in the diet. 3. Increase fluid and dietary fiber intake. 4. Increase the intake of sugar-free products.

3 Rationale:Increase of fluid intake and dietary fiber will help change the consistency of the stool, making it easier to pass. Increasing the intake of rice and bananas will increase constipation. Increasing sugar-free products and potassium in the diet will not assist in alleviating constipation.

The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, should the nurse question? 1.Digoxin 2.Furosemide 3.Indomethacin 4.Propranolol hydrochloride

3 Rationale:Indomethacin is a nonsteroidal anti-inflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Digoxin is a cardiac medication. Furosemide is a loop diuretic. Propranolol hydrochloride is a beta-adrenergic blocking agent. Digoxin, furosemide, and propranolol are not contraindicated in clients with gastric disorders.

The nurse is caring for a client admitted to the hospital with suspected acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? 1.White blood cell (WBC) count of 4000 mm3 (4 × 109/L) 2.WBC count of 8000 mm3 (8 × 109/L) 3.WBC count of 18,000 mm3 (18 × 109/L) 4.WBC count of 26,000 mm3 (26 × 109/L)

3 Rationale:Laboratory findings do not establish the diagnosis of appendicitis, but there is often a moderate elevation of the WBC count (leukocytosis) to 10,000 to 18,000 mm3 (10 to 18 × 109/L) with an increased number of immature WBCs. An inflammatory process causes a rise in the WBC count. A rise to 26,000 mm3 (26 × 109/L) may indicate a perforated appendix (greater than 20,000 mm3 [20 × 109/L]).

The nurse teaches a preoperative client about the use of a nasogastric (NG) tube for the planned surgery. Which statement indicates to the nurse that the client understands when the tube can be removed in the postoperative period? 1."When I can tolerate food without vomiting." 2."When my gastrointestinal system is healed enough." 3."When my bowels begin to function again, and I begin to pass gas." 4."When my primary health care provider says the tube can come out."

3 Rationale:NG tubes are discontinued when normal function returns to the gastrointestinal (GI) tract. Food would not be administered unless bowel function returns. The tube will be removed before GI healing. Although the primary health care provider (PHCP) determines when the NG tube will be removed, it does not determine effectiveness of teaching and the need for the NG tube.

The nurse is developing a teaching plan for a client with viral hepatitis. The nurse should plan to include which information in the teaching session? 1.The diet should be low in calories. 2.Meals should be large to conserve energy. 3.Activity should be limited to prevent fatigue. 4.Alcohol intake should be limited to 2 ounces per day.

3 Rationale:Rest is necessary for the client with hepatitis, and the client with viral hepatitis should limit activity to avoid fatigue. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per day. Alcohol is strictly forbidden.

The nurse is providing instructions to a client regarding measures to minimize the risk of dumping syndrome. The nurse should make which suggestion to the client? 1.Maintain a high-carbohydrate diet. 2.Increase fluid intake, particularly at mealtime. 3.Maintain a low-Fowler's position while eating. 4.Ambulate for at least 30 minutes following each meal.

3 Rationale:The client at risk for dumping syndrome should be instructed to maintain a low-Fowler's position while eating and lie down for at least 30 minutes after eating. The client also should be told that small, frequent meals are best and to avoid liquids with meals. Avoiding high-carbohydrate food sources also will assist in minimizing dumping syndrome.

The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement? 1."I know I must sign the consent form." 2."I hope the throat spray keeps me from gagging." 3."I'm glad I don't have to lie still for this procedure." 4."I'm glad some intravenous medication will be given to relax me."

3 Rationale:The client does have to lie still for ERCP, which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.

The nurse has given postprocedure instructions to a client who has undergone a colonoscopy. Which statement by the client indicates the need for further teaching? 1."It is normal to feel gassy or bloated after the procedure." 2."The abdominal muscles may be tender from the procedure." 3."It is all right to drive once I've been home for an hour or so." 4."Intake should be light at first and then progress to regular intake."

3 Rationale:The client should not drive for several hours after discharge because of the sedative medications used during the procedure. Important decisions also should be delayed for at least 12 to 24 hours for the same reason. The client may experience gas, bloating, or abdominal tenderness for a short while after the procedure, and this is normal. The client should resume intake slowly and progress as tolerated.

A client with gastric hypersecretion is scheduled for surgery. The nurse teaches the client that the procedure will lessen the stomach's production of acid by altering which structure? 1.Portal vein 2.Celiac artery 3.Vagus nerve 4.Pyloric valve

3 Rationale:Vagotomy is a procedure that can reduce innervation to the stomach, thereby reducing the production of gastric acid. The portal vein drains venous blood from the stomach. The celiac artery brings arterial blood to the stomach. The pyloric valve separates the stomach from the duodenum. The pyloric valve may undergo surgical repair if it becomes stenosed; this procedure is known as pyloroplasty.

The nurse plans care for a client postoperatively following creation of a colostomy. Which potential client problem should the nurse include in the plan of care? 1.Fear 2.Anxiety 3.Sexual dysfunction 4.Upset about appearance

4 Rationale:Being upset about appearance relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). There are no data in the question to support the remaining problems.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube? 1.Checking for normal serum electrolyte levels 2.Checking for normal pH of the gastric aspirate 3.Checking for proper nasogastric tube placement 4.Checking for the presence of bowel sounds in all 4 quadrants

4 Rationale:Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, pH of the gastric aspirate, and tube placement are important assessments for the client with a nasogastric tube in place but would not assist in determining the readiness for removing the nasogastric tube.

A client is scheduled for an upper gastrointestinal (GI) endoscopy. Which assessment is essential to include in the plan of care following the procedure? 1.Assessing pulses 2.Monitoring urine output 3.Monitoring for rectal bleeding 4.Assessing for the presence of the gag reflex

4 Rationale:Following the procedure, the client remains NPO (nothing by mouth) until the gag reflex returns, which is usually in 1 to 2 hours. The remaining options are not specific assessments related to this procedure.

The nurse is performing an admission assessment on a client who has been admitted to the hospital with a diagnosis of suspected gastric ulcer. The nurse is asking the client questions about pain. Which client statement supports the diagnosis of gastric ulcer? 1."The pain doesn't usually come right after I eat." 2."The pain gets so bad that it wakes me up at night." 3."The pain that I get is located on the right side of my chest." 4."My pain comes shortly after I eat, maybe a half hour or so later."

4 Rationale:Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be exacerbated by intake of food. The pain occurs 30 to 60 minutes after a meal and rarely occurs at night. Duodenal ulcer pain is usually located to the right of the epigastrium. The pain associated with a duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the client at night.

The registered nurse is precepting a new nurse who is caring for a client with pernicious anemia as a result of a gastrectomy. Which statement made by the new nurse indicates understanding of this diagnosis? 1."It's due to insufficient production of vitamin B12 in the colon." 2."Increased production of intrinsic factor in the stomach leads to this type of anemia." 3."Overproduction of vitamin B12 in the large intestine can result in pernicious anemia." 4."Decreased production of intrinsic factor by the stomach affects absorption of vitamin B12 in the small intestine."

4 Rationale:Intrinsic factor is produced in the stomach but is used to aid in the absorption of vitamin B12 in the small intestine. This vitamin is not produced or absorbed in the large intestine.

A client with Crohn's disease is experiencing acute pain, and the nurse provides information about measures to alleviate the pain. Which statement by the client indicates the need for further teaching? 1."I know I can massage my abdomen." 2."I will continue using antispasmodic medication." 3."One of the best things I can do is use relaxation techniques." 4."The best position for me is to lie supine with my legs straight."

4 Rationale:Pain associated with Crohn's disease is alleviated by the use of analgesics and antispasmodics and also by practicing relaxation techniques, applying local cold or heat to the abdomen, massaging the abdomen, and lying with the legs flexed. Lying with the legs extended is not useful because it increases the muscle tension in the abdomen, which could aggravate inflamed intestinal tissues as the abdominal muscles are stretched.

A client with a diagnosis of stomach ulcer from gastric hyperacidity asks the nurse why the acid has not caused an ulcer in the small intestine as well. The nurse responds that the pH of intestinal contents is raised by bicarbonate, which is present in which area of the body? 1.Bile 2.Parietal cells 3.Liver enzymes 4.Pancreatic juice

4 Rationale:Pancreatic juice is rich is bicarbonate, which helps to neutralize the gastric acid in food entering the small intestine from the stomach. The duodenal papilla, which is an opening about 10 cm below the level of the pylorus, is responsible for carrying bile and pancreatic juices into the duodenum. Bile, parietal cells, and liver enzymes are not substances rich in bicarbonate and are incorrect.

A client with peptic ulcer disease states that stress frequently causes exacerbation of the disease. The nurse determines that which item mentioned by the client is most likely to be responsible for the exacerbation? 1.Sleeping 8 to 10 hours a night 2.Ability to work at home periodically 3.Eating 5 or 6 small meals per day 4.Frequent need to work overtime on short notice

4 Rationale:Psychological or emotional stressors that exacerbate peptic ulcer disease may be found either at home or in the workplace. Of the items listed, the frequent need to work overtime on short notice is potentially the most stressful because it is the item over which the client has the least control. An ability to work at home periodically is not necessarily stressful because it allows increased client control over timing and location of work. Adequate rest and a proper dietary pattern (options 1 and 3) should alleviate symptoms, not worsen them.

A client who has undergone creation of a colostomy has a concern about body image. What action by the client indicates the most significant progress toward identified goals? 1.Looking at the ostomy site 2.Reading the ostomy product literature 3.Watching the nurse empty the ostomy bag 4.Practicing proper cutting of the ostomy appliance

4 Rationale:The client is expected to have body image disturbance after colostomy. The client progresses through normal grieving stages to adjust to this change. The client demonstrates the greatest degree of acceptance when he or she participates in the actual colostomy care. Each incorrect option represents an interest in colostomy care but is a passive activity. The correct option shows the client participating in self-care.

The nurse is caring for a client on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, the nurse should take which action? 1. Document the findings. 2. Reassess the pH in 4 hours. 3. Instill 30 mL of sterile water. 4. Administer a dose of a prescribed antacid.

4 Rationale:The client on a mechanical ventilator who has a nasogastric tube in place should have the gastric pH monitored at the beginning of each shift or at least every 12 hours. Because of the risk of stress ulcer formation, a pH lower than 5 (acidic) should be treated with prescribed antacids. If there is no prescription for the antacid, the primary health care provider should be notified. Documentation of the findings should be done after the administration of an antacid. Sterile water instillation is not an appropriate treatment.

A client is resuming a diet after hemigastrectomy, and the nurse provides dietary instructions. Which statement by the client indicates a need for further teaching? 1."I plan to lie down after eating." 2."I know to avoid sweets in my diet." 3."I will eat several small meals per day." 4."I will drink plenty of liquids with meals."

4 Rationale:The client who has had a hemigastrectomy is at risk for dumping syndrome. This client should be placed on a diet that is high in protein, moderate in fat, and high in calories. The client should avoid drinking liquids with meals. Frequent small meals are encouraged, and the client should avoid concentrated sweets. Lying down for a short period of time after eating is beneficial.

A client has a large, deep duodenal ulcer diagnosed by endoscopy. Which sign or symptom indicative of a complication should the nurse look for during the client's postprocedure assessment? 1.Bradycardia 2.Nausea and vomiting 3.Numbness in the legs 4.A rigid, board-like abdomen

4 Rationale:The client with a large, deep duodenal ulcer is at risk for perforation of the ulcer. If this occurs, the client will experience sudden, sharp, intolerable, and severe pain beginning in the midepigastric area and spreading over the abdomen, which then becomes rigid and board-like. Tachycardia, not bradycardia, may occur as hypovolemic shock develops. Nausea and vomiting may not occur if the pyloric sphincter is intact. Numbness in the legs is not an associated finding.

A client with cirrhosis complicated by ascites is admitted to the hospital. The client reports a 10-lb weight gain over the past 1½ weeks. The client has edema of the feet and ankles, and his abdomen is distended, taut, and shiny with striae. Which client problem is most appropriate at this time? 1.Difficulty with sleeping 2.Risk for skin breakdown 3.Difficulty with breathing 4.Excessive body fluid volume

4 Rationale:The client with weight gain who also has cirrhosis complicated by ascites most often is retaining fluid. This is especially true when the client has not demonstrated an appreciable increase in food intake or when the weight gain is massive in relation to the time frame given. Therefore, excessive body fluid volume is the most appropriate problem. No data are given to support difficulty with breathing, although in some clients upward pressure on the diaphragm from ascites does impair respiration. Risk for skin breakdown assumes a lower priority because it is a risk rather than an actual problem. There are no data in the question that indicate that the client is having difficulty with sleep.

A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client? 1.Carrots and ranch dip 2.Whole-grain cereal and milk 3.A cup of popcorn and a cola drink 4.Applesauce and a graham cracker

4 Rationale:The diet for the client with ulcerative colitis should be low fiber (low residue). The nurse should avoid providing foods such as whole-wheat grains, nuts, and fresh fruits or vegetables. Typically, lactose-containing foods also are poorly tolerated. The client also should avoid caffeine, pepper, and alcohol.

The nurse should instruct a client with an ileostomy to include which action as part of essential care of the stoma? 1.Massage the area below the stoma. 2.Take in high-fiber foods such as nuts. 3.Limit fluid intake to prevent diarrhea. 4.Cleanse the peristomal skin meticulously.

4 Rationale:The peristomal skin must receive meticulous cleansing because ileostomy drainage has more enzymes and is more caustic to the skin than colostomy drainage. The area below the ileostomy may be massaged as needed if the ileostomy becomes blocked by high-fiber foods. Foods such as nuts and those with seeds will pass through the ileostomy. The client should be taught that these foods will remain undigested. Fluid intake should be at least 6 to 8 glasses of water per day to prevent dehydration.

The nurse is caring for a group of clients on the surgical nursing unit. The nurse anticipates that the client who underwent which procedure is most likely to have some long-term residual difficulty with absorption of nutrients? 1.Colectomy 2.Appendectomy 3.Ascending colostomy 4.Small bowel resection

4 Rationale:The small intestine is responsible for the absorption of most nutrients. The client who has undergone removal of a segment of the small bowel is the one who has a decreased area with which to absorb nutrients. Decreased absorption is not a likely complication with the surgical procedures identified in the remaining options.

The nurse assists a primary health care provider in performing a liver biopsy. After the procedure, the nurse should place the client in which position? 1.Prone 2.Supine 3.Left side 4.Right side

4 Rationale:To splint and provide pressure at the puncture site, the client is kept on the right side for a minimum of 2 hours after a liver biopsy. Therefore, the remaining positions are incorrect.

The client with a small bowel obstruction asks the nurse to explain the purpose of the nasogastric tube attached to continuous gastric suction. The nurse determines that teaching has been effective if the client makes which statement? 1."It will help to provide me with nourishment." 2."It will help to relieve the congestion from excess mucus." 3."It is used to remove gastric contents for laboratory testing." 4."It will help to remove gas and fluids from my stomach and intestine."

4 Rationale:Treatment of intestinal obstruction is directed toward decompression of the intestine by removal of gas and fluid. Nasogastric tubes may be used to decompress the stomach and bowel. Continuous gastric suction does not provide nourishment. The purpose of tracheal suctioning (not gastric suctioning) is to remove excess mucus that has led to congestion. Although gastric contents may be sent for laboratory analysis, it is not the main purpose for continuous gastric suction.

A primary health care provider (PHCP) prescribes a Salem sump tube for gastrointestinal intubation. Which item should the nurse obtain from the supply room? 1.A Dobbhoff weighted tube 2.A Sengstaken-Blakemore tube 3.A tube with a large lumen and an air vent 4.A tube with a single lumen that connects to suction

3 Rationale:A tube with a large lumen and an air vent is a Salem sump tube. A Dobbhoff weighted tube is a type of feeding tube. A Sengstaken-Blakemore tube is used to control bleeding in the esophagus. A tube with a single lumen is called a Levin tube.

The nurse has been caring for a client who required a Sengstaken-Blakemore tube because other treatment measures for esophageal varices were unsuccessful. The primary health care provider (PHCP) arrives on the nursing unit and deflates the esophageal balloon. Which assessment finding by the nurse is the most important and should be reported to the PHCP immediately? 1.Hematemesis 2.Bloody diarrhea 3.Swelling of the abdomen 4.An elevated temperature and a rise in blood pressure

1 Rationale:A Sengstaken-Blakemore tube may be inserted in a client with a diagnosis of cirrhosis with bleeding esophageal varices. It has both an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices, manifested as vomiting of blood (hematemesis). The remaining options are unrelated to deflating the esophageal balloon.

A client with cirrhosis is beginning to show signs of hepatic encephalopathy. The nurse should plan a dietary consultation to limit the amount of which ingredient in the client's diet? 1.Protein 2.Calories 3.Minerals 4.Carbohydrates

1 Rationale:Ammonia is formed as a product of protein metabolism. Clients with hepatic encephalopathy have a high serum ammonia level, which is responsible for the symptoms of encephalopathy. Limiting protein intake will prevent further elevation in the serum ammonia level and prevent further deterioration of the client's mental status. It is not necessary to limit calories, minerals, or carbohydrates.

A client is admitted to the hospital with a diagnosis of acute diverticulitis. What should the nurse expect to be prescribed for this client? 1.NPO (nothing by mouth) status 2.Ambulation at least 4 times daily 3.Cholinergic medications to reduce pain 4.Coughing and deep breathing every 2 hours

1 Rationale:During the acute phase of diverticulitis, the goal of treatment is to rest the bowel and allow the inflammation to subside. The client remains NPO and is placed on bed rest. Pain occurs from bowel spasms, and increased intra-abdominal pressure (coughing and deep breathing) may precipitate an attack. Ambulation and cholinergics will increase peristalsis.

A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? 1.Assessment of vital signs 2.Completion of abdominal examination 3.Insertion of the prescribed nasogastric tube 4.Thorough investigation of precipitating events

1 Rationale:The priority nursing action is to assess the vital signs. This would provide information about the amount of blood loss that has occurred and provide a baseline by which to monitor the progress of treatment. The client may be unable to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority. Insertion of a nasogastric tube is not the priority and will require a prescription; in addition, the vital signs should be checked before performing this procedure.

The nurse is providing instructions to a client diagnosed with irritable bowel syndrome (IBS) who is experiencing abdominal distention, flatulence, and diarrhea. What interventions should the nurse include in the instructions? Select all that apply. 1.Eat yogurt. 2.Take loperamide to treat diarrhea. 3.Use stress management techniques. 4.Avoid foods such as cabbage and broccoli. 5.Decrease fiber intake to less than 15 g/day.

1234 Rationale:IBS is a common, chronic functional disorder, meaning that no organic cause is currently known. Treatment is directed at psychological and dietary factors and medications to regulate stool output. Options 1, 2, 3, and 4 are correct, as clients diagnosed with IBS whose primary symptoms are abdominal distention and flatulence should be advised to avoid common gas-producing foods such as broccoli and cabbage and to consume yogurt, as it may be better tolerated than milk. In addition, the probiotics found in yogurt may be beneficial because alterations in intestinal bacteria are believed to exacerbate IBS. The client should be advised to take loperamide, a synthetic opioid that slows intestinal transit and treats diarrhea when it occurs. Also, psychological stressors are associated with development and exacerbation of IBS, so stress management techniques are important. Option 5, decrease fiber intake, is incorrect, as clients should be encouraged to have a dietary fiber intake of at least 20 g/day.

The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply. 1.Jaundice 2.Flu-like symptoms 3.Clay-colored stools 4.Elevated bilirubin levels 5.Dark or tea-colored urine

1345 Rationale:There are 3 stages associated with viral hepatitis. The first (preicteric) stage includes flu-like symptoms only. The second (icteric) stage includes the appearance of jaundice and associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay-colored stools. The third (posticteric) stage occurs when the jaundice decreases and the colors of the urine and stool return to normal.

The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which finding should the nurse interpret as a sign or symptom of portal hypertension? 1.Flat neck veins 2.Abdominal distention 3.Hemoglobin of 14.2 g/dL (142 mmol/L) 4.Platelet count of 600,000 mm3 (600 × 109/L)

2 Rationale:With portal hypertension, proteins shift from the blood vessels via the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, they leak through the liver capsule into the peritoneal cavity. This is called ascites, and abdominal distention would be the consequence. Increased portal pressure can lead to findings associated with right-sided heart failure, such as distended jugular veins. Thrombocytopenia, leukopenia, and anemia are caused by the splenomegaly that results from backup of blood from the portal vein into the spleen (portal hypertension).

The nurse should incorporate which in the dietary plan to ensure optimal nutrition for the client during the acute phase of hepatitis? Select all that apply. 1.Select foods high in protein content. 2.Consume multiple small meals throughout the day. 3.Select foods low in carbohydrates to prevent nausea. 4.Allow the client to select foods that are most appealing. 5.Eliminate fatty foods from the meal trays until nausea subsides. 6.Eat a nutritious dinner because it is typically the best tolerated meal of the day.

245 Rationale:Because the client with hepatitis experiences general malaise, small, more frequent meals are better tolerated than large meals, with breakfast being the best tolerated meal of the day. Self-selection of foods may enhance appetite over randomly selected foods. Fatty foods can exacerbate nausea and need to be avoided during the acute phase. The diseased liver may be unable to metabolize large amounts of protein at this time. The client should receive a diet high in carbohydrates to assist with meeting increased caloric needs. Anorexia typically increases as the day goes on.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which sign(s)/symptom(s) of duodenal ulcer? 1.Weight loss 2.Nausea and vomiting 3.Pain relieved by food intake 4.Pain radiating down the right arm

3 Rationale:A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the mid-epigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.

The clinic nurse is performing an abdominal assessment on a client and preparing to auscultate bowel sounds. The nurse should place the stethoscope in which quadrant first? Click on the image to indicate your answer. 1. RUQ 2 LUQ 3 RLQ 4 LLQ

3 Rationale:To auscultate bowel sounds, the nurse should begin in the right lower quadrant, at the ileocecal valve area, because normally bowel sounds are always present there. The diaphragm endpiece is used because bowel sounds are relatively high pitched. The stethoscope is held lightly against the skin because pressing too hard can stimulate more bowel sounds.

A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that in this disorder, because the stomach lining produces a decreased amount of a substance known as the intrinsic factor, the client will need which medication? 1.An antacid 2.An antibiotic 3.Vitamin B6 injections 4.Vitamin B12 injections

4 Rationale:A lack of the intrinsic factor needed to absorb vitamin B12 is a feature of pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Vitamin B6 is not specifically lacking in pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers.

A client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which actions should the nurse plan to promote client safety? Select all that apply. 1.Monitor serum potassium levels. 2.Weigh client daily, and monitor trends. 3.Monitor for symptoms of fluid retention. 4.Provide the client with a soft toothbrush. 5.Instruct the client to use an electric razor. 6.Monitor all secretions for frank or occult blood.

456 Rationale:Fibrinogen is produced by the liver and is necessary for normal clotting. A client who has insufficient levels is at risk for bleeding. The PT is prolonged when one or more of the clotting factors (II, V, VII, or X) is deficient, so the client's risk for bleeding is also increased. A soft toothbrush, an electric razor, and monitoring secretions for evidence of bleeding are measures that provide for client safety.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence? 1.Inability to pass flatus 2.Loss of anal sphincter control 3.Severe, constant pain with rapid onset 4.Firm, nontender mass palpable at the lower right costal margin

1 Rationale:An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually manifests as a more constant generalized discomfort. Option 4 is the description of the physical finding of liver enlargement. The liver may be enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction.

The nurse is caring for a client with common bile duct obstruction. The nurse should anticipate that the primary health care provider (PHCP) will prescribe which diet for this client? 1.Low fat 2.High protein 3.High carbohydrate 4.Low in water-soluble vitamins

1 Rationale:Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum. Bile acids or bile salts are produced by the liver to emulsify or break down fats. The diets listed in the remaining options are incorrect.

The nurse has taught the client with chronic pancreatitis about risk factor modification to reduce the incidence of recurrences. The nurse determines that teaching was effective if the client states that it will be necessary to control which factor? 1.Alcohol intake 2.Ulcer 3.Crohn's disease 4.Diabetes mellitus

1 Rationale:Chronic pancreatitis is aggravated by continued alcohol intake. Each of the other options is not specifically associated with pancreatitis.

The nurse has provided dietary instructions to a client with a diagnosis of peptic ulcer disease. Which client statement indicates that education was effective? 1."Baked foods such as chicken or fish are all right to eat." 2."Citrus fruits and raw vegetables need to be included in my daily diet." 3."I can drink beer as long as I consume only a moderate amount each day." 4."I can drink coffee or tea as long as I limit the amount to 2 cups daily."

1 Rationale:Dietary modifications for the client with peptic ulcer disease include eliminating foods that can cause irritation to the gastrointestinal (GI) tract. Items that should be eliminated or avoided include highly spiced foods, alcohol, caffeine, chocolate, and citrus fruits. Other foods may be taken according to the client's level of tolerance for that food.

The nurse is caring for a client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which food? 1.Pork 2.Milk 3.Chicken 4.Broccoli

1 Rationale:Dietary modifications for the client with peptic ulcer disease include eliminating foods that can cause irritation to the gastrointestinal (GI) tract. Items that should be eliminated or avoided include highly spiced foods, alcohol, caffeine, chocolate, and citrus fruits. Other foods may be taken according to the client's level of tolerance for that food.

A client experiencing chronic dumping syndrome makes the following comments to the nurse. Which one indicates the need for further teaching? 1."I eat at least 3 large meals each day." 2."I eat while lying in a semirecumbent position." 3."I have eliminated taking liquids with my meals." 4."I eat a high-protein, low- to moderate-carbohydrate diet."

1 Rationale:Dumping syndrome describes a group of symptoms that occur after eating. It is believed to result from rapid dumping of gastric contents into the small intestine, which causes fluid to shift into the intestine. Signs and symptoms of dumping syndrome include diarrhea, abdominal distention, sweating, pallor, palpitations, and syncope. To manage this syndrome, clients are encouraged to decrease the amount of food taken at each sitting, eat in a semirecumbent position, eliminate ingesting fluids with meals, and avoid consumption of high-carbohydrate meals.

The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client on the signs and symptoms associated with dumping syndrome. Which client statement indicates that teaching was effective? 1."It will cause diaphoresis and diarrhea." 2."I have to monitor for hiccups and diarrhea." 3."It will be associated with constipation and fever." 4."I have to monitor for fatigue and abdominal pain."

1 Rationale:Dumping syndrome occurs after gastric surgery because food is not held for as long in the stomach and is dumped into the intestine as a hypertonic mass. This causes fluid to shift into the intestine, causing cardiovascular and gastrointestinal symptoms. Symptoms can typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea. The remaining options are not signs of dumping syndrome.

The nurse is giving dietary instructions to a client who has a new colostomy. The nurse should encourage the client to eat foods representing which diet for the first 4 to 6 weeks postoperatively? 1.Low fiber 2.Low calorie 3.High protein 4.High carbohydrate

1 Rationale:For the first 4 to 6 weeks after colostomy formation, the client should consume a low-fiber diet. After this period, the client should eat a high-carbohydrate, high-protein diet. The client also is instructed to add new foods, including those with fiber, one at a time to determine tolerance to that food.

A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? 1.Lying recumbent following meals 2.Consuming small, frequent, bland meals 3.Taking H2-receptor antagonist medication 4.Raising the head of the bed on 6-inch (15 cm) blocks

1 Rationale:Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm where the esophagus usually is positioned. The client usually experiences pain from reflux caused by ingestion of irritating foods, lying flat following meals or at night, and eating large or fatty meals. Relief is obtained with the intake of small, frequent, and bland meals; use of H2-receptor antagonists and antacids; and elevation of the thorax following meals and during sleep.

The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? 1."I need to limit my intake of dietary fiber." 2."I need to drink plenty, at least 8 to 10 cups daily." 3."I need to eat regular meals and chew my food well." 4."I will take the prescribed medications because they will regulate my bowel patterns."

1 Rationale:IBS is a functional gastrointestinal disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. Dietary fiber and bulk help to produce bulky, soft stools and establish regular bowel elimination habits. Therefore, the client should consume a high-fiber diet. Eating regular meals, drinking 8 to 10 cups of liquid a day, and chewing food slowly help to promote normal bowel function. It is important to note that food and fluid tolerance is different with every client, and high fiber foods may trigger diarrhea for some. Medication therapy depends on the main symptoms of IBS. Bulk-forming laxatives or antidiarrheal agents or other agents may be prescribed.

The nurse is completing an admission assessment for a client with suspected esophageal cancer. Which statement made by the client indicates the presence of a risk factor for esophageal cancer? 1."I've been smoking for 20 years now." 2."I eat plenty of fresh fruits and vegetables." 3."I'm 5 feet, 8 inches tall and weigh 160 pounds." 4."My alcohol consumption is about 2 beers per month."

1 Rationale:Primary risk factors associated with the development of esophageal cancer are smoking and obesity. The compounds in tobacco smoke may be responsible for the genetic mutations seen in many squamous cell carcinomas of the esophagus. Malnutrition, untreated gastroesophageal reflux disease (GERD), and excessive alcohol intake are also associated with esophageal cancer. Diets that are chronically deficient in fresh fruits and vegetables have also been implicated in the development of squamous cell carcinoma of the esophagus.

Sulfasalazine is prescribed for a client with a diagnosis of ulcerative colitis, and the nurse instructs the client about the medication. Which statement made by the client indicates a need for further teaching? 1."The medication will cause constipation." 2."I need to take the medication with meals." 3."I may have increased sensitivity to sunlight." 4."This medication should be taken as prescribed."

1 Rationale:Sulfasalazine is an anti-inflammatory sulfonamide. Constipation is not associated with this medication. It can cause photosensitivity, and the client should be instructed to avoid sun and ultraviolet light. It should be administered with meals, if possible, to prolong intestinal passage. The client needs to take the medication as prescribed and continue the full course of treatment even if symptoms are relieved.

A client presents to the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. In planning care, which nursing action should be the priority for this client? 1.Assessment of vital signs 2.Complete abdominal examination 3.Thorough investigation of precipitating events 4.Insertion of a nasogastric tube and Hematest of emesis

1 Rationale:The priority nursing action is to assess the vital signs. This would indicate the amount of blood loss that has occurred and also provides a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority.

The nurse is caring for a client with acute pancreatitis. Which finding should the nurse expect to note when reviewing the laboratory results? 1. Elevated serum lipase level 2. Elevated serum bilirubin level 3. Decreased serum trypsin level 4. Decreased serum amylase level

1 Rationale:The serum lipase level is elevated in the presence of pancreatic cell injury. Serum trypsin and amylase levels are also elevated in pancreatic injury. Although bilirubin can be elevated in the client with pancreatitis, it is secondary to the hepatobiliary obstructive process.

The nurse is preparing to teach a client with a new colostomy about how to perform a colostomy irrigation. Which information should the nurse include in the teaching plan? 1.Use 500 to 1000 mL of warm tap water. 2.Suspend the irrigant 36 inches above the stoma. 3.Insert the irrigation cone ½ inch into the stoma. 4.If cramping occurs, open the irrigation clamp farther.

1 Rationale:The usual procedure for colostomy irrigation includes using 500 to 1000 mL of warm tap water. The solution is suspended 18 inches above the stoma. The cone is inserted 2 to 4 inches into the stoma but should never be forced. If cramping occurs, the client should decrease the flow rate of the irrigant as needed by closing the irrigation clamp. This practice is not common because of odor-proof pouches.

The nurse is caring for a client with a low thrombin level as a result of liver dysfunction. Based on this finding it is most important for the nurse to monitor the client for signs and symptoms of which potential complication? 1.Bleeding 2.Infection 3.Dehydration 4.Malnutrition

1 Rationale:Thrombin is produced by the liver and is necessary for normal clotting. The client who has an insufficient level of this substance is at risk for bleeding. Therefore, the client should be monitored for evidence of blood loss, such as visual cues and vital sign changes

The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the primary health care provider (PHCP)? 1.Dark red drainage 2.Dark brown drainage 3.Green-tinged drainage 4.Light yellowish-brown drainage

1 Rationale:For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a green tinge. The PHCP should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.

A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. 1.Administer stool softeners as prescribed. 2.Instruct the client to limit fluid intake to avoid urinary retention. 3.Encourage a high-fiber diet to promote bowel movements without straining. 4.Apply cold packs to the anal-rectal area over the dressing until the packing is removed. 5.Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding.

1,3,4 Rationale:Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance of bleeding and incision rupture. Stool softeners and a high-fiber diet will help the client avoid straining, thereby reducing the chances of rupturing the incision. An ice pack will increase comfort and decrease bleeding. Options 2 and 5 are incorrect interventions.

The nurse has inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts to slowly advance the NG tube with each swallow. The client begins to cough, gag, and choke. Which actions should the nurse take that will result in proper tube insertion and promote client relaxation? Select all that apply. 1.Pull the tube back slightly. 2.Instruct the client to breathe slowly. 3.Assist the client to take sips of water. 4.Continue to slowly advance the tube to the desired distance. 5.Check the back of the pharynx using a tongue blade and flashlight.

1235 Rationale:As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx and obstruct the airway, pulling the tube back slightly will remove it from the larynx; advancing the tube might position it in the trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Slow breathing helps the client relax, which reduces the gag response. The nurse should check the back of the client's throat to note whether the tube has coiled. The tube may be advanced after the client relaxes.

The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions should be included in the care plan for this client? Select all that apply. 1.Monitor daily weight. 2.Measure abdominal girth. 3.Monitor respiratory status. 4.Place the client in a supine position. 5.Assist the client with care as needed.

1235 Rationale:Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby impairing the client's breathing patterns. The client should be placed in a semi-Fowler's position with the arms supported on a pillow to allow for free diaphragm movement. The correct options identify appropriate nursing interventions to be included in the plan of care for the client with ascites.

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply. 1.Coffee 2.Chocolate 3.Peppermint 4.Nonfat milk 5.Fried chicken 6.Scrambled eggs

1235 Rationale:Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus will increase reflux and exacerbate the symptoms of GERD and therefore should be avoided. Aggravating substances include coffee, chocolate, peppermint, fried or fatty foods, carbonated beverages, and alcohol. Options 4 and 6 do not promote this effect.

The nurse is providing discharge instructions for a client following a Roux-en-Y gastric bypass surgery 3 days ago. What will the nurse include in the instructions? Select all that apply. 1.Do not drink fluids with meals. 2.Avoid foods high in carbohydrates. 3.Take an extended-release multivitamin daily. 4.Maintain a clear liquid diet for about 6 weeks. 5.Eat 6 small meals a day that are high in protein.

125 Rationale:A Roux-en-Y gastric bypass is a combination of restrictive and malabsorptive surgery in which the size of the stomach is made much smaller and a large part of the small intestine (which absorbs food) is bypassed. Because the stomach is so small, clients are instructed to not drink fluids with meals because providers do not want them to fill up on less nutritional liquids before having food; to avoid foods high in carbohydrates because they are not as nutritional and tend to promote diarrhea and dumping syndrome; and to eat frequent, small meals that are high in protein. An extended-release vitamin will not be absorbed by the client since much of the small intestine is bypassed and food moves through quickly, and 6 weeks is too long a period to be on clear liquids. The typical bariatric surgery client is only on clear liquids for a few days and should then be on a high-protein diet.

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1.Maintain NPO (nothing by mouth) status. 2.Encourage coughing and deep breathing. 3.Give small, frequent high-calorie feedings. 4.Maintain the client in a supine and flat position. 5.Give hydromorphone intravenously as prescribed for pain. 6.Maintain intravenous fluids at 10 mL/hr to keep the vein open.

125 Rationale:The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions, so adequate intravenous hydration is necessary. Because abdominal pain is a prominent symptom of pancreatitis, pain medications such as morphine or hydromorphone are prescribed. Meperidine is avoided, as it may cause seizures. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted.

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Maintain NPO (nothing by mouth) status. 2. Encourage coughing and deep breathing. 3. Give small, frequent high-calorie feedings. 4. Maintain the client in a supine and flat position. 5. Give hydromorphone intravenously as prescribed for pain. 6. Maintain intravenous fluids at 10 mL/hour to keep the vein open.

125 Rationale:The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions, so adequate intravenous hydration is necessary. Because abdominal pain is a prominent symptom of pancreatitis, pain medications such as morphine or hydromorphone are prescribed. Meperidine is avoided, as it may cause seizures. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help to ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted.

The nurse is caring for a hospitalized client with pancreatitis. Which findings should the nurse look for and expect to note when reviewing the laboratory results? Select all that apply. 1.Elevated lipase level 2.Elevated lactase level 3.Elevated trypsin level 4.Elevated amylase level 5.Elevated sucrase level

134 Rationale:Lipase, trypsin, and amylase are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively. Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Sucrase is produced in the small intestine and converts sucrose into glucose and fructose.

The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply. 1.Nuts 2.Corn 3.Liver 4.Apples 5.Lentils 6.Bananas

135 Rationale:Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of function of the parietal cells. The source of intrinsic factor is lost, which results in an inability to absorb vitamin B12, leading to development of pernicious anemia. Clients must increase their intake of vitamin B12 by increasing consumption of foods rich in this vitamin, such as nuts, organ meats, dried beans, citrus fruits, green leafy vegetables, and yeast.

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. 1.Fever 2.Positive Cullen's sign 3.Complaints of indigestion 4.Palpable mass in the left upper quadrant 5.Pain in the upper right quadrant after a fatty meal 6.Vague lower right quadrant abdominal discomfort

135 Rationale:During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula or shoulder or experience epigastric pain after a fatty or high-volume meal. Fever and signs of dehydration would also be expected, as well as complaints of indigestion, belching, flatulence, nausea, and vomiting. Options 4 and 6 are incorrect because they are inconsistent with the anatomical location of the gallbladder. Option 2 (Cullen's sign) is associated with pancreatitis.

A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week; however, he is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern that he will not be able to continue the tube feedings at home. Which nursing response is most appropriate at this time? 1."Do you want to stay here in this facility for a few more days?" 2."Tell me more about your concerns with your diet after going home." 3."Have you discussed your feelings with your primary health care provider?" 4."You need to talk to your primary health care provider about these concerns."

2 Rationale:A client often has fears about leaving the secure, cared-for environment of the health care facility. This client has a fear about not being able to care for himself at home and of not being able to handle the tube feedings at home. A therapeutic communication statement such as "Tell me more about . . ." often leads to valuable information about the client and his concerns. The statements in the remaining options are nontherapeutic.

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse should anticipate a prescription from the primary health care provider for which type of diet for this client? 1.A low-fat diet 2.A low-fiber diet 3.A high-protein diet 4.A high-carbohydrate diet

2 Rationale:A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. Clients should avoid high-fiber foods when experiencing acute diverticulitis. As the attack resolves, fiber can be added gradually to the diet.

The nurse is assessing a client with liver disease for signs and symptoms of low albumin. Which sign or symptom should the nurse expect to note? 1.Weight loss 2.Peripheral edema 3.Capillary refill of 5 seconds 4.Bleeding from previous puncture sites

2 Rationale:Albumin is responsible for maintaining the osmolality of the blood. When the albumin level is low, osmotic pressure is decreased, which in turn can lead to peripheral edema. Weight loss is not a sign or symptom for hypoalbuminemia. Capillary refill of 5 seconds is a delayed filling time but is not associated with decreased albumin levels. Clotting factors produced by the liver (not albumin) are responsible for coagulation, and lack of clotting factors can result in bleeding from old puncture sites. The total protein level may decrease if the albumin level is low.

A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? 1.Select foods high in fat. 2.Increase intake of fluids, including juices. 3.Eat a good supper when anorexia is not as severe. 4.Eat less often, preferably only 3 large meals daily.

2 Rationale:Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet, as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.

A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain, and appendicitis is suspected. Laboratory tests are performed, and the nurse notes that the client's white blood cell (WBC) count is elevated. On the basis of these findings, the nurse should question which primary health care provider (PHCP) prescription documented in the client's medical record? 1.Apply a cold pack to the abdomen. 2.Administer 30 mL of milk of magnesia (MOM). 3.Maintain nothing by mouth (NPO) status. 4.Initiate an intravenous (IV) line for the administration of IV fluids.

2 Rationale:Appendicitis should be suspected in a client with an elevated WBC count complaining of acute right lower abdominal quadrant pain. Laxatives are never prescribed because if appendicitis is present, the effect of the laxative may cause a rupture with resultant peritonitis. Cold packs may be prescribed for comfort. The client would be NPO and given IV fluids in preparation for possible surgery.

The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy? 1.Restlessness 2.Presence of asterixis 3.Complaints of fatigue 4.Decreased serum ammonia levels

2 Rationale:Asterixis is a flapping tremor of the hand that is an early sign of hepatic encephalopathy. The exact cause of this disorder is not known, but abnormal ammonia metabolism may be implicated. Increased serum ammonia levels are thought to interfere with normal cerebral metabolism. Tremors and drowsiness also would be noted.

A client is experiencing blockage of the common bile duct. Which food selection made by the client indicates the need for further teaching? 1.Rice 2.Whole milk 3.Broiled fish 4.Baked chicken

2 Rationale:Bile acids or bile salts are produced by the liver to emulsify or break down fats. Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum, thus preventing breakdown of fatty intake. Knowledge of this should direct you to the option of whole milk. Dairy products, such as whole milk, ice cream, butter, and cheese, are high in cholesterol and fat and should be avoided.

After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication? 1. Stroke 2. Pernicious anemia 3. Bacterial meningitis 4. Peripheral arterial disease

2 Rationale:Billroth I surgery involves removing one half to two thirds of the stomach and reanastomosing the remaining segment of the stomach to the duodenum. With the loss of this much of the stomach, development of pernicious anemia is not uncommon. Pernicious anemia is a macrocytic anemia that most commonly is caused by the lack of intrinsic factor. During a Billroth I procedure, a large portion of the parietal cells, which are responsible for producing intrinsic factor (a necessary component for vitamin B12 absorption), are removed. In this anemia, the red blood cell is larger than usual and hence does not last as long in the circulation as normal red blood cells do, causing the client to have anemia with resultant fatigue. Vitamin B12 also is necessary for normal nerve function. Because of the lack of the necessary intrinsic factor, persons with pernicious anemia also experience paresthesias, impaired gait, and impaired balance. Although the symptoms could possibly indicate the other options listed, pernicious anemia is the most logical based on the surgery the client underwent.

The nurse is obtaining a health history for a client with chronic pancreatitis. The health history is most likely to include which as a most common causative factor in this client's disorder? 1.Weight gain 2.Use of alcohol 3.Exposure to occupational chemicals 4.Abdominal pain relieved with food or antacids

2 Rationale:Chronic pancreatitis occurs most often in alcoholics. Abstinence from alcohol is important to prevent the client from developing chronic pancreatitis. Clients usually experience malabsorption with weight loss. Chemical exposure is associated with cancer of the pancreas. Pain will not be relieved with food or antacids.

A hospitalized client with liver disease has a dietary protein restriction. The nurse encourages intake of which source of complete proteins to maximize the availability of essential amino acids? 1.Nuts 2.Meats 3.Cereals 4.Vegetables

2 Rationale:Complete proteins contain all of the essential amino acids, which are acids that the body cannot produce from other available sources. Complete proteins derive from animal sources, such as meat, cheese, milk, and eggs. Incomplete proteins can be found in fruits, vegetables, nuts, cereals, breads, and legumes.

The nurse is caring for a client who is prescribed a nasogastric (NG) tube for the purpose of stomach decompression. The nurse should anticipate a primary health care provider prescription for which type of suction? 1.High and intermittent 2.Low and intermittent 3.High and continuous 4.Low and continuous

2 Rationale:Gastric mucosa can be traumatized and pulled into the tube if the suction pressure is placed on high or if the suction is continuous. The suction should be set on low pressure and intermittent suction control.

The primary health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis? 1."I have had unprotected sex with multiple partners." 2."I ate shellfish about 2 weeks ago at a local restaurant." 3."I was an intravenous drug abuser in the past and shared needles." 4."I had a blood transfusion 30 years ago after major abdominal surgery."

2 Rationale:Hepatitis A is transmitted by the fecal-oral route via contaminated water or food (improperly cooked shellfish), or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids, such as in the cases of intravenous drug abuse, history of blood transfusion, or unprotected sex with multiple partners.

A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention is appropriate? 1.Encourage foods that are high in protein. 2.Monitor for fluid and electrolyte imbalance. 3.Explain that high-fat diets usually are better tolerated. 4.Explain that most daily calories need to be consumed in the evening hours.

2 Rationale:If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. It is important to explain to the client that most calories should be eaten in the morning hours because nausea is most common in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated.

The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the primary health care provider? 1.Stoma is beefy red and shiny 2.Purple discoloration of the stoma 3.Skin excoriation around the stoma 4.Semiformed stool noted in the ostomy pouch

2 Rationale:Ischemia of the stoma would be associated with a dusky or bluish or purple color. A beefy red and shiny stoma is normal and expected. Skin excoriation needs to be addressed and treated but does not require as immediate attention as purple discoloration of the stoma. Semiformed stool is a normal finding

The nurse is performing discharge teaching for a client with chronic pancreatitis. Which information should the nurse include? 1.Alcohol should be consumed in moderation. 2.Avoid caffeine because it may aggravate symptoms. 3.Diet should be high in carbohydrates, fats, and proteins. 4.Frothy, fatty stools indicate that enzyme replacement is working.

2 Rationale:Knowing that caffeinated beverages, such as coffee, tea, and soda, will worsen symptoms, such as pain, will direct you to select the correct option. Alcohol can precipitate an attack of pancreatitis and needs to be avoided. The recommended diet is moderate carbohydrates, low fat, and moderate protein. Frothy, fatty stools indicate that the replacement enzyme dose needs to be increased.

The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? 1.Leukopenia with a shift to the left 2.Leukocytosis with a shift to the left 3.Leukopenia with a shift to the right 4.Leukocytosis with a shift to the right

2 Rationale:Laboratory findings do not establish the diagnosis of appendicitis, but there is often an elevation of the white blood cell count (leukocytosis) with a shift to the left (an increased number of immature white blood cells). Options 1, 3, and 4 are incorrect because they are not associated findings in acute appendicitis.

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? 1.Administer the prescribed pain medication. 2.Notify the primary health care provider (PHCP). 3.Call and ask the operating room team to perform surgery as soon as possible. 4.Reposition the client and apply a heating pad on the warm setting to the client's abdomen.

2 Rationale:On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the PHCP. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the PHCP probably would perform the surgery earlier than the prescheduled time.

A client with ulcerative colitis has a prescription to begin a salicylate compound medication to reduce inflammation. What instruction should the nurse give the client regarding when to take this medication? 1.On arising 2.After meals 3.On an empty stomach 4.30 minutes before meals

2 Rationale:Salicylate compounds, such as sulfasalazine, act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and increase fluid intake throughout the day. The medication needs to be taken after meals to reduce gastrointestinal irritation. The other options are incorrect and could cause gastric irritation.

The nurse is providing instructions to a client with a colostomy about measures to reduce the odor from the colostomy. Which client statement indicates that the educational session was effective? 1."I should be sure to eat at least 1 cucumber every day." 2."Beet greens, parsley, or yogurt will help to control the colostomy odor." 3."I will need to increase my egg intake and try to eat ½ to 1 egg per day." 4."Green vegetables such as spinach and broccoli will prevent odor, and I should eat these foods every day."

2 Rationale:The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also may reduce odor, but it is a gas-forming food and should be avoided. Cucumbers, eggs, and broccoli also are gas-forming foods and should be avoided or limited by the client.

A client with a new colostomy is concerned about the odor from stool in the ostomy drainage bag. The nurse should teach the client to include which food in the diet to reduce odor? 1.Eggs 2.Yogurt 3.Broccoli 4.Cucumbers

2 Rationale:The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas-forming food as well. Broccoli, cucumbers, and eggs are gas-forming foods. There are also optional charcoal filters that can deodorize the colostomy.

The nurse is giving instructions to a client with cholecystitis about food to exclude from the diet. Which food item identified by the client indicates that the educational session was successful? 1.Fresh fruit 2.Brown gravy 3.Fresh vegetables 4.Poultry without skin

2 Rationale:The client with cholecystitis should decrease overall intake of dietary fat. Foods that should be avoided include sausage, gravies, fatty meats, fried foods, products made with cream, and desserts. Appropriate food choices include fruits and vegetables, fish, and poultry without skin.

A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse determines that education about positioning to reduce pain was effective if the client avoids which action? 1.Sitting up 2.Lying flat 3.Leaning forward 4.Drawing the legs to the chest

2 Rationale:The pain of pancreatitis is aggravated by lying supine or walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation will intensify the irritation of the posterior peritoneal wall with these positions or movements. Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) will alleviate some of the pain associated with pancreatitis. The fetal position (with the legs drawn up to the chest) may decrease the abdominal pain of pancreatitis.

Cholestyramine resin is prescribed for a client with an elevated serum cholesterol level. The nurse should instruct the client to take the medication in which way? 1.After meals 2.Mixed with fruit juice 3.Via a rectal suppository 4.At least 3 hours before meals

2 Rationale:This medication binds with bile salts in the intestines to form a compound that is excreted in the feces. The client should be instructed to mix the medication with 3 to 6 ounces of water, milk, fruit juice, or soup. It should be administered before meals. It is not administered via rectal suppository.

A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching? 1."I should avoid drinking alcohol." 2."I can go back to work right away." 3."My partner should get the vaccine." 4."A condom should be used for sexual intercourse."

2 Rationale:To prevent transmission of hepatitis, vaccination of the partner is advised. In addition, a condom is advised during sexual intercourse. Alcohol should be avoided because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that liver function has returned to normal. The client's activity is increased gradually, and the client should not return to work right away.

The nurse caring for a client diagnosed with inflammatory bowel disease (IBD) recognizes that which classifications of medications may be prescribed to treat the disease and induce remission? Select all that apply. 1.Antidiarrheal 2.Antimicrobial 3.Corticosteroid 4.Aminosalicylate 5.Biological therapy 6.Immunosuppressant

23456 Rationale:Pharmacological treatment for IBD aims to decrease the inflammation to induce and then maintain a remission. Five major classes of medications used to treat IBD are antimicrobials, corticosteroids, aminosalicylates, biological and targeted therapy, and immunosuppressants. Medications are chosen based on the location and severity of inflammation. Depending on the severity of the disease, clients are treated with either a "step-up" or "step-down" approach. The step-up approach uses less toxic therapies (e.g., aminosalicylates and antimicrobials) first, and more toxic medications (e.g., biological and targeted therapy) are started when initial therapies do not work. The step-down approach uses biological and targeted therapy first. Option 1, antidiarrheals, is incorrect. Although an antidiarrheal may be used to treat the symptoms of IBD, it does not treat the disease (the inflammation) or induce remission. In addition, antidiarrheals should be used cautiously in IBD because of the danger of toxic megacolon (colonic dilation greater than 5 cm).

The nurse is caring for a client with acute pancreatitis. Which medications should the nurse expect to be prescribed for treatment of this problem? Select all that apply. 1.Insulin 2.Morphine 3.Dicyclomine 4.Pancrelipase 5.Pantoprazole 6.Acetazolamide

2356 Rationale:Medications used to treat acute pancreatitis include pain medications such as morphine, antispasmodics such as dicyclomine, proton pump inhibitors such as pantoprazole, and acetazolamide to decrease the volume and bicarbonate concentration of pancreatic secretions. Insulin is used in chronic pancreatitis to treat diabetes mellitus or hyperglycemia if needed, and pancreatic enzyme products are used for replacement of pancreatic enzymes.

The nurse is assigned to care for a client with a Sengstaken-Blakemore tube. Which laboratory result is most focused on evaluating the effectiveness of this tube? 1.Sodium 2.Creatinine 3.Hemoglobin 4.Ammonia

3 Rationale:A Sengstaken-Blakemore tube may be used in a client with a diagnosis of cirrhosis with ruptured esophageal varices if other treatment measures are unsuccessful. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could harm the client. Evaluation of the client's hemoglobin level trends will determine if the tube is effective. Sodium, creatinine, and ammonia levels are not related to monitoring for blood loss.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which manifestation of duodenal ulcer? 1.Weight loss 2.Nausea and vomiting 3.Pain relieved by food intake 4.Pain radiating down the right arm

3 Rationale:A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the midepigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.

The nurse is preparing to administer an intermittent enteral feeding through a nasogastric (NG) tube. Which priority assessment should the nurse perform? 1.Observe for digestion of formula. 2.Assess fluid and electrolyte status. 3.Evaluate absorption of the last feeding. 4.Evaluate percussion tone of the stomach.

3 Rationale:All stomach contents are aspirated and measured before a tube feeding is administered. This procedure measures the gastric residual. The gastric residual is assessed to confirm whether undigested formula from a previous feeding remains, thereby evaluating absorption of the last feeding. It is important to assess gastric residual because administration of an enteral feeding to a full stomach could result in overdistention, predisposing the client to regurgitation and possible aspiration. The remaining options do not relate to the purpose of assessing residual.

A client with a gastric ulcer is prescribed both magnesium hydroxide and cimetidine twice daily. How should the nurse schedule the medications for administration? 1.Drink 8 ounces of water between taking each medication. 2.Administer the cimetidine and magnesium hydroxide at the same time twice daily. 3.Administer each dose of cimetidine 1 hour prior to the administration of magnesium hydroxide. 4.Collaborate with the primary health care provider (PHCP), as the client should not be receiving both medications.

3 Rationale:Antacids, such as magnesium hydroxide, can decrease absorption of cimetidine. At least 1 hour should separate administration of an antacid and cimetidine. The remaining options are incorrect.

The nurse is caring for a client who is receiving bolus feedings via a nasogastric tube. As the nurse is finishing the feeding, the client asks for the bed to be positioned flat for sleep. The nurse understands that which is the appropriate position for this client at this time? 1.Head of bed flat, with the client supine for 60 minutes 2.Head of bed flat, with the client in the supine position for at least 30 minutes 3.Head of bed elevated 30 to 45 degrees, with the client in the right lateral position for 60 minutes 4.Head of bed in a semi-Fowler's position, with the client in the left lateral position for 60 minutes

3 Rationale:Aspiration is a possible complication associated with nasogastric tube feeding. The head of the bed is elevated 30 to 45 degrees for 60 minutes after a bolus tube feeding to prevent vomiting and aspiration. The right lateral position uses gravity to facilitate gastric emptying and thus prevent vomiting. The flat supine position is to be avoided for the first 30 minutes after a tube feeding.

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? 1.Roast pork 2.Cheese omelet 3.Pasta with sauce 4.Tuna fish sandwich

3 Rationale:Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. The serum ammonia level assesses the ability of the liver to deaminate protein byproducts. Normal reference interval is 10 to 80 mcg/dL (6 to 47 mcmol/L). Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. Foods high in protein should be avoided since the client's ammonia level is elevated above the normal range; therefore, pasta with sauce would be the best selection.

A client with viral hepatitis is having difficulty coping with the disorder. Which question by the nurse is the most appropriate in identifying the client's coping problem? 1."Do you have a fever?" 2."Are you losing weight?" 3."Have you enjoyed having visitors?" 4."Do you rest sometime during the day?"

3 Rationale:Clients with hepatitis may experience anxiety because of an anticipated change in lifestyle or fear of prognosis. They also may have a disturbance in body image related to the stigma of having a communicable disease or a change in appearance because of jaundice. The correct option relates to the client's possible feelings of not wanting to be seen by others because of altered appearance. Remember that the client with hepatitis is jaundiced.

The nurse is caring for a client experiencing an exacerbation of Crohn's disease. Which intervention should the nurse anticipate the primary health care provider prescribing? 1.Enteral feedings 2.Fluid restrictions 3.Oral corticosteroids 4.Activity restrictions

3 Rationale:Crohn's disease is a form of inflammatory bowel disease that is a chronic inflammation of the gastrointestinal (GI) tract. It is characterized by periods of remission interspersed with periods of exacerbation. Oral corticosteroids are used to treat the inflammation of Crohn's disease, so option 3 is the correct one. In addition to treating the GI inflammation of Crohn's disease with medications, it is also treated by resting the bowel. Therefore, option 1 is incorrect. Option 2 is incorrect, as clients with Crohn's disease typically have diarrhea and would not be on fluid restrictions. Option 4, activity restrictions, is not indicated. The client can do activities as tolerated but should avoid stress and strain.

The nurse is assisting a client with Crohn's disease to ambulate to the bathroom. After the client has a bowel movement, the nurse should assess the stool for which characteristic that is expected with this disease? 1.Blood in the stool 2.Chalky gray stool 3.Loose, watery stool 4.Dry, hard, constipated stool

3 Rationale:Crohn's disease is characterized by nonbloody diarrhea of usually not more than 4 or 5 stools daily. Over time, the episodes of diarrhea increase in frequency, duration, and severity. Options 1, 2, and 4 are not characteristics of the stool in Crohn's disease.

The nurse is evaluating the plan of care for a client with peptic ulcer disease (PUD) who is experiencing acute pain. The nurse determines that the expected outcomes have been met if the nursing assessment reveals which result? 1.The client reports some pain before meals. 2.The client frequently is awakened at 2 a.m. with heartburn. 3.The client has eliminated any irritating foods from the diet. 4.The client's pain is minimal with histamine H2-receptor antagonists.

3 Rationale:Expected outcomes for the client with PUD who is experiencing pain include elimination of irritating foods from the diet, effectiveness of prescribed medications to eliminate pain, self-reporting of absence of pain with medication, and an ability to sleep through the night without pain. The client who continues to be awakened by pain requires further modification of medication therapy, which may include adjustment of timing of histamine H2-receptor antagonist administration or an additional dose of antacid before the time when pain usually awakens the client.

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? 1.Clamp the T-tube. 2.Irrigate the T-tube. 3.Document the findings. 4.Notify the primary health care provider.

3 Rationale:Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output.

The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? 1.Leg exercises 2.Early ambulation 3.Irrigating the nasogastric tube 4.Coughing and deep-breathing exercises

3 Rationale:In a gastrojejunostomy (Billroth II procedure), the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically prescribed by the primary health care provider. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions.

The nurse manager is providing an educational session to nursing staff members about the phases of viral hepatitis. The nurse manager tells the staff that which clinical manifestation(s) are primary characteristics of the preicteric phase? 1.Pruritus 2.Right upper quadrant pain 3.Fatigue, anorexia, and nausea 4.Jaundice, dark-colored urine, and clay-colored stools

3 Rationale:In the preicteric phase, the client has nonspecific complaints of fatigue, anorexia, nausea, cough, and joint pain. The remaining options are clinical manifestations that occur in the icteric phase. In the posticteric phase, jaundice decreases, the color of urine and stool returns to normal, and the client's appetite improves.

The nurse is caring for a postoperative client who has just returned from surgery for creation of a colostomy. The nurse inspects the colostomy stoma and recognizes that which is a normal assessment finding for this client? 1. A pale color 2. A purple color 3. A brick-red color 4. A large amount of red drainage

3 Rationale:Normal characteristics of a stoma include a rose to brick-red color indicating viable mucosa, mild to moderate edema during the initial postoperative period, and a small amount of oozing blood from the stoma mucosa (because of its high vascularity) when it is touched. A pale color may indicate anemia. A stoma that is dark red to purple indicates inadequate blood supply to the stoma or bowel due to adhesions, low blood flow state, or excessive tension on the bowel at the time of construction. A small amount of bleeding is considered normal, but a moderate to large amount of bleeding from the stoma mucosa could indicate coagulation factor deficiency, stomal varices secondary to portal hypertension, or lower gastrointestinal bleeding.

The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, should the nurse report to the primary health care provider (PHCP)? 1.Hypotension 2.Bloody diarrhea 3.Rebound tenderness 4.A hemoglobin level of 12 mg/dL (120 mmol/L)

3 Rationale:Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the PHCP.

The nurse has given instructions to a client with hepatitis about postdischarge management during convalescence. The nurse determines that further teaching is needed if the client makes which statement? 1."I need to avoid alcohol and aspirin." 2."I should eat a high-carbohydrate, low-fat diet." 3."I can resume a full activity level within 1 week." 4."I need to take the prescribed amounts of vitamin K."

3 Rationale:The client with hepatitis is easily fatigued and may require several weeks to resume a full activity level. It is important for the client to get adequate rest so that the liver can heal. The client should avoid hepatotoxic substances such as aspirin and alcohol. The client should take in a high-carbohydrate and low-fat diet. Vitamin K may be prescribed for prolonged clotting times.

The nurse is caring for a client with gastroesophageal reflux disease (GERD) and provides client education on measures to decrease GERD. Which statement made by the client indicates a need for further teaching? 1."I plan to eat 4 to 6 small meals a day." 2."I should sleep in the right side-lying position." 3."I plan to have a snack 1 hour before going to bed." 4."I will stop having a glass of wine each evening with dinner."

3 Rationale:The control of GERD involves lifestyle changes to promote health and control reflux. These include eating 4 to 6 small meals a day; avoiding alcohol and smoking; sleeping in the right side-lying position to promote oxygenation and frequent swallowing to clear the esophagus; and avoiding eating at least 3 hours before going to bed because reflux episodes are most damaging at night.

The nurse has implemented a bowel maintenance program for an unconscious client. The nurse would evaluate the plan as best meeting the needs of the client if which method was successful in stimulating a bowel movement? 1.Fleet enema 2.Fecal disimpaction 3.Glycerin suppository 4.Soap solution enema (SSE)

3 Rationale:The least amount of invasiveness needed to produce a bowel movement is best. Use of glycerin suppositories is the least invasive method and usually stimulates bowel evacuation within a half hour. Enemas may be needed on an every-other-day basis, but they are used cautiously (even if not contraindicated) because the Valsalva maneuver can increase intracranial pressure. Fecal disimpaction is done only when the client's rectum has become impacted from constipation as a result of inattention or failure of other measures. Stool softeners may be prescribed on a regular schedule for some clients to avoid hard, dry stools, but oral medication is not administered to an unconscious client.

The nurse is caring for a client with pancreatitis. Which finding should the nurse expect to note when reviewing the client's laboratory results? 1.Elevated level of pepsin 2.Decreased level of lactase 3.Elevated level of amylase 4.Decreased level of enterokinase

3 Rationale:The serum level of amylase, an enzyme produced by the pancreas, increases with pancreatitis. Amylase normally is responsible for carbohydrate digestion. Pepsin is produced by the stomach and is used in protein digestion. Lactase and enterokinase are enzymes produced by the small intestine; lactase splits lactose into galactose and fructose, and enterokinase activates trypsin.

A client with gastritis asks the nurse at a screening clinic about analgesics that will not cause epigastric distress. The nurse should tell the client that which medication is unlikely to cause epigastric distress? 1.Ibuprofen 2.Indomethacin 3.Acetaminophen 4.Naproxen sodium

3 ~ Analgesics, such as acetaminophen, are unlikely to cause epigastric distress. Ibuprofen, indomethacin, and naproxen sodium are nonsteroidal antiinflammatory medications (NSAIDs) and are irritating to the gastrointestinal tract, so they should be avoided in clients with gastritis.

A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? 1.Folate deficiency 2.Malabsorption of fat 3.Intestinal obstruction 4.Fluid and electrolyte imbalance

4 Rationale:A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.

The nurse should anticipate that the primary health care provider (PHCP) will prescribe which treatment for a client with pernicious anemia? 1.Oral iron tablets 2.Blood transfusions 3.Gastric tube feedings 4.Vitamin B12 injections

4 Rationale:A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Iron is used for anemia that results from a lack of iron. Blood transfusions are not needed for pernicious anemia because a lack of red blood cells is not the problem. Gastric tube feedings will not replace vitamin B12. Vitamin B12 needs to be given by injection to ensure absorption.

The nurse is caring for a client after abdominal surgery and creation of a colostomy. The nurse is assessing the client for a prolapsed stoma and should expect to note which observation if this is present? 1. A sunken and hidden stoma 2. A narrow and flattened stoma 3. A stoma that is dusky or bluish 4. A stoma that is elongated with a swollen appearance

4 Rationale:A prolapsed stoma is one in which the bowel protrudes, causing an elongated and swollen appearance of the stoma. A retracted stoma is characterized by a sinking of the stoma. A stoma with a narrow opening is described as being stenosed. Ischemia of the stoma would be associated with a dusky or bluish color.

The nurse is caring for a client who has just returned from the operating room after the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is appropriate based on this assessment? 1.Apply ice to the stoma site. 2.Apply pressure to the stoma site. 3.Notify the primary health care provider (PHCP). 4.Document the amount and characteristics of the drainage.

4 Rationale:During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Applying ice or pressure to the stoma site are inappropriate actions. Notifying the PHCP is unnecessary because this is an expected finding

A client receiving a cleansing enema complains of pain and cramping. The nurse should take which corrective action? 1.Discontinue the enema. 2.Reassure the client, and continue the flow. 3.Raise the enema bag so that the solution can be completed quickly. 4.Clamp the tubing for 30 seconds, and restart the flow at a slower rate.

4 Rationale:Enema fluid should be administered slowly. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. This action decreases the likelihood of intestinal spasm and premature ejection of the solution. Therefore, the actions in the remaining options are incorrect.

The nurse is performing an assessment on a client with suspected acute pancreatitis. Which complaint made by the client supports the diagnosis? 1."I have epigastric pain radiating to my neck." 2."I have severe abdominal pain that is relieved after vomiting." 3."My temperature has been running between 96º F (35.5º C) and 97º F (36.1º C)." 4."I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting."

4 Rationale:Nausea and vomiting are common presenting manifestations of acute pancreatitis. A hallmark symptom is severe abdominal pain that is not relieved by vomiting. The vomitus characteristically consists of gastric and duodenal contents. Fever also is a common sign. Epigastric pain radiating to the neck area is not a characteristic symptom.

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? 1.Bradycardia 2.Numbness in the legs 3.Nausea and vomiting 4.A rigid, board-like abdomen

4 Rationale:Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.

The nurse is caring for a client with pernicious anemia. Which prescription by the primary health care provider (PHCP) should the nurse anticipate? 1.Iron 2.Folic acid 3.Vitamin B6 4.Vitamin B12

4 Rationale:Pernicious anemia is caused by a deficiency of vitamin B12. Treatment consists of administration of high doses of oral vitamin B12. Monthly injections of vitamin B12 can also be administered but are less comfortable when compared to oral administration. Thiamine is most often prescribed for the client with alcoholism, folic acid is prescribed for folic acid deficiency, and vitamin B6 is ordered when there is pyridoxine deficiency

The nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which client factor documented by the nurse would increase the risk for PUD? 1.Recently retired from a job 2.Significant other has a gastric ulcer 3.Occasionally drinks 1 cup of coffee in the morning 4.Takes nonsteroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis

4 Rationale:Risk factors for PUD include Helicobacter pylori infection, smoking (nicotine), chewing tobacco, corticosteroids, aspirin, NSAIDs, caffeine, alcohol, and stress. When an NSAID is taken as often as is typical for osteoarthritis, it will cause problems with the stomach. Certain medical conditions such as Crohn's disease, Zollinger-Ellison syndrome, and hepatic and biliary disease also can increase the risk for PUD by changing the amount of gastric and biliary acids produced. Recent retirement should decrease stress levels rather than increase them. Ulcer disease in a first-degree relative also is associated with increased risk for an ulcer. A significant other is not a first-degree relative; therefore, no genetic connection is noted in this relationship. Although caffeinated drinks are a known risk factor for PUD, the option states that the client drinks 1 cup of coffee occasionally.

A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? 1.Monitoring the temperature 2.Monitoring complaints of heartburn 3.Giving warm gargles for a sore throat 4.Assessing for the return of the gag reflex

4 Rationale:The nurse places highest priority on assessing for return of the gag reflex. This assessment addresses the client's airway. The nurse also monitors the client's vital signs and for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client's airway is the priority.

The nurse is caring for a client with spinal cord injury (SCI) who is participating in a bowel retraining program. What should the nurse anticipate to promote during the bowel retraining program? 1.Sufficiently low water content in the stool 2.Low intestinal roughage that promotes easier digestion 3.Constriction of the anal sphincter based on voluntary control 4.Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord

4 Rationale:The principal reflex center for defecation is located in the parasympathetic center at the S1 to S4 level of the spinal cord. This center is most active after the first meal of the day. Other factors that contribute to satisfactory stool passage are sufficient fluid and roughage in the diet and the Valsalva maneuver (which is lost with SCI). During defecation, the anal sphincter relaxes.

The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis? 1.Hypercalcemia 2.Hypernatremia 3.Frothy, fatty stools 4.Decreased hemoglobin

4 Rationale:Ulcerative colitis is an inflammatory disease of the large colon. Findings associated with ulcerative colitis include diarrhea with up to 10 to 20 liquid bloody stools per day, weight loss, anorexia, fatigue, increased white blood cell count, increased erythrocyte sedimentation rate, dehydration, hyponatremia, and hypokalemia (not hypercalcemia). Because of the loss of blood, clients with ulcerative colitis commonly have decreased hemoglobin and hematocrit levels. Clients with ulcerative colitis have bloody diarrhea, not steatorrhea (fatty, frothy, foul-smelling stools).

Pancreatin is prescribed for a client with postgastrectomy syndrome. Which assessment finding would indicate a therapeutic effect of this medication? 1.The client's appetite improves. 2.The client experiences weight loss. 3.Vitamin B12 deficiency is controlled. 4.The stool is less fatty and decreases in frequency.

4 Rationale:Pancreatin aids in the digestion of protein, carbohydrate, and fat in the gastrointestinal tract. It is used to treat steatorrhea associated with postgastrectomy syndrome after bowel resection. The nurse should record the number of stools per day and the stool consistency to monitor the effectiveness of this enzyme therapy. If it is effective, the stools should become less frequent and less fatty. The remaining options are not indications of a therapeutic effect of the medication

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. 1.Diarrhea 2.Black, tarry stools 3.Hyperactive bowel sounds 4.Gray-blue color at the flank 5.Abdominal guarding and tenderness 6.Left upper quadrant pain with radiation to the back

456 Rationale:Grayish-blue discoloration at the flank is known as Grey-Turner's sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity. The client may demonstrate abdominal guarding and may complain of tenderness with palpation. The pain associated with acute pancreatitis is often sudden in onset and is located in the epigastric region or left upper quadrant with radiation to the back. The other options are incorrect.