Sanders: Gastrointestinal

The nurse should include which information when reinforcing home care instructions for a client who has peptic ulcer disease? 1. Limit intake of trigger foods. 2. Smoke only when not eating. 3. Learn to use stress reduction techniques. 4. Take nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief.

Answer: 3. Learn to use stress reduction techniques Rationale: Identifying and reducing stress is essential to a comprehensive ulcer management plan. The client also should avoid intake of foods that aggravate pain, quit smoking, and avoid irritants such as NSAIDs. Antibiotic therapy often cures the client of this problem in many instances.

It has been determined that a client with hepatitis has contracted the infection from contaminated food. Which type of hepatitis is this client most likely experiencing? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D

Answer: 1. Hepatitis A Rationale: Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are most commonly transmitted via infected blood or body fluids.

The nurse should include which instruction in a teaching plan for a client who has peptic ulcer disease? 1. Smoke at bedtime only. 2. Learn to use stress reduction techniques. 3. Continue to eat the same diet as before the diagnosis. 4. Take nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief.

Answer: 2. Learn to use stress reduction techniques Rationale: Identifying and reducing stress are essential to a comprehensive ulcer management plan. The client should also limit intake of foods that aggravate pain, quit smoking, and avoid irritants such as NSAIDs. Antibiotic therapy is often prescribed to treat this disease

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1. Right side 2. Low-Fowler's position 3. High-Fowler's position 4. Supine, with the head flat

Answer: 3. High-Fowler's position Rationale: During the insertion of a nasogastric tube, the client is placed in a sitting or high-Fowler's position to reduce the risk of pulmonary aspiration if the client should vomit. Options 1, 2, and 4 do not facilitate the insertion of the tube or prevent aspiration

The nurse who is assisting in the care of a client within the first 24 hours following a total gastrectomy for gastric cancer should avoid which intervention? 1. Assessing for bowel sounds 2. Irrigating the nasogastric (NG) tube 3. Measuring the drainage from the nasogastric (NG) tube 4. Keeping the nasogastric (NG) tube connected to suction

Answer: 2. Irrigating the nasogastric (NG) tube Rationale: After gastric surgery, the nasogastric tube should not be irrigated. To do so may cause the suture line in the stomach to tear. Bowel sounds should be assessed, the drainage from the NG tube should be measured and the tube should be kept to suction, to be sure the stomach does not become distended.

The nurse is caring for a client with a nasogastric (NG) tube and tests the pH of the aspirate to determine correct placement. The nurse notes that the pH is 5. Which information does this indicate? 1. The NG tube needs to be reinserted. 2. Placement of the NG tube is accurate. 3. The pH of the aspirate needs to be rechecked. 4. The NG tube needs to be pulled back approximately 1 inch.

Answer: 2. Placement of the NG tube is accurate Rationale: After the nurse inserts an NG tube into a client, the correct location of the tube must be verified. Testing the pH of the gastric fluid and determining its acidity further verifies that the tube is in the stomach. The stomach contents are acidic, and a pH of 5 should indicate accurate placement. Options 1, 3, and 4 are incorrect.

The nurse is reinforcing medication instructions to a client with peptic ulcer disease. Which represents correct information given by the nurse? 1. Antacids coat the lining of the stomach. 2. Omeprazole (Prilosec) will coat the ulcer to help it heal. 3. Sucralfate (Carafate) changes the acidity of fluid in the stomach. 4. Cimetidine (Tagamet) results in decreased secretion of stomach acid.

Answer: 4. Cimetidine (Tagamet) results in decreased secretion of stomach acid. Rationale: Cimetidine and other histamine H2-receptor antagonists decrease the secretion of gastric acid in the stomach. Antacids neutralize acid in the stomach. Omeprazole inhibits gastric acid secretion. Sucralfate promotes healing by coating the ulcer.

The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred? 1. Dark and bluish 2. Sunken and hidden 3. Narrowed and flattened 4. Protruding and swollen

Answer: 4. Protruding and swollen Rationale: A prolapsed stoma is one in which bowel protrudes through the stoma, with an elongated and swollen appearance. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with dusky or bluish color. A stoma with a narrowed opening, either at the level of the skin or fascia, is said to be stenosed.

The nurse is caring for a client with acute pancreatitis and a history of alcoholism and is monitoring the client for complications. Which data should be indicative of paralytic ileus? 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

Answer: 1. Inability to pass flatus 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 sign/symptom of paralytic ileus. Loss of 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, nontender mass palpable at the lower right costal margin describes the physical finding of liver enlargement. The liver is usually enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, it is not a sign of paralytic ileus or intestinal obstruction.

A client with hiatal hernia chronically experiences heartburn after meals. Which should the nurse teach the client to avoid? 1. Lying recumbent after meals 2. Eating small, frequent, bland meals 3. Raising the head of the bed on 6-inch blocks 4. Taking histamine receptor antagonist medication, as prescribed

Answer: 1. Lying recumbent after meals 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 generally experiences pain caused by reflux resulting from ingestion of irritating foods, lying flat following meals or at night, and consuming large or fatty meals. Relief is obtained by eating small, frequent, and bland meals; histamine antagonists and antacids; and elevation of the thorax after meals and during sleep.

A client in the emergency department reports right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescriptions? Select all that apply. 1. Milk of magnesia 2. Heat pad to the abdomen 3. Cold pack to the abdomen 4. Nothing per mouth (NPO) 5. Intravenous fluids at a rate of 100 mL/hr

Answer: 1. Milk of magnesia 2. Heat pad to the abdomen Rationale: A client with right lower quadrant abdominal pain may have appendicitis. This client would be NPO and given intravenous (IV) fluids for hydration. Cold packs may provide comfort. Laxatives are not prescribed; heat might bring enough blood and fluid to the appendix to cause it to rupture and cause peritonitis, therefore, the nurse would question the cathartic prescription and heat application.

The nurse provides information to a client following a gastrectomy who is now diagnosed with pernicious anemia. Which instructions about pernicious anemia should the nurse reinforce? Select all that apply. 1. Provide meticulous and frequent oral hygiene. 2. Use additional lightweight blankets as needed. 3. Encourage a diet of foods with high iron content. 4. Check blood serum vitamin B12 levels every 1 to 2 years. 5. Administer replacement vitamin B12 monthly for the next 5 years.

Answer: 1. Provide meticulous and frequent oral hygiene. 2. Use additional lightweight blankets as needed. 4. Check blood serum vitamin B12 levels every 1 to 2 years. Rationale: Vitamin B12 deficiency occurs from lack of intrinsic factor normally secreted by specialized cells in the gastric mucosa. Meticulous frequent oral hygiene will promote an improved appetite and prevent infection. The client has a sensitivity to cold, so additional blankets may be needed. Serum blood vitamin B12 levels need to be checked every 1 to 2 years to make sure replacement therapy is adequate. A diet high in iron content is appropriate for iron deficiency anemia rather than vitamin B12 deficiency. Replacement therapy is given for a lifetime, not just 5 years.

A client has undergone subtotal gastrectomy and the nurse is preparing the client for discharge. Which item should be included when reinforcing instructions to the client about ongoing self-management? 1. Smaller, more frequent meals should be eaten. 2. The client can resume full activity immediately. 3. Stress can no longer exacerbate gastrointestinal symptoms. 4. Follow-up visits with the health care provider are no longer needed.

Answer: 1. Smaller, more frequent meals should be eaten. Rationale: Following gastric surgery, the client should eat smaller, more frequent meals to facilitate digestion. The client should resume activity gradually and should minimize stressors to prevent recurrence of symptoms. The client does require ongoing medical supervision and evaluation.

A client is admitted to the hospital with a diagnosis of acute pancreatitis. The nurse plans care, knowing that which problem occurs with this disorder? 1. Excess fluid volume related to sodium retention 2. Alteration in comfort related to abdominal pain 3. Alteration in fluid and electrolyte balance related to hyperkalemia 4. Potential for hypoglycemia related to a low blood glucose secondary to increased insulin secretion

Answer: 2. Alteration in comfort related to abdominal pain Rationale: Abdominal pain is the predominant symptom of acute pancreatitis. Shock and hypovolemia may occur from hemorrhage, toxemia, or loss of fluid into the peritoneal space. Potassium and sodium may be lost due to gastric suction and frequent vomiting. Hyperglycemia may result from impaired carbohydrate metabolism.

The nurse is assigned to care for a client who had a Sengstaken-Blakemore tube inserted when more conservative treatment failed to alleviate the condition. The nurse should suspect that the client has which diagnosis? 1. Gastritis 2. Esophageal varices 3. Bowel obstruction 4. Small bowel tumor

Answer: 2. Esophageal varices Rationale: A Sengstaken-Blakemore tube is inserted in a client with a diagnosis of cirrhosis with ruptured esophageal varices when other measures used to treat the varices are unsuccessful or contraindicated for the client. 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. This tube is not used to treat the conditions noted in the remaining options.

A client diagnosed with pernicious anemia asks the nurse what caused the deficiency. The nurse replies that it is likely a result of which condition that is part of the client's health history? 1. Hypothyroidism 2. Hemigastrectomy 3. Excessive vitamin C intake 4. Decreased dietary intake of iron

Answer: 2. Hemigastrectomy Rationale: The client who has had surgical resection of the stomach or small intestine may develop pernicious anemia as a complication. This results from decreased production of intrinsic factor (gastrectomy) or decreased surface area for vitamin B12 absorption (intestinal resection). The client then requires vitamin B12 injections for life. Decreased iron intake leads to iron deficiency anemia, which is often easily treated with iron supplements. Excessive vitamin C intake and hypothyroidism are unrelated to pernicious anemia.

The nurse is reviewing the medication record of a client with acute gastritis. Which medication noted on the client's record should the nurse question? 1. Digoxin (Lanoxin) 2. Ibuprofen (Motrin) 3. Furosemide (Lasix) 4. Propranolol hydrochloride (Inderal LA)

Answer: 2. Ibuprofen (Motrin) Rationale: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) and can cause ulceration of the esophagus, stomach, duodenum, or small intestine. It is contraindicated in a client with a gastrointestinal disorder. Furosemide is a loop diuretic. Digoxin is an antidysrhythmic. Propranolol hydrochloride is a beta-adrenergic blocker. Furosemide, digoxin, and propranolol hydrochloride are not contraindicated in clients with gastric disorders.

The nurse is reinforcing discharge instructions to a client with a hiatal hernia. Which should the nurse include in the teaching session? Select all that apply. 1. Lie flat for at least 30 minutes after meals. 2. It is advisable to stop smoking cigarettes. 3. Wait at least 1 hour after meals to perform chores. 4. Be sure to elevate the head of the bed during sleep. 5. Foods with moderate fat should be a part of your diet.

Answer: 2. It is advisable to stop smoking cigarettes. 3. Wait at least 1 hour after meals to perform chores. 4. Be sure to elevate the head of the bed during sleep. Rationale The client should elevate the head of the bed during sleep and wait at least 1 hour after meals to perform chores. Smoking cigarettes increases acid secretion so the client should be advised to stop smoking. The consumption of low-fat or nonfat foods is recommended not moderate fat. The client should remain upright for an hour after eating.

The nurse is caring for a client within the first 24 hours following a total gastrectomy for gastric cancer. During this time frame, on which intervention should the nurse focus? 1. Providing the client with an oral diet 2. Maintaining a patent nasogastric (NG) tube 3. Promoting the use of stress reduction techniques 4. Teaching the client about the symptoms of dumping syndrome

Answer: 2. Maintaining a patent nasogastric (NG) tube Rationale: An NG tube is inserted during surgery and is left in place for 24 to 48 hours to decompress the gastrointestinal tract, which enhances sealing of the suture line. It is essential that the NG tube does not become occluded because this could disrupt the suture lines if distention occurs. The other options are also appropriate, but not within the first 24 hours following surgery.

The nurse is admitting a client to the hospital for the treatment of dehydration. The client reports nausea, vomiting, diarrhea, and cramping for the past week. The nurse asks the client about medications he is taking. The client denies taking prescription medications but states he has been taking some herbs given to him by his cousin. The nurse alerts the health care provider when the client states he has been taking which herb? 1. Dill 2. Senna 3. Kaolin 4. Green tea

Answer: 2. Senna Rationale: Senna is used to treat constipation and as a bowel preparation for surgery. Its side effects are nausea, vomiting, diarrhea, anorexia, and cramping. Side effects of kaolin are nausea, anorexia, and constipation. Common gastrointestinal (GI) side effects of green tea are nausea and heartburn, and there are no known GI side effects from dill.

A client had a Miller-Abbott tube inserted 24 hours ago. The nurse is asked to check the client to determine whether the tube is in the appropriate location at this time. Which finding would indicate adequate location of the tube? 1. Bowel sounds are absent. 2. The aspirate from the tube has a pH of 7.45. 3. The aspirate from the tube has a pH of 6.5. 4. The tube can be palpated to the right of the umbilicus

Answer: 2. The aspirate from the tube has a pH of 7.45 Rationale: The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine (to correct a bowel obstruction). The end of the tube should be located in the intestine. The pH of the gastric fluid is acidic, and the pH of the intestinal fluid is 7 or higher if the tube is adequately located. Location of the tube can also be determined by x-ray, not palpation. Options 1 and 3 are incorrect and would not determine adequate location of the tube.

The nurse is caring for a client with a nasogastric tube. Which observation is most reliable in determining that the tube is correctly placed? 1. The aspirate is dark green. 2. The pH of the aspirate is 5. 3. The aspirate is negative for guaiac. 4. The tube is inserted the length measured from the client's ear to nose and nose to xiphoid process.

Answer: 2. The pH of the aspirate is 5. Rationale: After the nurse inserts a nasogastric tube into a client, the correct location of the tube must be verified. The nurse follows the approved procedure for inserting a nasogastric tube, including correct measurement and aspirating fluid with the visible characteristics of gastric fluid. The presence of blood (option 3) is unrelated to the location of the tube. Aspirate is dark green, and the tube is inserted the length measuring from the client's ear to nose and nose to xiphoid process. However, testing the pH of the gastric fluid and determining its acidity is the most reliable verification that the tube is correctly placed.

Which statement by the spouse of a client with end-stage liver failure indicates the need for further teaching by the multidisciplinary team regarding the management of pain? 1. "If constipation is a problem, increased fluids will help." 2. "If the pain increases, I must let the doctor know immediately." 3. "This opioid will cause very deep sleep, which is what my husband needs." 4. "I should have my husband try the breathing exercises to help control pain."

Answer: 3. "This opioid will cause very deep sleep, which is what my husband needs." Rationale: Changes in level of consciousness are an indicator of potential opioid overdose, as well as indicative of numerous fluid, electrolyte, and oxygenation deficits. It is important for the spouse to understand the differences in sleep related to the relief of pain and changes in neurological status related to overdose or deficits. All remaining options are indicative of an understanding of appropriate steps to be taken in the management of pain.

Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. Which is the best rationale for checking gastric residual volume before administering the tube feeding? 1. Observe the digestion of formula. 2. Check fluid and electrolyte status. 3. Evaluate absorption of the last feeding. 4. Confirm proper nasogastric tube placement.

Answer: 3. Evaluate absorption of the last feeding. Rationale: All the stomach contents are aspirated and measured before administering a tube feeding. This procedure measures the gastric residual volume. The gastric residual volume is checked to confirm whether undigested formula from a previous feeding remains and thereby evaluates the absorption of the last feeding. It is important to check the gastric residual before administration of a tube feeding. A full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration. If residual feeding is obtained, the health care provider's prescription and agency policy are checked to determine the course of action (hold or reduce the volume of the intermittent tube feeding).

The nurse is reinforcing discharge instructions to a client after a gastrectomy. Which measure should the nurse include in client teaching to help prevent dumping syndrome? 1. Ambulate after a meal. 2. Eat high-carbohydrate foods. 3. Limit the fluids taken with meals. 4. Sit in a high-Fowler's position during meals.

Answer: 3. Limit the fluids taken with meals. Rationale: The client should be instructed to decrease the amount of fluid taken at meals. The client should also be instructed to avoid high-carbohydrate foods, including fluids such as fruit nectars; assume a low-Fowler's position during meals; lie down for 30 minutes after eating to delay gastric emptying; and take antispasmodics as prescribed.

The nurse is caring for a client with a Sengstaken-Blakemore tube. To prevent ulceration and necrosis of oral and nasal mucosa, the nurse should plan to perform which action? 1. Provide tracheal suction as needed. 2. Keep scissors at the bedside for emergency deflation. 3. Provide frequent oral and nasal care on a regular basis. 4. Have a family member remain with the client as much as possible.

Answer: 3. Provide frequent oral and nasal care on a regular basis. Rationale: Frequent oral and nasal care is necessary to prevent irritation to the mucosa. A family member's presence will not prevent this from occurring nor will the actions taken in options 1 and 2. Keeping scissors at the bedside is a good action, however, because these are used to cut the tube if the client begins to have airway maintenance problems.

A postgastrectomy client who is being discharged from the hospital tells the nurse, "I hope my stomach problems are over. I need to get back to work right away. I've missed a lot of work, and I'm really behind. If I don't get my act together, I may lose my job." Based on the client's statement, the nurse determines that at this time, it is appropriate to discuss which topic? 1. Wound care 2. An exercise program 3. Reducing stressors in life 4. The postgastrectomy diet

Answer: 3. Reducing stressors in life Rationale: Some clients need help reducing stressors in their lives. This may be extremely important for recovery. Clients may expect a rapid recovery and are disappointed when this does not occur. The client's statement provides an opportunity for the nurse to discuss stress and its relationship to gastrointestinal disorders. The data in the question are unrelated to options 1, 2, and 4.

The nurse is reinforcing home care instructions to a client following a gastric resection. The nurse should include which instruction? 1. Avoid iron supplementation. 2. Eat a diet high in vitamin B12. 3. Take actions to prevent dumping syndrome. 4. Self-monitor for signs and symptoms of lower gastrointestinal hemorrhage.

Answer: 3. Take actions to prevent dumping syndrome. Rationale: Dumping syndrome can occur in clients after gastric surgery and may occur as an early or late complication. Upper rather than lower gastrointestinal hemorrhage may also occur. A diet high in vitamin B12 will not prevent pernicious anemia because the client lacks intrinsic factor needed for absorption of the vitamin. Instead, the client requires injections to supplement this vitamin. Iron supplements are necessary to help the absorption of parenteral vitamin B12.

The nurse is caring for a client with esophageal varices who is going to have a Sengstaken-Blakemore tube inserted. The nurse brings which priority item to the bedside so that it is available at all times? 1. An obturator 2. A Kelly clamp 3. An irrigation set 4. A pair of scissors

Answer: 4. A pair of scissors Rationale: When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client's bedside at all times. The client must be observed for sudden respiratory distress, which occurs if the gastric balloon ruptures, moving the entire tube upward. If this occurs, all balloon lumens are cut and the tube is removed. An obturator and a Kelly clamp would be kept at the bedside of a client with a tracheostomy. An irrigation set may be kept at the bedside, but it is not the priority item.

A client with peptic ulcer disease is scheduled for a pyloroplasty, and the client asks the nurse about the procedure. The nurse bases the response on which information? 1. A pyloroplasty involves cutting the vagus nerve. 2. A pyloroplasty involves removing the distal portion of the stomach. 3. A pyloroplasty involves removal of the ulcer and a large portion of the cells that produce hydrochloric acid. 4. A pyloroplasty involves an incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum.

Answer: 4. A pyloroplasty involves an incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum. Rationale: Option 4 describes the procedure for a pyloroplasty. A vagotomy involves cutting the vagus nerve. A subtotal gastrectomy involves removing the distal portion of the stomach. A Billroth II procedure involves removal of the ulcer and a large portion of the cells that produce hydrochloric acid.

A client is receiving bolus feedings via a nasogastric tube. The nurse plans to place the client's head of the bed (HOB) in which optimal position once the feeding is completed? 1. Flat with the client prone for at least 60 minutes 2. Elevated 45 to 60 degrees with the client supine for 15 minutes 3. Supine with the client in the left lateral position for 10 minutes 4. Elevated 30 to 45 degrees with the client in the right lateral position for 60 minutes

Answer: 4. Elevated 30 to 45 degrees with the client in the right lateral position for 60 minutes Rationale: Aspiration is a possible complication associated with nasogastric tube feeding. The HOB should be elevated 30 to 45 degrees for 60 minutes following bolus tube feeding to prevent vomiting and aspiration. The right lateral position uses gravity to facilitate gastric emptying, which also will reduce the risk of vomiting. The flat or supine position should be avoided because of the risk of aspiration.

The nurse is collecting data on a client with a diagnosis of peptic ulcer disease. Which history is least likely associated with this disease? 1. History of alcohol abuse 2. History of tarry black stools 3. History of gastric pain 2 to 4 hours after meals 4. History of the use of acetaminophen (Tylenol) for pain and discomfort

Answer: 4. History of the use of acetaminophen (Tylenol) for pain and discomfort Rationale: Unlike aspirin (acetylsalicylic acid [ASA]), acetaminophen has little effect on platelet function, doesn't affect bleeding time, and generally produces no gastric bleeding. The data in options 1, 2, and 3, if reported by the client, are indications of peptic ulcer disease.

The nurse is assisting in planning stress management strategies for the client with irritable bowel syndrome. Which suggestion should the nurse give to the client? 1. Rest in bed as much as possible. 2. Limit exercise to reduce bowel stimulation. 3. Try to avoid every possible stressful situation. 4. Learn measures such as biofeedback or progressive relaxation.

Answer: 4. Learn measures such as biofeedback or progressive relaxation Rationale: Treatment for irritable bowel syndrome includes stress reduction measures such as biofeedback, progressive relaxation, and regular exercise. The client should also learn to limit responsibilities. Other measures include increased fluid and fiber in the diet as prescribed and antispasmodic or sedative medications as needed.

The nurse observes that a client with a nasogastric tube connected to continuous gastric suction is mouth breathing, has dry mucous membranes, and has a foul breath odor. In planning care, which nursing intervention would be best to maintain the integrity of this client's oral mucosa? 1. Offer small sips of water frequently. 2. Encourage the client to suck on sour, hard candy. 3. Use lemon glycerin swabs to provide oral hygiene. 4. Use diluted mouthwash and water to rinse the mouth after brushing teeth.

Answer: 4. Use diluted mouthwash and water to rinse the mouth after brushing teeth. Rationale: After the nasogastric tube is in place, mouth care is extremely important. With one naris occluded, the client tends to mouth breathe, drying the mucous membranes. Frequent oral hygiene may be required to prevent or care for dry, irritated mucous membranes. Frequent, small sips of water would be contraindicated when the client is on gastric suction. The hard candy would increase the salivation but would not be useful in cleaning the oral cavity. Lemon glycerin swabs have a drying or irritating effect on the mucous membranes.

The nurse has been reinforcing dietary teaching for a client with gastroesophageal reflux disease (GERD) who has a routine follow-up visit. Which behavior is the best indicator of a successful outcome for this client? 1. A decrease in sour eructation 2. Taking in increased dairy products 3. Use of only decaffeinated coffee and tea 4. Decreased use of as-needed (PRN) medications

Answer: 1. A decrease in sour eructation Rationale: A decrease in sour eructation (burping) represents a change in the client's health status and is an effective indicator of a successful outcome. Options 2 and 3 are not consistent with minimizing disease symptoms. Option 4 represents healthy behavior by the client, but it is not as positive as is the correct option.

A client who has undergone a colostomy several days ago is reluctant to leave the hospital and has not yet looked at the ostomy site. Which measures are most likely to promote coping? Select all that apply. 1. Ask a member of the local ostomy club to visit with the client before discharge. 2. Ask the enterostomal nurse specialist to consult with the client before discharge. 3. Remind the client frequently that infection is a major complication of a colostomy. 4. Remind the client frequently that he will be responsible for caring for the colostomy at home. 5. Ask the client to begin doing one part of the ostomy care and increase tasks daily.

Answer: 1. Ask a member of the local ostomy club to visit with the client before discharge. 2. Ask the enterostomal nurse specialist to consult with the client before discharge. 5. Ask the client to begin doing one part of the ostomy care and increase tasks daily. Rationale: A member of the local ostomy club will be able to provide realistic encouragement. The enterostomal nurse specialist will be able to provide helpful information to the client. Asking the client to assist with tasks may encourage the client to take on more advanced skills and become more adjusted to the ostomy. Reminding the client about the responsibility for caring for the colostomy and telling the client that infection is a major complication (which is incorrect) will alarm the client.

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. To aid the client in symptom management, the nurse suggests which diet? 1. A low-fat diet 2. A high-fat diet 3. A low-fiber diet 4. A high-carbohydrate diet

Answer: 3. A low-fiber diet Rationale: A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. This diet is used for acute diverticulitis, ulcerative colitis, and irritable bowel syndrome. The diets identified in options 1, 2, and 4 will not aid in symptom management in acute diverticulitis.

The nurse is caring for a client with pneumonia with a history of bleeding esophageal varices. Based on this information, the nurse plans care, knowing that which could result in a potential complication? 1. Pain 2. Diarrhea 3. Frequent swallowing 4. Vigorous coughing

Answer: 4. Vigorous coughing Rationale: Increased intrathoracic pressure contributes to rupturing of varices. Straining at stool, coughing, and vomiting all increase intrathoracic pressure. The nurse needs to implement measures that will prevent increased intrathoracic pressure. Options 1, 2, and 3 will not increase intrathoracic pressure.

The nurse documents that a client with a hiatal hernia is implementing effective health maintenance measures after the client reports doing which action? 1. Eating low-fat or nonfat foods 2. Elevating the foot of the bed during sleep 3. Doing household chores immediately after eating 4. Sleeping with the head of the bed slightly down

Answer: 1. Eating low-fat or nonfat foods Rationale: The use of low-fat or nonfat foods is recommended to reduce gastric pressure and prevent sliding of the hernia through the cardiac sphincter. The client should also elevate the head of the bed during sleep, and wait at least 1 hour after meals to perform chores.

Which infection control method should be the priority to include in the plan of care to prevent hepatitis B in a client considered to be at high risk for exposure? 1. Hepatitis B vaccine 2. Proper personal hygiene 3. Use of immune globulin 4. Correct hand-washing technique

Answer: Hepatitis B vaccine Rationale: Immunization is the most effective method of preventing hepatitis B infection. Other general measures include hand washing. Immune globulin may be used to prevent hepatitis A and is used for prophylaxis if the client is traveling to endemic areas. Personal hygiene, such as hand washing after a bowel movement and before eating, also helps prevent the transmission of hepatitis A.

A client has asymptomatic diverticular disease. Which type of diet should the nurse anticipate being prescribed? 1. High-iron diet 2. High-fiber diet 3. Low-purine diet 4. Low-sodium diet

Answer: 2. High-fiber diet Rationale: A high-fiber diet is the diet of choice for asymptomatic diverticular disease to help prevent straining from constipation. A high-iron diet is for clients with anemia to help make hemoglobin. A low-purine diet is for clients with gout to prevent formation of stones and crystals. Hypertensive clients and clients with cardiac problems may require a low-sodium diet to prevent increased fluid volume.

A health care provider asks the nurse to obtain a Salem Sump tube for gastric intubation. The nurse selects which tube from the unit storage area? 1. Miller-Abbott tube 2. Sengstaken-Blakemore tube 3. Tube with just a single lumen 4. Tube with a lumen and an air vent

Answer: 4. Tube with a lumen and an air vent Rationale: A Salem Sump tube is used commonly for gastric intubation and has a large suction lumen and a small air vent. A Sengstaken-Blakemore tube is a tube used for gastroesophageal bleeding and has a balloon that controls bleeding. A Miller-Abbott tube is a long double-lumen tube used to drain and decompress the small intestine. Option 3 describes a Levin tube. A Levin tube does not have an air vent but is used for the same functions as a Salem Sump tube.

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

Answer: 1. Fatigue Rationale: Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic 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 participating in a health screening clinic and is preparing materials about colorectal cancer. The nurse plans to include which risk factor for colorectal cancer in the material? 1. Age of 20 years 2. High-fiber, low-fat diet 3. Distant relative with colorectal cancer 4. Personal history of ulcerative colitis or gastrointestinal (GI) polyps

Answer: 4. Personal history of ulcerative colitis or gastrointestinal (GI) polyps Rationale: Common risk factors for colorectal cancer include age over 40 years; first-degree relative with colorectal cancer; high-fat, low-fiber diet; and history of bowel problems such as ulcerative colitis or familial polyposis.

The nurse is evaluating the effect of dietary counseling on the client with cholecystitis. The nurse determines that the client understands the instructions given if the client states that which food item is acceptable to include in the diet? 1. Beef chili 2. Grilled steak 3. Mashed potatoes 4. Turkey and lettuce sandwich

Answer: 4. Turkey and lettuce sandwhich Rationale: The client with cholecystitis should decrease overall intake of dietary fat. Red meats (hamburger and steak) contain fat. Mashed potatoes are usually made with milk and butter. The correct food item that is low in fat is the turkey and lettuce sandwich.

The nurse is interpreting the laboratory results of a client who has a history of chronic ulcerative colitis. Which result indicates a complication of ulcerative colitis? 1. Hemoglobin 10.2 g/dL 2. Potassium 4.1 mEq/L 3. Prothrombin time 10.9 seconds 4. White blood cell count 6,300 cells/mm3

Answer: 1. Hemoglobin 10.2 g/dL Rationale: A normal hemoglobin level ranges from 12 to 16 g/dL. The client with ulcerative colitis is most likely anemic because of chronic blood loss in small amounts with exacerbations of the disease. These clients often have bloody stools and are at increased risk for anemia. The other laboratory results are within a normal range.

A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. The LPN should reinforce instructing the client to perform which action? 1. Exhale. 2. Inhale and exhale quickly. 3. Take and hold a deep breath. 4. Perform Valsalva's maneuver.

Answer: 3. Take and hold a deep breath. Rationale: When the NG tube is removed, the client is instructed to take and hold a deep breath. This will close the epiglottis, and the airway will be temporarily obstructed during the tube removal. This allows for the easy withdrawal of the tube through the esophagus into the nose. The tube is removed with one very smooth, continuous pull. Options 1, 2, and 4 are incorrect.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The health care provider has now prescribed the nasogastric tube to be discontinued. To determine the client's readiness for discontinuation of the nasogastric tube, which measure should the nurse check? 1. The pH of the gastric aspirate 2. Proper nasogastric tube placement 3. The client's serum electrolyte levels 4. Presence of bowel sounds in all four quadrants

Answer: 4. Presence of bowel sounds in all four quadrants Rationale: Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction, and a nasogastric tube may be used to empty the stomach and relieve distention and vomiting. Bowel sounds return to normal as the obstruction is relieved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function returns may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, tube placement, and pH of gastric aspirate are important assessments for the client with a nasogastric tube in place, but these would not assist in determining the readiness for removing the nasogastric tube.

The nurse is reinforcing dietary instructions for a client with peptic ulcer disease. Which statement made by the client indicates a need for further teaching? 1. I will eat a bland diet only. 2. I will be sure not to skip meals. 3. I will exclude coffee and tea from my diet. 4. If spicy foods cause pain I will avoid them in my diet.

Answer: 1. I will eat a bland diet only. Rationale: A bland diet is unnecessary. The client should not skip meals, avoid tea and coffee, as they cause an increase in acid production, and discontinue eating spicy foods if they cause pain.

A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting, and a gastric ulcer is suspected. The nurse should gather which additional supportive data from the client for this diagnosis? 1. History of alcohol use, smoking, and weight loss 2. Frequent "heartburn" with a sour taste in the mouth 3. Complaints of stress with a history of chronic kidney disease 4. Blood group and history of chronic obstructive pulmonary disease with weight gain

Answer: 1. History of alcohol use, smoking, and weight loss Rationale: Alcohol use, smoking, and weight loss are most commonly associated with gastric ulcers. The other options do not identify risk factors commonly associated with this disorder. The symptoms listed in option 2 may be seen in gastroesophageal reflux disease.