NURSING 121 Unit 2- GI
A nurse is preparing to administer a nasogastric tube feeding. List the steps of the procedure in the order in which they should be performed. 1. Wash the hands 2. Verify the solution to be administered 3. Aspirate the contents of the stomach 4. Instill the prescribed solution 5. Document the client's response to the procedure
12345
A client describes abdominal discomfort following ingestion of milk. Which enzyme, as a result of a genetic deficiency, should the nurse consider to be the cause of the client's discomfort? A. Lactase B. Sucrase C. Maltase D. Amylase
A
A client has laparoscopic surgery to remove a calculus from the common bile duct. What postoperative client response indicates to the nurse that bile flow into the duodenum is reestablished? A. Stools become brown B. Liver tenderness is relieved C. Colic is absent after ingestion of fats D. Serum bilirubin level returns to the expected range
A
A client is admitted to the hospital with ascites. The client reports drinking a quart (liter) of vodka mixed in orange juice every day for the past three months. To assess the potential for withdrawal symptoms, which question would be appropriate for the nurse to ask the client? A. "When was your last drink of vodka?" B. "What prompts your drinking episodes?" C. "Do you also eat when you drink?" D. "Why do you mix the vodka with orange juice?"
A
A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. What is the priority nursing action during the first 48 hours after the client's admission? A. Monitor the client's vital signs. B. Increase the client's fluid intake. C. Improve the client's nutritional status. D. Determine the client's reasons for drinking.
A
Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? A. Incontinence and inability to move independently B. Periodic diaphoresis and occasional sliding down in bed C. Reaction to just painful stimuli and receiving tube feedings D. Adequate nutritional intake and spending extensive time in a wheelchair
A
A nurse is instructing a client with peptic ulcer disease (PUD) about the diet that should be followed during the acute phase. Which type of diet should the nurse stress? A. Bland foods B. Regular diet C. Gluten-free foods D. Low-carbohydrate foods
A. Bland Foods
A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply. 3 A. Rye B. Oats C. Rice D. Corn E. Wheat
ABE
A client is admitted to the hospital with slight jaundice and reports of pain on the left side and back. A diagnosis of acute pancreatitis is made. Which common response to acute pancreatitis should the nurse monitor in the client? A. Crackles B. Hypovolemia C. Gastric reflux D. Jugular vein distention
B
When assessing a client's abdomen, the nurse palpates the area directly above the umbilicus. By what term is this area known? A. Iliac area B. Epigastric area C. Hypogastric area D. Suprasternal area
B
A client had a colon resection and formation of a colostomy two days ago. Which color indicates to the nurse the stoma is viable? A. Blue B. Gray C. Brick red D. Dark purple
C
A client has a hiatal hernia. The client is 5 feet 3 inches tall (163 cm) and weighs 160 pounds (72.6 kg). Which information should the nurse include when discussing prevention of esophageal reflux? A. Increase your intake of fat with each meal. B. Lie down after eating to help your digestion. C. Reduce your caloric intake to foster weight reduction. D. Drink several glasses of fluid during each of your meals.
C
A client is instructed to avoid straining on defecation postoperatively. Which food item chosen by the client indicates successful learning? A. Ripe bananas B. Milk products C. Green vegetables D. Creamed potatoes
C
A nurse is teaching menu planning to a client who has a high triglyceride level. Which item avoided by the client indicates that teaching about foods that are high in saturated fat is understood? A. Fruits B. Grains C. Red meat D. Vegetable oils
C
A client is admitted to the hospital with a diagnosis of intestinal obstruction. The healthcare provider prescribes intestinal suction via a nasoenteric decompression tube. The loss of which constituents associated with intestinal suctioning is most important to consider when caring for this client? A. Protein enzymes B. Energy carbohydrates C. Vitamins and minerals D. Water and electrolytes
D
A client is admitted to the hospital with jaundiced skin and acute abdominal pain. What is the nurse's most therapeutic response when the client refuses all visitors? A. Listen to the client's fears B. Encourage the client to socialize C. Grant the client's request about visitors D. Darken the client's room by pulling the drapes
A
A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. What explanation does the nurse give for why a PEG tube is preferred for administering a tube feeding? A. There is less chance of aspiration. B. This procedure does not require a pump. C. Self-administration of the feeding is possible. D. More tube feeding mixture can be given each time.
A
A self-help group of clients with irritable bowel syndrome have invited a nurse to present a program on nutrition. Which substance should the nurse teach the clients to minimize in the diet to decrease gastrointestinal (GI) irritability? A. Cola drinks B. Gelatin C. Fiber D. Rice
A
A client with colitis inquires as to whether surgery eventually will be necessary. When teaching about the disease and its treatment, what should the nurse emphasize? A. Medical treatment is curative; surgery is not required. B. For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful. C. For most clients, surgery is recommended early in the course of treatment. D. Medical treatment is all that will be needed if the client can maintain emotional stability.
B
A client with gastroesophageal reflux disease reports having difficulty sleeping at night. What should the nurse instruct the client to do? A. Drink a glass of milk before retiring. B. Elevate the head of the bed on blocks. C. Eliminate carbohydrates from the diet. D. Take antacids, such as sodium bicarbonate.
B
A client is prescribed ranitidine 150 mg daily to treat peptic ulcer disease (PUD). Which instruction would the nurse give to the client about when to take this medication? A. As needed B. With meals C. At bedtime D. When indigestion occurs
C
A client is diagnosed with hepatitis A. The nurse provides the client with information about untoward signs and symptoms related to hepatitis. The nurse instructs the client to contact the primary healthcare provider if the client develops what symptom? A. Fatigue B. Anorexia C. Yellow urine D. Clay-colored stools
D
A client is diagnosed with cancer of the pancreas and is apprehensive and restless. Which nursing action should be included in the plan of care? A. Encouraging expression of concerns B. Administering antibiotics as prescribed C. Teaching the importance of getting rest D. Explaining that everything will be all right
A
A client is diagnosed with cancer of the stomach and is scheduled for a partial gastrectomy. The teaching on postoperative care provided by the nurse should cover what topic? A. Gastric suction B. Oxygen therapy C. Fluid restriction D. Urinary catheter
A
A client has surgery for an incarcerated hernia. The healthcare provider returns the incarcerated tissue to the abdominal cavity and uses a mesh to reinforce the muscle wall. What specific instructions should be included in the discharge instructions? A. Reduce dietary roughage. B. Avoid lifting heavy items. C. Increase dietary potassium intake. D. Keep the head of the bed elevated.
B
A client who is suspected of having salmonellosis asks the nurse how the diagnosis is confirmed. The nurse responds that the medical diagnosis is established with what laboratory test? A. Urinalysis B. Stool culture C. Febrile agglutinin test D. Complete blood count
B
A client had surgery for a ruptured appendix. Postoperatively, the health care provider prescribes an antibiotic to be administered intravenously twice a day. The nurse administers the prescribed antibiotic via a secondary line into the primary infusion of 0.9% sodium chloride. During the administration of the antibiotic, the client becomes restless and flushed, and begins to wheeze. What should the nurse do after stopping the antibiotic infusion? A. Check the client's temperature. B. Take the client's blood pressure. C. Obtain the client's pulse oximetry. D. Assess the client's respiratory status.
D
The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What nursing intervention is the priority? A. Weigh the client daily. B. Restrict the client's oral fluid intake. C. Measure the client's urine specific gravity. D. Observe the client for increasing confusion.
D
A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results? A. Sodium and chloride levels B. Bicarbonate and sulfate levels C. Magnesium and protein levels D. Calcium and phosphate level
A
A client is scheduled for a colonoscopy, and the healthcare provider prescribes a tap water enema. In which position should the nurse place the client during the enema? A. Left Sims B. Back lying C. Knee chest D. Mid-Fowler
A
A client reports experiencing nausea, dyspnea, and right upper quadrant pain unrelieved by antacids. The pain occurs most often after eating in fast-food restaurants. Which diet should the nurse instruct the client to follow? A. Low fat B. Low carbohydrate C. Soft-textured and bland D. High protein and kilocalories
A
A client with a 20-year history of excessive alcohol use has developed jaundice and ascites and is admitted to the hospital. What is the priority nursing action during the first 48 hours after the client's admission? A. Monitor vital signs B. Increase fluid intake C. Obtain a foam mattress D. Improve nutritional status
A
A client with advanced bone cancer is experiencing cachexia. The nurse discusses the nutritional aspect of palliative care with the family. What is the importance of the nurse explaining these nutritional interventions to the family? A. Enhances the quality of the client's life B. Reduces the likelihood of a respiratory infection C. Prevents the malabsorption syndrome from occurring D. Cures the cachexia that results from bone cancer and chemotherapy
A
A female client who had a colostomy recently is asking questions about how normal her life will be now that she has a colostomy. Which statement by the client indicates a need for further teaching? A. "I wanted another child, and now pregnancy is not an option for me." B. "I must allow extra time for irrigating my colostomy when traveling." C. "It is good to know that I can swim every day after my incision heals." D. "I'm glad I won't have to have special clothing and I can wear what I have."
A
A financially struggling, large family is instructed by the home health nurse about ways to increase the dietary intake of calcium. Which suggestion should the nurse make? A. Collards or kale in one meal a day B. Fruit-flavored yogurt every other day C. Bread made with cornmeal each morning D. Eight ounces (240 mL) of milk with every meal
A
A healthcare provider explains a cystectomy and an ileal conduit for a client with invasive carcinoma of the bladder. Later the client expresses concerns about the possibility of offensive odors associated with this procedure. What is the best response by the nurse? A. "Tell me more about what you are thinking." B. "Products are available to limit this problem." C. "This is a problem, but the surgery is necessary." D. "Most people who have this surgery share this same concern."
A
A nurse is reviewing discharge plans with a client who is hospitalized with hepatitis A. The nurse concludes that the client understands preventive measures to reduce the risk of spreading the disease when the client makes what statement? A. "I should wash my hands frequently." B. "I should launder my clothes separately." C. "I should put used tissues in the garbage." D. "I should wear a mask when leaving the house."
A
After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for what treatment? A. Monthly injections of cyanocobalamin B. Regular daily use of a stool softener C. Weekly injections of iron dextran D. Daily replacement therapy of pancreatic enzymes
A
After an acute episode of upper gastrointestinal (GI) bleeding, a client vomits undigested antacids and reports having severe epigastric pain. The nursing assessment reveals an absence of bowel sounds, a pulse rate of 134, and shallow respirations of 32 per minute. In addition to calling the healthcare provider, what is the priority nursing action? A. Prepare the client for surgery. B. Administer oxygen per nasal catheter. C. Place in the supine position, with legs elevated. D. Ask the client if there have been any black stools.
A
During a health symposium a nurse teaches the group how to prevent food poisoning. Which statement by one of the participants indicates the teaching is understood? A. "Meats and cream-based foods need to be refrigerated." B. "Once most food is cooked, it does not need to be refrigerated." C. "Poultry should be stuffed and then refrigerated before cooking." D. "Cooked food should be cooled before being put into the refrigerator."
A
The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do? A. Monitor for nonverbal cues of pain B. Check the pressure dressing for bleeding C. Assist the client to ambulate around his room D. Irrigate the client's nasogastric tube with sterile water
A
Twelve hours after a subtotal gastrectomy, a nurse identifies large amounts of bloody drainage from the client's nasogastric (NG) tube. Which action should the nurse take? A. Obtain vital signs B. Clamp the NG tube C. Instill 30 mL of iced normal saline into the NG tube D. Record the observations and continue monitoring the client
A
Which recommendation is most important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet? A. Use lemon juice to season meat. B. Put condiments on food to add flavor. C. Include canned vegetables in meal preparation. D. Drink carbonated beverages instead of decaffeinated coffee.
A
A client is admitted to the hospital for a laparoscopic cholecystectomy. What should the nurse encourage the client to add to the diet to help normalize bowel function after surgery? A. Vitamins B. Whole bran C. Cod liver oil D. Amino acids
B
A client is scheduled for gastrointestinal surgery. What is the most important nursing action that should be implemented the evening before surgery? A. Describing the specific surgical procedure B. Ensuring the bowel preparation is initiated C. Encouraging the client to socialize with other clients D. Providing the client's food preferences for the evening meal
B
A client who had a choledochostomy to explore the common bile duct is returned to the surgical unit with a T-tube in place. What is the priority intervention when caring for this client? A. Irrigate the T-tube as necessary B. Protect the abdominal skin from bile drainage C. Have the client wear a binder when out of bed D. Empty the T-tube drainage bag every two hours
B
A client who had an abdominoperineal resection and colostomy refuses to allow any family members to see the incision or stoma. The client is noncompliant with most of the dietary recommendations. The nurse concludes that the client is experiencing what response? A. Reaction formation; this is related to the client's recent altered body image B. Denial; the client is having difficulty accepting reality C. Impotency resulting from the surgery; sexual counseling may be indicated D. Suicidal thoughts; consultation with a psychiatrist should be prescribed
B
A healthcare provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is most appropriate for the nurse to teach the client about meal management? A. Snack daily in the evenings B. Divide food into four to six meals a day C. Eat the last of three daily meals by 8:00 PM D. Suck a peppermint candy after each meal
B
A nurse assesses a client with the diagnosis of an intestinal obstruction in the descending colon. When auscultating the midabdomen, what should the nurse expect to hear? A. Tympany B. Borborygmi C. Abdominal bruit D. Pleural friction rub
B
A nurse is obtaining a health history from a client with the diagnosis of peptic ulcer disease. Which client statement provides evidence to support the identification of a possible contributory factor? A. "My blood type is A positive." B. "I smoke one pack of cigarettes a day." C. "I have been overweight most of my life." D. "My blood pressure has been high lately."
B
A nurse reviews the laboratory results of a client with acute pancreatitis. Which test is most significant in determining the client's response to treatment? A. Platelet count B. Amylase level C. Red blood cell count D. Erythrocyte sedimentation rate
B
The nurse is caring for a client in the postanesthesia care unit immediately after the client had a subtotal gastrectomy. The nurse identifies small blood clots in the client's gastric drainage. What action should the nurse take? A. Clamp the tube. B. Consider this an expected event. C. Instill the tube with iced normal saline. D. Notify the surgeon immediately.
B
The nurse is caring for a client with a hiatal hernia. The client states that favorite beverages include ginger ale, apple juice, orange juice, and cola beverages. Of the four the client listed, which is the only beverage that should remain in the client's diet? A. Ginger ale B. Apple juice C. Orange juice D. Cola beverages
B
The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump? A. Checking for the last bowel movement B. Checking for residual stomach contents C. Checking to determine time of last medication for nausea D. Checking to make sure the head of bed is elevated at least 15 degrees
B
The nurse is providing postoperative care for a client who had an extensive surgical revision of the head of the pancreas. To decrease the risk of hemorrhage at the operative site, what action should the nurse take? A. Keep the client in the supine position. B. Maintain patency of the nasogastric tube. C. Replace fat-soluble vitamins as necessary. D. Administer prescribed tube feedings to the client slowly.
B
Three days before surgery for a permanent colostomy for cancer of the colon, a client is receptive of all procedures, responds pleasantly when approached, and does not question staff about what is being done. What is the most appropriate conclusion for the nurse to make based on these behaviors? A. The client has been fully informed about what to expect. B. The client is not verbalizing feelings about what will happen. C. The client cannot accept the illness and the need for surgery. D. The client feels reassured by frequent contact with health team members.
B
A client is hospitalized after four days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, Pco2 50 mm Hg, bicarbonate 58 mEq/L (58 mmol/L), chloride 55 mEq/L (55 mmol/L), sodium 132 mEq/L (132 mmol/L), and potassium 3.8 mEq/L (3.8 mmol/L). What condition does the nurse determine the results to indicate? A. Hypernatremia B. Hyperchloremia C. Metabolic alkalosis D. Respiratory acidosis
C
A client tells the nurse about recent recurrent episodes of bleeding hemorrhoids. What should the nurse advise the client to do to help prevent future hemorrhoidal episodes? A. Exercise to improve circulation B. Eat bland foods and avoid spices C. Consume a high-fiber diet and drink adequate water D. Use laxatives to avoid constipation and the Valsalva maneuver
C
A client who had previously signed a consent form for a liver biopsy reconsiders and decides not to have the procedure. What is the nurse's best initial response? A. "Why did you sign the consent form originally?" B. "I can understand why you changed your mind." C. "Can you tell me your reasons for refusing the procedure?" D. "You must be afraid about something concerning the procedure."
C
A client who is a heavy smoker has been prescribed a high-calorie, high-protein diet. The nurse should encourage the client to eat foods that are high in which vitamin? A. Niacin B. Thiamine C. Vitamin C (ascorbic acid) D. Vitamin B12
C
A client, experiencing an exacerbation of Crohn disease, is admitted to the hospital for intravenous steroid therapy. The nurse should not assign this client to a room with a roommate who has which illness? A. Pancreatitis B. Thrombophlebitis C. Bacterial meningitis D. Acute cholecystitis
C
A nurse identifies a moderate amount of bright red blood in a client's gastric drainage four hours after a subtotal gastrectomy. What should the nurse do first? A. Clamp the nasogastric tube. B. Irrigate the tube gently with normal saline. C. Record the observation and continue to monitor the drainage from the tube. D. Reduce the pressure of the suction and record observations of the drainage characteristics.
C
A nurse is caring for a client on the second day after an abdominoperineal resection. Which finding does the nurse document as normal in the stoma? A. Dry, pale pink, and even with the skin B. Moist, skin-colored, and flush with the skin C. Moist, red, and raised above the skin surface D. Dry, purple, and depressed below the skin surface
C
A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome? A. Low-residue, bland diet B. Fluid intake below 500 mL C. Small, frequent feeding schedule D. Low-protein, high-carbohydrate diet
C
A nurse reviews the plan of care for a geriatric client with less than adequate nutritional intake. The nurse should question which prescription? A. Have client sit in a chair for meals to prevent aspiration of food/liquid into the lungs. B. Provide six small feedings in 24 hours whenever requested by the client. C. Give one can of diet supplement at 8:00 AM with breakfast and 4:00 PM prior to evening meal. D. Encourage the client's family members to bring food from home, especially their favorite dishes.
C
A nurse teaches a client about limiting the discomfort associated with a hiatal hernia. Which statement from the client indicates teaching by the nurse is effective? A. "After meals I will take a 10-minute walk." B. "After meals I will drink 8 oz (240 mL) of water." C. "After meals I will rest in a sitting position for one hour." D. "After meals I will lie down in bed for at least 20 minutes."
C
The home health nurse provides education to a client with cancer of the tongue who will begin gastrostomy feedings at home. Which statement by the client indicates teaching by the nurse is effective? A. "Before I start the procedure, I will don sterile gloves." B. "Before I start the procedure, I will obtain my body weight." C. "Before I start the procedure, I will measure the residual volume." D. "Before I start the procedure, I will instill one ounce (30 mL) of a carbonated liquid."
C
The nurse provides discharge teaching to a client related to management of the client's new colostomy. The client states, "I hope I can handle all of this at home; it's a lot to remember." What is the nurse's best response? A. "I'm sure you will be able to do it." B. "Maybe a family member can do it for you." C. "You seem to be nervous about going home." D. "Perhaps you can stay in the hospital another day."
C
Two days after abdominal surgery a client experiences extensive flatus. The nurse administers the Harris flush (Harris drip). Which finding indicates a therapeutic effect? A. Client has a bowel movement. B. Client's returns are finally clear. C. Client's abdomen is less distended. D. Client is able to retain a half liter of fluid.
C
A client is admitted to the hospital with gastrointestinal bleeding, and a nasogastric tube is inserted. The healthcare provider prescribes the nasogastric tube to be irrigated with normal saline whenever necessary to maintain patency. What should the nurse do first when it is determined that the nasogastric tube is not patent? A. Instill normal saline. B. Assess breath sounds. C. Auscultate for bowel sounds. D. Check the tube for placement.
D
A client is diagnosed with cancer of the rectum and has surgery for an abdominoperineal resection and colostomy. Which nursing care should be implemented during the postoperative period? A. Limiting fluid intake for several days B. Withholding fluids for 72 hours C. Having the client change the colostomy bag D. Keeping the client's skin around the stoma clean
D
A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea? A. Increased fiber intake B. Bacterial contamination C. Inappropriate positioning D. High osmolarity of the feedings
D
A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is most important for the nurse to determine when collecting information about the constipation? A. Presence of distention B. Extent of weight gained C. Amount of high-fiber food consumed D. Length of time this problem has existed
D
A client with ascites is scheduled for a paracentesis. To prepare the client for the abdominal paracentesis, what should the nurse do? A. Shave the client's abdomen. B. Medicate the client for pain. C. Encourage the client to drink fluids. D. Instruct the client to empty the bladder.
D
Discharge planning for a client with chronic pancreatitis includes dietary teaching. Which statement indicates to the nurse that the client needs more teaching? A. "I must eat foods high in calories." B. "I should avoid alcoholic beverages." C. "I will eat more often but in smaller amounts." D. "I can eat foods high in fat now that the acute stage is over."
D
During administration of an enema, a client reports having intestinal cramps. What should the nurse do? A. Discontinue the procedure. B. Instill the fluid at a slower rate. C. Lower the height of the container. D. Stop the fluid until the cramps subside
D
The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. Which will be most appropriate to include in the client's dietary plan? A. Offer soft-textured foods to reduce the digestive burden B. Offer low-cholesterol foods to avoid further formation of gallstones C. Increase protein intake to promote tissue healing and improve energy reserves D. Decrease fat intake to avoid stimulation of the cholecystokinin mechanism for bile release
D
The nurse understands that research demonstrates that malnutrition occurs in as many as 50% of hospitalized clients. The nurse should assess a postoperative client with anorexia for what sign of malnutrition? A. Dependent edema B. Spoon-shaped nails C. Loose, decayed teeth D. Delayed wound healing
D
A client diagnosed with gastroesophageal reflux disease (GERD) is being treated with antacid therapy. When teaching the client about the therapy, what does the nurse reinforce? A. Antacids should be taken 1 hour before meals. B. These should be scheduled at 4-hour intervals. C. Antacid tablets are just as fast and effective as the liquid form. D. Antacids commonly interfere with the absorption of other drugs.
D. Antacids commonly interfere with the absorption of other drugs