Elsevier Gastrointestinal System EAQ

A client is scheduled for a colonoscopy, and the healthcare provider prescribes a tap water enema. In which position should the nurse place the client during the enema? A. Left Sims B. Back lying C. Knee chest D. Mid-Fowler

A. Left Sims To take advantage of the anatomic position of the sigmoid colon and the effect of gravity, the client should be placed in the left Sims or left side-lying position for the enema. Back lying, knee-chest, or mid-Fowler positions do not facilitate the flow of fluid into the sigmoid colon by gravity.

A client had a colon resection and formation of a colostomy two days ago. Which color indicates to the nurse the stoma is viable? A. Blue B. Gray C. Brick red D. Dark purple

C. Brick red A brick red stoma indicates adequate vascular perfusion. A blue, gray, or dark purple color indicates inadequate perfusion of the stoma.

A nurse is caring for a client on the second day after an abdominoperineal resection. Which finding does the nurse document as normal in the stoma? A. Dry, pale pink, and even with the skin B. Moist, skin-colored, and flush with the skin C. Moist, red, and raised above the skin surface D. Dry, purple, and depressed below the skin surface

C. Moist, red, and raised above the skin surface The surface of a stoma is mucous membrane and should be dark pink to red, moist, and shiny; the stoma usually is raised beyond the skin surface to allow drainage to go into the appliance rather than onto the skin. The stoma should be moist, not dry. Pale pink may indicate limited circulation to the stoma. Although some stomas can be flush with the skin, a raised stoma is more common. Although the stoma should be moist, a skin-colored stoma indicates limited circulation to the stoma. A purple color indicates compromised circulation.

A client diagnosed with gastroesophageal reflux disease (GERD) is being treated with antacid therapy. When teaching the client about the therapy, what does the nurse reinforce? A. Antacids should be taken 1 hour before meals. B. These should be scheduled at 4-hour intervals. C. Antacid tablets are just as fast and effective as the liquid form. D. Antacids commonly interfere with the absorption of other drugs.

D. Antacids commonly interfere with the absorption of other drugs. Antacids interfere with absorption of drugs such as anticholinergics, barbiturates, tetracycline, and digoxin. Liquid antacids are faster acting and more effective than antacid tablets. Antacids should be taken 1 or 2 hours after meals and at bedtime. Antacid tablets may be taken more frequently than every 4 hours.

A client is admitted to the hospital with jaundiced skin and acute abdominal pain. What is the nurse's most therapeutic response when the client refuses all visitors? A. Listen to the client's fears B. Encourage the client to socialize C. Grant the client's request about visitors D. Darken the client's room by pulling the drapes

A. Listen to the client's fears Voicing fears often reduces the associated anxiety. Socialization, when feelings need exploration, is not therapeutic. Although the client's request about visitors should be granted, simply accepting the client's wishes is not by itself therapeutic. Darkening the client's room avoids the problem and is not therapeutic.

A client with ascites is scheduled for a paracentesis. To prepare the client for the abdominal paracentesis, what should the nurse do? A. Shave the client's abdomen. B. Medicate the client for pain. C. Encourage the client to drink fluids. D. Instruct the client to empty the bladder.

D. Instruct the client to empty the bladder. Emptying the bladder of urine keeps the bladder in the pelvic area and prevents puncture when the abdominal cavity is entered. Shaving the client's abdomen and medicating the client for pain are not necessary. Encouraging fluids is unsafe; the bladder will rise into the abdominal cavity and may be punctured.

During administration of an enema, a client reports having intestinal cramps. What should the nurse do? A. Discontinue the procedure. B. Instill the fluid at a slower rate. C. Lower the height of the container. D. Stop the fluid until the cramps subside

D. Stop the fluid until the cramps subside Administration of additional fluid when a client reports experiencing abdominal cramps adds to discomfort because of additional pressure. By clamping the tubing a few minutes, the nurse allows the cramps to subside, and the enema can be continued. Cramps are not a reason to discontinue the enema entirely; temporary clamping of the tubing usually relieves the cramps, and the procedure can be continued. Slowing the rate decreases pressure but does not reduce it entirely. Lowering the height of the container will reduce the flow of the solution, which will decrease pressure but not reduce it entirely.

A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply. A. Rye B. Oats C. Rice D. Corn E. Wheat

A, B, & E Rye, oats, and wheat should be avoided because they are irritating to the gastrointestinal mucosa. Gluten is not found in rice or corn; therefore, these items do not have to be avoided.

A financially struggling, large family is instructed by the home health nurse about ways to increase the dietary intake of calcium. Which suggestion should the nurse make? A. Collards or kale in one meal a day B. Fruit-flavored yogurt every other day C. Bread made with cornmeal each morning D. Eight ounces (240 mL) of milk with every meal

A. Collards or kale in one meal a day Leafy green vegetables are an excellent source of calcium, are inexpensive, and can be home-grown; collards and kale are high in calcium. Yogurt does contain calcium, but it is costly for a large, financially struggling family. Cornbread and other bread products provide limited sources of calcium unless specifically enriched, making them more expensive. Although milk contains calcium, serving milk at every meal exceeds the recommended amount of milk for adults and is costly.

After an acute episode of upper gastrointestinal (GI) bleeding, a client vomits undigested antacids and reports having severe epigastric pain. The nursing assessment reveals an absence of bowel sounds, a pulse rate of 134, and shallow respirations of 32 per minute. In addition to calling the healthcare provider, what is the priority nursing action? A. Prepare the client for surgery. B. Administer oxygen per nasal catheter. C. Place in the supine position, with legs elevated. D. Ask the client if there have been any black stools.

A. Prepare the client for surgery. These symptoms are classic indicators of a perforated ulcer, for which immediate surgery is indicated; this should be anticipated. Although oxygen may be helpful, it is not the priority. The symptoms are more indicative of perforation than of shock, so placing the client in the supine position with legs elevated is not appropriate at this time. Black, tarry stools indicate bleeding, not perforation.

Two days after abdominal surgery a client experiences extensive flatus. The nurse administers the Harris flush (Harris drip). Which finding indicates a therapeutic effect? A. Client has a bowel movement. B. Client's returns are finally clear. C. Client's abdomen is less distended. D. Client is able to retain a half liter of fluid.

C. Client's abdomen is less distended. The Harris flush removes accumulated gas in the intestine, which reduces distention of the abdomen. Stimulating evacuation is not the purpose of a Harris flush; a bowel movement indicates that an enema, not a Harris flush, was effective. The returns of a Harris flush usually contain small amounts of fecal material; the technique is not used for cleansing the bowel. The fluid is not retained; small amounts are instilled slowly and then permitted to return slowly, taking gas with it.

A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. What is the priority nursing action during the first 48 hours after the client's admission? A. Monitor the client's vital signs. B. Increase the client's fluid intake. C. Improve the client's nutritional status. D. Determine the client's reasons for drinking.

A. Monitor the client's vital signs. A client's vital signs, especially the pulse and temperature, will increase before the client demonstrates any of the more severe symptoms of withdrawal from alcohol. Increasing intake is contraindicated initially because it may cause cerebral edema. Improving nutritional status becomes a priority after the problems of the withdrawal period have subsided. Determining the client's reasons for drinking is not a priority until after the detoxification process.

Which recommendation is most important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet? A. Use lemon juice to season meat. B. Put condiments on food to add flavor. C. Include canned vegetables in meal preparation. D. Drink carbonated beverages instead of decaffeinated coffee.

A. Use lemon juice to season meat. Lemon juice adds flavor and is low in sodium. Condiments (e.g., mustard, ketchup) are high in sodium and should be avoided. Canned vegetables contain a large amount of sodium; fresh vegetables should be encouraged. Carbonated beverages generally contain sodium; coffee, even if it is decaffeinated, does not contain sodium.

A nurse assesses a client with the diagnosis of an intestinal obstruction in the descending colon. When auscultating the midabdomen, what should the nurse expect to hear? A. Tympany B. Borborygmi C. Abdominal bruit D. Pleural friction rub

B. Borborygmi Borborygmi are rapid, high-pitched bowel sounds that are indicative of the hyperperistalsis that occurs behind an intestinal obstruction. Tympany is not auscultated but percussed, and it is described as high pitched or musical because of the presence of gas. An aortic bruit is auscultated above the umbilicus; a renal bruit is heard laterally above the umbilicus. Neither bruit can be auscultated at the midabdomen, and neither is related to an intestinal obstruction. A pleural friction rub is heard in the chest; it is associated with inflamed lung pleura.

A client who had a choledochostomy to explore the common bile duct is returned to the surgical unit with a T-tube in place. What is the priority intervention when caring for this client? A. Irrigate the T-tube as necessary B. Protect the abdominal skin from bile drainage C. Have the client wear a binder when out of bed D. Empty the T-tube drainage bag every two hours

B. Protect the abdominal skin from bile drainage The enzymatic activity of bile can cause excoriation and skin breakdown; the skin should be protected. A T-tube is not irrigated. A binder will not protect the skin, although it may support abdominal musculature. Drainage is emptied when the bag is full or at routine intervals (usually every 8 to 12 hours).

A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome? A. Low-residue, bland diet B. Fluid intake below 500 mL C. Small, frequent feeding schedule D. Low-protein, high-carbohydrate diet

C. Small, frequent feeding schedule Small feedings reduce the amount of bulk passing into the jejunum and therefore reduce the fluid that shifts into the jejunum. Although a diet high in roughage may be avoided, a low-residue, bland diet is not necessary. Total fluid intake does not have to be restricted; however, fluids should not be taken immediately before, during, or after a meal because they promote rapid stomach emptying. Concentrated sweets pass rapidly out of the stomach and increase fluid shifts; the diet should be low in carbohydrates. Relatively high protein is needed to promote tissue repair.

The nurse understands that research demonstrates that malnutrition occurs in as many as 50% of hospitalized clients. The nurse should assess a postoperative client with anorexia for what sign of malnutrition? A. Dependent edema B. Spoon-shaped nails C. Loose, decayed teeth D. Delayed wound healing

D. Delayed wound healing Delayed wound healing often is caused by a lack of nutrients, such as protein and vitamin C, in the diet. Dependent edema usually occurs with severe protein deficiency and heart failure. Spoon-shaped nails usually occur with iron deficiency anemia. Loose, decayed teeth usually indicate prolonged malnutrition.

The nurse is caring for a client in the postanesthesia care unit immediately after the client had a subtotal gastrectomy. The nurse identifies small blood clots in the client's gastric drainage. What action should the nurse take? A. Clamp the tube. B. Consider this an expected event. C. Instill the tube with iced normal saline. D. Notify the surgeon immediately.

B. Consider this an expected event. As a result of the trauma of surgery, some bleeding can be expected for four to five hours. Clamping the tube will cause increased pressure on the gastric sutures from a buildup of gas and fluid. Iced saline rarely is used because it causes vasoconstriction, local ischemia, and a reduction in body temperature. Notifying the client's surgeon of this finding is not necessary; this is an expected occurrence.

The nurse is caring for a client with a hiatal hernia. The client states that favorite beverages include ginger ale, apple juice, orange juice, and cola beverages. Of the four the client listed, which is the only beverage that should remain in the client's diet? A. Ginger ale B. Apple juice C. Orange juice D. Cola beverages

B. Apple juice Apple juice is not irritating to the gastric mucosa. Carbonated beverages like ginger ale distend the stomach and promote regurgitation. The acidity of orange juice aggravates the disorder. Most colas should be avoided because they contain caffeine, which causes increased acidity and aggravates the disorder; also they are carbonated, which distends the stomach and promotes regurgitation.

A client is admitted to the hospital with ascites. The client reports drinking a quart (liter) of vodka mixed in orange juice every day for the past three months. To assess the potential for withdrawal symptoms, which question would be appropriate for the nurse to ask the client? A. "When was your last drink of vodka?" B. "What prompts your drinking episodes?" C. "Do you also eat when you drink?" D. "Why do you mix the vodka with orange juice?"

A. "When was your last drink of vodka?" The nurse must determine when the client had the last drink to gauge when the body may react to lack of alcohol (withdrawal). Factors that prompt drinking are important but do not affect the body's response to withdrawal from the substance. Whether the client also eats when the client drinks will not influence the body's response to withdrawal from the alcohol. Whether the client mixes vodka with orange juice will not influence the body's withdrawal from the alcohol.

A nurse is reviewing discharge plans with a client who is hospitalized with hepatitis A. The nurse concludes that the client understands preventive measures to reduce the risk of spreading the disease when the client makes what statement? A. "I should wash my hands frequently." B. "I should launder my clothes separately." C. "I should put used tissues in the garbage." D. "I should wear a mask when leaving the house."

A. "I should wash my hands frequently." Hepatitis A microorganisms are transmitted via the anal-oral route; handwashing, particularly after toileting, is the most important precaution. The response "Launder my clothes separately" will not deter the spread of the virus; handwashing is necessary. Putting used tissue in the garbage is important, but handwashing is the most important precaution. Hepatitis A microorganisms exit through the rectum, not the respiratory tract.

During a health symposium a nurse teaches the group how to prevent food poisoning. Which statement by one of the participants indicates the teaching is understood? A. "Meats and cream-based foods need to be refrigerated." B. "Once most food is cooked, it does not need to be refrigerated." C. "Poultry should be stuffed and then refrigerated before cooking." D. "Cooked food should be cooled before being put into the refrigerator."

A. "Meats and cream-based foods need to be refrigerated." A cold environment limits growth of microorganisms. All food should be refrigerated before and after it is cooked to limit the growth of microorganisms. Stuffing and then refrigerating poultry promotes the growth of microorganisms because the stuffing will still be warm for a period before the refrigerator's cold environment cools the center of the bird. It is advocated that poultry not be stuffed. If it is stuffed, it should be done immediately before cooking. Cooling foods before refrigeration promotes the growth of microorganisms because microorganisms thrive in warm, moist environments.

A client is diagnosed with cancer of the pancreas and is apprehensive and restless. Which nursing action should be included in the plan of care? A. Encouraging expression of concerns B. Administering antibiotics as prescribed C. Teaching the importance of getting rest D. Explaining that everything will be all right

A. Encouraging expression of concerns Open communication helps to decrease anxiety. Antibiotics will have no direct effect on the client's anxiety. Knowledge does not always reduce anxiety and promote rest. Explaining that everything will be all right is false reassurance.

A client has laparoscopic surgery to remove a calculus from the common bile duct. What postoperative client response indicates to the nurse that bile flow into the duodenum is reestablished? A. Stools become brown B. Liver tenderness is relieved C. Colic is absent after ingestion of fats D. Serum bilirubin level returns to the expected range

A. Stools become brown The return of brown color to the stool indicates that bile is entering the duodenum and being converted to urobilinogen by bacteria. Liver tenderness is unrelated to bile flow. The absence of biliary colic is related to the removal of the calculus, not the flow of bile. The serum bilirubin level is not affected.

When assessing a client's abdomen, the nurse palpates the area directly above the umbilicus. By what term is this area known? A. Iliac area B. Epigastric area C. Hypogastric area D. Suprasternal area

B. Epigastric area The stomach is located within the sternal angle, known as the epigastric area. The iliac area is in the area of the iliac bones. The hypogastric area is the lowest middle abdominal area. The suprasternal area is the area above the sternum.

The nurse is providing postoperative care for a client who had an extensive surgical revision of the head of the pancreas. To decrease the risk of hemorrhage at the operative site, what action should the nurse take? A. Keep the client in the supine position. B. Maintain patency of the nasogastric tube. C. Replace fat-soluble vitamins as necessary. D. Administer prescribed tube feedings to the client slowly.

B. Maintain patency of the nasogastric tube. A patent nasogastric tube prevents distention and compression in the surgical area. The supine position will place too much tension on the abdominal wall. A low-Fowler position is preferred; movement should be encouraged. Replacement of vitamins is a dependent function; vitamins must be prescribed by the healthcare provider. Tube feedings are contraindicated because peristalsis is absent for one to three days after surgery and because the feeding will place pressure on the suture line.

A client who is suspected of having salmonellosis asks the nurse how the diagnosis is confirmed. The nurse responds that the medical diagnosis is established with what laboratory test? A. Urinalysis B. Stool culture C. Febrile agglutinin test D. Complete blood count

B. Stool culture The Salmonella bacilli can be visualized via microscopic examination of stool. Although a urinalysis might be done, it is not definitive for the diagnosis of salmonellosis. Although a febrile agglutinin test might be done, it is not definitive for the diagnosis of salmonellosis. Although a complete blood count might be done, it is not definitive for the diagnosis of salmonellosis.

A client is admitted to the hospital for a laparoscopic cholecystectomy. What should the nurse encourage the client to add to the diet to help normalize bowel function after surgery? A. Vitamins B. Whole bran C. Cod liver oil D. Amino acids

B. Whole bran Whole bran provides bulk that promotes intestinal motility and a regular bowel movement. Vitamins are not related to normalizing bowel function. Cod liver oil is not related to regulating bowel function. Amino acids are not related to regulating bowel function.

A nurse teaches a client about limiting the discomfort associated with a hiatal hernia. Which statement from the client indicates teaching by the nurse is effective? A. "After meals I will take a 10-minute walk." B. "After meals I will drink 8 oz (240 mL) of water." C. "After meals I will rest in a sitting position for one hour." D. "After meals I will lie down in bed for at least 20 minutes."

C. "After meals I will rest in a sitting position for one hour." Gravity (sitting up after meals) facilitates digestion and prevents reflux of stomach contents into the esophagus. Exercise immediately after eating may prolong the digestive process. Water should not be taken with or immediately after meals because it overdistends the stomach. Lying down in bed for at least 20 minutes is not an appropriate action because it promotes the reflux of gastric contents into the esophagus.

A client is prescribed ranitidine 150 mg daily to treat peptic ulcer disease (PUD). Which instruction would the nurse give to the client about when to take this medication? A. As needed B. With meals C. At bedtime D. When indigestion occurs

C. At bedtime Ranitidine is administered typically in a single dose at bedtime. This medication is used for 4 to 6 weeks in combination with other therapy; it is not used as needed, with meals, or when indigestion occurs.

A client is instructed to avoid straining on defecation postoperatively. Which food item chosen by the client indicates successful learning? A. Ripe bananas B. Milk products C. Green vegetables D. Creamed potatoes

C. Green vegetables Green vegetables contain fiber, which promotes defecation. Bananas, milk products, and creamed potatoes have a constipating effect, which results in straining at stool.

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What nursing intervention is the priority? A. Weigh the client daily. B. Restrict the client's oral fluid intake. C. Measure the client's urine specific gravity. D. Observe the client for increasing confusion.

D. Observe the client for increasing confusion. An increased serum ammonia level impairs the central nervous system, causing an altered level of consciousness. Increasing ammonia levels are not related to weight. An alteration in fluid intake will not affect the serum ammonia level. Measuring the client's urine specific gravity is not the priority; the priority is to monitor the client's neurological status.

A self-help group of clients with irritable bowel syndrome have invited a nurse to present a program on nutrition. Which substance should the nurse teach the clients to minimize in the diet to decrease gastrointestinal (GI) irritability? A. Cola drinks B. Gelatin C. Fiber D. Rice

A. Cola drinks The caffeine in cola is chemically irritating to the intestinal mucosa. Caffeine also promotes secretion of gastric juice. Gelatin is absorbed slowly and is not irritating. Rice does not irritate the bowel and need not be restricted. Fiber is increased in irritable bowel syndrome to provide bulk and regular bowel habits.

A nurse reviews the laboratory results of a client with acute pancreatitis. Which test is most significant in determining the client's response to treatment? A. Platelet count B. Amylase level C. Red blood cell count D. Erythrocyte sedimentation rate

B. Amylase level In 90% of clients with acute pancreatitis, the amylase level is elevated up to three times over baseline; serum amylase usually returns to expected adult levels within three days after treatment begins. The platelet count is not an indicator of the response to treatment for pancreatitis; platelets are important in the control of bleeding. The red blood cell count is unchanged in acute pancreatitis, unless hemorrhage is present. The erythrocyte sedimentation rate is not an indicator of a response to treatment for pancreatitis.

A nurse is teaching menu planning to a client who has a high triglyceride level. Which item avoided by the client indicates that teaching about foods that are high in saturated fat is understood? A. Fruits B. Grains C. Red meat D. Vegetable oils

C. Red meat Red meat is high in dense saturated fats and should be avoided. Fruits do not contain saturated fats. Grains do not contain saturated fats. Vegetable oils contain unsaturated fats.

A client is diagnosed with cancer of the rectum and has surgery for an abdominoperineal resection and colostomy. Which nursing care should be implemented during the postoperative period? A. Limiting fluid intake for several days B. Withholding fluids for 72 hours C. Having the client change the colostomy bag D. Keeping the client's skin around the stoma clean

D. Keeping the client's skin around the stoma clean If the area is not kept both clean and dry, drainage from the colostomy can quickly cause a breakdown of the skin around the stoma. This, in combination with a warm, moist surface, predisposes the individual to infection. Although oral fluids are withheld until peristalsis returns, it is essential that parenteral fluids be administered to replace the losses incurred by surgery. The client is often unable to accept the altered body image and must be given time to adjust before participating actively in self-care.

A client is diagnosed with hepatitis A. The nurse provides the client with information about untoward signs and symptoms related to hepatitis. The nurse instructs the client to contact the primary healthcare provider if the client develops what symptom? A. Fatigue B. Anorexia C. Yellow urine D. Clay-colored stools

D. Clay-colored stools Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines. It is unnecessary to call the healthcare provider because fatigue and anorexia are characteristic of hepatitis from the onset of clinical manifestations. Yellow is the expected color of urine.

Twelve hours after a subtotal gastrectomy, a nurse identifies large amounts of bloody drainage from the client's nasogastric (NG) tube. Which action should the nurse take? A. Obtain vital signs B. Clamp the NG tube C. Instill 30 mL of iced normal saline into the NG tube D. Record the observations and continue monitoring the client

A. Obtain vital signs Large amounts of blood or excessive bloody drainage 12 hours postoperatively indicate that the client is hemorrhaging. Vital signs should be taken. Clamping the tube is contraindicated; accumulation of secretions causes pressure on the suture line, preventing further observation of drainage. The primary healthcare provider must prescribe instilling 30 mL of iced normal saline into the nasogastric tube. Continuing to monitor the drainage and record the observations is an unsafe intervention at this time; action must be taken to address and stop the hemorrhaging.

A female client who had a colostomy recently is asking questions about how normal her life will be now that she has a colostomy. Which statement by the client indicates a need for further teaching? A. "I wanted another child, and now pregnancy is not an option for me." B. "I must allow extra time for irrigating my colostomy when traveling." C. "It is good to know that I can swim every day after my incision heals." D. "I'm glad I won't have to have special clothing and I can wear what I have."

A. "I wanted another child, and now pregnancy is not an option for me." Pregnancy is possible; it should be determined whether the client is referring to physiologic capability or emotional concern about sexual relationships. Extra time usually is necessary in an unfamiliar environment and should be calculated into traveling plans. Swimming is permitted; the water will not injure the stoma or intestine. There are no adaptations or restrictions on the types of clothing.

A nurse is instructing a client with peptic ulcer disease (PUD) about the diet that should be followed during the acute phase. Which type of diet should the nurse stress? A. Bland foods B. Regular diet C. Gluten-free foods D. Low-carbohydrate foods

A. Bland foods A bland, nonirritating diet is recommended during the acute symptomatic phase. During the acute phase, a regular diet can cause discomfort. Clients should be instructed to avoid substances that increase gastric acid secretion, such as coffee, tea, and cola. Bedtime snacks should be avoided because they may stimulate gastric acid secretion as well. Gluten-free foods do not decrease gastric acid secretion. Low-carbohydrate foods do not decrease gastric acid secretion.

A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. What explanation does the nurse give for why a PEG tube is preferred for administering a tube feeding? A. There is less chance of aspiration. B. This procedure does not require a pump. C. Self-administration of the feeding is possible. D. More tube feeding mixture can be given each time.

A. There is less chance of aspiration. When tube feedings are given via a PEG tube, they bypass the upper gastrointestinal tract (oropharynx, esophagus, cardiac sphincter of the stomach), which reduces the risk of tracheal aspiration. A gastrostomy tube may be attached to a pump for continuous feedings. Clients can be taught to feed themselves with either method. The amount of the feeding is not affected.

Three days before surgery for a permanent colostomy for cancer of the colon, a client is receptive of all procedures, responds pleasantly when approached, and does not question staff about what is being done. What is the most appropriate conclusion for the nurse to make based on these behaviors? A. The client has been fully informed about what to expect. B. The client is not verbalizing feelings about what will happen. C. The client cannot accept the illness and the need for surgery. D. The client feels reassured by frequent contact with health team members.

B. The client is not verbalizing feelings about what will happen. Both a diagnosis of cancer and a colostomy drastically alter self-image and body image. People react differently to this stress, often finding it difficult to express their concerns verbally; however, their actions may demonstrate awareness of the situation. Not enough information is available to support the conclusions that the client is fully informed about expectations, is not accepting of the illness and the need for surgery, or is feeling reassured by healthcare members.

A client has a hiatal hernia. The client is 5 feet 3 inches tall (163 cm) and weighs 160 pounds (72.6 kg). Which information should the nurse include when discussing prevention of esophageal reflux? A. Increase your intake of fat with each meal. B. Lie down after eating to help your digestion. C. Reduce your caloric intake to foster weight reduction. D. Drink several glasses of fluid during each of your meals.

C. Reduce your caloric intake to foster weight reduction. Weight reduction decreases intraabdominal pressure, thereby decreasing the tendency to reflux into the esophagus. Fats decrease emptying of the stomach, extending the period that reflux can occur; fats should be decreased. Lying down after eating increases the pressure against the diaphragmatic hernia, increasing symptoms. Drinking several glasses of fluid during each meal will increase pressure; fluid should be discouraged with meals.

Discharge planning for a client with chronic pancreatitis includes dietary teaching. Which statement indicates to the nurse that the client needs more teaching? A. "I must eat foods high in calories." B. "I should avoid alcoholic beverages." C. "I will eat more often but in smaller amounts." D. "I can eat foods high in fat now that the acute stage is over."

D. "I can eat foods high in fat now that the acute stage is over." The nurse needs to follow up on the client statement that indicates eating foods high in fat can be allowed. A low-fat diet should be followed to avoid diarrhea. All the rest of the client responses are correct and do not require additional teaching. The response to eating foods high in calories is appropriate because additional calories are needed to maintain weight. The response to avoiding alcoholic beverages is appropriate to prevent overstimulation of the pancreas. Small, frequent meals limit stimulation of the pancreas and is appropriate.

A nurse is preparing to administer a nasogastric tube feeding. List the steps of the procedure in the order in which they should be performed. 1. Wash the hands 2. Verify the solution to be administered 3. Aspirate the contents of the stomach 4. Instill the prescribed solution 5. Document the client's response to the procedure

1, 2, 3, 4, 5 The hands should be washed to prevent contamination of the formula and the delivery system. Because numerous formulas may be used to correct specific nutritional problems, the nurse should verify that the formula to be administered is the one prescribed. The stomach contents should be aspirated to observe the fluid removed and to ascertain the feeding tube's location in the stomach. If the tube is correctly positioned, the solution is administered. The amount of formula given, the length of time involved, and the client's response to the procedure are recorded.

A healthcare provider explains a cystectomy and an ileal conduit for a client with invasive carcinoma of the bladder. Later the client expresses concerns about the possibility of offensive odors associated with this procedure. What is the best response by the nurse? A. "Tell me more about what you are thinking." B. "Products are available to limit this problem." C. "This is a problem, but the surgery is necessary." D. "Most people who have this surgery share this same concern."

A. "Tell me more about what you are thinking." The response "Tell me more about what you are thinking" is an open-ended statement that focuses on the client's concerns and allows further verbalization of feelings. Although true, the response "This is a problem, but the surgery is necessary" may increase anxiety and cut off communication. The responses "Products are available to limit this problem" and "Most people who have this surgery share this same concern" move the focus away from the client and minimize the client's concerns.

A client with advanced bone cancer is experiencing cachexia. The nurse discusses the nutritional aspect of palliative care with the family. What is the importance of the nurse explaining these nutritional interventions to the family? A. Enhances the quality of the client's life B. Reduces the likelihood of a respiratory infection C. Prevents the malabsorption syndrome from occurring D. Cures the cachexia that results from bone cancer and chemotherapy

A. Enhances the quality of the client's life Nutritional interventions to decrease cachexia will not necessarily contribute to survival, but they may enhance the client's quality of life. Palliative care focuses on reducing symptoms and increasing quality; it does not focus on finding a cure. Nutritional interventions cannot prevent the occurrence of respiratory infections; this requires mobilization of respiratory secretions to prevent stasis. Malabsorption cannot be prevented with teaching; malabsorption may or may not occur depending upon the disease process and functioning of the client's gastrointestinal tract.

A client is diagnosed with cancer of the stomach and is scheduled for a partial gastrectomy. The teaching on postoperative care provided by the nurse should cover what topic? A. Gastric suction B. Oxygen therapy C. Fluid restriction D. Urinary catheter

A. Gastric suction After gastric surgery a nasogastric tube is in place for drainage of blood and gastric secretions that allow healing at the site of anastomosis. Oxygen is not required unless the client experiences a complication necessitating its administration. An IV to meet fluid needs and replace gastric losses is given to the average client. A urinary catheter may or may not be necessary.

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? A. Incontinence and inability to move independently B. Periodic diaphoresis and occasional sliding down in bed C. Reaction to just painful stimuli and receiving tube feedings D. Adequate nutritional intake and spending extensive time in a wheelchair

A. Incontinence and inability to move independently Constant exposure to moisture (urine) and prolonged pressure that compresses capillary beds place a client at high risk for pressure ulcers. Although periodic exposure to moisture and occasional friction are risk factors for pressure ulcers, they do not place a client at highest risk. Although immobility places a client at risk for pressure ulcers, tube feedings should meet the client's nutritional needs and promote tissue integrity. Although being chair-bound increases a client's risk for pressure ulcers, adequate nutritional intake supports tissue integrity. If the client has upper body strength, weight can be shifted periodically to relieve pressure.

A client describes abdominal discomfort following ingestion of milk. Which enzyme, as a result of a genetic deficiency, should the nurse consider to be the cause of the client's discomfort? A. Lactase B. Sucrase C. Maltase D. Amylase

A. Lactase Milk and milk products are not tolerated well because they contain lactose, a sugar that is converted to galactose by lactase. Sucrase assists in the digestion of sucrose, which is not a milk sugar. Maltase assists in the digestion of maltose, which is not a milk sugar. Amylase assists in the digestion of starch, which is not a milk sugar.

A client reports experiencing nausea, dyspnea, and right upper quadrant pain unrelieved by antacids. The pain occurs most often after eating in fast-food restaurants. Which diet should the nurse instruct the client to follow? A. Low fat B. Low carbohydrate C. Soft-textured and bland D. High protein and kilocalories

A. Low fat The presence of fat in the duodenum stimulates painful contractions of the gallbladder to release bile, causing right upper quadrant pain; fat intake should be restricted. Carbohydrates do not have to be restricted. A reduction in spices and bulk is not necessary. Although a diet high in protein and kilocalories might be desirable as long as the protein is not high in saturated fat, a high-calorie diet generally is not prescribed.

The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do? A. Monitor for nonverbal cues of pain B. Check the pressure dressing for bleeding C. Assist the client to ambulate around his room D. Irrigate the client's nasogastric tube with sterile water

A. Monitor for nonverbal cues of pain Asian clients tend to be stoic regarding pain and usually do not acknowledge pain; therefore, the nurse should assess these clients further. This type of surgery does not require pressure dressings. First, the client must be assessed further for pain. If there is pain, the client should ambulate after, not before, receiving pain medication. Postoperatively, nasogastric tubes are irrigated when needed, not routinely.

A client with a 20-year history of excessive alcohol use has developed jaundice and ascites and is admitted to the hospital. What is the priority nursing action during the first 48 hours after the client's admission? A. Monitor vital signs B. Increase fluid intake C. Obtain a foam mattress D. Improve nutritional status

A. Monitor vital signs The vital signs, especially pulse and temperature, will increase before the client demonstrates any of the more severe signs and symptoms of withdrawal from alcohol. Increasing fluid intake is contraindicated initially because it may cause cerebral edema and the client has ascites. Although the client will be more comfortable on a foam mattress, it is not the priority. Improving nutritional status becomes a priority after problems of the withdrawal period have subsided.

After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for what treatment? A. Monthly injections of cyanocobalamin B. Regular daily use of a stool softener C. Weekly injections of iron dextran D. Daily replacement therapy of pancreatic enzymes

A. Monthly injections of cyanocobalamin Intrinsic factor is lost with removal of the stomach, and cyanocobalamin is needed to maintain the hemoglobin level once the client is stabilized; injections are given monthly for life. Adequate diet, fluid intake, and exercise should prevent constipation. Weekly injections of iron dextran are not considered routine. Daily replacement therapy of pancreatic enzymes does not affect pancreatic enzymes.

A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results? A. Sodium and chloride levels B. Bicarbonate and sulfate levels C. Magnesium and protein levels D. Calcium and phosphate level

A. Sodium and chloride levels Sodium, which helps regulate the extracellular fluid volume, is lost with vomiting. Chloride, which balances cations in the extracellular compartment, also is lost with vomiting. Because sodium and chloride are parallel electrolytes, hyponatremia will accompany hypochloremia. Bicarbonate and sulfate levels, magnesium and protein levels, and calcium and phosphate levels do not provide significant information in relation to the effects of vomiting.

A nurse is obtaining a health history from a client with the diagnosis of peptic ulcer disease. Which client statement provides evidence to support the identification of a possible contributory factor? A. "My blood type is A positive." B. "I smoke one pack of cigarettes a day." C. "I have been overweight most of my life." D. "My blood pressure has been high lately."

B. "I smoke one pack of cigarettes a day." Smoking cigarettes increases the acidity of gastrointestinal secretions, which damages the mucosal lining. While blood type O is more frequently associated with duodenal ulcer, type A has no significance. Being overweight is unrelated to peptic ulcer disease. High blood pressure is not directly related to peptic ulcer disease.

A client has surgery for an incarcerated hernia. The healthcare provider returns the incarcerated tissue to the abdominal cavity and uses a mesh to reinforce the muscle wall. What specific instructions should be included in the discharge instructions? A. Reduce dietary roughage. B. Avoid lifting heavy items. C. Increase dietary potassium intake. D. Keep the head of the bed elevated.

B. Avoid lifting heavy items. Avoiding lifting helps prevent increased intraabdominal pressure that may disrupt the surgical repair. Roughage helps prevent constipation, thus avoiding straining and increased intraabdominal pressure. There is no indication for potassium supplements. The client can assume any position of comfort.

The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump? A. Checking for the last bowel movement B. Checking for residual stomach contents C. Checking to determine time of last medication for nausea D. Checking to make sure the head of bed is elevated at least 15 degrees

B. Checking for residual stomach contents Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. Aspiration can occur if a feeding is started with excessive residual. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Knowledge of last nausea medication is not necessary at this time. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees.

A client who had an abdominoperineal resection and colostomy refuses to allow any family members to see the incision or stoma. The client is noncompliant with most of the dietary recommendations. The nurse concludes that the client is experiencing what response? A. Reaction formation; this is related to the client's recent altered body image B. Denial; the client is having difficulty accepting reality C. Impotency resulting from the surgery; sexual counseling may be indicated D. Suicidal thoughts; consultation with a psychiatrist should be prescribed

B. Denial; the client is having difficulty accepting reality As long as no one else confirms the presence of the stoma and the client does not adhere to a prescribed regimen, the client's denial is supported. There is no evidence to document that reaction formation is being used. There are no data to support the conclusion that the client has an inability to function sexually. There is no evidence that suicidal thoughts are present or will be acted upon.

A healthcare provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is most appropriate for the nurse to teach the client about meal management? A. Snack daily in the evenings B. Divide food into four to six meals a day C. Eat the last of three daily meals by 8:00 PM D. Suck a peppermint candy after each meal

B. Divide food into four to six meals a day The volume of food in the stomach should be kept small to limit pressure on the lower esophageal sphincter. Snacking in the evening can cause reflux. The last meal should be eaten at least three hours before bedtime; individual bedtimes vary. Peppermint promotes reflux because it relaxes the lower esophageal sphincter, allowing food to be regurgitated into the esophagus.

A client with gastroesophageal reflux disease reports having difficulty sleeping at night. What should the nurse instruct the client to do? A. Drink a glass of milk before retiring. B. Elevate the head of the bed on blocks. C. Eliminate carbohydrates from the diet. D. Take antacids, such as sodium bicarbonate.

B. Elevate the head of the bed on blocks. Elevating the head of the bed on blocks raises the upper torso and minimizes reflux of gastric contents. Increasing the content of the stomach before lying down will aggravate the symptoms associated with gastroesophageal reflux. Eliminating carbohydrates from the diet will have no effect on the reflux of gastric contents. The effect of antacids is not long-lasting enough to promote a full night's sleep; sodium bicarbonate is not recommended as an antacid.

A client is scheduled for gastrointestinal surgery. What is the most important nursing action that should be implemented the evening before surgery? A. Describing the specific surgical procedure B. Ensuring the bowel preparation is initiated C. Encouraging the client to socialize with other clients D. Providing the client's food preferences for the evening meal

B. Ensuring the bowel preparation is initiated It is essential that the gastrointestinal tract be cleansed for surgery; proper visualization and prevention of peritonitis depend on the intestine being as clean of feces as possible. A specific and detailed description may cause anxiety and is unnecessary unless the client asks for this information. Encouraging the client to socialize with others is not the priority; however, therapeutic communication between the nurse and the client should be encouraged. Generally with gastrointestinal surgery, clear liquids are prescribed at least 24 to 48 hours before surgery and then nothing by mouth after midnight the night before surgery.

A client with colitis inquires as to whether surgery eventually will be necessary. When teaching about the disease and its treatment, what should the nurse emphasize? A. Medical treatment is curative; surgery is not required. B. For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful. C. For most clients, surgery is recommended early in the course of treatment. D. Medical treatment is all that will be needed if the client can maintain emotional stability.

B. For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful. Medical treatment is directed toward reducing motility of the inflamed bowel, restoring nutrition, and preventing and treating infection; surgery is used selectively for those who are acutely ill or have excessive exacerbations. That medical treatment for colitis is curative and that surgery is not required is untrue; medical treatment is symptomatic, not curative. It usually is performed as a last resort. Although there is an emotional component, the physiological adaptations determine whether surgery is necessary.

A client is admitted to the hospital with slight jaundice and reports of pain on the left side and back. A diagnosis of acute pancreatitis is made. Which common response to acute pancreatitis should the nurse monitor in the client? A. Crackles B. Hypovolemia C. Gastric reflux D. Jugular vein distention

B. Hypovolemia Hypovolemia that results from a fluid shift from the intravascular compartment to the peritoneal cavity can cause circulatory collapse; this is a life-threatening event that requires immediate intervention. Crackles indicate an accumulation of fluid in the alveoli associated with hypervolemia, not hypovolemia. Gastric reflux occurs with gastroesophageal reflux disease (GERD), not with pancreatitis. Jugular vein distention indicates hypervolemia, not hypovolemia.

The home health nurse provides education to a client with cancer of the tongue who will begin gastrostomy feedings at home. Which statement by the client indicates teaching by the nurse is effective? A. "Before I start the procedure, I will don sterile gloves." B. "Before I start the procedure, I will obtain my body weight." C. "Before I start the procedure, I will measure the residual volume." D. "Before I start the procedure, I will instill one ounce (30 mL) of a carbonated liquid."

C. "Before I start the procedure, I will measure the residual volume." Measuring the residual volume establishes whether an adequate volume of the previous feeding was absorbed. If a residual exceeds the parameter identified by the healthcare provider or is over 200 mL, a feeding may be held. This prevents adding excess feeding solution that may lead to abdominal distention, nausea, vomiting, and aspiration. Clean, not sterile, gloves are necessary to protect the client from contamination with gastric secretions. Weights are taken and reported weekly or monthly depending on the client's condition and clinical goals. A carbonated beverage may be used if the tube becomes clogged; it is not used routinely.

A client who had previously signed a consent form for a liver biopsy reconsiders and decides not to have the procedure. What is the nurse's best initial response? A. "Why did you sign the consent form originally?" B. "I can understand why you changed your mind." C. "Can you tell me your reasons for refusing the procedure?" D. "You must be afraid about something concerning the procedure."

C. "Can you tell me your reasons for refusing the procedure?" The response "Can you tell me your reasons for refusing the procedure?" attempts to explore why the client is refusing the procedure; the question promotes communication. The response "Why did you sign the consent form originally?" is accusatory; the client has the right to withdraw consent at any time. The response "I can understand why you changed your mind" is a conclusion without appropriate data; it may also increase the client's anxiety level. "You must be afraid about something concerning the procedure" is a conclusion without appropriate data; it also puts the client on the defensive.

The nurse provides discharge teaching to a client related to management of the client's new colostomy. The client states, "I hope I can handle all of this at home; it's a lot to remember." What is the nurse's best response? A. "I'm sure you will be able to do it." B. "Maybe a family member can do it for you." C. "You seem to be nervous about going home." D. "Perhaps you can stay in the hospital another day."

C. "You seem to be nervous about going home." Reflection of feelings conveys acceptance and encourages further communication. The response "I'm sure you will be able to do it" is false reassurance that does not help to reduce anxiety. The response "Maybe a family member can do it for you" provides false reassurance and promotes dependence. The response "Perhaps you can stay in the hospital another day" is unrealistic and does not address the client's concern in a way that supports the ventilation of feelings.

A client, experiencing an exacerbation of Crohn disease, is admitted to the hospital for intravenous steroid therapy. The nurse should not assign this client to a room with a roommate who has which illness? A. Pancreatitis B. Thrombophlebitis C. Bacterial meningitis D. Acute cholecystitis

C. Bacterial meningitis The bacteria that cause meningitis are transmitted via air currents; the client should be in a private room with airborne precautions to protect other people. Pancreatitis is not a communicable disease; it is most often caused by autodigestion of pancreatic tissue by its own enzymes. Thrombophlebitis is not a communicable disease; it is inflammation of a vein (phlebitis) associated with thrombus formation. Cholecystitis is not a communicable disease; it is inflammation of the gallbladder.

A client tells the nurse about recent recurrent episodes of bleeding hemorrhoids. What should the nurse advise the client to do to help prevent future hemorrhoidal episodes? A. Exercise to improve circulation B. Eat bland foods and avoid spices C. Consume a high-fiber diet and drink adequate water D. Use laxatives to avoid constipation and the Valsalva maneuver

C. Consume a high-fiber diet and drink adequate water Consuming a high-fiber diet and drinking adequate water promote regular bowel function, prevents constipation, and prevent straining, which can make hemorrhoids worse; a high-fiber diet provides bulk that stimulates peristalsis, and water promotes a soft stool. Exercise is advisable, but the purpose in this instance is to increase peristalsis, not improve circulation. Bland foods and spices are unrelated to hemorrhoids; bland foods are preferred for clients with gastric or intestinal problems. Laxatives are contraindicated because they are irritating to the bowel, decrease intestinal tone, and promote dependency. The Valsalva maneuver should also be avoided.

A nurse reviews the plan of care for a geriatric client with less than adequate nutritional intake. The nurse should question which prescription? A. Have client sit in a chair for meals to prevent aspiration of food/liquid into the lungs. B. Provide six small feedings in 24 hours whenever requested by the client. C. Give one can of diet supplement at 8:00 AM with breakfast and 4:00 PM prior to evening meal. D. Encourage the client's family members to bring food from home, especially their favorite dishes.

C. Give one can of diet supplement at 8:00 AM with breakfast and 4:00 PM prior to evening meal. Supplements given before meals will make a client less hungry at meal times; supplements should be given after meals. Sitting in an upright position facilitates passage of food to the stomach. Small, frequent meals are less overwhelming and generally more appealing for the nutritionally-challenged client. Clients are more likely to eat food familiar to them than institutional food.

A client is hospitalized after four days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, Pco2 50 mm Hg, bicarbonate 58 mEq/L (58 mmol/L), chloride 55 mEq/L (55 mmol/L), sodium 132 mEq/L (132 mmol/L), and potassium 3.8 mEq/L (3.8 mmol/L). What condition does the nurse determine the results to indicate? A. Hypernatremia B. Hyperchloremia C. Metabolic alkalosis D. Respiratory acidosis

C. Metabolic alkalosis The normal plasma pH value is 7.35 to 7.45; the client is in alkalosis. The normal plasma bicarbonate value is 23 to 25 mEq/L (23 to 25 mmol/L); the client has an excess of base bicarbonate, indicating a metabolic cause for the alkalosis. The normal plasma sodium value is 135 to 145 mEq/L (135 to 145 mmol/L); the client has hyponatremia. The normal plasma chloride value is 95 to 105 mEq/L (95 to 105 mmol/L); the client has hypochloremia because of vomiting of gastric secretions. With respiratory acidosis the pH is decreased to less than 7.35.

A nurse identifies a moderate amount of bright red blood in a client's gastric drainage four hours after a subtotal gastrectomy. What should the nurse do first? A. Clamp the nasogastric tube. B. Irrigate the tube gently with normal saline. C. Record the observation and continue to monitor the drainage from the tube. D. Reduce the pressure of the suction and record observations of the drainage characteristics.

C. Record the observation and continue to monitor the drainage from the tube. Some bright red blood at this point is an expected finding that should be monitored; large amounts of blood or bleeding should be reported immediately. Clamping the nasogastric tube is contraindicated; secretions will accumulate and cause pressure on the suture line. Also, clamping the tube prevents observation of gastric drainage. If the tube is draining, there is no need to irrigate; also, irrigations are traumatic. Reducing suction pressure allows secretions to accumulate and causes pressure on the suture line.

A client who is a heavy smoker has been prescribed a high-calorie, high-protein diet. The nurse should encourage the client to eat foods that are high in which vitamin? A. Niacin B. Thiamine C. Vitamin C (ascorbic acid) D. Vitamin B12

C. Vitamin C (ascorbic acid) Smoking accelerates oxidation of tissue vitamin C (ascorbic acid). As a result, smokers need an additional 35 mg/day. Niacin is not oxidized more rapidly in the smoker. Thiamine is not oxidized more rapidly in the smoker. Vitamin B12 is not oxidized more rapidly in the smoker.

A client had surgery for a ruptured appendix. Postoperatively, the health care provider prescribes an antibiotic to be administered intravenously twice a day. The nurse administers the prescribed antibiotic via a secondary line into the primary infusion of 0.9% sodium chloride. During the administration of the antibiotic, the client becomes restless and flushed, and begins to wheeze. What should the nurse do after stopping the antibiotic infusion? A. Check the client's temperature. B. Take the client's blood pressure. C. Obtain the client's pulse oximetry. D. Assess the client's respiratory status.

D. Assess the client's respiratory status. The client is experiencing an allergic reaction that may progress to anaphylaxis. Anaphylactic shock can lead to respiratory distress as a result of laryngeal edema or severe bronchospasm. Assessing and maintaining the client's airway is the priority. Checking the client's temperature and taking the client's blood pressure are not the priority; vital signs should be obtained after airway patency is ensured and maintained. Pulse oximetry is only one portion of the needed respiratory status assessment.

A client is admitted to the hospital with gastrointestinal bleeding, and a nasogastric tube is inserted. The healthcare provider prescribes the nasogastric tube to be irrigated with normal saline whenever necessary to maintain patency. What should the nurse do first when it is determined that the nasogastric tube is not patent? A. Instill normal saline. B. Assess breath sounds. C. Auscultate for bowel sounds. D. Check the tube for placement.

D. Check the tube for placement. Checking the tube for placement reduces the risk of introducing the irrigant into the lungs. Instilling normal saline increases the risk of introducing irrigant into the lungs if the tube is not in the stomach. Assessing for breath sounds is not related to the steps associated with instilling a nasogastric tube with an irrigant. Auscultating for bowel sounds is not related to the steps associated with instilling a nasogastric tube with an irrigant.

The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. Which will be most appropriate to include in the client's dietary plan? A. Offer soft-textured foods to reduce the digestive burden B. Offer low-cholesterol foods to avoid further formation of gallstones C. Increase protein intake to promote tissue healing and improve energy reserves D. Decrease fat intake to avoid stimulation of the cholecystokinin mechanism for bile release

D. Decrease fat intake to avoid stimulation of the cholecystokinin mechanism for bile release Fat intake stimulates cholecystokinin release that signals the gallbladder to contract, causing pain. Soft-textured foods are unnecessary. Eating low-cholesterol foods to avoid further formation of gallstones is not true for all clients with cholecystitis; low-cholesterol foods are necessary if the cholecystitis is precipitated by cholelithiasis and the stones are composed of cholesterol. An increase in protein intake is necessary to promote tissue healing and improve energy reserves after a cholecystectomy, but is not as important as fat intake for cholecystitis.

A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea? A. Increased fiber intake B. Bacterial contamination C. Inappropriate positioning D. High osmolarity of the feedings

D. High osmolarity of the feedings The increased osmolarity (concentration) of many formulas draws fluid into the intestinal tract, which can cause diarrhea; such feedings may need to be diluted initially until the client develops tolerance or is changed to a more iso-osmolar strength formula. Formulas frequently have reduced fiber content. Bacterial contamination is not a factor if the manufacturer's recommendations are followed. Inappropriate positioning may increase the risk for aspiration, but it does not cause diarrhea.

A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is most important for the nurse to determine when collecting information about the constipation? A. Presence of distention B. Extent of weight gained C. Amount of high-fiber food consumed D. Length of time this problem has existed

D. Length of time this problem has existed First, the nurse should establish when the client last defecated because the client may have perceived constipation. Abdominal distention may or may not be observed with constipation. Weight gain has no relationship to constipation. Although lack of bulk in the diet can lead to constipation, particularly in clients with limited activity or an inadequate fluid intake, the lack of bulk in the diet is not the most significant information to obtain at this time.

A client is admitted to the hospital with a diagnosis of intestinal obstruction. The healthcare provider prescribes intestinal suction via a nasoenteric decompression tube. The loss of which constituents associated with intestinal suctioning is most important to consider when caring for this client? A. Protein enzymes B. Energy carbohydrates C. Vitamins and minerals D. Water and electrolytes

D. Water and electrolytes Fluid and electrolytes are lost through intestinal decompression; on a daily basis about 20% of the total body water is secreted into and almost completely reabsorbed by the gastrointestinal (GI) tract. Because the client is kept nothing by mouth (NPO), there is no stimulus to cause enzymes to be secreted into the GI tract. Intravenous dextrose supplies some carbohydrates as a source of energy; carbohydrates will not be drawn from storage by intestinal decompression. Because the client is being kept NPO, vitamins and minerals are not entering the GI tract and therefore are not lost.