Week 1: GI Disorders

A nurse is assessing a client who reports abdominal pain, nausea, and diarrhea. What does the nurse consider first when palpating the abdomen?

Palpation alters abdominal sounds from baseline. The correct sequence for abdominal examination is inspection, auscultation, percussion, and palpation. This sequence differs from that used for other body regions (which is inspection, palpation, percussion, and auscultation) because palpation and percussion increase intestinal activity, altering bowel sounds. Therefore, the nurse should not palpate or percuss the abdomen before auscultating. Assessment of any body system or region starts with inspection; therefore, auscultating or palpating the abdomen first would be incorrect.

A client with cancer of the stomach had a total gastrectomy 2 days earlier. Which indicates the client is ready to try a liquid diet?

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

Which goal is most important for a client with acute pancreatitis?

The client reports minimal abdominal pain. Abdominal pain can be a significant problem in acute pancreatitis. An expected outcome is to decrease or eliminate the pain the client is experiencing. Patterns of bowel elimination and liver function are not typically affected by pancreatitis. The client should avoid alcohol.

The nurse assesses a client who is receiving a tube feeding. Which situation would require prompt intervention from the nurse?

The feeding that is infusing has been hanging for 8 hours. Feeding solutions that have not been infused after hanging for 8 hours should be discarded because of the increased risk of bacterial growth. Sitting the client upright during the feeding helps prevent aspiration of the feeding. A gastric residual of 25 mL is considered acceptable. A gastric residual of 100 to 150 mL, or a residual greater than 100% of the previous hour's intake, indicates delayed emptying. The feeding solution should be at room or body temperature.

Which diet would be most appropriate for the client with ulcerative colitis?

high-protein, low-residue Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid exc

Metoclopramide is prescribed as a premedication for a client about to undergo a gastroduodenoscopy. What expected therapeutic effect of this drug should the nurse assess in this client?

increased gastric emptying Metoclopramide is an antiemetic given because of its gastric emptying ability, which is necessary in gastrointestinal procedures. It does not increase gastric pH, reduce anxiety, or inhibit respiratory secretions.

When assessing a client's inguinal hernia, the nurse should place the client in which position?

standing For the best assessment of an inguinal hernia, the client should be in a standing position to allow the examiner to palpate for the inguinal ring. After being examined in the standing position, the client may be asked to lie down to determine whether the hernia can be reduced and its sac contents returned to the abdominal cavity.The sitting position, left side-lying position, and right side-lying position do not allow the examiner to palpate for the inguinal ring.

Which finding is the best indication that the goals for total parenteral nutrition (TPN) are being achieved for the client?

weight gain of 0.5 lb/day (0.2 kg/day) Steady and progressive weight gain is the best indication that the client's nutritional goals are being met by TPN.The laboratory values are within normal limits but do not indicate attainment of nutritional goals. Hyperglycemia may be a metabolic complication of TPN with concomitant glycosuria. The client's blood glucose level is monitored, and insulin is prescribed as needed. Electrolyte values are assessed daily to determine the client's response to TPN.

A client reports having bloody stools to the nurse. What question(s) will the nurse ask the client? Select all that apply.

"Are you having constipation?" "Do you have a history of hemorrhoids?" "When is the last time you had a colonoscopy?" The nurse will ask about constipation, hemorrhoids, and a colonoscopy to obtain all stool history and gastrointestinal information. The voiding at night and the number of times the client voids during the day are not necessary, as this is not part of the gastrointestinal system.

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?

"Avoid coffee and alcoholic beverages." To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren't gastric irritants.

A client one day postoperative cholecystectomy reports severe pain radiating to the shoulder. What should be the first nursing action?

Assess the patency of the T-tube. Commonly, clients will have pain from the irritation to the phrenic nerve from the CO2 that is injected during a laproscopic cholecystectomy. The first and least restrictive action is to place the client in Sim's position to help remove the air pocket away from the diaphragm. Assessing the T-tube is important to determine the cause of the pain. Hydromorphone aggravates gallbladder pain and should be avoided, and range of motion of the arms may aggravate the pain.

A client arrives to the emergency department with suspected appendicitis. The admitting nurse performs an assessment. Order the following steps according to the sequence in which they are performed. All options must be used.

Obtain a health history. Inspect the abdomen, noting the shape, contours, and any visible peristalsis or pulsations. Auscultate bowel sounds in all four quadrants. Percuss all four abdominal quadrants. Gently palpate all four quadrants, saving the painful area for last. The first step in the data collection process is to obtain a health history. Then, the nurse would visually inspect the abdomen. Of the three remaining steps, it is important to auscultate before percussing or palpating the client's abdomen. Touching or palpating the abdomen before listening may actually change the bowel sounds, leading to faulty data.

The health care provider prescribes sulfasalazine for the client with ulcerative colitis. Which instruction should the nurse give the client about taking this medication?

Take it with a full glass (240 mL) of water. Adequate fluid intake of at least eight glasses a day prevents crystalluria and stone formation during sulfasalazine therapy. Sulfasalazine can cause gastrointestinal distress and is best taken after meals and in equally divided doses. Sulfasalazine gives alkaline urine an orange-yellow color, but it is not necessary to stop the drug when this occurs.

Why are antacids administered regularly, rather than as needed, in peptic ulcer disease?

To keep gastric pH at 3.0 to 3.5 To maintain a gastric pH of 3.0 to 3.5 throughout each 24-hour period, regular (not as needed) doses of an antacid are needed to treat peptic ulcer disease. Frequent administration of an antacid tends to decrease client compliance rather than promote it. Antacids don't regulate bowel patterns, and they decrease pepsin activity.

The nurse is assigned a client with a nasogastric (NG) tube. What intervention will the nurse include in the client's plan of care?

assessment of lung sounds every 4 hours Assessment of lung sounds assesses for aspiration, lavage of "blue port" or air vent of a Salem-sump will prevent the air lumen from working, irrigation should occur every 4 hours and as needed, and medications are never given with enteral feeds.

Which goal for the client's care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis?

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

When planning care for a client with hepatitis A, the nurse should review labororatory reports for which laboratory value?

prolonged prothrombin time The prothrombin time may be prolonged because of decreased absorption of vitamin K and decreased production of prothrombin by the liver. The client should be assessed carefully for bleeding tendencies. Blood glucose, serum potassium, and serum calcium levels are not affected by hepatitis.

The nurse assigns an unlicensed assistive personnel (UAP) to provide care for a client with peptic ulcer disease. Concerned about possible ulcer perforation, the nurse should instruct the UAP to report to the nurse immediately if the client has:

severe abdominal pain. A sign of ulcer perforation is the onset of sudden, severe abdominal pain. The nurse should instruct all unlicensed assistive personnel to report this symptom immediately because a perforated ulcer is a medical emergency.An elevated pulse and confusion may occur for various reasons; the assistant should report all vital signs, but the severe pain must be brought to the nurse's attention immediately.Constipation will not require immediate intervention.

A client has had a nasogastric tube connected to low intermittent suction. What is the client at risk for?

muscle cramping Muscle cramping is a sign of hypokalemia. Potassium is an electrolyte lost with nasogastric suctioning. Confusion is seen with hypercalcemia. Edema is seen with protein deficit or fluid volume overload. Tremors are seen with hypomagnesemia.

A client returns from the operating room after undergoing extensive abdominal surgery. The client is receiving 1,000 ml of lactated Ringer's solution via a central line infusion. The health care provider orders the intravenous fluid to be infused at 125 ml/hour and additional intravenous fluids based on total output of the last hour. The drip factor of the tubing is 15 gtt/ml and the output for the previous hour was 75 ml via Foley catheter, 50 ml via nasogastric tube, and 10 ml via Jackson Pratt tube. For how many drops (gtt) per minute would the nurse set the intravenous flow rate to deliver the correct amount of fluid? Record your answer as a whole number.

65 irst, calculate the volume to be infused (in milliliters):75 ml + 50 ml + 10 ml = 135 ml total output for the previous hour>135 ml + 125 ml ordered as a constant flow = 260 ml to be infused over the next hour.Next, use the formula:Volume to be infused/Total minutes to be infused × Drop factor = Drops per minute.In this case:(260 ml/60 minutes) × 15 gtt/minute = 65 gtt/minute.

The client with a nasogastric (NG) tube has abdominal distention. What should the nurse do first?

Check the function of the suction equipment. When a client with a NG tube exhibits abdominal distention, the nurse should first check the suction machine. If the suction equipment is functioning properly, then the nurse should take other steps, such as repositioning the tube or checking tube patency by irrigating it. If these steps are not effective, then the HCP should be called.

At 0800, the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), what should the nurse do next?

Evaluate the tube for patency. The t-tube should drain approximately 300 to 500 mL in the first 24 hours, and after 3 to 4 days the amount should decrease to less than 200 mL in 24 hours. With the sudden decrease in drainage at 0800, the nurse should immediately assess the tube for obstruction of flow that can be caused by kinks in the tube or the client lying on the tube. Drainage color must also be assessed for signs of bleeding. The tube should not be irrigated or clamped without a prescription.

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. A client with appendicitis is at Risk for infection related to inflammation, perforation, and surgerybecause obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Elderly, not middle-aged, clients are especially susceptible to appendix rupture.

A nurse is caring for a client who had gastric bypass surgery two days ago. Which assessment finding requires immediate intervention?

The client's right lower leg is red, swollen, and warm to touch. A red, swollen extremity is a possible sign of a thromboembolism, a common complication after gastric surgery. The nurse should inform the physician of the finding. Pain at the surgical site upon rising is normal, but splinting should be reinforced. A reddened surgical site is concerning, but the red, swollen leg is a higher priority. Abdominal bloating occurs due to the carbon dioxide used during the laparoscopy and will lessen when it gets absorbed. Additional teaching is needed to be sure the client does not strain at the toilet.

A nurse is teaching a group of middle-aged clients about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention

alcohol abuse and smoking. The nurse should mention that risk factors for peptic (gastric and duodenal) ulcers include alcohol abuse, smoking, and stress. A sedentary lifestyle and a history of hemorrhoids aren't risk factors for peptic ulcers. Chronic renal failure, not acute renal failure, is associated with duodenal ulcers.

A nurse is providing postprocedure instructions for a client who is to undergo a esophagogastroduodenoscopy. The nurse should begin this process

before the procedure. A client who undergoes esophagogastroduodenoscopy receives sedation during the procedure, and their memory becomes impaired. Clients tend not to remember instructions provided after the procedure. The nurse's best course of action is to give the instructions prior to the client going to the procedure. The client needs to be aware at discharge of potential complications and signs and symptoms to report to the physician.

A client is diagnosed with pancreatitis. Which assessment would be of most concern to the nurse?

bluish discoloration in periumbilical area All symptoms are expected in a client with pancreatitis. However, bluish discoloration in the periumbilical area (Cullen's sign) may indicate seepage of blood-stained exudate from the pancreas that may lead to hemorrhage or shock.

A client with a bleeding ulcer is vomiting bright red blood. The nurse should assess the client for which indicator of early shock?

heart rate above 100 beats/minute In early shock, the body attempts to meet its perfusion needs through tachycardia, vasoconstriction, and fluid conservation.The skin becomes cool and clammy.Urine output in early shock may be normal or slightly decreased.The client may experience increased restlessness and anxiety from hypoxia, but loss of consciousness is a late sign of shock.

A nurse is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, and a temperature of 100°F (37.8°C). The nurse questions the client about a past diagnosis of what condition?

inflammatory bowel disease (IBD) IBD is a collective term for several GI inflammatory diseases with unknown causes. The most prominent sign of IBD is mild diarrhea, which sometimes is accompanied by fever and abdominal discomfort. Colorectal cancer is usually diagnosed after the client complains of bloody stools; the client will rarely have abdominal discomfort with colorectal cancer. A client with diverticulitis commonly reports chronic constipation with occasional diarrhea, nausea, vomiting, and abdominal distention. Jaundice, coagulopathies, edema, and hepatomegaly are common signs of liver failure.

While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct?

making a copy of the incident report for the client A nurse shouldn't copy an incident report for anyone. An incident report is a confidential and privileged document available to agency personnel for risk-management activities. After completing the report, the nurse should submit it according to facility policy. The nurse should document the incident factually in the client's record and notify the health care provider of the incident and the client's condition.

A client with chronic pancreatitis should be assessed for which finding?

nausea and vomiting Common manifestations of chronic pancreatitis include nausea, vomiting, and intermittent pain. Chronic pancreatitis does not cause confusion or agitation. There is no change in vital signs, and there are no musculoskeletal manifestations such as muscle twitching.

A client with acute diarrhea is requesting an as-needed medication for loose, watery stools. After reviewing the physician's orders, which medication should the nurse administer?

paregoric 5 ml P.O. Paregoric helps decrease peristalsis and diarrhea caused by muscle spasms of the GI tract. Morphine sulfate, chlorpheniramine polistirex and hydrocodone polistirex, and alprazolam aren't indicated for diarrhea.

After a cholecystectomy, the client is to follow a low-fat diet. Which food would be most appropriate to include in a low-fat diet?

roast beef sandwich with lettuce and tomato Lean meats, such as beef, lamb, veal, and well-trimmed lean ham and pork, are low in fat. Rice, pasta, and vegetables are low in fat when not served with butter, cream, or sauces. Fruits are low in fat. The amount of fat allowed in a client's diet after a cholecystectomy will depend on the client's ability to tolerate fat. Typically, the client does not require a special diet but is encouraged to avoid excessive fat intake. A cheese omelet and peanut butter have high fat content. Ham salad is high in fat from the fat in a mayonnaise-based salad dressing.

A nurse is teaching a client with malabsorption syndrome about the disorder and its treatment. The client asks which part of the GI tract absorbs food. The nurse tells the client that products of digestion are absorbed mainly in the

small intestine. The small intestine absorbs products of digestion, completes food digestion, and secretes hormones that help control the secretion of bile, pancreatic juice, and intestinal secretions. The stomach stores, mixes, and liquefies the food bolus into chyme and controls food passage into the duodenum; it doesn't absorb products of digestion. Although the large intestine completes the absorption of water, chloride, and sodium, it plays no part in absorbing food. The rectum is the portion of the large intestine that forms and expels feces from the body; its functions don't include absorption.

A client comes to the emergency department with suspected cholecystitis. Which data collection findings are characteristic of this diagnosis? Select all that apply.

transient epigastric pain radiating to the back and right shoulder burning in the chest after eating fried foods flatulence nausea Cholecystitis (inflammation of the gallbladder) is characterized by epigastric pain that radiates to the back and right shoulder. This pain commonly occurs after eating foods high in fat, especially those that are fried. A client with cholecystitis may also experience nausea, vomiting, and flatulence. Urticaria is not commonly associated with cholecystitis.

A client with peptic ulcer disease is taking ranitidine. What is the expected outcome of this drug?

Limit gastric acid secretion. Histamine2 (H2) receptor antagonists, such as ranitidine, reduce gastric acid secretion. Antisecretories, or proton-pump inhibitors, such as omeprazole, help ulcers heal quickly in 4 to 8 weeks. Cytoprotective drugs, such as sucralfate, protect the ulcer surface against acid, bile, and pepsin. Antacids reduce acid concentration and help reduce symptoms.

After insertion of a nasoenteric tube, the nurse should place the client in which position?

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

A client with a bleeding peptic ulcer is admitted to an acute care facility. As part of therapy, the physician orders cimetidine I.V. Infusing this medication too rapidly may cause

hypotension. When given by rapid I.V. infusion, cimetidine may cause profound hypotension and other cardiotoxic effects. Tetany and bronchospasms aren't associated with cimetidine. Although the drug may cause hallucinations, this adverse reaction doesn't result simply from rapid administration.

The nurse should assess the client with severe diarrhea for which acid-base imbalance?

metabolic acidosis A client with severe diarrhea loses large amounts of bicarbonate, resulting in metabolic acidosis. Metabolic alkalosis does not result in this situation. Diarrhea does not affect the respiratory system.

Which nursing intervention would most likely promote self-care behaviors in the client with a hiatal hernia?

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

A client who underwent abdominal surgery and has a nasogastric (NG) tube in place begins to complain of abdominal pain described as "feeling full and uncomfortable." Which assessment should the nurse perform first?

Assess patency of the NG tube. When an NG tube is no longer patent, stomach contents collect in the stomach, giving the client a sensation of fullness. The nurse should begin by assessing patency of the NG tube. The nurse can measure abdominal girth, auscultate bowels, and assess vital signs, but the nurse should check NG tube patency first to help relieve the client's discomfort.

During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy. Which vitamin would be affected by this?

vtamin K Intestinal bacteria synthesize such nutritional substances as vitamin K, thiamine, riboflavin, vitamin B12, folic acid, biotin, and nicotinic acid. Antibiotic therapy may interfere with synthesis of these substances, including vitamin K. Intestinal bacteria do not synthesize vitamins A, D, or E.

An enterostomy nurse is providing an in-service session on caring for colostomies. Which statement by a nurse indicates the need for further teaching?

"I can make a small pin hole in the bag to let the gas out, so I don't have to change the appliance frequently." The nurse requires additional teaching if stateing that they can make a hole in the drainage bag to let gas out. Any hole in the drainage bag, no matter how small, will destroy the odor-proof seal. Removing or unclamping the bag is the only appropriate method for releasing the gas accumulated in the bag. Odor-relieving tablets, usually made of charcoal, can be placed in the bag to help with the odor.

After the nurse teaches the parent of an infant with pyloric stenosis about the condition, which cause, if stated by the parent, indicates effective teaching?

"an enlarged muscle below the stomach" Pyloric stenosis involves hypertrophy of the pylorus muscle distal to the stomach and obstruction of the gastric outlet resulting in vomiting, metabolic acidosis, and dehydration. Telescoping of the bowel is called intussusception. Overfeeding, feeding too quickly, or underfeeding is not associated with pyloric stenosis. The stomach is obstructed, but it is not smaller than normal.

The nurse has received a prescription to add 20 mEq of potassium chloride to a 1,000-mL bottle of IV fluid. The nurse has a 30-mL, multiple-dose vial of potassium chloride. The label reads 2 mEq/mL. How many milliliters should the nurse add to the IV fluid? Record your answer using a whole number.

10 To administer 20 mEq of potassium chloride, the nurse needs to administer 10 mL. The following formula is used to calculate the correct dosage:20 mEq/X mL = 2 mEq/1 mL; X = 10 mL.

A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. What should the nurse do? Select all that apply.

Change the feeding apparatus every 24 hours. Slow the administration rate. Use a diluted formula, gradually increasing the volume and concentration. Anticipate changing to a lactose-free formula. Although about 50% of diarrhea in clients receiving tube feedings is caused by sorbitol-containing medications, the nurse should assess for other possible causes. Diarrhea can occur as a result of bacterial contamination if fresh formula is not used or stored in a refrigerator, or if the feeding apparatus is not changed at least every 24 hours. Lactose intolerance, rapid formula administration, low serum albumin level, and hypertonic solutions may also cause diarrhea. Hypotonic solutions would not be a likely cause of diarrhea, abdominal distention, or cramping

A nurse is caring for a client with gastroenteritis. The nurse administers an as-needed dose of kaolin and pectin mixture as ordered. The nurse should complete which assessment 30 minutes after administering the medication?

Determine if the client has had any more loose stools. Kaolin and pectin is given to decrease the amount of loose stools. The onset of kaolin and pectin occurs within 30 minutes. The nurse should follow up with the client to determine if the frequency of the loose stools is decreasing to assess for drug effectiveness. Performing a pain assessment, monitoring for respiratory depression, and determining if the client has relief from nausea aren't necessary assessments for this client.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has

cirrhosis. Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.

Which expected outcome about nutrition would be appropriate for a client who has had a total gastrectomy for gastric cancer? The client will:

maintain adequate nutrition through oral or parenteral feedings. An appropriate expected outcome is for the client to maintain nutrition either through oral or total parenteral feedings. Oral and total parenteral nutrition may also be used concurrently.It is not realistic to expect the client to regain weight loss within 4 weeks of surgery.After surgery, it is recommended that the client eat six small meals a day rather than three full meals to decrease symptoms of dumping syndrome.Enteral feedings are not part of the expected outcome for gastric surgery.

Prochlorperazine is prescribed postoperatively. The nurse should evaluate the drug's therapeutic effect when the client expresses relief from which symptom?

nausea Prochlorperazine is administered postoperatively to control nausea and vomiting. Prochlorperazine is also used in psychotherapy because of its effects on mood and behavior. It is not used to treat dizziness, abdominal spasms, or abdominal distention.

The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should:

place the client on nothing-by-mouth (NPO) status. The nurse should place the client on NPO status in anticipation of surgery. The nurse can initiate pain relief strategies, such as relaxation techniques, but the surgeon will likely not prescribe narcotic medication prior to surgery. The nurse can place the client in a position that is most comfortable for the client. Heat is contraindicated because it may lead to perforation of the appendix.

A client with pancreatitis returns from an endoscopic retrograde cholangiopancreatography (ERCP). Which assessment would be of most concern to the nurse?

poor gag reflex A poor gag reflex may lead to inability of the client to handle oral secretions and lead to decreased oxygen saturation. Upper abdominal pain is expected from the injection of CO2 to visualize the duodenum. Retrograde amnesia is expected from conscious sedation and a sore throat is expected from the endoscope being inserted during the procedure.

Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. Which additional assessment finding will the nurse assess for?

severe abdominal pain with direct palpation or rebound tenderness Peritonitis decreases intestinal motility and causes intestinal distention. A classic sign of peritonitis is a sudden, diffuse, severe abdominal pain that intensifies in the area of the underlying causative disorder (such as appendicitis, diverticulitis, ulcerative colitis, or a strangulated obstruction). The client may also have rebound tenderness. Tenderness and pain in the right upper abdominal quadrant suggest cholecystitis. Jaundice and vomiting are signs of cirrhosis of the liver. Rectal bleeding or a change in bowel habits may indicate colorectal cancer.

A client with a Sengstaken-Blakemore tube has a sudden drop in SpO2 and an increase in respiratory rate to 40 breaths/min. What should the nurse do in order from first to last? All options must be used.

Affirm airway obstruction by the tube. Deflate the tube by cutting with bedside scissors. Remove the tube. Apply oxygen via face mask. The nurse should first assess the client to determine if the tube is obstructing the airway; assessment is done by assessing air flow. Once obstruction is established, the tube should be deflated and then quickly removed. A set of scissors should always be at the bedside to allow for emergency deflation of the balloon. Oxygen via face mask should then be applied once the tube is removed.

A client has been hospitalized with pancreatitis for 3 days. The nurse assesses the client and documents the accompanying results. The nurse realizes these findings are a manifestation of what sign?

Cullen's sign Cullen's sign is evidenced by discoloration at the periumbilical area. This sign may indicate an underlying subcutaneous intraperitoneal hemorrhage. Chvostek's sign is a facial nerve spasm and Trousseau's sign is a carpopedal spasm; both signs occur with hypocalcemia. Broca's area, not sign, is an area within the brain that controls the motor functions involved in speech.

Which discharge instruction would be appropriate for a client who has had a laparoscopic cholecystectomy and has sutures covered by a dressing?

Leave dressing in place until seeing the surgeon at the postoperative visit. After a laparoscopic cholecystectomy when there are sutures covered by a dressing the client should not remove dressings from the puncture sites but should wait until visiting the surgeon. The client may shower 48 hours after surgery. A client can return to work within 1 week, but only if approved by the surgeon and no strenuous activity is involved. The client should report any fever, which could be an indication of a complication.

While obtaining a client's medication history, the nurse learns that the client takes ranitidine, as ordered, to treat a peptic ulcer. The nurse continues gathering medication history data to assess for potential drug interactions. The nurse should intervene when the nurse learns the client takes which class of drugs?

antacids The nurse should intervene by providing additional teaching if the client reports that they take antacids. Antacids can interact with ranitidine and interfere with its absorption. Ranitidine doesn't interact with antibiotics, antipsychotics, or antiarrhythmics.

The nurse is obtaining a health history from a client who has a sliding hiatal hernia associated with reflux. The nurse should ask the client about the presence of which symptom?

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

Which client requires immediate nursing intervention? The client who

presents with a rigid, boardlike abdomen. A rigid, boardlike abdomen is a sign of peritonitis, a possibly life-threatening condition. Epigastric pain occurring 90 minutes to 3 hours after eating may indicate a duodenal ulcer. Anorexia and periumbilical pain are characteristic of appendicitis. A client with a large-bowel obstruction may have ribbonlike stools.

A nurse is giving instructions to client with a new colostomy. The client states, "I'm so tired today; I just can't think." The nurse should:

reschedule the appointment at a time when the client is rested. The client's readiness to learn is compromised by fatigue and lack of concentration. The teaching session should be rescheduled to a better time for improved learning readiness.Written instructions or involving the spouse can supplement verbal instructions but cannot replace teaching the client directly.

After instructing a client with diverticulosis about appropriate self-care activities, which comment by the client indicates effective teaching? Select all that apply.

"I should follow a diet that is high in fiber." "It is important for me to drink at least 2,000 mL of fluid every day." "I should exercise regularly." Clients who have diverticulosis should be instructed to maintain a diet high in fiber and, unless contraindicated, should increase their fluid intake to a minimum of 2,000 mL/day. Participating in a regular exercise program is also strongly encouraged. Diverticulosis can be controlled with treatment but cannot be cured. Clients should be instructed to avoid the regular use of cathartic laxatives. Bulk laxatives and stool softeners may be helpful to maintain regularity and decrease straining.

A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?

"I'll avoid eating or drinking anything 6 to 8 hours before the test." The client demonstrates understanding of a barium swallow when they state that they must refrain from eating or drinking for 6 to 8 hours before the test. No other preparation is needed. Before a lower GI series, the client should eat a low-residue or clear liquid diet for 2 days and take a potent laxative and an oral liquid preparation.

A client with a history of alcohol abuse was admitted with bleeding esophageal varices. After several days of treatment, the client is ready for discharge. The nurse enters the client's room to review discharge instructions with the client when the client tells the nurse that they want help to quit drinking. How should the nurse respond?

"I'll notify your physician and call the social worker so they can discuss treatment options with you." The nurse should notify the physician and call the social worker so the social worker can discuss treatment options with the client. The social worker may be able to arrange inpatient treatment for the client immediately after discharge if the client wishes. Telling the client to wait to discuss their concerns minimizes their feelings. Telling the family about the client's wishes breaches client confidentiality.

A client diagnosed with ulcerative colitis also experiences obsessive compulsive anxiety disorder (OCD). In helping the client understand her illness, the nurse should respond with which statement?

"It's possible that your desire to have everything be perfect has caused stress that may have worsened your colitis, but there is no proof that either disorder caused the other." Though ulcerative colitis and OCD have some features in common, and stress can make both illnesses worse, there is no definitive cause-effect relationship between ulcerative colitis and OCD. Therefore, the only appropriate nursing response would be to acknowledge the effect of stress on both illnesses and indicate there is no proof that either illness causes the other.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse. The client's morning ammonia level is 110 mcg/dl. The nurse should suspect which situation?

The client's hepatic function is decreasing. The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the morning dose of lactulose was not taken, the client wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings are not indicative of reduced renal filtration.

The nurse teaches the client who has had rectal surgery the proper timing for a cleansing sitz baths. What will indicate to the nurse that the client has understood when to take the sitz bath? The client will take the sitz bath:

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

A nurse is caring for a client who underwent a subtotal gastrectomy 24 hours ago. The client has a nasogastric (NG) tube. The nurse should

irrigate the NG tube gently with normal saline solution if ordered. The nurse can gently irrigate the tube if ordered, but must be careful not to reposition it. Repositioning can cause bleeding. The nurse should apply suction continuously — not every hour. The nurse shouldn't clamp the NG tube postoperatively because secretions and gas will accumulate, stressing the suture line.

A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?

nothing by mouth Bleeding must be controlled before oral intake, so the client should receive nothing by mouth. When the bleeding is controlled, the diet is gradually increased, starting with ice chips and then clear liquids. Dairy shouldn't be given because it increases gastric acid production, which could prolong bleeding. A clear liquid diet is the first diet offered after bleeding is controlled.

A nurse is caring for a client 1 hour post-laparotomy who reports abdominal pain rating 5/10. What will the nurse prioritize when administering the ordered morphine?

administer the medication before the pain becomes severe For greatest analgesic effectiveness, the nurse should administer an opioid agonist, such as morphine, before the client's pain becomes severe. If the nurse waits until the pain becomes severe, the medication will be less effective, taking longer to provide relief. Giving morphine every 3 hours around the clock whether or not the client has pain would be inappropriate because the client may have increased side effects of the medication such as respiratory depression. Minimizing medication administration to avoid dependency would cause needless suffering for the client.

A nurse has been asked to obtain a client's signature on an operative consent form. When the nurse approaches the client, who is scheduled for a cholycystectomy later in the day, the client asks the nurse why the procedure is needed. Which response by the nurse is appropriate?

"I will ask the surgeon to come speak to you about the procedure." It is the surgeon's responsibility to explain the procedure to the client and to answer questions so the client can provide an informed consent. The nurse can reinforce the information after the consent is obtained and clarify the information, but the surgeon must explain the procedure initially

A client with constipation takes psyllium granules as 1 rounded teaspoon mixed in fruit juice 3 times daily. Which of the following statements by the client indicates that further teaching is required?

"I will need to take the medication for 4 weeks." Psyllium is a bulk-forming laxative used to treat constipation. It absorbs liquid in the intestines, swells, and forms a bulky, easy-to-pass stool. Psyllium comes in the following forms: powder, granules, capsule, liquid, and wafer to take by mouth. It is usually taken 1 to 3 times daily. It should not be taken for more than 1 week unless advised. Clients cannot continue this drug for 4 weeks. Regular use may prevent normal bowel function, cause adverse drug reactions, and delay treatment for conditions that cause constipation. The powder or granules must be mixed with 8 oz (240 mL) of pleasant tasting liquid such as fruit juice right before use. Therapeutic effects (soft to semi-liquid stools) occur in approximately 1 to 3 days with bulk-forming laxatives like psyllium and stool softeners, while effects (liquid to semi-liquid stools) occur in 1 to 3 hours with saline cathartics and castor oil. These granules absorb water rapidly in the intestines and solidify into a gelatinous mass, so the client should drink 6 to 10 glasses of water or juice daily.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. Based on the diagnosis of acute pancreatitis the nurse will provide which explanation for the prescribed interventions?

"You are not allowed anything by mouth so that your pancreas can rest." The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Interventions include parenteral pain management preferably with an opioid, NPO status to decrease pancreatic activity, and bed rest to decrease body metabolism. Antibiotics are not usually indicated. The focus is on pain management and fluid replacement intraveneously. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse cannot help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

During the assessment of a client's mouth, the nurse notes the absence of saliva. The client reports having pain behind the ear. The client has been nothing-by-mouth (NPO) for several days but now can have liquids. What should the nurse do next?

Encourage the client to suck on hard candy. The lack of saliva, pain near the area of the ear, and the prolonged NPO status of the client are indications that the client may be developing parotitis, or inflammation of the parotid gland. Parotitis usually develops with dehydration combined with poor oral hygiene or when clients have been NPO for an extended period. Preventive measures include the use of sugarless hard candy or gum to stimulate saliva production, adequate hydration, and frequent mouth care. The client does not have indications of stomatitis (inflammation of the mouth), which produces excessive salivation and a sore mouth. The client does not have indications of oral candidiasis (thrush), which causes bluish white mouth lesions, and the nurse does not need to request a prescription for an antifungal mouthwash. There are no indications that the client has gingivitis, which can be recognized by the inflamed gingiva and bleeding that occur during toothbrushing, and while the client should brush the teeth and gums, increasing salivation to prevent parotitis is the priority at this time.

The client underwent a bowel resection and was in the postanesthesia recovery unit for 1 hour. On return from the recovery room, the client reports having pain and asks for medication. In what order (from first to last) should the nurse perform the actions? All options must be used.

Establish the location and severity of the pain. Reposition the client to the opposite side. Determine when the client last received pain medication. Administer pain medication as prescribed. Thorough assessment of the client's pain is always the first step in treating pain. Clients may experience pain for a variety of reasons. The nurse must first determine the probable cause of the pain and its intensity on a pain scale. The pain is most likely incisional but could result from positioning, an excessively tight dressing, or anxiety, and the nurse can next reposition the client to promote comfort. Because the client spent an hour in the postanesthesia recovery unit, the nurse would next determine if the client had been medicated for pain in that unit. Last, the nurse can administer the pain medication as prescribed.

A nurse is assisting with the removal of a central venous access device (CVAD). What should the nurse do to prepare the client?

Instruct the client to take a deep breath and hold it. The client should be asked to perform the Valsalva maneuver (take a deep breath and hold it) during insertion and removal of a CVAD. This increases central venous pressure during the procedure and prevents air embolism. Trendelenburg is the preferred position for CVAD insertion and removal. If not possible, supine position is sufficient for CVAD removal. The client should hold the breath, not exhale.

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instructions would be most appropriate?

Maintain a high-carbohydrate, low-fat diet. A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake is not necessary because chronic pancreatitis is not associated with hyponatremia or fluid loss.

An adult client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, board-like abdomen. After obtaining the client's vital signs, what should the nurse do next?

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

A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that the blood pressure is 96/60 mm Hg, with a heart rate of 120 bpm. The client just vomited coffee-ground-like material. Based on these data what should the nurse do first?

Prepare to insert a nasogastric (NG) tube. The nurse should prepare to insert an NG tube. The data collected provide evidence that the client is experiencing an upper gastrointestinal bleed secondary to a peptic ulcer. The client will be placed on nothing-by-mouth status, and an NG tube will be inserted to provide gastric decompression and alleviate vomiting. Administering antiemetics is not a priority action for a client who is hypotensive and vomiting coffee-ground emesis. Assessment of client stressors is appropriate after emergency care has been provided and the client stabilized. A modified Trendelenburg position is inappropriate for clients who are vomiting.

One month following a subtotal gastrectomy for cancer, the nurse is evaluating the nursing care goal related to nutrition. What indicates that the client has attained the goal? The client has:

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

The nurse working in an internal medicine clinic receives four phone calls from clients with chronic pancreatitis. Which client should the nurse contact first?

The client reporting increased thirst and hunger. Clients with chronic pancreatitis are likely to develop diabetes as a result of the pancreatic fibrosis that occurs. The pancreas becomes unable to secrete insulin. Increased thirst and hunger are symptoms of diabetes. Chronic abdominal pain can be recurrent for months to years. The client with the need for pancreatic enzymes prescription refill is not in acute distress and can be called back later. A symptom of chronic pancreatitis is steatorrhea (fatty stools) and can become severe. The nurse should follow-up with the client to assess for volume and frequency of the stools, however, this client is not the priority.

A physician orders lactulose, 30 ml three times daily, for a client with cirrhosis to treat elevated serum ammonia level. The nurse will know that this medication is effective by which finding?

The client's level of consciousness (LOC) would improve. In cirrhosis, the liver fails to convert ammonia to urea. Ammonia then builds up in the blood and is carried to the brain, causing cerebral dysfunction. When this occurs, the client will often have a decreased level of consciousness and appear confused. Lactulose is administered to promote ammonia excretion in the stool and thus improve cerebral function. Because LOC is an accurate indicator of cerebral function, the nurse can evaluate the effectiveness of lactulose by monitoring the client's LOC. Monitoring urine output, abdominal girth, and stool frequency helps evaluate the progress of cirrhosis, not the effectiveness of lactulose.

A client arrives for an annual physical examination. During the history, the client reports recurrent symptoms of heartburn, a sour taste in the mouth, and hoarseness in the throat. In anticipation of client teaching, illustrate on the diagram the location of the structure which frequently enables these symptoms to occur.

The lower esophageal sphincter is a ring of muscle fibers that prevents food from moving backward from the stomach into the esophagus. If this sphincter does not close well, food, fluids, and stomach contents can irritate and even damage the esophagus. Symptoms include heartburn, a sour taste in the mouth, hoarseness, dysphagia, and feelings of a lump in the throat.

A graduate nurse and the nurse's preceptor are establishing priorities for their morning assessments. Which client should they assess first?

The newly admitted client with acute abdominal pain The graduate nurse and their preceptor should assess the new admission with acute abdominal pain first because they just arrived on the floor and might be unstable. Next, they should change the abdominal dressing for the postoperative client or measure feeding tube residual in the client with continuous tube feedings. These tasks are of equal importance. They should assess the sleeping client who received pain medication 1 hour ago last because they just received relief from pain and are able to sleep.

A client has had an incisional cholecystectomy. Which of the following nursing interventions has the highest priority in postoperative care for this client?

Using incentive spirometry every 2 hours while awake. A major goal of postoperative care for the client who has had an incisional cholecystectomy is the prevention of respiratory complications. Because of the location of the incision, the client has a difficult time breathing deeply. Use of incentive spirometry promotes chest expansion and decreases atelectasis. Performing leg exercises each shift is not frequent enough; they should be performed hourly. Maintaining a weight reduction diet may be appropriate for the client, but it is not the highest priority in the immediate postoperative phase. Promoting wound healing is important, but respiratory complications are most common after a cholecystectomy.

A nurse is caring for a client with history of chronic intestinal irritation. The client asks, "Is there any type of colostomy where I would not need a continuous colostomy bag?" Indicate the location where a client could have an ostomy that eventually might not require wearing an ostomy bag.

With a sigmoid colostomy, the feces are solid; therefore, the client may eventually gain enough control that they would not need to wear a colostomy bag. With a descending colostomy, the feces are semi-mushy. With a transverse colostomy, the feces are mushy. With an ascending colostomy, the feces are fluid. In these three latter cases, it's unlikely that the client could gain control of elimination; consequently, wearing an ostomy bag would be necessary.

A client develops chronic pancreatitis. What would be the appropriate home diet for a client with chronic pancreatitis?

a low-fat, bland diet distributed over five to six small meals daily A low-fat, bland diet prevents stimulation of the pancreas while providing adequate nutrition.Dietary protein and fiber are not directly related to pancreatitis.Although calcium is important, the low-fat content is more significant.The hyperglycemia of acute pancreatitis is usually transient and does not require long-term dietary modification.

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to their back. Which intervention takes priority for this client?

administering morphine I.V. as ordered The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

Which nursing intervention has the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting?

administering pain medication. Administering pain medication would have the highest priority during the first hour after the client's admission.Completing the admission history can be done after the client's pain is controlled.Maintaining hydration is important but will be accomplished over time. In the first hour after admission, the highest priority is pain relief.It is not appropriate to try to teach while a client is in pain. Teaching about planned diagnostic tests can occur after the client is comfortable.

A client with liver and renal failure has severe ascites. On initial shift rounds, the primary nurse finds the indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, the nurse finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal?

albumin Albumin is an abnormal finding in a routine urine specimen. Ascites present in liver failure contain albumin; therefore, if the bladder ruptured, ascites containing albumin would drain from the indwelling urinary catheter because the catheter is no longer contained in the bladder. Creatinine, urobilinogen, and chloride are normally found in urine.

Which hospitalized client is at risk to develop parotitis?

an 80-year-old client who has poor oral hygiene and is dehydrated Parotitis is inflammation of the parotid gland. Although any of the clients listed could develop parotitis, given the data provided, the one most likely to develop parotitis is the elderly client who is dehydrated with poor oral hygiene. Any client who experiences poor oral hygiene is at risk for developing parotitis. To help prevent parotitis, it is essential for the nurse to ensure the client receives oral hygiene at regular intervals and has an adequate fluid intake.

A nurse is caring for a client with an endotracheal tube who receives enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as residual volume. The purpose of the nurse's actions is to prevent

aspiration. Checking tube placement and checking for residual volume protects the client from aspiration, which can cause pneumonia, a potentially life-threatening disorder. The nurse's actions don't prevent gastric ulcers. Although abdominal distention and diarrhea can be associated with tube feeding the nurse's actions don't prevent their occurrence, and neither condition is immediately life-threatening.

A client, age 82, is admitted to an acute care facility for treatment of an acute flare-up of a chronic GI condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the GI tract. Which age-related change increases the risk of anemia?

atrophy of the gastric mucosa Atrophy of the gastric mucosa reduces hydrochloric acid secretion; this, in turn, impairs absorption of iron and vitamin B12, increasing the risk of anemia as a person ages. A decrease in hydrochloric acid increases, not decreases, intestinal flora; as a result, the client is at increased risk for infection, not anemia. A reduction, not increase, in bile secretion may lead to malabsorption of fats and fat-soluble vitamins. Dulling of nerve impulses associated with aging increases the risk of constipation, not anemia.

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to

auscultate bowel sounds. If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.

?Which risk factor would most likely contribute to the development of a client's hiatal hernia

being 5 feet, 3 inches (160 cm) tall and weighing 190 lb (86.2 kg) Any factor that increases intra-abdominal pressure, such as obesity, can contribute to the development of hiatal hernia. Other factors include abdominal straining, frequent heavy lifting, and pregnancy. Hiatal hernia is also associated with older age and occurs in women more frequently than in men. Having a sedentary desk job, using laxatives frequently, or being 40 years old is not likely to be a contributing factor in development of a hiatal hernia.

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?

clay-colored stools Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored) as a result of soluble bilirubin in the urine. Hematocrit levels aren't affected by obstructive jaundice. Because obstructive jaundice prevents bilirubin from reaching the intestine (where it's converted to urobilinogen), the urine contains no urobilinogen.

When assessing a client who has been diagnosed with hepatic cirrhosis, the nurse should obtain which information when conducting a focused assessment? Select all that apply.

current use of alcohol nutritional status. mental status For the client with hepatic cirrhosis, it would be important to assess the client's current use of alcohol because alcohol consumption can have a significant impact on liver function and is, in fact, the major cause of cirrhosis. Continued use of alcohol further destroys liver cells and affects liver function. Assessing the client's nutritional status is also important because impaired nutrition develops in many clients due to gastrointestinal problems and the inability of the liver to metabolize nutrients. Mental status can be affected by the accumulation of ammonia in the blood, leading to hepatic coma if left untreated. The assessments of heart sounds and capillary refill time, while important components of a physical examination, are not priority assessments in the client with cirrhosis.

The client has been taking magnesium hydroxide to control hiatal hernia symptoms. The nurse should assess the client for which condition most commonly associated with the ongoing use of magnesium-based antacids?

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

A client with cirrhosis of the liver is in the hospital. The nurse involves the client in developing a plan of care. What would be important aspects to include in this plan?

discussing collaborative goals and involving the client in identifying and prioritizing important interventions Involvement of the client in determining the goals and interventions is very important to enhance the client's compliance with the care measures. The other choices do not directly address the goals and a plan of care.

When receiving a client from the postanesthesia care unit after a splenectomy, which should the nurse assess next after obtaining vital signs?

dressing fter a splenectomy, the client is at high risk for hypovolemia and hemorrhage. The dressing should be checked often; if drainage is present, a circle should be drawn around the drainage and the time noted to help determine how fast bleeding is occurring. The nasogastric tube should be connected, but this can wait until the dressing has been checked. A urinary catheter is not needed. The last pain medication administration and the client's current pain level should be communicated in the exchange report. Checking for hemorrhage is a greater priority than assessing pain level.

A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to

drink liquids only between meals. A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in the prevention of rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals.

A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that

enteric precautions must be continued. The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route. No safe and effective antiviral agent is available specifically for treating viral gastroenteritis. The Norwalk virus isn't transmitted by droplets

A surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member?

enterostomal nurse The surgeon should collaborate with the enterostomal nurse, who can address the client's concerns. The enterostomal nurse may schedule a visit with a client who has a colostomy to offer support to the client. The clinical educator can provide information about the colostomy when the client is ready to learn. The staff nurse and social worker aren't specialized in colostomy care, so they aren't the best choices for this situation.

A client with a long history of ulcerative colitis takes sulfasalazine to control the condition. The nurse should evaluate the client for which nutritional deficit that can occur as a result of taking this drug?

folic acid deficit lients who take sulfasalazine are susceptible to developing impaired folic acid absorption. Common clinical manifestations of a folic acid deficiency are gastrointestinal disturbances, such as anorexia, nausea, vomiting, and a smooth, beefy red tongue. The client should be encouraged to eat food high in folic acid, such as green leafy vegetables, meat, fish, legumes, and whole grains. Cobalamin deficiency, niacin deficiency, and iron deficiency are not side effects of sulfasalazine.

A client has been placed on long-term sulfasalazine therapy for treatment of ulcerative colitis. The nurse should encourage the client to eat which foods to help avoid the nutrient deficiencies that may develop as a result of this medication?

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

A client with severe inflammatory bowel disease is receiving total parenteral nutrition (TPN). When administering TPN, the nurse must take care to maintain the ordered flow rate because giving TPN too rapidly may cause

hyperglycemia. Hyperglycemia may occur if TPN is administered too rapidly, exceeding the client's glucose metabolism rate. With hyperglycemia, the renal threshold for glucose reabsorption is exceeded and osmotic diuresis occurs, leading to dehydration and electrolyte depletion. Although air embolism may occur during TPN administration, this problem results from faulty catheter placement, not overly rapid administration. TPN may cause diarrhea, not constipation, especially if administered too rapidly. Dumping syndrome results from food moving through the GI tract too quickly; because TPN is given I.V., it can't cause dumping syndrome.

A client is recovering from a gastric resection for peptic ulcer disease. Which outcome indicates that the goal of adequate nutritional intake is being achieved 3 weeks following surgery? The client

increases food intake and tolerance gradually. Weight gain will be slow and gradual because less food can be eaten at one time due to the decreased stomach size. More food and fluid will be tolerated as edema at the suture line decreases and healing progresses. The remaining stomach may stretch over time to accommodate more food.Nausea and vomiting can interfere with nutritional intake.Water provides hydration, but not calories and nutrients.Rapid weight gain may be due to fluid retention and would not reflect adequate nutrition.

A client is admitted with increased ascites related to cirrhosis. The client has a large round and firm abdomen. The client is not able to lie flat in bed and requests to be placed in a high Fowler's position to sleep. Which nursing diagnosis should receive top priority?`

ineffective breathing pattern In ascites, accumulation of large amounts of fluid causes extreme abdominal distention, which may put pressure on the diaphragm and interfere with respiration. If uncorrected, this problem may lead to atelectasis or pneumonia. Although fluid volume excess is present, the diagnosis ineffective breathing pattern takes precedence because it can lead more quickly to life-threatening consequences. The nurse can deal with fatigue and altered nutrition after the client establishes and maintains an effective breathing pattern.

A client is in a metabolic acidosis from severe diarrhea. What assessment finding would be mostconcerning?

irregular heart rate Diarrhea causes a bicarbonate deficit. With loss of the relative alkalinity of the lower GI tract, the relative acidity of the upper GI tract predominates, leading to metabolic acidosis. The diarrhea would result in skin breakdown. Abdominal cramping would be anticipated. Kussmaul respirations are anticipated as a compensatory response. Irregular heart rate could be a sign of electrolyte imbalances and is most concerning.

A physician orders spironolactone, 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?

loss of 2.2 lb (1 kg) in 24 hours Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.

The nurse monitors IV replacement therapy for a client with a nasogastric (NG) tube attached to low suction in order to:

maintain fluid and electrolyte balance. The primary purpose of fluid replacement therapy for a client receiving gastric suction is to maintain fluid and electrolyte balance. Gastric suctioning interrupts the normal intake and absorption of fluids. Fluids and electrolytes are lost through the nasogastric drainage. IV fluids are required to replace the fluid and electrolyte loss. Since the client with an NG tube is also NPO, IV fluids will help prevent a fluid volume deficit from developing and will help maintain an adequate urine output.IV fluids are not used for this client to promote urination.Postoperatively, IV fluids are not typically used to facilitate osmotic diuresis.The administration of IV fluids may help balance the client's fluid intake and output, but the primary reason for administering fluids is to maintain fluid and electrolyte balance.

The nurse is teaching a client who is recovering from an abdominal-perineal resection with a colostomy about health promotion. What is an expected outcome for a client during the first 2 weeks after surgery?

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

When planning care for a client with a small-bowel obstruction, which should the nurse consider to be the primary goal?

maintaining fluid balance Because a client with a small-bowel obstruction can't tolerate oral intake, fluid volume deficit may occur and can be life-threatening. Therefore, maintaining fluid balance is the primary goal. Pain relief and maintaining body weight don't reflect life-threatening conditions. Ambulation would not be the priority because of nasogastric suctioning and pain control.

The nurse is assessing a client who has been admitted to the hospital with chest pain. The client has been taking simvastatin 40 mg daily for 3 years. The nurse notes that the client has yellow scle

notify the health care provider. Liver damage is a side effect of simvastatin and the client is demonstrating signs of liver damage (jaundice and concentrated urine). The nurse should report these findings to the health care provider (HCP). Although clients should not consume large amounts of alcohol while taking simvastatin, the cause of the liver damage is likely related to the use of simvastatin and not alcohol intake unless the nursing assessment has revealed that alcohol intake may be a factor as well. The client should follow a diet low in saturated fat, but this is not the priority at this time. Increasing fluid intake will not reverse the liver damage.

After gastric resection surgery, which signs alert the nurse to the development of a leaking anastomosis?

pain, fever, and abdominal rigidity Pain, fever, and abdominal rigidity are signs and symptoms of inflammation or peritonitis caused by the leaking anastomosis.Diarrhea with fat in the stool is steatorrhea and is not present in peritonitis.Palpitations, pallor, and diaphoresis after eating are vasomotor symptoms of gastric retention.Feelings of fullness and nausea after eating are not present in peritonitis.

A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these findings, the nurse should further assess the client for which complication?

peritonitis Complications of acute appendicitis are perforation, peritonitis, and abscess development. Signs of the development of peritonitis include abdominal pain and distention, tachycardia, tachypnea, nausea, vomiting, and fever. Because peritonitis can cause hypovolemic shock, hypotension can develop. Deficient fluid volume would not cause a fever. Intestinal obstruction would cause abdominal distention, diminished or absent bowel sounds, and abdominal pain. Bowel ischemia has signs and symptoms similar to those found with intestinal obstruction.

When admitting an elderly client for nausea and vomiting that has lasted for 3 days, the nurse should assess for which clinical findings?

poor skin turgor In a client with persistent nausea and vomiting, the nurse should anticipate that the client may be dehydrated and exhibit signs of a fluid deficit, such as poor skin turgor. Other typical findings include lethargy, dry mucous membranes, tachycardia, weight loss, and decreased urine output.Blood pressure is usually within normal limits in the case of a mild to moderate fluid deficit because of the compensatory mechanisms of sympathetic nervous system stimulation of the heart (causing tachycardia) and peripheral vasoconstriction.

A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for which signs and symptoms? Select all that apply.

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

A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm the nurse's diagnosis?

recent weight loss and temperature elevation Assessment findings associated with pancreatitis include recent weight loss and temperature elevation. Inflammation of the pancreas causes a response that elevates temperature and leads to abdominal pain that typically occurs with eating. Nausea and vomiting may occur as a result of pancreatic tissue damage that's caused by the activation of pancreatic enzymes. The client may experience weight loss because of the lost desire to eat. Blood in stools and recent hypertension aren't associated with pancreatitis; fatty diarrhea and hypotension are usually present. Presence of easy bruising and bradycardia aren't found with pancreatitis; the client typically experiences tachycardia, not bradycardia. Adventitious breath sounds and hypertension aren't associated with pancreatitis.

A nurse is caring for a client who has had paraplegia for 6 years. The client is admitted with a bleeding peptic ulcer. What would be a priority teaching concern for the nurse?

recommending foods included in a bland diet The nurse should teach the client about consuming a bland diet. Although repositioning and retention is important for paraplegia, the client has dealt with this condition for many years. The more important concern is dealing with the new diagnosis. Increasing fluid intake will prevent constipation in a client with paraplegia, but will not treat the peptic ulcer disease.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds the client very difficult to arouse. The diagnostic information which best explains the client's behavior is

subnormal serum glucose and elevated serum ammonia levels. In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.

A client with appendicitis is experiencing excruciating abdominal pain. An abdominal X-ray film reveals intraperitoneal air. What should the nurse prepare the client for?

surgery The client should be prepared for surgery because the signs and symptoms indicate bowel perforation. Appendicitis is a common cause of bowel perforation. Because perforation can lead to peritonitis and sepsis, surgery would not be delayed to perform other interventions, such as colonoscopy, NG tube insertion, or a barium enema. These procedures are not necessary at this point.

A client with colon cancer had a left hemicolectomy 3 weeks ago. The client is still having difficulty maintaining an adequate oral intake to meet metabolic needs for optimal healing. The nurse should recommend to the health care provider which nutritional support to maintain the nutritional needs of the client?

total parenteral nutrition through a central catheter Total parenteral nutrition solutions supply the body with sufficient amounts of dextrose, amino acids, fats, vitamins, and minerals to meet metabolic needs. Clients who are unable to tolerate adequate quantities of foods and fluids and those who have had extensive bowel surgery may not be candidates for enteral feedings. The nurse would anticipate total parenteral nutrition via central catheter to promote wound healing. IV dextrose does not supply all the nutrients required to promote wound healing.

The expected outcome of withholding food and fluids from a client who will receive general anesthesia is to help prevent:

vomiting and possible aspiration of vomitus during surgery. Oral food and fluids are withheld before surgery when a client receives general anesthesia primarily to help prevent vomiting and possible aspiration of stomach contents.Constipation after surgery is influenced by multiple factors, such as the nature of the surgery, the postoperative diet, and use of opioid analgesics.Food and fluids are not withheld prior to surgery to relieve pressure on the diaphragm and increase lung expansion.Withholding food and fluids before surgery does not eliminate gas pains or abdominal distention in the postoperative period. General anesthesia and manipulation of abdominal contents can cause peristaltic action to cease temporarily. This leads to abdominal distention and gas pain.

A client with peptic ulcer disease is ordered aluminum-magnesium complex. When teaching about this antacid preparation, the nurse should instruct the client to take it with

water The nurse should instruct the client to take antacids with water because water helps transport an antacid to the stomach. The client shouldn't take an antacid with fruit juice or a food rich in vitamin C or D because the antacid may impair absorption of important nutrients in the juice or food

A nurse is caring for a client with watery diarrhea and dehydration. Given the client's recent history of heavy antibiotic use, what interventions should the nurse consider?

wearing gown and gloves when working in the room The client presents with the risk factors and symptoms of Clostridium difficile diarrhea, which requires contact isolation. Changing diet or giving anti-diarrhea medications will not improve the situation; specific antibiotics are effective in most cases. It is important to encourage fluids but I.V. would be preferred since oral fluids are expelled in the stool.

A client is learning about caring for an ileostomy. Which statement would indicate that the client understands how to care for the ileostomy pouch?

"I'll empty my pouch when it is about one-third full." The pouch should be emptied when it is about one-third full to prevent the pouch's weight from breaking the seal.The client with an ileostomy must wear a pouch at all times to collect stool.The client should change the pouch at a time when the stoma is least likely to function; 2 to 4 hours after a meal is generally the most appropriate time.A pouch can be worn for 3 to 7 days before being changed.

When a client has an acute attack of diverticulitis, what should the nurse do first?

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

A nurse is caring for a client that received a colostomy 2 days ago. Which is the priority intervention?

Assess the drainage from the stoma. Assessing the stoma is important because of the potential for surgical site infection. Teaching on irrigation and dietary planning should be performed before discharge. The client should be encouraged to look at the stoma, but this is not the priority.

Which nursing intervention should the nurse perform for a client receiving enteral feedings through a gastrostomy tube?

Change the tube feeding administration set at least every 24 hours. The nurse should change tube feeding administration sets at least every 24 hours. Doing so prevents contamination and bacterial growth. The head of the bed should be elevated 30 to 45 degrees continuously to prevent aspiration. Checking for gastrostomy tube placement is performed before initiating the feedings and every 4 hours during continuous feedings. Clients may ambulate during feedings.

A client with ascites is experiencing severe respiratory distress and refuses endotracheal intubation. What should be the nurse's first action?

Determine whether the client is competent to make the decision. Informed decision-making requires that the decision be voluntary, that the client have the capacity and competence to understand their decision, and that the client have adequate information on which to base the decision. In this instance, the nurse must determine whether the client is competent to refuse endotracheal intubation because severe respiratory distress leads to hypoxemia, which may impair the client's ability to make the decision. The nurse should inform the physician of the client's decision after determining the client's competency. A DNR form requires a physician's order, and the physician is responsible for discussing the implications of a DNR order with the client. The Patient's Bill of Rights guarantees the client autonomy to make decisions about their care plan, including the right to refuse recommended treatment. As an advocate, the nurse should support the client's decision, which may be in opposition to family members' opinions

A nurse is caring for an unconscious client recovering from a closed-head injury following placement of a percutaneous endoscopic gastrostomy (PEG) tube. Which action has the highest priority?

Elevate the head of the bed during and after the PEG tube feedings. A client who is unconscious and receiving PEG tube feedings should be positioned with the head of the bed elevated during and after feedings to decrease the risk of aspiration. Considering client safety is the priority intervention; the others are not the priority.

Following an emergency cholecystectomy, the client has a Jackson-Pratt drain with closed suction. After 4 hours, the drainage unit is full. What should the nurse do?

Empty the drainage unit. Portable suction units should be emptied and drained every shift or when full. It is normal for the unit to fill within the first hours after surgery; the nurse does not need to contact the surgeon. There should not be bleeding on the dressing if the drainage system is emptied when full. The drain should not be removed until prescribed by the health care provider (HCP).

The nurse is preparing a client for a paracentesis. What should the nurse do?

Have the client void immediately before the procedure. Immediately before a paracentesis, the client should empty the bladder to prevent perforation. The client will be placed in a high Fowler's position or seated on the side of the bed for the procedure. IV sedatives are not usually administered. The client does not need to be NPO.

A nurse is planning care for an adult who is hospitalized for diarrhea and dehydration. The client is receiving intravenous fluids but continues to have watery stools. The nurse reviews the intake and output record for the last 24 hours (view the chart). Which action should the nurse take?

Increase fluids. The client's intake and output record indicates that the client's output exceeds intake. The goal is to restore fluid balance by increasing fluid intake. The client will likely receive intravenous fluids with electrolytes. The nurse should not restrict fluids, and there is no need for the client to suck on ice chips. If the client has diarrhea, the health care provider may also prescribe an antidiarrheal drug. Because the client does not appear to be losing fluids from vomiting, the nurse should not administer an antiemetic.

A client takes 30 ml of magnesium hydroxide and aluminum hydroxide with simethicone P.O. 1 hour and 3 hours after each meal and at bedtime for treatment of a duodenal ulcer. Why does the client take this antacid so frequently?

It has a short duration of action. Because of the short duration of action, frequent doses of antacids are needed. Antacids usually provide a rapid to immediate onset of action, don't have prolonged half-lives, and aren't highly metabolized.

A client with ascites had a paracentesis. Which post-procedure intervention should the nurse implement?

Monitor the client's temperature. Infection is a complication of paracentesis. The nurse needs to monitor temperature and observe for classic signs of infection. The client does not need to remain NPO, or void post-procedure. The question does not state where the catheter was placed; positioning is not a concern.

The nurse has completed the discharge process for a client, but the client has turned on the nurse call light, and on assessment, the nurse notices the client has indigestion, shortness of breath, and is diaphoretic and anxious. The client's blood pressure and heart rate are elevated. The nurse notifies the health care provider who tells the nurse to discharge the client. The nurse explains the situation again, but the health care provider hangs up. What should the nurse do next?

Notify the charge nurse and request a second opinion. A reasonable and prudent nurse would act as the client's advocate and question a prescription that places a client at risk. Consulting the charge nurse to assess the client shifts responsibility to the next in command with higher authority and will validate the nurse's assessment. The client should not be discharged until the client is stable. While the client may require home health services, the client is not ready for discharge at this time. It is not appropriate to notify the risk manager at this time, and if necessary would be the role of the charge nurse or nurse manager.

A client with acute pancreatitis has a blood pressure of 88/40 mm Hg, heart rate of 128 bpm, respirations of 28 breaths/min, and Grey Turner's sign. What prescription should the nurse implement first?

Place an intravenous line. Grey Turner's sign is a bluish discoloration in the flank area caused by retroperitoneal bleeding. The vital signs are showing hemodynamic instability. IV access should be obtained to provide immediate volume replacement. The urine output will provide information on the fluid status. A nasogastric tube is indicated for clients with uncontrolled nausea and vomiting or gastric distension. Repositioning the client may be considered for pain management once the client's vital signs are stable.

A client has undergone a laparoscopic cholecystectomy. Which instruction should the nurse include in the discharge teaching?

Report bile-colored drainage from any incision. There should be no bile-colored drainage coming from any of the incisions postoperatively. A laparoscopic cholecystectomy does not involve a bile bag. Breathing deeply into a paper bag will prevent a person from passing out due to hyperventilation; it does not alleviate nausea. If the adhesive dressings have not already fallen off, they are removed by the surgeon in 7 to 10 days, not 6 weeks.

A client admitted to the hospital with peptic ulcer disease tells the nurse about having black, tarry stools. What should the nurse do?

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

An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?

Take a stool softener such as docusate sodium daily. Stool softeners taken daily promote absorption of liquid into the stool, creating a softer mass. They may be taken on a daily basis without developing a dependence. Dependence is an adverse effect of daily laxative use. Enemas used daily or on a frequent basis can also lead to dependence of the bowel on an external source of stimulation.

A client has anemia resulting from bleeding from ulcerative colitis and is to receive two units of packed red blood cells (PRBCs). The client is receiving an infusion of total parenteral nutrition (TPN). In preparing to administer the PRBCs, what should the nurse do to ensure client comfort and safety?

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

An adult client had an abdominal perineal resection with a colostomy 4 days ago and is ready for discharge. Which is an expected outcome at this point?

The client discusses concerns about sexual functioning. Clients often have concerns about their sexuality after a fecal diversion. The nurse should encourage the client to discuss any questions about sexual functioning.The client will not need to maintain a high-fiber diet but will be encouraged to avoid any foods that cause odor and flatulence.The client should be able to ambulate and sit out of bed for several hours at a time at this point.Fluid intake will be encouraged, not restricted.

The nurse assesses the client's stoma during the initial postoperative period. What observation should the nurse report to the health care provider (HCP) immediately?

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

When giving a client a tube feeding, what should the nurse do first?

Verify position of the tube before beginning feeding. The position of the tube should be verified before the feeding is implemented. Warming the solution is not necessary or desirable because it can encourage bacterial growth; however, if the solution has been refrigerated, the nurse can bring the solution to room temperature. The client should be lying down with the head elevated or sitting upright during administration of the feeding. Gastric residual should be aspirated and then reinstilled to prevent electrolyte losses.

When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as

a canker sore of the oral soft tissues. Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks. Aphthous stomatitis isn't an acute stomach infection, acid indigestion, or early sign of peptic ulcer disease.

What observation should the nurse instruct the client with an ileostomy to report immediately?

absence of drainage from the ileostomy for 6 or more hours Any sudden decrease in drainage or onset of severe abdominal pain should be reported to the health care provider (HCP) immediately because it could mean that an obstruction has developed. The ileostomy drains liquid stool at frequent intervals throughout the day. Undigested food may be present at times. A temperature of 99.8° F (37.7° C) is not necessarily abnormal or a cause for concern.

A client reports abdominal pain and vomiting for 24 hours. The client's blood pressure is 98/48 mm Hg. The client is diagnosed with large-bowel obstruction. What is the priority nursing diagnosis for the client?

deficient fluid volume Feces, fluid, and gas accumulate above a bowel obstruction. Then the absorption of fluids decreases and gastric secretions increase. This process leads to a loss of fluids and electrolytes in circulation. In addition the client has been vomiting for 24 hours and has a low blood pressure. Therefore, deficient fluid volume is the priority diagnosis. deficient knowledge and ineffective tissue perfusion are applicable but not the primary nursing diagnoses. Pain is an issue with this client; however, treating the client's hypovolemia is the priority.

The client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client decreases the intake of which foods?

fats Fats are associated with decreased esophageal sphincter tone, which increases reflux. Obesity contributes to the development of hiatal hernia, and a low-fat diet might also aid in weight loss. Carbohydrates and foods high in sodium or calcium do not affect gastroesophageal reflux.

A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention best determines the TPN is providing adequate nutrition?

monitoring the client's weight every day By weighing the client every day, the nurse helps the team evaluate the client's response to TPN. Maintenance of the current weight is one indicator of adequate nutrition; weight loss may indicate inadequate nutrition, whereas weight gain may indicate adequate nutrition or fluid retention. Complications of TPN include blood glucose elevation and serum electrolye imbalances and should be monitored closely, but they are not the best indicator of nutritional status. The nurse records intake and output to evaluate fluid replacement, not the nutritional adequacy of TPN.

Diphenoxylate/atropine has been prescribed to treat a client's diarrhea. The nurse should teach the client to report:

urine retention. Diphenoxylate/atropine has anticholinergic properties. Common side effects include urine retention, blurred vision, constipation, palpitations, nervousness, and decreased sweating.Diaphoresis, hypotension, and lethargy are not common side effects of diphenoxylate/atropine.

A client who is having an abdominal perineal resection with permanent colostomy asks, "Where will my colostomy be placed?" The nurse should tell the client:

"A permanent colostomy is usually located on the left side of the abdomen." Because the colon normally absorbs large quantities of water, placing the colostomy near the end of the colon will result in near-normal stool consistency.Optimal placement of an ostomy is usually determined by an enterostomal therapist before surgery.Client preference will not be the determining factor in ostomy placement. The enterostomal therapist will work closely with the client to select the optimal site.When possible, the preferred site for a permanent colostomy is in the lower portion of the descending colon; hence, placement is on the left side of the body.

After teaching a client about collecting a stool sample for occult testing, which client statement indicates effective teaching? Select all that apply.

"I will avoid eating meat for 1 to 3 days before getting a stool sample." "I will take the sample from different areas of the stool that I have passed." When a client collects stool for occult blood, the nurse should instruct the client to avoid eating meat, especially red meat, for 1 to 3 days before the sample collection because meat eliminated in the stool can lead to false-positive results. Eating foods high in fiber a few days before sample collection may be recommended because doing so improves the chances of finding occult blood if a lesion is present. The client should take stool samples from different sites of the stool for a better sample. The stool sample should be covered to protect everyone from body secretions. The specimen does not have to be sent to the laboratory immediately. Some medications, herbs, foods, and activities can lead to false results of the occult testing. For example, iron pills, turnips, and horseradish lead to false-positive results. Vitamin C leads to false-negative results. Some anti-inflammatory drugs and aspirin should be avoided due to antiplatelet properties that increase the risk of gastrointestinal bleeding.

A client has had sucralfate prescribed as treatment for peptic ulcer disease. Which statement indicates that the client understands how to take the medication?

"It's important that I take this drug on an empty stomach." Sucralfate should be taken on an empty stomach 1 hour before or 2 hours after meals, and at bedtime. It is usually taken four times a day. There is no need to avoid milk products while taking the drug. Sucralfate does not affect hemoglobin levels.

A client who is recovering from a subtotal gastrectomy experiences dumping syndrome and is to eat six small meals a day. The client asks the nurse, "When will I be able to eat three meals a day again like I used to?" Which response by the nurse is most appropriate?

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

The nurse is caring for a client who is 24 hours after gastric bypass surgery. The client has experienced four episodes of vomiting in the past 12 hours, each producing between 500 and 800 ml of bright yellow-green liquid emesis. What action should the nurse take?

Contact health are provider for a STAT abdominal x-ray prescription. The client is producing bilious emesis (bright yellow-green liquid emesis that resembles bile), which is a warning sign of gastrointestinal obstruction. Obstruction is a rare but serious complication of gastric bypass procedures. The nurse should request the prescription for an x-ray to investiage this possibility. The nurse should also keep the client NPO (not on clear fluids) and may increase fluids, but this is dependent on the client's hydration status and current blood pressure and urine output: information that is not provided. While antiemetic medication may be requested, the diagnosis of the bowel obstruction is most important. If an obstruction is present, the client's vomiting will not be well controlled with medication.

On the 2nd day following an abdominal-perineal resection, the nurse notes that the wound edges are not approximated and one-half of the incision has torn apart. What should the nurse do first?

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

A client has massive bleeding from esophageal varices. In what order from first to last should the interprofessional team provide care for this client? All options must be used.

Maintain a patent airway. Control hemorrhaging. Replace fluids. Relieve the client's anxiety. The goal that has the highest priority when a client has a massive bleed from esophageal varices is to maintain a patent airway. The nurse should position the client to prevent aspiration and assess respirations and oxygen saturation. The nurse should then assist the health care provider (HCP) in controlling the hemorrhage by using esophageal balloon tamponade. Octreotide may be administered to reduce portal pressure. The third priority is to restore circulating blood volume with blood and IV fluids. Esophageal bleeding is an anxiety-provoking event for the client, and although life-saving measures are the priority, the nurse and health care team should explain procedures to the client and provide reassurance as needed.

The nurse is providing postoperative instructions to a client who will be discharged with a biliary catheter and must learn to irrigate the catheter. Which explanation would the nurse provide to the client regarding the procedure?

Notify the healthcare provider if there are any signs of purulent drainage. Purulent drainage would be a sign of infection and the healthcare provider would need to be notified immediately. There is a risk for infection, even with aseptic technique by the patient or caregiver, because the catheter is being opened for irrigation. The client or caregiver would not aspirate due to the risk of drawing duodenal contents into the catheter or biliary tree. The client or caregiver would use sterile saline or water to irrigate with, not tap water.

A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, and weak, thready pulses. What should the nurse should do first?

Provide parenteral rehydration therapy as prescribed. Initially, the extracellular fluid volume with isotonic IV fluids until adequate circulating blood volume and renal perfusion are achieved. Vital signs should be monitored as parenteral and oral rehydration are achieved. Oral fluid intake should be greater than 1,000 mL/day. Turning and repositioning the client at regular intervals aids in the prevention of skin breakdown, but it is first necessary to rehydrate this client.

The nurse is preparing a client for an ileostomy. Two weeks before the surgery, what should the nurse instruct the client to do?

Stop taking drugs that will interfere with clotting. The nurse should instruct the client to stop taking drugs that would interfere with clotting, such as aspirin or ibuprofen. The client should follow a high-fiber diet with increased fluids during the 2-week preoperative period. It is not necessary to limit fluids. The client does not need to report having a temperature above 99° F (37.2° C) to the health care provider (HCP) as this is within normal limits; however, if the temperature is higher, this could indicate an infection, and the client should notify the HCP.

In the early postoperative period following abdominal surgery, the nurse notes a bright red, 3″ × 5″ (7.6 × 12.7 cm) area of drainage on the client's dressing. What should be the nurse's first action in response to this observation?

Take the client's vital signs. The sudden onset of bright red drainage of this magnitude needs to be further assessed. Assessing vital signs is an important nursing action to determine whether there have been any changes in the client's status. Additional steps would include reinforcing the dressing and notifying the health care provider (HCP). Increasing the IV flow rate does not address the bleeding. Changing the dressing would be done only if the HCP prescribed it.

The nurse administers a tap water enema to a client. While the solution is being infused, the client has abdominal cramping. What should the nurse do first?

Temporarily stop the infusion, and have the client take deep breaths. If the client begins to experience abdominal cramping during administration of the enema fluid, the nurse's first action is to temporarily stop the infusion and have the client take a few deep breaths. After the cramping subsides, the nurse can continue with the enema solution. If the cramping does not subside, the nurse should clamp the tubing and remove it. Raising the height of the container will increase the flow of fluid and cause the cramping to increase. Rubbing the abdomen while infusing the enema fluid will not stop the cramping.

A client has a newly created colostomy. After participating in a teaching session with the nurse and receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which behavior suggests that the client is beginning to accept the change in body image?

The client touches the altered body part. By touching the altered body part, the client recognizes the body change and establishes that the change is real. Talking about the surgery and making menu choices shows the nurse that the teaching was successful, but does not show acceptance. Asking the spouse to leave the room signifies that the client is ashamed of the change and not coping with it.

A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which nursing observation indicates this client is ready to be discharged?

The client voids 500 mL of urine. Urinary elimination in the first 8 hours postoperatively is a requirement before the client who has had an inguinal hernia repair can be discharged from same-day surgery. Ingestion of fluids without nausea and vomiting is important, but eating solid foods is not a requirement for discharge from same-day surgery. Being completely pain free is an unrealistic expectation for the time frame and is not a requirement for leaving same-day surgery. However, the client should be comfortable, and his pain should be controlled. It is not a requirement for the client to ambulate in the hallway, but the client should be able to sit up and go to the bathroom without assistance.

Following the formation of an ileal conduit, the nurse notes that the client's urinary drainage appliance contains pale yellow urine with large amounts of mucus. How should the nurse interpret these data?

These findings are normal for a client with an ileal conduit. A segment of the terminal ileus is used to form the conduit that collects urine from the ureters. Hence, the client with an ileal conduit can be expected to excrete urine that contains mucus from this intestinal mucous membrane. Mucus production is not a result of infection or stomal irritation. Mucus production is not a result of glycosuria. There is no reason to expect to find glucose in the client's urine.

After completing assessment rounds, which client should the nurse discuss with the health care provider (HCP) first?

a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular A change in a client's baseline vital signs should be brought to the HCP's attention immediately. In this case, the client's heart rate has increased, and the rhythm appears to have changed; the HCP may prescribe an ECG to determine if treatment is necessary. The nurse should also have a complete set of current vital signs as well as a physical assessment before providing the HCP information using the SBAR format. The nutritional as well as psychological needs of a client must be addressed but are not first priority. A rash that develops after a new antibiotic is started must be brought to the HCP attention; however, this client is stable and is not the first priority. The nurse is responsible to facilitate discussion between the client, the client's family, and the HCP but only after all of the immediate physical and psychological needs of all clients have been met.

The nurse is checking the client's chart for possible contraindications, before administering meperidine, 50 mg I.M., to a client with pain after an appendectomy. The nurse should hold the meperidine when the nurse sees an order for what type of drug?

a monoamine oxidase (MAO) inhibitor The nurse should hold the meperidine if the nurse sees an order for an MAO inhibitor because MAO inhibitors increase the effects of meperidine and can cause rigidity, hypotension, and excitation. The client shouldn't receive meperidine within 14 days after administration of an MAO inhibitor. Antibiotics, antiemetics, and loop diuretics don't cause significant drug interactions when administered concurrently with meperidine.

The nurse is instructing the client with a new colostomy about protecting the skin around the colostomy. Which skin barrier should the nurse tell the client is best to apply around the colostomy?

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

The nurse is caring for a 70-year-old male client after a colectomy. The client has received chemotherapy prior to surgery and has hypertension and diabetes mellitus. Which factors put this client at risk for sepsis? Select all that apply.

age abdominal surgery diabetes mellitus Known risk factors for sepsis include age (less than 1 year and greater than 65 years old), chronic illness, and invasive procedures. Immunosuppression and malnourishment are also risk factors. There is no correlation between gender or age and risk for sepsis. Nurses must be aware of risk factors and monitor clients at risk closely for any signs of sepsis.

A client with a recent history of rectal bleeding is being prepared for a colonoscopy. Initially. The nurse knows that positioning the client lying on their left side with the knees bent is an appropriate intervention. The nurse recognizes that this position will

allow proper visualization of the large intestine. For a colonoscopy, the nurse initially should position the client on the left side with knees bent. Placing the client on the right side with legs straight, prone with the torso elevated, or bent over with hands touching the floor would not allow proper visualization of the large intestine.

A client with esophageal cancer decides against placement of a jejunostomy tube. Which ethical principle is a nurse upholding by supporting the client's decision?

autonomy Autonomy refers to an individual's right to make their own decisions. Fidelity is equated with faithfulness. Nonmaleficence is the duty to "do no harm." Veracity refers to telling the truth.

A physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should

collect the specimen in a sterile container. The nurse should collect the stool specimen using sterile technique and a sterile stool container. The stool may be collected for 3 consecutive days. Although a stool culture should be taken to the laboratory as soon as possible, it need not be delivered immediately (unlike stool being examined for ova and parasites). Applying a solution to a stool specimen would contaminate it; this procedure is done when testing stool for occult blood, not organisms. The nurse shouldn't store a stool culture on ice because the abrupt temperature change could kill the organisms.

A client with gastric cancer is having a resection. What is the nursing management priority for this client?

correcting nutritional deficits Clients with gastric cancer commonly have nutritional deficits and may have cachexia. Therefore, correcting nutritional deficits is a top priority. Discharge planning before surgery is important, but correcting the nutritional deficits is a higher priority. Radiation therapy hasn't been proven effective for gastric cancer, and teaching about it preoperatively wouldn't be appropriate. Preventing DVT isn't a high priority before surgery, but it assumes greater importance after surgery.

A client with cholecystitis is taking propantheline bromide. What should the nurse tell the client to expect as a result of taking this drug?

decreased biliary spasm Propantheline bromide is an anticholinergic used to decrease biliary spasm. Decreasing biliary spasm helps to reduce pain in cholecystitis. Propantheline does not increase bile production or have an antiemetic effect, and it is not effective in treating infection.

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for

diaphoresis, vomiting, and diarrhea. The nurse must monitor for diaphoresis, vomiting, and diarrhea because these signs suggest an intolerance to the ordered enteral feeding solution. Other signs and symptoms of feeding intolerance include abdominal cramps, nausea, aspiration, and glycosuria. Electrolyte disturbances, constipation, dehydration, and hypercapnia are complications of enteral feedings, not signs of intolerance. Hyperglycemia, not hypoglycemia, is a potential complication of enteral feedings.

The nurse is caring for a client with esophageal varices. The nurse should discuss which laboratory report finding with the health care provider (HCP)?

elevated PT/INR The client with esophageal varices is at even higher risk for bleeding with elevated PT/INR. The nurse and HCP collaborate to prevent bleeding. The other laboratory findings are not as life-threatening. A decreased serum albumin can cause fluid to move into the interstitial tissues. Increased ammonia levels are toxic to the brain. Calcium loss is more common to pancreatitis.

A client is to have a nasogastric (NG) tube inserted. When inserting the tube, the nurse should:

have the client flex the head when the tube is above the oropharynx. The nurse should have the client tilt the head toward the ceiling as the NG tube is inserted. When the tube is above the oropharynx, the client should be instructed to bring the head forward a bit by flexing the neck. This technique closes the trachea and opens the esophagus to receive the tube.Correct technique includes lubricating the tube with a water-soluble lubricant and having the client swallow as the tube is passed into the stomach.The client should not be instructed to hold the breath.The client should be placed in a sitting position.

The nurse is teaching a client with hepatitis A about long-term health maintenance. The client has understood the teaching when the client states the most common problem will be:

maintaining a positive, optimistic outlook. Convalescence after hepatitis A may take weeks or even months. To support healing, activity is limited, but bed rest is not prescribed.Boredom and depression are common problems that the client should anticipate.Abdominal pain is not usually a symptom of hepatitis A.Maintaining a regular bowel elimination pattern is not usually a problem with hepatitis.Problems preventing respiratory complications are unlikely.

The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance?

metabolic alkalosis Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory status.

A client is being admitted to the hospital with abdominal pain, anemia, and bloody stools. The client complains of feeling weak and dizzy. The client has rectal pressure and needs to urinate and move their bowels. The nurse should help the client

onto the bedpan. A client who's dizzy and anemic is at risk for injury because of their weakened state. Assisting the client with the bedpan would best meet their needs at this time without risking the client's safety. The client may fall if walking to the bathroom, left alone to urinate, or trying to stand up.

The nurse administers fat emulsion solution during TPN to a malnourished client. What should the nurse tell the client about the purpose of this solution? Fat emulsion solution:

provides essential fatty acids. The administration of fat emulsion solution provides additional calories and essential fatty acids to meet the body's energy needs. Fatty acids are lipids, not carbohydrates. Fatty acids do not aid in the metabolism of glucose. Although they are necessary for meeting the complete nutritional needs of the client, fatty acids do not necessarily help a client maintain normal body weight.

Immediately following endoscopy of the upper gastrointestinal tract, it is most important for the nurse to assess for:

return of the gag reflex. Prior to an upper gastrointestinal endoscopy, a local anesthetic is applied to the posterior pharynx. This results in temporary loss of the gag reflex, which facilitates passage of the endoscope. The client is at risk for aspiration until the gag reflex returns. Therefore, monitoring the client for return of the gag reflex is a priority nursing assessment.An upper gastrointestinal endoscopy does not affect bowel sounds.Peripheral pulses are not affected by an upper gastrointestinal endoscopy.It is useful to monitor the client's intake and output until he has completely recovered from sedation; however, monitoring the airway is always the highest priority.

A client with nausea, vomiting, and abdominal cramps and distention is admitted to the healthcare facility. Which test result is most significant?

serum potassium level of [3 mEq/L (3.0 mmol/L)] A serum potassium level of 3 mEq/L is below normal, indicating hypokalemia. Because hypokalemia may cause cardiac arrhythmias and asystole, it's the most significant finding. In a client with a potential fluid volume imbalance, such as from vomiting, the other options are expected but none are as life-threatening as hypokalemia. A BUN level of 29 mg/dl indicates slight dehydration. A serum sodium level of 132 mEq/L is slightly below normal but not life-threatening. A urine specific gravity of 1.025 is normal.

The nurse is irrigating a client's colostomy. The client has abdominal cramping after receiving about 100 mL of the irrigating solution. The nurse should first:

stop the flow of solution. The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside.Repositioning the client to the right side will not alleviate the cramping.Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed.Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.

A client has a suspected slow gastrointestinal bleed. Because of this, the nurse specifically instructs the unlicensed assistive personnel to look for and report which symptom?

tarry stools A client with a suspected slow gastrointestinal bleed should be observed for tarry (black) stools, which indicate slow bleeding from an upper gastrointestinal site. The longer the blood remains in the system, the darker it becomes from the degradation of hemoglobin and release of iron.Hypotension does not occur with a slow gastrointestinal bleed.Bright red blood indicates bleeding from the lower gastrointestinal tract or profuse, massive gastrointestinal bleeding.Jaundice is not an indicator of gastrointestinal bleeding, but it is an indicator of liver or biliary tract dysfunction.

As the nurse administers a tap water enema, the client begins to have abdominal cramping. The nurse should first:

temporarily stop the infusion until the cramping subsides. When the client initially begins to have abdominal cramping during an enema, the nurse should temporarily stop the infusion until the cramping subsides. If, on resuming the flow of enema fluid, the client continues to have cramping or inability to retain further fluid, the nurse should discontinue the enema. Having the client take slow, deep breaths can help decrease the amount of cramping. Telling the client to hold the breath will not relieve cramping and is inappropriate. The client should be placed in a left Sims' position, not a supine position, to facilitate flow of the fluid into the colon.

A client is scheduled for bowel resection with anastomosis involving the large intestine. The nurse formulates the nursing diagnosis of Risk for infection. The nurse knows that the risk for infection is most likely related to

the presence of bacteria at the surgical site. The nurse should add "related to the presence of bacteria at the surgical site" to the diagnosis of Risk for infection. The large intestine normally contains bacteria because its alkaline environment permits growth of organisms that putrefy and break down remaining proteins and indigestible residue. These organisms include Escherichia coli, Aerobacter aerogenes, Clostridium perfringens, and Lactobacillus. Although bowel resection with anastomosis is considered major surgery, it poses no greater risk of infection than any other type of major surgery. Malnutrition seldom follows bowel resection with anastomosis because nutritional absorption (except for some water, sodium, and chloride) is completed in the small intestine. An NG tube is placed through a natural opening, not a wound, and therefore does not increase the client's risk of infection.

A client presents to the emergency department with reports of acute GI distress, bloody diarrhea, weight loss, and fever. A family history of what would be significant to this client's diagnosis?

ulcerative colitis A family history of ulcerative colitis, particularly if the relative affected is a first-degree relative, increases the likelihood of the client having ulcerative colitis. Crohn's disease does not have inflammatory symptoms, but rather more abdominal pain related. A family history of peptic ulcers is not a genetic risk factor as well as appendicitis.

A nurse is supervising a new nurse who is preparing to perform wound care for a client whose abdominal wound is infected with vancomycin-resistant enterococci. The supervising nurse should make sure that the new nurse:

wears a gown and gloves while caring for the client. Caring for a client infected with vancomycin-resistant enterococci requires contact precautions. The nurse should wear a gown and gloves. Protective eyeware is not required for contact precautions. Gloves are most contaminated, so the nurse should remove them first when exiting the room to prevent infection transmission. The nurse should assemble all needed supplies before putting on personal protective equipment and entering the client's room.