Case Study 9: GI Problems

"An RN is the leader of a team caring for clients with gas-trointestinal (GI) disorders on a medical-surgical unit.The team includes a newly graduated RN who has recently completed hospital orientation, an experienced unlicensed assistive personnel (UAP), and a nursing student. The fol-lowing information about the six assigned clients is included in the hand-off report. (Note to student: Use the information from the hand-off report to make brief notes about these six clients and refer to the notes as you work through the case study. This gives you practice in identifying important information and simulates how you would use the notes to remember and keep track of six clients over the course of a shift.) Ms. H, a 42-year-old woman, has right upper quadrant pain that radiates to the right shoulder. She has a history of gallstones. She was admitted through the emergency department last night with acute cholecystitis. The night shift nurse reports, "She had a good night." Ms. D, a 60-year-old woman, was admitted with vomiting and pain in the midabdomen related to a bowel obstruction. She reports abdominal pain that has gradu-ally improved since the insertion of a nasogastric (NG)tube. She is receiving IV fluids and is currently to have nothing by mouth (NPO)."

...

--"Ms. T, a 29-year-old woman, was admitted for an acute exacerbation of ulcerative colitis. She appears wasted and malnourished. She has severe diarrhea and reports prede-fecation abdominal pain and generalized tenderness to palpation. She is receiving total parenteral nutrition(TPN) through a central line." --"Mr. A, a 26-year-old man, will be discharged in the afternoon. He is homeless and frequently sleeps in a nearby shelter. He had discharge teaching from the enter-ostomal therapist yesterday regarding his infected wound secondary to a ruptured appendix; he wants a review of the wound care instructions before he leaves." --"Mr. K, an 85-year-old man, is frail but alert and oriented 2. He was transferred from an extended-care facility to receive a percutaneous endoscopic gastrostomy" --"(PEG) tube that was placed 5 days ago. He has a large family. They ask a lot of questions and argue continuously among themselves and with the staff. His vital signs are stable. Mr. R, a 57-year-old man, has periumbilical pain. The Pain is very severe, despite medication, and radiates to the back. Mr. R was admitted with acute pancreatitis.He is nothing by mouth and has an NG tube and IV line.He is belligerent and confused. The white blood cell(WBC) count and blood glucose level are increased."

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31. The HCP has been paged and is en route to see Mr. R for complications related to acute pancreatitis. The client is increasingly agitated and confused. He pulls out his IV line and NGT and removes the O2 nasal cannula. His skin is pale and clammy. His HR is 140, BP is 140/60. List the following steps, in order of priority, in caring for Mr. R with 1 bring the first and 6 being the last 2,3,4,1,5,6 1. Restart IV 2. Stay with client and call for assistance 3. Replace nasal cannula for supplemental O2 4. Have a colleague gather IV supplies, glucometer, pulse oximeter, and non rebreather mask 5. Check blood glucose level 6. Delegate UAP to take vital signs every 15 minutes

2,3,4,1,5,6

14. The nurse is reviewing the medication administration record for Ms. T (ulcerative colitis). Which situation needs immediate investigation? a. Two tablets of senna were given yesterday morning b. One dose of atropine sulfate was given yesterday c. IV infusion of infliximab 5 mg/kg was given last. d. IV hydrocortisone 100 mg was given last evening

A

11. The new RN asks the team leader if it is okay to give Ms. D (bowel obstruction) a dose of psyllium using the HCP's standing orders. Ms. D says."she feels constipated and takes psyllium on a regular basis at home." What is the team leader's best response? a. "Call the HCP to see if the standing orders apply to Ms. D" b. "Give psyllium according to the standing orders" c. "Laxatives can cause perforation if there is a bowel obstruction" d. "The client can't be constipated because she is NPO"

C

12. Ms. D (bowel obstruction) reports feeling weak. She seems more confused compared with her baseline. The NG drainage container has a large amount of watery bile-colored fluid. Which lab value should be checked first? a. BUN and creatinine levels b. Platelet count and WBC count c. Na & K levels, pH of blood d. Bilirubin, hematocrit, and hemoglobin

C

15. Ms. T is receiving an oral dose of sulfasalazine 500 mg every 6 hours for treatment of ulcerative colitis. Which assessment finding is cause for greatest concern? a. Decreased appetite b. Nausea and vomiting c. Decreased urine output d. Headache

C

18. While the nurse is teaching Mr. A about dressing changes for his appendectomy wound, he says,"When you live on the street, you can't do everything the way you nurses do in the hospital." What is the most important thing to emphasize in helping him to accomplish self-care? a. "Change the dressing in the AM and the PM." b. "Use the gauze package to make a sterile field." c. "Wash your hands before a dressing change." d. "Discard any opened packages of unused gauze."

C

20. Mr. A (appendectomy) will be discharged with prescriptions for pain medication and an antibiotic. What is the most important point that the nurse will emphasize about the medications a. "Take the pain medication before the pain becomes severe" b. "The pain medication may make you feel drowsy or sleepy" c. "All of the antibiotics should be taken, even if you feel good." d. "The antibiotics should not be shared with any other person"

C

1. The night shift nurse has just finished giving the team leader a report on the six clients. Which client has the highest acuity level and is at greatest risk for shock during the shift? a. Ms. H (acute cholecystitis) b. Ms. D (bowel obstruction) c. Ms. T (ulcerative colitis) d. Mr. A (appendectomy) e. Mr. K (PEG-tube) f. Mr. R (acute pancreatitis)

F

19. Psychosocial assessment reveals that Mr. A (appendectomy) faces several financial and personal problems. Which finding has the most impact on discharge teaching for wound care and other follow-up issues? a. He is homeless and has no family in the city b. He has no money for the prescribed medications c. He has no transportation to the follow-up appointment d. He cannot read or write very well

A

2. Which clients would be best to assign to the new RN? Select all that apply a. Ms. H (acute cholecystitis) b. Ms. D (bowel obstruction) c. Ms. T (ulcerative colitis) d. Mr. A (appendectomy) e. Mr. K (PEG-tube) f. Mr. R (acute pancreatitis)

A, B, D

30. What information regarding Mr. R (acute pancreatitis) is appropriate to report to the HCP? Select all that apply a. Hematocrit is decreased by more than 10% b. Calcium level is less than 9mg/dL c. Partial O2 pressure (PO2) is less than 60 d. Pain is unrelieved by medication e. Blood type is O+ f. NGT and IV line are intact

A, B, C, D

3. Which tasks can be delegated to the UAP? Select all that apply a. Assisting Ms. T with perineal care after diarrheal episodes b. Measuring vital signs Q2 hours for Mr. R c. Transporting Ms. H off the unit for a procedure d. Gently cleaning the nares around Ms. D's NGT e. Removing Mr. A's dressing f. Helping Mr. K to brush his teeth

A, B, C, D, F

25. In the care of Mr. K (PEG tube), which health care team members are demonstrating the roles and responsibilities that support interprofessional collaboration? Select all that apply a. The UAP tells Mr. K's family that she will be in at 10:00AM to assist Mr. K with hygiene b. The RN gives the UAP specific instructions about how to clean around Mr. K's PEG tube c. The RN acknowledges that the UAP has the best working relationship with Mr. K's daughter d. The enterostomal therapist performs care for Mr. K, but staff and family are unsure about follow-up e. The nursing student reorganizes that dealing with Mr. K's family dynamics exceeds her abilities f. The surgeon does mini-grand rounds with nursing students to explain the purpose of Mr. K's PEG tube

A, B, C, E, F

9. The RN is observing the nursing student perform an abdominal assessment on Ms. D, who was admitted for a bowel obstruction. For which actions will the supervising nurse intervene? Select all that apply a. Palpating for abdominal distension with the index fingertip b. Auscultating for bowel sounds with the NGT attached to low wall suction c. Performing the physical assessment before asking about pain d. Checking the NG collection canister for quantity and quality of drainage e. Inspecting for visible signs of peristaltic waves or abdominal distension f. Checking for skin turgor over the lower abdominal area

A, B, C, F

21. To provide good continuity of care for Mr. A (appendectomy), who is homeless, which members of the interdisciplinary team should routinely have access to Mr. A's medical records? Select all that apply a. Hospital social worker who is helping Mr. A to locate resources b. Surgeon who performed Mr. A's appendectomy c. An epidemiologist who is collecting data on the homeless d. All of the UAP's who work in the medical-surgical area e. Administrator of the shelter where Mr. A frequently stays f. Nurse who works at the shelter where Mr. A frequently stays

A, B, F

24. Because of Mr. K's (PEG tube) advanced age, complications of enteral feedings may occur? Select All that apply a. Hyperglycemia b. Hypotension c. Aspiration d. Diarrhea e. Fluid overload f. Weight loss

A, C, D, E

16. The UAP asks, "Why can't Ms. T (ulcerative colitis) get out of bed and do things for herself? She's only29 years old." What is the team leader's best response? a. "The HCP ordered bed rest for a few days." b. "Decreasing activity helps to decrease the diarrhea." c. "I see you're frustrated; just do your best to help." d. "She is too depressed to get out of bed"

B

22. The RN is teaching the nursing student about enteral feedings for clients such as Mr. K, who has a PEG tube. In the postoperative period, when can enteral feedings be started? a. Within 6-8 hours after the procedure b. When bowel sounds occur, usually within 24 hours c. When the client reports feelings hungry d. On a schedule determined by the pharmacy

B

23. "Mr. K (PEG tube) needs 1200 kcal/day. The enteral feeding formula provides 1 kcal/mL. Yesterday's formula feedings were 100 mL at 7:00 AM, 50 mL at 11:00 AM, 200 mL at 3:00 PM, and 100 mL at 7:00 PM. What should the nurse do first? a. Give additional feedings to catch up on nutritional needs b. Look at the original prescription to determine the frequency and amount c. Look at weight trends to see if client is losing or maintaining weight d. Call the nurse who cared for Mr. K yesterday and ask what happened

B

27. What instructions will the nurse give to th eUAP about how to reposition Mr. R to relieve discomfort related to acute pancreatitis? a. Place him in a high fowler position b. Help him to lie in a side-lying fetal position c. Lay the bed flat and put the clients legs on a pillow d. Help him to dit to edge of bed and dangle his legs

B

28. MR. R (acute pancreatitis) demonstrates a dry cough. He reports left-sided chest pain when breathing deeply and SOB. He also has a low-grade fever. Which potential complication does the nurse suspect? a. Hypovolemic shock b. Pleural effusion c. Paralytic ileus d. Acute respiratory distress syndrome

B

5. Which question should the oncoming RN team leader pose to the night shift nurse to help determine the priority actions for Ms. H who was admitted for acute cholecystitis? a. "What are her vital signs?" b. "Is she going to surgery or radiology this morning?" c. "Is she still having pain?" d. "Does she need any morning medications?"

B

29. The nurse notes that Mr. R (acute pancreatitis) has a small amount of blood oozing from the IV insertion site, and there is a palm-shaped bruise on the anterior lateral humerus. What action should the nurse take first? a. Remove the IV line and restart it at different site b. Remind the UAP to handle Mr. R very gently c. Assess for other signs of obvious or occult bleeding d. Obtain an order for coagulation studies

C

32. The HCP arrives while the RN team leader is caring for Mr. R. Because of Mr. R's deteriorating status, the team leader would advocate for which intervention? a. Perform additional lab tests and continue monitoring b. Prepare Mr. R for emergency surgery c. Prepare Mr. R for transfer to the ICU d. Reestablish NG suction and apply restraints or use 1:1

C

6. The health care provider (HCP) told Ms. H (acute cholecystitis) that she would probably need a laparo-scopic cholecystectomy; however, the hepatobiliary iminodiacetic acid (HIDA) scan and laboratory results are still pending. Ms. H asks, "What should I expect?"What is the best intervention at this point? a. Describe the surgical procedure b. Call the HCP to come and speak with her c. Provide some written material about gallbladder disease and options d. Explain general postoperative care, such as coughing and deep breathing exercises

C

4. "Which reporting tasks are appropriate to delegate to the UAP? Select all that apply. a. Reporting on the condition of Ms. T's perineal area after application of ointment b. Reporting the quality and color of NG drainage forMs. D c. Reporting whether Mr. R's blood pressure is below100/60 mm Hg d. Reporting if any of the clients indicate pain e. Reporting if Mr. A is seen leaving the unit to smoke a cigarette f. Reporting that Mr. K's family has questions. The night nurse gives a brief and incomplete report

C, D, E, F

10. The RN is supervising the nursing student in administering Ms. D's (bowel obstruction) medications through the NGT. When would the nurse intervene? a. The student compares medication administration record with the original prescription b. The student draws up 30 mL of sterile water for flush in a large-bore syringe c. The student performs three checks of medication names and dosages d. The student crushes tablets and puts all medications in the same cup

D

13. Ms. T is discouraged and dispirited about her ulcerative colitis. She is resistant to TPN because "I'm being kept alive with tubes." Which explanation will encourage Ms. T to continue with the TPN therapy? a. "It will help you regain your weight." b. "It will create a positive nitrogen balance" c. "Your HCP has ordered this important therapy for you" d. "Your bowel can rest, and the diarrhea will decrease"

D

17. Because of Ms. T's (ulcerative colitis) severe diarrhea, the nurse is reviewing the laboratory results. Which Laboratory results are cause for greatest concern? a. The WBC count is slightly increased b. The hemoglobin and hematocrit are slightly decreased c. The erythrocyte sedimentation (ESR)rate is increased d. The serum sodium and potassium levels are decreased

D

26. For Mr. K (PEG tube), several new medications and a change in the enteral feeding solution are included in the discharge plan. Which team member is the nurse most likely to consult before teaching the client and family about these new medications and enteral solution> a. Nutritionist to verify that the calories and other nutrients are sufficient b. Home health nurse to verify that follow-up teaching will be performed c. Social worker to verify that medications and formula are covered by insurance d. Pharmacist to verify that medications are compatible with feeding solution

D

33. Towards the end of the shift, the team leader finds the new RN in the bathroom crying. The new nurse says," I'm a terrible nurse. I'm so disorganized, and I'm so far behind. I'm going to quit. I hate this job." What is the best thing to do? a. Have her take a short break off the unit b. Offer to take one of her clients c. Ask the UAP to help her d. Calm her down and help her prioritize

D

7. Ms. H's (acute cholecystitis) (HIDA) scan shows a decreased bile flow with gallbladder disease and obstruction. Because of the obstruction, the nurse is vigilant for the complication of biliary colic. What are they key signs and symptoms that the nurse will watch for? a. Rebound tenderness and a sausage-shaped mass in the right upper quadrant b. Flatulence, dyspepsia, and eructation after eating or drinking c. Right upper quadrant abdominal pain that radiates to the right shoulder or scapula d. Severe abdominal pain with tachycardia, pallor, diaphoresis, and prostration

D

8. All of these clients must receive their routine morning medications. Which client should receive his or her medication last? a. Ms. H (acute cholecystitis) b. Ms. D (bowel obstruction) c. Ms. T (ulcerative colitis) d. Mr. K (PEG-tube)

D