Adult health exam 3

The client with acute diverticulitis has a nasogastric tube draining green liquid bile. Which intervention should the nurse implement? 1. Document the findings as normal 2. Assess the client's bowel sounds 3. Determine the client's last bowel movement 4. Insert the N/G tube at least 2 more inches

1

The client has an eviscerated abdominal wound. Which intervention should the nurse implement? 1. Apply sterile normal saline dressing 2. Use sterile gloves to replace protruding parts 3. Place the client in reverse Trendelenburg position 4. Administer intravenous antibiotic STAT

1 - Evisceration is a life-threatening condi- tion in which the abdominal contents protrude through the ruptured incision. The nurse must protect the bowel from the environment by placing a sterile nor- mal saline gauze on it, which prevents the intestines from drying out and necrosing.

The female client presents to the clinic for an examination because she has not had a menstrual cycle for several months and wonders if she could be pregnant. The client is 5′10′′ tall and weighs 45 kg. Which assessment data should the nurse obtain first? 1. Ask the client to recall what she ate for the last 24 hours. 2. Determine what type of birth control the client has been using. 3. Reweigh the client to confirm the data. 4. Take the client's pulse and blood pressure.

1 - Menses will cease if the client is severely emaciated. A 24-hour dietary recall is a step toward assessing the client's eating patterns.

The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard rigid abdomen and T 102 degrees Fahrenheit. Which intervention should the nurse implement? 1. Notify the HCP 2. Prepare to administer a Fleet's enema 3. Administer an antipyretic suppository 4. Continue to monitor the client closely

1 - These are signs of peritonitis, which is life threatening. The health-care provider should be notified immediately.

The nurse is caring for clients on a medical unit. Which client information should be brought to the attention of the HCP immediately? 1. A serum sodium of 139 mEq/L in a client diagnosed with obstipation. 2. The client diagnosed with fecal impaction who had two (2) hard formed stools. 3. A serum potassium level of 3.0 mEq/L in a client diagnosed with diarrhea. 4. The client with diarrhea who had two (2) semi-liquid stools totaling 300 mL.

1 - normal sodium levels are 135-152

The client who had an abdominal surgery has a Jackson Pratt (JP) drainage tube. Which assessment data warrants immediate intervention by the nurse? 1. The bulb is round and has 40 mL of fluid 2. The drainage tube is taped to the dressing 3. The JP insertion site is pink and has no drainage 4. The JP bulb has suction and is sunken in

1 - round bulb means its full

The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis? SATA 1. Eat a high-fiber diet. 2. Increase fluid intake. 3. Elevate the HOB after eating. 4. Walk 30 minutes a day. 5. Take an antacid every two (2) hours.

1,2,4

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

1,2,5 1. Clay-colored stools are caused by recurring stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome. 2. Yellow-tinted sclera and skin indicate residual effects of stricture of the common bile duct, which is a sign of post- cholecystectomy syndrome. 5. Abdominal pain indicates a residual effect of a stricture of the common bile duct, inflammation, or calculi, which is a sign of post-cholecystectomy syndrome.

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

1,3,5 1. Colostomy stomas are openings through the abdominal wall into the colon, through which feces exit the body. Feces can be irritating to the abdominal skin, so careful and thorough skin care is needed. 3. Because of the perineal wound, the client will have an indwelling catheter to keep urine out of the incision. 5. The client should not sit upright because this causes pressure on the perineum.

The client diagnosed with AIDS is experiencing voluminous diarrhea. Which interventions should the nurse implement? Select all that apply. 1. Monitor diarrhea, charting amount, character, and consistency. 2. Assess the client's tissue turgor every day. 3. Encourage the client to drink carbonated soft drinks. 4. Weigh the client daily in the same clothes and at the same time. 5. Assist the client with a warm sitz bath PRN.

1,4,5.

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

1. A UGI series requires the client to swallow barium, which passes through the intestines, making the stools a chalky white color.

The 36-year-old female client diagnosed with anorexia tells the nurse "I am so fat. I won't be able to eat today." Which response by the nurse is most appropriate? 1. "Can you tell me why you think you are fat?" 2. "You are skinny. Many women wish they had your problem." 3. "If you don't eat, we will have to restrain you and feed you." 4. "Not eating might cause physical problems."

4.

The female client is more than 10% over ideal body weight. Which nursing intervention should the nurse implement first? 1. Ask the client why she is eating too much. 2. Refer the client to a gymnasium for exercise. 3. Have the client set a realistic weight loss goal. 4. Determine the client's eating patterns.

4.

The client is placed on percutaneous gastrostomy (PEG) tube feedings. Which occurrence would warrant immediate intervention by the nurse? 1. The client tolerates the feedings being infused at 50 mL/hour. 2. The client pulls the nasogastric feeding tube out. 3. The client complains of being thirsty. 4. The client has green, watery stool.

4. This client needs to be cleaned immediately

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

4. This would be an expected outcome for the client scheduled for surgery. This indicates preoperative teaching has been effective.

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

3. The ERCP requires an anesthetic spray be used prior to insertion of the endoscope. If medications, food, or fluid are given orally prior to the return of the gag reflex, the client may aspirate.

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

1. A heating pad should be applied for 15 to 20 minutes to assist the migration of the CO2 used to insufflate the abdomen. Shoulder pain is an expected occurrence.

The nurse is teaching the client diagnosed with diverticulosis. Which instruction should the nurse include in the teaching session? 1. Discuss the importance of drinking 1,000mL of water daily 2. Instruct the client to exercise at least three (3) times a week 3. Teach the client about eating a low-residue diet 4. Explain the need to have daily bowel movements

4 - constipation can cause diverticulitis

The client presents to the emergency department experiencing frequent watery, bloody stools after eating some undercooked meat at a fast food restaurant. Which intervention should be implemented first? 1. Provide the client with a specimen collection to collect a stool sample. 2. Initiate antibiotic therapy intravenously. 3. Have the laboratory draw a complete blood count. 4. Administer the antidiarrheal medication Lomotil.

1. This client may have developed an infection from the undercooked meat. The nurse should try to get a specimen for the laboratory to analyze and for the nurse to be able to assess.

The client has had a stool that is dark, watery, and shiny in appearance. Which intervention should be the nurse's first action? 1. Check for a fecal impaction. 2. Encourage the client to drink fluids. 3. Check the chart for sodium and potassium levels. 4. Apply a protective barrier cream to the perianal area.

1. This is a symptom of diarrhea moving around an impaction higher up in the colon.

The client diagnosed with diverticulitis is complaining of severe pain in the left lower quadrant and has an oral temperature of 100.6 degrees Fahrenheit. Which intervention should the nurse implement first? 1. Notify the HCP 2. Document the findings in the chart 3. Administer an oral antipyretic 4. Assess the client's abdomen

4 - needs to determine id abdomen is soft or rigid, rigid indicates peritonitis

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

1. A long history of low-fiber, high-fat, and high-protein diets results in a prolonged transit time. This allows the carcinogenic agents in the waste products to have a greater exposure to the lumen of the colon.

Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning? 1. Fluid volume deficit. 2. Nausea. 3. Risk for aspiration. 4. Impaired urinary elimination.

1. Fluid volume deficit secondary to diarrhea is the priority because of the potential for metabolic acidosis and hypokalemia, which are both life threatening, especially in the elderly.

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

1. Hepatitis B can be transmitted by sharing any type of needles, especially those used by drug abusers. 2. Hepatitis B can be transmitted through sexual activity; therefore, the nurse should recommend abstinence, mutual monogamy, or barrier protection. 3. Three doses of hepatitis B vaccine provide immunity in 90% of healthy adults.

The client is diagnosed with salmonellosis secondary to eating some slightly cooked hamburger meat. Which clinical manifestations should the nurse expect the client to report? 1. Abdominal cramping, nausea, and vomiting. 2. Neuromuscular paralysis and dysphagia. 3. Gross amounts of explosive bloody diarrhea. 4. Frequent "rice water stool" with no fecal odor.

1. Symptoms develop 8 to 48 hours after ingesting the Salmonella bacteria and include diarrhea, abdominal cramping, nausea, and vomiting, along with low-grade fever, chills, and weakness.

The client who is morbidly obese has undergone gastric bypass surgery. Which immediate postoperative intervention has the greatest priority? 1. Monitor respiratory status. 2. Weigh the client daily. 3. Teach a healthy diet. 4. Assist the client in behavior modification.

1. The client that is morbidly obese will have a large abdomen that prevents the lungs from expanding

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

1. The hepatitis A virus is in the stool of infected people and takes up to two (2) weeks before symptoms develop.

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

1. The nurse should mark the drainage on the dressing to determine if active bleeding is occurring, because dark reddish-brown drainage indicates old blood.

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

1. The white blood cell count should be elevated in clients with chronic inflammation.

The client diagnosed with anorexia nervosa is admitted to the hospital. The client is 67 inches tall and weighs 40 kg. Which client problem has the highest priority? 1. Altered nutrition. 2. Low self-esteem. 3. Disturbed body image. 4. Altered sexuality

1. This client is severely underweight and nutrition is the priority.

The client has a nasogastric tube. The health-care provider orders IV fluid replacement based on the previous hour's output plus the baseline IV fluid ordered of 125 mL/hr. From 0800 to 0900 the client's N/G tube drained 45 mL. At 0900, what rate should the nurse set the IV pump?_______

170 mL/hr

The 22-year-old female who is obese is discussing weight loss programs with the nurse. Which information should the nurse teach? 1. Jog for two (2) to three (3) hours every day. 2. Lifestyle behaviors must be modified. 3. Eat one large meal every day in the evening. 4. Eat 1000 calories a day and don't take vitamins

2

The post-anesthesia care nurse is caring for a client who has had abdominal surgery. The client is complaining of nausea. Which intervention should the nurse implement first? 1. Medicate the client with a narcotic analgesic IVP. 2. Assess the nasogastric tube for patency. 3. Check the temperature for elevation. 4. Hyperextend the neck to prevent stridor.

2

The nurse is caring for the following clients on a surgical unit. Which client would the nurse assess first? 1. The client who had an inguinal hernia repair and has not voided in four (4) hours. 2. The client who was admitted with abdominal pain who suddenly has no pain. 3. The client four (4) hours postoperative abdominal surgery with no bowel sounds. 4. The client who is one (1) day postoperative appendectomy who is being discharged.

2 - A sudden cessation of pain may indicate a ruptured appendix, which could lead to peritonitis, a life-threatening complica- tion; therefore, the nurse should assess this client first.

The client is one (1) day postoperative major abdominal surgery. Which client problem is priority? 1. Impaired skin integrity. 2. Fluid and electrolyte imbalance. 3. Altered bowel elimination. 4. Altered body image.

2 - After abdominal surgery, the body distributes fluids to the affected area as part of the healing process. These fluids are shifted from the intravascular com- partment to the interstitial space, which causes potential fluid and electrolyte imbalance.

The nurse is preparing to administer the initial does of an aminoglycoside antibiotic to the client just admitted with a diagnosis of acute diverticulitis. Which intervention should the nurse implement? 1. Obtain a serum trough level. 2. Ask about drug allergies. 3. Monitor the peak level. 4. Assess the vital signs.

2 - always ask about drug allergies before administering antibiotics

The client is admitted to the medical floor with acute diverticulitis. Which collaborative intervention would the nurse anticipate the health-care provider ordering? 1. Administer total parenteral nutrition. 2. Maintain NPO and nasogastric tube. 3. Maintain on a high-fiber diet and increase fluids. 4. Obtain consent for abdominal surgery.

2 - the bowel needs to be put to rest

The client who is obese presents to the clinic before beginning a weight loss program. Which interventions should the nurse teach? SATA 1. Walk for 30 minutes three (3) times a day. 2. Determine situations that initiate eating behavior. 3. Weigh at the same time every day. 4. Limit sodium in the diet. 5. Refer to a weight support group.

2, 5.

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

2. Adequate rest is needed for maintaining optimal immune function.

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

2. After removal of the gallbladder, some clients experience abdominal discomfort when eating fatty foods.

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

2. An open cholecystectomy requires a large incision under the diaphragm. Deep breathing places pressure on the diaphragm and the incision, causing pain. Shallow respirations indicate inadequate pain control, and the nurse should intervene.

The dietician and nurse in a long-term care facility are planning the menu for the day. Which foods would be recommended for the immobile clients for whom swallowing is not an issue? 1. Cheeseburger and milk shake. 2. Canned peaches and a sandwich on whole-wheat bread. 3. Mashed potatoes and mechanically ground red meat. 4. Biscuits and gravy with bacon.

2. Canned peaches are soft and can be chewed and swallowed easily while providing some fiber, and whole-wheat bread is higher in fiber than white bread. These foods will be helpful for clients whose gastric motility is slowed as a result of lack of exercise or immobility.

The client is being admitted to the outpatient psychiatric clinic diagnosed with bulimia. While assessing the client, which question should the nurse ask to identify behaviors that suggest bulimia? 1. "When was the last time you exercised?" 2. "What over-the-counter medications do you take?" 3. "How long have you had a positive self-image?" 4. "Do you eat a lot of high-fiber foods for bowel movements?"

2. Clients diagnosed with bulimia frequently take cathartic laxatives to prevent absorption of calories from the food consumed.

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

2. Cruciferous vegetables, such as broccoli, cauliflower, and cabbage, are high in fiber. One of the risks for cancer of the colon is a high-fat, low-fiber, and high-protein diet. The longer the transit time (the time from ingestion of the food to the elimination of the waste products), the greater the chance of developing cancer of the colon.

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

2. Excess fluid volume could be secondary to portal hypertension. Therefore, no increase in abdominal girth would be an appropriate short-term goal, indicating no excess of fluid volume.

Which statement made by the client admitted with electrolyte imbalance from frequent cathartic use demonstrates an understanding of the discharge teaching? 1. "In the future I will eat a banana every time I take the medication." 2. "I don't have to have a bowel movement every day." 3. "I should limit the fluids I drink with my meals." 4. "If I feel sluggish, I will eat a lot of cheese and dairy products."

2. It is not necessary to have a bowel movement every day to have normal bowel functioning.

Which nursing interventions should be included in the care plan for the 84-year-old client diagnosed with acute gastroenteritis? Select all that apply. 1. Assess the skin turgor on the back of the client's hands. 2. Monitor the client for orthostatic hypotension. 3. Record the frequency and characteristics of sputum. 4. Use Standard Precautions when caring for the client. 5. Institute safety precautions when ambulating the client.

2. Orthostatic hypotension indicates fluid volume deficit, which can occur in an elderly client who is having many episodes of diarrhea. 4. Standard Precautions, including wearing gloves and hand washing, help prevent the spread of the infection to others. 5. The elderly client is at risk for orthostatic hypotension; therefore, safety precautions should be instituted to ensure the client doesn't fall as a result of a decrease in blood pressure.

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

2. Standard Precautions apply to blood, all body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood.

The 79-year-old client diagnosed with acute gastroenteritis is admitted to the medical unit. Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Evaluate the client's intake and output. 2. Take the client's vital signs. 3. Change the client's intravenous solution. 4. Assess the client's perianal area.

2. The UAP can take the vital signs for a client who is stable; the nurse must interpret and evaluate the vital signs.

The female client came to the clinic complaining of abdominal cramping and at least 10 episodes of diarrhea every day for the last two (2) days. The client just returned from a trip to Mexico. Which intervention should the nurse implement? 1. Instruct the client to take a cathartic laxative daily. 2. Encourage the client to drink lots of Gatorade. 3. Discuss the need to increase protein in the diet. 4. Explain the client should weigh herself daily.

2. The client probably has traveler's diarrhea, and oral rehydration is the preferred choice for replacing fluids lost as a result of diarrhea. An oral glucose electrolyte solution, such as Gatorade, All-Sport, or Pedialyte, is recommended.

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

2. The client should be on a regular diet, and the colostomy will have been working for several days prior to discharge.

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

2. The nurse should determine what is concerning the client. It could be a misunderstanding or a real situation where the client's care is unsafe or inadequate.

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

2. There is no instrument used at home to test daily ammonia levels. The ammonia level is a serum level requiring venipuncture and laboratory diagnostic equipment.

The charge nurse has completed report. Which client should be seen first? 1. The client diagnosed with Crohn's disease who had two (2) semi-formed stools on the previous shift. 2. The elderly client admitted from another facility who is complaining of constipation. 3. The client diagnosed with AIDS who had a 200-mL diarrhea stool and has elastic skin tissue turgor. 4. The client diagnosed with hemorrhoids who had some spotting of bright red blood on the toilet tissue.

2. This client has just arrived so the nurse does not know if the complaint is valid and needs intervention unless this client is seen and assessed. The elderly have difficulty with constipation as a result of decreased gastric motility, medications, poor diet, and immobility.

The client diagnosed with gastroenteritis is being discharged from the emergency department. Which intervention should the nurse include in the discharge teaching? 1. If diarrhea persists for more than 96 hours, contact the health-care provider. 2. Instruct the client to wash hands thoroughly before handling any type of food. 3. Explain the importance of decreasing steroids gradually as instructed. 4. Discuss how to collect all stool samples for the next 24 hours.

2. Washing hands should be done by the client at all times, but especially when the client has gastroenteritis. The bacteria in feces may be transferred to other people via food if hands are not washed properly.

The nurse is caring for a client diagnosed with bulimia nervosa. Which nursing intervention should the nurse implement after the client's evening meal? 1. Praise the client for eating all the food on the tray. 2. Stay with the client for 45 minutes to an hour. 3. Allow the client to work out on the treadmill. 4. Place the client on bed rest until morning

2. the client will be prevented from inducing vomiting and ridding the body of the meal before it can be metabolized.

The client has had abdominal surgery and tells the nurse, "I felt as something just give way in my stomach." Which action should the nurse implement first? 1. Notify the surgeon immediately. 2. Instruct the client to splint the incision. 3. Assess for serosanguineous wound drainage. 4. Administer pain medication intravenously

3

The client is diagnosed with peritonitis. Which assessment data indicate the client's condition is improving? 1. The client is using more pain medication on a daily basis. 2. The client's nasogastric tube is draining coffee-ground material. 3. The client has a decrease in temperature and a soft abdomen. 4. The client has had two (2) soft, formed bowel movements

3

The 84-year-old client comes to the clinic complaining of right lower abdominal pain. Which question would be most appropriate for the nurse to ask the client? 1. "When was your last bowel movement?" 2. "Did you have a high-fat meal last night?" 3. "How long have you had this pain?" 4. "Have you been experiencing any gas?"

3 - An elderly client may experience a ruptured appendix with minimal pain; therefore, the nurse should assess the characteristics of the pain.

The nurse is working in an outpatient clinic. Which client is most likely to have a diagnosis of diverticulosis? 1. A 60-year-old male with a sedentary lifestyle 2. A 72-year-old female with multiple childbirths 3. A 63-year-old female with hemorrhoids 4. A 40-year-old male with a family history of diverticulosis

3 - Hemorrhoids would indicate the client has chronic constipation, which is a strong risk factor for diverticulosis. Constipation increases the intraluminal pressure in the sigmoid colon, leading to weakness in the intestinal lining, which, in turn, causes outpouchings, or diverticula.

The nurse is assessing the client recovering from abdominal surgery who has a PCA pump. The client has shallow respirations and refuses to deep breathe. Which intervention should the nurse implement? 1. Insist the client take deep breaths 2. Notify the surgeon to request a chest x-ray 3. Determine the last time the client used the PCA pump 4. Administer oxygen at 2 L/min via nasal cannula

3 - Shallow respirations and refusal to deep breathe could be the result of abdominal pain. The nurse should assess the client for pain and determine the last time the PCA pump was used.

The clinic nurse is talking on the phone to a client who has diarrhea. Which intervention should the nurse discuss with the client? 1. Tell the client to measure the amount of stool. 2. Recommend the client come to the clinic immediately. 3. Explain the client should follow the BRAT diet. 4. Discuss taking an over-the-counter histamine-2 blocker.

3 - The BRAT (bananas, rice, applesauce, and toast) diet is recommended for a client with diarrhea because it is low residue and produces nutrition while not irritating the GI system.

The client is admitted to the medical unit with a diagnosis of acute diverticulitis. Which health-care provider's order should the nurse question? 1. Insert a nasogastric tube. 2. Start IV D5W at 125 mL/hr. 3. Put client on a clear liquid diet. 4. Place client on bed rest with bathroom privileges.

3 - because bowel needs to be on total rest, which means NPO

The nurse, a licensed practical nurse, and an unlicensed nursing assistant are caring for clients on a medical floor. Which nursing task would be most appropriate to assign to the licensed practical nurse? 1. Assist the unlicensed nursing assistant to learn to perform blood glucose checks. 2. Monitor the potassium levels of a client with diarrhea. 3. Administer a bulk laxative to a client diagnosed with constipation. 4. Assess the abdomen of a client who has had complaints of pain.

3 - they can administer laxatives

The nurse is discussing the therapeutic diet for the client diagnosed with diverticulosis. Which meal indicates the client understands the discharge teaching? 1. Fried fish, mashed potatoes, and iced tea. 2. Ham sandwich, applesauce, and whole milk. 3. Chicken salad on whole-wheat bread and water. 4. Lettuce, tomato, and cucumber salad and coffee.

3- Chicken salad, which has vegetables such as celery, grapes, and apples, and whole-wheat bread are high in fiber, which is the therapeutic diet prescribed for clients with diverticulosis. An adequate intake of water helps prevent constipation.

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

3. The American Cancer Society recommends a colonoscopy at age 50 and every five (5) to 10 years thereafter, and a flexible sigmoidoscopy and a barium enema every five (5) years.

Which medication should the nurse expect the HCP to order to treat the client diagnosed with botulism secondary to eating contaminated canned goods? 1. An antidiarrheal medication. 2. An aminoglycoside antibiotic. 3. An antitoxin medication. 4. An ACE inhibitor medication.

3. A botulism antitoxin neutralizes the circulating toxin and is prescribed for a client with botulism.

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

3. A day surgery client can be ambulated to the bathroom, so this task can be delegated to the UAP.

The occupational health nurse observes the chief financial officer eat large lunch meals. The client disappears into the restroom after a meal for about 20 minutes. Which observation by the nurse would indicate the client has bulimia? 1. The client jogs two (2) miles a day. 2. The client has not gained weight. 3. The client's teeth are a green color. 4. The client has smooth knuckles.

3. Bulimia is characterized by bingeing and purging by inducing vomiting after a meal. Stomach contents are acidic and the acid wears away the enamel on the teeth, leaving the teeth a green color

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

3. Clay-colored stools and hemorrhoids are gastrointestinal effects of liver failure.

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

3. Direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure.

The client is diagnosed with gastroenteritis. Which laboratory data warrant immediate intervention by the nurse? 1. A serum sodium level of 137 mEq/L. 2. Arterial blood gases of pH 7.37, Pao2 95, Paco2 43, HCO3 24. 3. A serum potassium level of 3.3 mEq/L. 4. A stool sample positive for fecal leukocytes.

3. In gastroenteritis, diarrhea often results in metabolic acidosis and loss of potassium. The normal serum potassium level is 3.5 to 5.5 mEq/L; therefore, a level of 3.3 mEq/L would require immediate intervention. Hypokalemia can lead to life-threatening cardiac dysrhythmias.

The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented? 1. Administer an antidiarrheal medication, every day and PRN. 2. Perform bowel training every two (2) hours. 3. Administer oil retention enemas. 4. Prepare for an upper gastrointestinal (UGI) series x-ray.

3. Oil retention enemas will help to soften the feces and evacuate the stool.

Which statement indicates to the emergency department nurse the client diagnosed with acute gastroenteritis understands the discharge teaching? 1. "I will probably have some leg cramps while I have gastroenteritis." 2. "I should decrease my fluid intake until the diarrhea subsides." 3. "I should reintroduce solid foods very slowly back into my diet." 4. "I should only drink bottled water until the abdominal cramping stops."

3. Reintroducing solid foods slowly, in small amounts, will allow the bowel to rest and the mucosa to return to normal functioning after acute gastroenteritis.

The nurse has received the a.m. shift report. Which client should the nurse assess first? 1. The 44-year-old client diagnosed with peptic ulcer disease who is complaining of acute epigastric pain. 2. The 74-year-old client diagnosed with acute gastroenteritis who has had four (4) diarrhea stools during the night. 3. The 65-year-old client diagnosed with IBD who has tented skin turgor and dry mucous membranes. 4. The 15-year-old client diagnosed with food poisoning who has vomited several times during the night shift.

3. Tented skin turgor and dry mucous membranes indicate dehydration, which warrants the nurse assessing this client first.

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

3. The client is at risk for hypovolemia; therefore, vital signs will be assessed frequently to monitor for signs of hemorrhaging.

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

3. The most common symptom of colon cancer is a change in bowel habits, specifically diarrhea alternating with constipation.

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

3. The nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol.

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

3. This client has an intestinal blockage from a solid tumor blocking the colon. Although the client needs to be cleaned out for the colonoscopy, GoLYTELY could cause severe cramping without a reasonable benefit to the client and could cause a medical emergency.

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

3. This is the main reason the HCP decreases the client's medication dose and is an explanation appropriate for the client.

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

3. Turning the client to the side to assess the amount of drainage and possible bleeding is important prior to contacting the surgeon.

Which diagnostic tests should be monitored for the client diagnosed with severe anorexia nervosa? 1. Liver function tests. 2. Kidney function tests. 3. Cardiac function tests. 4. Bone density scan.

3. in severe anorexia muscle tissue is catabolized to provide energy to the body. The client is at risk for death from cardiac complications.

The male client has had abdominal surgery and is now diagnosed with peritonitis. Which assessment data support the client's diagnosis of peritonitis? 1. Absent bowel sounds and potassium level of 3.9 mEq/L. 2. Abdominal cramping and hemoglobin of 14 gm/dL. 3. Profuse diarrhea and stool specimen shows Campylobacter. 4. Hard, rigid abdomen and white blood cell count 22,000 mm.

4 - this indicates inflamed peritoneum resulting from infection which is why WBC are elevated

The client has been experiencing difficulty and straining when expelling feces. Which intervention should be taught to the client? 1. Explain that some blood in the stool will be normal for the client. 2. Instruct the client in manual removal of feces. 3. Encourage the client to use a cathartic laxative on a daily basis. 4. Place the client on a high-residue diet.

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The client is 2 hours post-colonoscopy. Which assessment data would warrant intermediate intervention by the nurse? 1. The client has a soft, nontender abdomen. 2. The client has a loose, watery stool. 3. The client has hyperactive bowel sounds. 4. The client's pulse is 104 and BP is 98/60.

4 - Bowel perforation is a potential complica- tion of a colonoscopy. Therefore, signs of hypotension—decreased BP and increased pulse—warrant immediate intervention from the nurse.

The client developed a paralytic ileum after abdominal surgery. Which intervention should the nurse include in the plan of care? 1. Administer a laxative of choice 2. Encourage client to increase oral fluids 3. Encourage client to take deep breaths 4. Maintain a patent nasogastric tube

4 - client is NPO so this will help with intake until bowel sounds return

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

4. "Flu-like" symptoms are the first com-plaints of the client in the preicteric phase of hepatitis, which is the initial phase and may begin abruptly or insidiously.

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

4. A pouch that becomes dislodged during the sexual act would cause embarrassment for the client, whose body image has already been dealt a blow.

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

4. Acute pain management is the highest priority client problem after surgery because pain may indicate a life-threatening problem.

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

4. Ammonia is a by-product of protein metabolism and contributes to hepatic encephalopathy. Reducing protein intake should decrease ammonia levels.

Which intervention should the nurse include when discussing ways to help prevent potential episodes of gastroenteritis from Clostridium botulism? 1. Make sure all hamburger meat is well cooked. 2. Ensure all dairy products are refrigerated. 3. Discuss why campers should drink only bottled water. 4. Discard damaged canned goods.

4. Any discolored food, food from a damaged can or jar, or food from a can or jar not having a tight seal should be destroyed without tasting or touching it.

Which data should the nurse expect to assess in the client diagnosed with acute gastroenteritis? 1. Decreased gurgling sounds on auscultation of the abdominal wall. 2. A hard, firm, edematous abdomen on palpation. 3. Frequent, small melena-type liquid bowel movements. 4. Bowel assessment reveals loud, rushing bowel sounds.

4. Borborygmi, or loud, rushing bowel sounds, indicates increased peristalsis, which occurs in clients with diarrhea and is the primary clinical manifestation in a client diagnosed with acute gastroenteritis.

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

4. Hepatitis A is transmitted via the fecal-oral route. Good hand washing helps to prevent its spread. Singing the happy birthday song takes approximately 30 seconds, which is how long an individual should wash his or her hands.

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

4. Refusing to turn, deep breathe, and cough places the client at risk for pneumonia. This client needs immediate intervention to prevent complications.

The nurse writes a nursing diagnosis of "altered nutrition: less than body requirements related to low self-esteem" for a client diagnosed with anorexia. Which client goal should be included in the plan of care? 1. The nurse will prevent the client from doing excessive exercise. 2. The client eats 50% of the meals provided. 3. Dietary will provide high-protein milk shakes t.i.d. 4. The client will verbalize one positive attribute.

4. The etiology of the diagnosis of anorexia is "low self-esteem." Therefore the goal must address the client's low self-esteem.

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

4. The pouch should be emptied when it is one-third to one-half full to prevent the contents from becoming too heavy for the seal to hold and to prevent leakage from occurring.

The nurse is preparing to administer a 250-mL intravenous antibiotic to the client. The medication must infuse in one (1) hour. An intravenous pump is not available and the nurse must administer the medication via gravity with IV tubing 10 gtts/min. At what rate should the nurse infuse the medication?_______

42 gtts/min.

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

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

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

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

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

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