AH1 - ATI GI Review
A nurse is teaching a patient about strategies to manage gastroesophageal reflux disease (GERD). Which of the following statements should the nurse include?
"Avoid eating 2 to 3 hours before bedtime."
A nurse is caring for an older adult patient who reports taking Bisacodyl tablets daily. What of the following responses should the nurse make?
"Excessive laxative use may cause an electrolyte imbalance."
A nurse is planning care for a patient who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan?
Administer furosemide. Implement a low-sodium diet. Measure the patient's abdominal girth.
A nurse is reviewing the laboratory data of the patient who has acute pancreatitis. The nurse should expect to find an elevation of which of the following values?
Amylase
A nurse is preparing to administer PO medication to a patient who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the patient medication?
Ask the patient to take a few sips of water.
A nurse is caring for a patient who has gastrointestinal bleeding. Which of the following actions should the nurse take first?
Assess orthostatic blood pressure.
A nurse is caring for a patient who has an active upper gastrointestinal bleed. After inserting a NG tube into the patient, which of the following findings should the nurse anticipate?
Coffee-ground drainage
Diagnostic results: 1700 Albumin 2.9 g/dL (3.5 to 5 g/dL) Ammonia 250 mcg/dL (10 to 80 mcg/dL) Sodium 138 mEq/L (136 to 145 mEq/L) Potassium 4.8 mEq/L (3.5 to 5 mEq/L) Fasting glucose 148 mg/dL (70 to 110 mg/dL) BUN 18 mg/dL (10 to 20 mg/dL) Creatinine 0.8 mg/dL (0.5 to 1 mg/dL) The patient is exhibiting manifestations of ________ due to the patient's _____________.
Encephalopathy Ammonia level
A nurse is providing care for a patient who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action?
Encourage ambulation once fully awake.
A nurse is assessing a patient who has an obstruction of the common bile duct resulting from chronic cholecysistis. Which of the following findings should the nurse expect?
Fatty stools
A nurse is caring for a patient who reports having chronic constipation. Which of the following herbal supplements should the nurse recommend?
Flaxseed
A nurse is planning care for a patient who has diverticulitis. Which of the following menu selections should the nurse include in the plan?
Grilled chicken breast with white rice.
A nurse is assessing a patient who is African-American and has jaundice. Which of the following areas is the most reliable for the nurse to inspect the patient for jaundice?
Hard palate
A nurse is caring for a patient immediately following a procedure that required spinal anesthesia. Which of the following findings indicates the patient is experiencing a complication of the anesthesia?
Headache
A nurse is assessing a patient who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?
Hematemesis
A nurse is review the medical record of a patient who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this condition?
History of NSAID use
A nurse is planning care for a patient who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis?
Increase ambulation
A nurse is providing teaching to a patient who has constipation. Which of the following information should the nurse include?
Increase fluid intake to 1500 mL daily. Include probiotic foods in the daily diet. Increase daily exercise.
A nurse admits a patient to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?
Increased serum amylase
A nurse is reviewing the provider's prescriptions for the patient experiencing a paralytic ileus following an appendectomy. Which of the following actions should the nurse take?
Insert nasogastric tube.
A nurse is caring for a patient who has gastric ulcer. Which of the following herbal supplements should the nurse recommend?
Licorice
A nurse is admitting a patient with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's' point.
McBurney's point is located by drawing a line from the navel to the right iliac crest. Divide the into three equal lengths. McBurney's point is midway between the naval to the iliac crest. Pressure over this point will elicit pain in the patients appendicitis.
Physical examination: 0800: Alert and oriented to person, place, and time Reports pain in mid-abdomen Rates pain as 7 on a 0 to 10 pain scale Upper abdomen distended with hyperactive bowel sounds Hypoactive bowel sounds present lower abdomen Peristaltic waves present upper and mid abdomen Heart sounds regular Lungs clear to auscultation bilaterally No peripheral edema noted Nurses notes: 0800: Vomits 150 mL bile colored emesis with mucous present Abdominal CT ordered 0930: Abdominal CT scan completed Salem sump nasogastric tube inserted right nare, connected to low wall continuous suction, with immediate return of 300 mL of bile colored fluid
Metabolic alkalosis due to nasogastric suctioning
Medical history: June 1 Rheumatoid arthritis Psoriasis Family history: Heart disease Arthritis Social history: 60-year smoking history Denies alcohol or other substance use Home Medications: Naproxen 250 mg PO BID PRN pain Aspirin 325 mg PO BID PRN pain Adalimumab 40 mg subcutaneous every other week Select the 3 findings from the patients medical record that increases their risk for peptic ulcer disease (PUD).
NSAID use Positive for H. pylori Smoking history
A nurse is teaching a patient about causes of biliary cirrhosis. Which of the following information should the nurse include in the teaching?
Obstruction of the bile duct
A nurse is preparing a teaching session about reducing the risk of complications of diabetes mellitus. Which of the following information should the nurse plan to include in the teaching? (Select all that apply.)
Reduce cholesterol and saturated fat intake. Increase physical activity and daily exercise. Enroll in a smoking-cessation program. Maintain optimal blood pressure to prevent kidney damage.
Vital signs: Heart rate 112/min Blood pressure 105/52 mm Hg Respiratory rate 28/min Temperature 38.4° C (101.1° F) O2 saturation 95% Diagnostic results: Amylase 450 units/L (20 to 220 units/L) Lipase 280 units/L (0 to 160 units/L) WBC count 12,500/mm3 (5,000 to 10,000/mm3) RBC count 3.9 (4.2 to 5.4) Hemoglobin 8 g/dL (12 g/dL to 16 g/dL for female; 14 to 18 g/dL for male) Hematocrit 24% (37% to 47% for female; 42% to 52% for male) Platelet count 160,000/mm3 (150,000 to 400,000/mm3) Blood glucose level 250 mg/dL (less than 200 mg/dL) Nurses' notes: Client reports abdominal pain as 10 on a scale of 0 to 10. Abdomen is tender to touch. Hypoactive bowel sounds on auscultation. Client reports nausea, no vomiting. Oriented x 4 but appears anxious and agitated. Skin is cool and clammy. Respiratory rate rapid, chest is clear on auscultation. Tachycardic Client is able to urinate with no reported difficulty. When prioritizing patient needs, the nurse should first address the patients ___________ followed by notifying the provider of the patients _______________.
Pain level Hgb and Hct level
Nurses' notes: Client admitted to the emergency department with new-onset confusion and urinary incontinence. Client appears agitated and is disoriented to place and time. Pupils 4 mm, equal and reactive to light. Hand grasps strong and equal. Facial muscles symmetrical. Caregiver reports client fell on their right hip this morning. Right hip with 5 cm (2 in) by 3 cm (1.2 in) area of ecchymosis Client able to bear weight equally to ambulate. Hips appear midline, range of motion equal bilaterally. Pedal pulses equal and palpable. Incontinent of foul-smelling urine in emergency department. Vital signs: Temperature 38.6º C (101.5º F)Blood pressure 96/50 mm HgPulse rate 101/minRespiratory rate 22/minOxygen saturation 95% on room air
Potential condition: Actions to take: Parameters to monitor:
Diagnostic results: HbA1c 8.4% (less than 7% for diabetics) Blood glucose 235 mg/dL (74 to 106 mg/dL) Hemoglobin 14.2 g/dL (12 to 18 g/dL) Hematocrit 42.6% (37 to 52%) Total WBC count 6000/mm3 (5000 to 10,000/mm3) HDL 75 mg/dL (greater than 55 mg/dL) LDL 124 mg/dL (less than 130 mg/dL) BNP 52 pg/ml (less than 100 pg/mL) Chest x-ray: Clear. No evidence of infiltrates.
Potential condition: type 1 diabetes mellitus Actions to take: assess the patient's feet for sensation, teach about the signs of hyperglycemia Parameters to monitor: fingerstick blood glucose , urinary output
A nurse is caring for a patient who is postoperative following a laryngectomy. Which of the following actions should the nurse take?
Provide humidified air for the patient.
A nurse in a PACU is assessing a patient who has a newly created colostomy. Which of the following findings should the nurse report to the provider?
Purplish-colored stoma
A nurse is planning a diet for a patient who is iron deficiency. Which of the following foods high in iron should the nurse include in the plan?
Red meat
A nurse is caring for a patient who requires total parenteral nutrition (TMN). Which of the following actions should the nurse take when finding that the TPN is infusing too rapidly?
Sit the patient upright.
The patient reports abdominal pain for the last two days that is now moving to the right lower quadrant. The pain has started to increase over the last hour and is 9 on a 0 to 10 scale. Bowel sounds positive x4 quadrants. The patient's tympanic temperature is 32.2°C (99.0°F). Respiratory rate 22/minute. Lung sounds clear, bilaterally. Oxygen saturation is 96% on room air. Heart rate 110/minute. Blood pressure 88/58 mmHg while lying down. Casual capillary blood glucose is 145 mg/dL. Select the findings the nurse should report to the provider.
The patient reports abdominal pain for the last two days that is now moving to the right lower quadrant. The pain that has started to increase over the last hour and is a 9 on a 0 to 10 scale. Respiratory rate 22/minute. Heart rate 110/minute. Blood pressure 88/58 mmHg while lying down.
A patient is prescribed Lansoprazole 15 mg PO once a day. At which of the following times should the nurse administer the medication?
Thirty minutes before breakfast
A patient is about to undergo an abdominal paracentesis. In which of the following positions should the nurse place the patinet.
Upright
A nurse is planning care for a patient who is to start receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include in the plan of care?
Use a 1.2 micron filter when infusing TPN with fat emulsions added.
A nurse is performing gastric lavage on a patient using a large-bore NG tube. Which of the following actions should the nurse take?
Withdraw fluid until it is clear.
A nurse is caring for a patient who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the patient's peristalsis is returning?
Passage of flatus
A nurse is providing instructions for a 52-year-old patient who is scheduled for a colonoscopy. The patient reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?
"Before the examination, your provider will give you a sedative that will make you sleepy."
A nurse is caring for a female patient who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the patient should the nurse report to the provider?
"I don't eat shellfish because it gives me hives."
A nurse at a provider's office is instructing a patient who is scheduled or an outpatient barium swallow. Which of the following statements by the patient indicates an understanding of the teaching?
"I should expect light-colored stools after the procedure."
A nurse is providing teaching about ileostomy care to a patient. Which of the following statements by the patient indicates a need for further teaching?
"I will be certain to take enteric-coated medications."
A nurse is providing information about pain control for a patient who has acute pain following a subtotal gastric resection. Which of the following patient statements indicates an understanding of pain control?
"I will call for pain medications before the previous dose wears off."
A nurse is teaching a patient who has a hiatal hernia about dietary recommendations. Which of the following patient statements indicates an understanding of the teaching? (Select all that apply
"I will consume less caffeine and fewer spicy foods." "I will sleep with the head of my bed elevated." "I will try not to gain weight."
A nurse is teaching a patient how to do fecal occult blood testing. Which of the following statements by the patient indicates a need for further taching?
"I will continue taking my Coumadin as prescribed."
A nurse is instructing a patient how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching?
"I will eat foods that are served at room temperature."
A nurse is instructing a patient who has GERD about positions that can help minimize the effects of reflux during sleep. Which of the following statements indicates to the nurse that the patient understands the instructions?
"I will lie on my right side to sleep at night."
A nurse is caring for a patient who is days postoperative following a total laryngectomy. The nurse removes the patient's NG tube and initiates oral feedings. Which of the following statements should the nurse make?
"It is no longer possible for you to choke on or aspirate food."
A nurse is providing discharge teaching to a patient who will be receiving total parenteral nutrition (TPN) at home. Which of the following instructions should the nurse include? (Select all that apply.)
"Keep the TPN refrigerated when not in use." "Infuse 10 percent dextrose and water if the solution runs out." "Maintain TPN infusion rate when behind schedule."
A nurse is providing discharge instructions to a patient who has rheumatoid arthritis and a prescription for oral Betamethoasone. Which of the following statements should the nurse make about how to take this medication?
"Take the medication with milk."
A patient who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?
"The laxative helps eliminate the barium."
A nurse is teaching a patient who is postoperative for a colectomy. The patient asks the nurse why he needs a large-bore NG tube. Which of the following statements should the nurse make?
"The tube will remove gas and fluid from your stomach."
A nurse is talking with a patient who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following patient statements indicates to the nurse understanding of the procedure?
"They are going to examine my gallbladder and ducts."
A nurse is planning a menu for a patient who has folic acid deficiency anemia. Which of the following foods should the nurse include as high in folate?
1/2 cup of asparagus
A nurse is caring for a patient who is receiving total parenteral nutrition (TPN). The nurse notices that the solution bag is almost empty and there is not another bag of TPN to administer. Which of the following IV solutions should the nurse administer until the next back of TPN solution is available?
10% dextrose in water (D10W)
A nurse is preparing to administer Metoclopramide 15 mg PO QID before meals and at bedtime for a patient who has GERD. The amount available is Metoclopramide 5 mg/mL. How many mL should the nurse administer?
15 mL
A nurse is assisting a group of patients in an outpatient clinic. For which of the following patients should the nurse anticipate scheduling a colonoscopy?
51-year-old who is being seen for an annual physical exam
A nurse is performing an integumentary assessment for a patient. Which of the following findings should the nurse identify as possible squamous cell carcinoma?
A firm nodule with a hard crust
Medical history: The client is complaining of cramping abdominal pain, vomiting, and is passing blood and mucus without fecal matter present. History: Hysterectomy 2010 and Crohn's disease since 2013 The client denies continuous pain and states that it is midabdominal and not lower abdominal. Medications: Stelara 90 mg subcutaneous every 8 weeks. Nurses' notes: 0800: Alert and oriented x 3Reports pain in mid-abdominal regionAbdominal distention noted upon inspection. Tenderness noted on palpation. Hyperactive bowel sounds auscultated.Rates pain as an 8 on a scale of 0 to 10Skin pale and coolHeart tones S1S2 auscultated. Bilateral breath sounds clear. Vital signs: Temperature 38.3° C (101° F) Apical pulse 120/minRespiratory rate 20/minBlood pressure 90/54 mm HgPulse oximetry 93% on room air Diagnostic results: CBC:RBC 4.9 million/mm3 (4.7 to 6.1 million/mm3)WBC 12,000 mm3 (5,000 to 10,000 mm3)Hemoglobin 16 g/dL (14 to 18 g/dL)Hematocrit 48% (42% to 52%)Platelets 200,000/mm3 (150,000 to 400,000/mm3) Basic Metabolic Profile:BUN 45 mg/dL (10 to 20 mg/dL)Creatinine 1.0 mg/dL (0.6 to 1.3 mg/dL)Total Calcium 9.5 mg/dL (9.0 to 10.5 mg/dL)Carbon Dioxide 27 mEq/L (23 to 30 mEq/L)Chloride 10 mEq/L (98 to 106 mEq/L)Glucose 80 mg/dL (74 to 106 mg/dL)Potassium 5.1 mEq/L (3.5 to 5 mEq/L)Sodium 150 mEq/L 136 to 145 mEq/L CT scan: CT scan shows marked distention of the small bowel with dilation of the small bowel loops
Anticipated: NG tube, 0.9% sodium chloride at 150 mL/hour Nonessential: oxygen 2 L per nasal cannula, chest x-ray on admission Contraindicated: Morhpine 4 mg IV PRN every 2 hours, 2,000 mg sodium diet
Physical examination: Day 1 1900 Client presents with left lower quadrant (LLQ) pain, rated 9 on a 0 to 10 pain scale with nausea and vomiting since yesterday. Client states, "I am unable to eat or drinking anything without vomiting." Last bowel movement 3 days ago. Bowel sounds hypoactive in all 4 quadrants, abdomen distended, tender to palpation with guarding. Client is alert and oriented to person, place, and time. Able to move all extremities. +2 peripheral pulses. Lungs clear to auscultation. 18 g peripheral IV catheter inserted to right forearm with 0.9% sodium chloride infusing at 75 mL/hr continuous via pump. Medical history: Diverticulitis 5 years ago Allergies: Penicillin
Anticipated: administer ampicillin/sulbactam IV bolus, type and cross match blood, change IV fluids to 0.9% sodium chloride with 20 KCL @ 125 mL/hour, CT of the abdomen with contrast Contraindicated: administer enema now X1, increase fiber intake
Nurses' notes: 1300 Client admitted from provider's office with report of vomiting brown emesis. Oriented to person, place, and time. Reports dizziness with movement. Skin is warm and moist. Decreased turgor. Dry mucous membranes. Pulse is rapid; S1S2 heard on auscultation. Peripheral pulses weak. Respirations rapid, rate 28/min, unlabored. Chest is clear on auscultation. Abdomen distended, client reports tenderness throughout with pain of 3 on a 0 to 10 pain scale. Hyperactive bowel sounds x 4 quadrants. Denies melena. Reports urination with no difficulty, "not much in the past few hours." Blood drawn for laboratory analysis per admission prescription. Client oriented to room, call bell in reach, side rails x 2. Instructed to call for needs or assistance. Client verbalized understanding. 1345 Client vomited 250 mL of coffee ground emesis. Vital signs obtained. Call placed to provider with update and laboratory results. Prescriptions received.
Anticipated: initiate continuous ECG monitoring, test stools for occult blood, insert a nasal gastric tube and attach to low suction, initiate IV fluids Nonessential: prepare patient for surgery, administer 1 unit of packed red blood cells Contraindicated: administer aspirin for abdominal pain
A nurse is caring for a patient who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The patient reports nausea and vomiting. Which of the following actions should the nurse take?
Auscultate bowel sounds
A nurse is providing teaching for a patient who has experience an acute episode of gastritis. Which of the following instructions should the nurse include in the teaching?
Avoid drinking alcohol.
A nurse is preparing dietary instructions for a patient who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?
Avoid foods high in fat.
A nurse is teaching a class about preventative care to patients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
Avoid foods prepared with tap water.
A nurse is caring for a patient who has ulcerative colitis and is teaching the patient about the common link with Crohn's disease. Which of the following information should the nurse include?
Both are inflammatory
A nurse is teaching a patient who has stomatitis. Which of the following instructions should the nurse include?
Brush teeth with a soft toothbrush.
A nurse is providing teaching for a patient who has a new diagnosis of gastroesophageal reflux disease (GERD). The patient asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid?
Chocolate
A nurse is teaching a patient who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to development of the anemia?
Chronic blood loss
A nurse i caring for a patient who has a history of alcohol use disorder and reports bruising and frequent nosebleeds. The nurse should recognize that this patient is manifesting which of the following conditions?
Cirrhosis
A nurse is assessing a patient who is in a body case. Which of the following manifestations should the nurse identify as possible cast syndrome?
Dilated pupils
A nurse is teaching a patient who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching?
Decompress the stomach.
A nurse is caring for a patient who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hours. Which of the following electrolyte imbalances should the nurse monitor the patient for?
Decreased potassium level
A nurse is admitting a patient who was prescribed antibiotic therapy and now as Clostridium difficile infection. Which of the following actions should the nurse take?
Disinfect the equipment in the patients room daily.
A nurse is caring for a patient who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the patient's gastrointestinal (GI) tract is digesting and absorbing blood?
Elevated blood urea nitrogen (BUN)
A nurse is caring for a patient who has cirrhosis and has a prescription for Bumetanide. When delivering the patient's lunch tray, which of the following items should the nurse identify as contraindicated for the patient?
Ham sandwich
A nurse is caring for a patient who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings?
Intellectual impairment
A nurse is providing discharge teaching for a patient who is postoperative following an inner maxillary fixation for facial fractures. Which of the following instructions should the nurse include in the teaching?
Keep wire cutters with you.
A nurse is caring for a patient who has diverticular disease. When palpating the patients abdomen, in which of the following locations should the nurse expect the patient to report abdominal pain?
Lower left quadrant
A nurse is administering a tap water enema to a patient who is constipated. During the administration of the enema, the patient states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the patient's discomfort?
Lower the height of the solution container.
A nurse is teaching a patient who has a hepatitis A. Which of the following information should the nurse include?
Manifestations of the virus are similar to flu-like symptoms.
Nurses' notes: 1030 Client reports nausea and indigestion for the past few days and worsens after meals and belches a lot. Denies vomiting. Client is alert and oriented to person, place and time. Client's skin is pink and moist to touch. Bowel sounds are normoactive in all quadrants. Abdomen is soft, nontender to touch and doesn't appear to be distended. Lungs sounds all clear. Last bowel movement was this morning. Peripheral pulses +2. No edema present.
Myocardial infarction: dyspnea, nausea, indigestion Gastroesophageal reflux disease: indigestion, hoarseness, eructation, nausea
A nurse is teaching a patient who is receiving treatment for metastatic colorectal cancer about the adverse effects of Bevacizumab with. The nurse should instruct the patient to report which of the following findings as an adverse effect of the medication?
Nosebleeds
A nurse is assessing a patient who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distension, and the patient passing no flatus. Which of the following conditions should the nurse suspect?
Paralytic ileus
A nurse is assessing a patient who has advanced cirrhosis. Which of the following manifestations should the nurse expect?
Petechiae
Nurses' Notes 3 months ago: 1100: The client presents for a follow-up visit post gastric bypass surgery 2 weeks ago. No reports of issues or concerns. The client reports minimal pain and adherence to diet and fluid intake. They remain on a pureed diet. No reports of alcohol consumption and the client stopped smoking before the surgery and plans to "stay a non-smoker." Physical Exam General no acute distress HEENT oropharynx clear, mucous membranes moist Respiratory breath sounds clear bilaterally Cardiovascular S1, S2, no murmur Extremities have good sensation, moves all extremities well. Today: 0900: The client presents for a 3-month post-surgical follow-up visit. The client reports tolerating solid foods without difficulty, though they state they are "still adjusting to the small portion size." The client also reports mild fatigue and some tingling in their hands and feet. Physical Exam General no acute distress HEENT oropharynx clear, smooth, beefy red tongue Respiratory breath sounds clear bilaterally Cardiovascular S1, S2, no murmur Extremities decreased sensation in hands and feet, moves all extremities well Laboratory Results 3 months ago: 1100: Hemoglobin 12.1 g/dL (12 to 16 g/dL) Hematocrit 36% (36% to 47%) MCV 93 fL (80 to 95 fL) Today: 0900: Hemoglobin 10 g/dL (12 to 16 g/dL) Hematocrit 30% (36% to 47%) MCV 110 fL (80 to 95 fL)
Potential complication: vitamin B12 deficiency Actions to take: educate the patient on foods that are rich in vitamin B12 and educate the patient that they will continuously need monthly vitamin B12 injections Parameters to monitor: monitor the patient's serum vitamin B12 levels and monitor the patients gait, coordination, and balance
Nurses' Notes: Day 1 0800: Client admitted to the medical-surgical unit for evaluation and treatment of cellulitis. Oropharynx clear, mucous membranes moist. Abdomen is soft, non-distended, and non-tender. Bowel sounds active in all 4 quadrants., Warmth, swelling, and tenderness noted to the right lower extremity. No drainage noted. Day 3 0800: Oropharynx clear, mucous membranes dry. No tenderness noted to McBurney's point, no rebound or guarding. Hyperactive bowel sounds noted. Right lower extremity minimally red with no tenderness or warmth to palpation. Client states that abdominal cramping and pain started yesterday evening. Client states that they have "been up pooping and haven't been able to stop having bowel movements since. I have been going about every thirty minutes, all night. Can you give me something to slow it down? I've never had diarrhea like this before."
Potential condition: clostridium difficile colitis Action to take: prepare to start IV fluids and place the patient on contact precautions Parameters to monitor: serum potassium and blood pressure
Nurses' Notes: Client is awake and alert. Breath sounds with crackles present bilaterally at bases. Productive cough with yellow, blood-tinged sputum. Client reports pleuritic chest pain upon inspiration. Client reports abdominal pain, frequent liquid, foul smelling, stools. Medication Administration Record: Ceftriaxone 1 g IV q12h Albuterol MDI 2.5 mg 2 inhalations q4h Acetaminophen 650 mg PO q6h PRN temperature greater than 38.5º C (101.3º F)
Potential condition: clostridium difficile infection Action to take: place the patient on contact precautions and obtain a stool culture Parameter to monitor: urine output and potassium level
Medical History: Cirrhosis Type 2 diabetes mellitus Hypertension Partner reports client drinks 12 cans of beer daily
Potential condition: encephalopathy Actions to take: administer lactulose as prescribed and assess for asterixis Parameters to monitor:
Received client awake, alert, and oriented x 3. Respiration even and unlabored. Breath sounds clear. Bowel sounds absent in all quadrants. Upper abdominal distention with visible peristaltic waves observed in center of abdomen. Client states, "that pain that started yesterday keeps getting worse; it's not the same pain from the surgery." Client reports the pain is constant and is 8 on a 0 to 10 pain scale in their abdomen described as dull, cramping, and achy. Client states surgical wound is causing no pain. "I'm not passing gas, and I'm very bloated." Client reports mild nausea and poor appetite. Provider notified of findings.
Potential condition: paralytic ileus Actions to take: make the patient NPO and prepare to insert a nasogastric tube Parameters to monitor: serum and potassium and pain
Nurses notes: Client presents to the emergency department with diaphoresis and reports severe epigastric pain that started 1 hr after eating breakfast. Client describes pain as a sharp, burning sensation. Abdomen is soft, nondistended with active bowel sounds. Epigastric region tender upon palpation. Client denies vomiting. Heart sounds regular. No peripheral edema present. Lung sounds are diminished in posterior lobes. Medical history: Obese, BMI 32 History of long-term use of NSAIDs for generalized discomfort Smoked 1 ½ packages of cigarettes per day for 40 years; quit 6 months ago History of angina x 2 years. Takes nitroglycerin 0.3 mg sublingual prn Chronic kidney disease, does home peritoneal dialysis three times per day
Potential condition: peptic ulcer disease Actions to take: obtain a stool specimen for H. pylori and request a proton pump inhibitor Parameters to monitor: orthostatic blood pressure and hemoglobin and hematocrit
A nurse is planning care for a patient who has viral hepatitis. Which of the following actions should the nurse include in the plan of care?
Provide a high carbohydrate diet.
A nurse is preparing a teaching session about reducing the risk of complications of diabetes mellitus. Which of the following information should the nurse plan to include in teaching? (Select all that apply.)
Reduce cholesterol and saturated fats. Increase physical activity and daily exercise. Enroll in smoking-cessation. Maintain optimal blood pressure to prevent kidney damage.
A nurse is teaching self-management to a patient who has hepatitis B. Which of the following instructions should the nurse include in the teaching?
Rest frequently throughout the day.
A nurse is assessing a patient who has cirrhosis. Which of the following is an expected finding for this patient?
Spider angiomas
A nurse is caring for a patient who has peptic ulcer disease. The nurse should monitor the patient for which of the following findings as an indication of gastrointestinal perforation.
Sudden abdominal pain
1500: Temperature: 39°C (102.2°F) Heart rate: 122/min Respiratory rate: 24/min BP: 106/54 mmHg Oxygen saturation: 95% on room air 1500: Client admitted from ED with reports of nausea, vomiting, diarrhea. Oriented to person, place, and time. Reports current new of headache, dizziness, Sinus tachycardia, S1, S2 heard on auscultation. Pulses palpable, mucous membranes dry. Respirations even, unlabored. Chest clear on auscultation. Bowel sounds hyperactive. States voiding with no difficulties. 1530: Client lethargic, reporting abdominal cramping, experiencing projectile vomiting. Voiding dark, concentrated urine. Client requesting water. Select the findings the nurse should report to the provider.
Temperature: 38°C (102.2°F) Heart rate: 122/minute Blood pressure: 106/54 mmHg Reports current new of headache, dizziness Mucous membranes dry Patient lethargic, reporting abdominal cramping, experiencing projectile vomiting - Voiding dark, concentrated urine
1400: Client reports to provider's office with report of nausea, vomiting, watery diarrhea for 48 hr following consumption of what they believe was undercooked meat. Oriented to person, place, and time, lethargic. Fever and chills present. Sinus tachycardia, S1, S2 heard on auscultation. Pulses palpable, mucous membranes dry. Bowel sounds hyperactive, abdominal cramping. Reports last bowel movement appeared blood tinged. Reports decreased urinary output with dark, concentrated urine. Gastroenteritis related to possible food-borne illness Fluid volume deficit Admit to acute care facility Which should the nurse implement first? Vital signs on admission and every 4 hr NPO Complete blood count Basic metabolic profile Arterial blood gases Hemoccult stool Stool culture and sensitivity Urine culture and sensitivity Sitz baths up to 3 times daily PRN Medications: Dextrose 5% in 0.45% sodium chloride IV at 125 mL/hr Metoclopramide 10 mg IV every 6 hr PRN nausea/vomiting Ciprofloxacin 400 mg IV every 12 hr
Vital signs on admission and every 4 hours. Stool culture and sensitivity. Urine culture and sensitivity. Dextrose 5% in 0.45% sodium chloride IV at 125 mL/hour.
A nurse is planning care for a patient who has pernicious anemia. Which of the following interventions should the nurse plan to implement?
Vitamin B12 injections
