Exam 2- MedSurg PrepU (ch 20, 38-41)

A client with a gastrointestinal condition asks why the mouth needs to be examined. Which response will the nurse make? "Your problem is in your mouth and not your abdomen." "It is a body part that is least examined." "It is a part of the assessment of every client." "Changes in the mouth can help explain why your condition is occurring."

"Changes in the mouth can help explain why your condition is occurring."

A nurse has just completed teaching with a client who has been prescribed a meter-dosed inhaler for the first time. Which statement if made by the client would indicate to the nurse that further teaching and follow-up care is necessary? "I do not need to rinse my mouth with this type of inhaler." "I will make sure to take a slow, deep breath as I push on my inhaler." "After I breathe in, I will hold my breath for 10 seconds." "If I use the spacer, I know I am only supposed to push on the inhaler once."

"I do not need to rinse my mouth with this type of inhaler."

The nurse determines that teaching for the client with peptic ulcer disease has been effective when the client makes which statement? "I have learned some relaxation strategies that decrease my stress." "I should continue my treatment regimen as long as I have pain." "I should stop all my medications if I develop any side effects." "I can buy whatever antacids are on sale because they all have the same effect."

"I have learned some relaxation strategies that decrease my stress." The nurse assists the client to identify stressful or exhausting situations. A hectic lifestyle and an irregular schedule may aggravate symptoms and interfere with regular meals taken in relaxed settings along with the regular administration of medications. The client may benefit from regular rest periods during the day, at least during the acute phase of the disease. Biofeedback, hypnosis, behavior modification, massage, or acupuncture may be helpful.

A home care nurse is caring for a client with reports of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test? "I'll drink full liquids the day before the test." "I'll take a laxative to clear my bowels before the test." "There is no need for special preparation before the test." "I'll avoid eating or drinking anything 6 to 8 hours before the test."

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

A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.) "It is probably your nerves." "You may have ingested some irritating foods." "It is a hereditary disease." "Is it possible that you are overusing aspirin." "It can be caused by ingestion of strong acids."

"It can be caused by ingestion of strong acids." "You may have ingested some irritating foods." "Is it possible that you are overusing aspirin."

The nurse asks a client to point to where pain is felt. The client asks why this is important. What is the nurse's best response? "Often the area of pain is referred from another area." "If the health care provider massages over the exact painful area, the pain will disappear." "The area may determine the severity of the pain." "This determines the pain medication to be ordered."

"Often the area of pain is referred from another area."

A patient has a gastric sump tube inserted and attached to low intermittent suction. The physician has ordered the tube to be irrigated with 30 mL of normal saline every 6 hours. When reviewing the patient's intake and output record for the past 24 hours, the nurse would expect to note that the patient received how much fluid with the irrigation?

120

A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours? 20 to 40 mL 80 to 120 mL 160 to 200 mL 50 to 75 mL

80 to 120 mL

A nurse is preparing a presentation for a local community group of older adults about colon cancer. What would the nurse include as the primary characteristic associated with this disorder? Frank blood in the stool Abdominal distention A change in bowel habits Abdominal pain

A change in bowel habits

The nurse is caring for a client recovering from a colonoscopy. Which assessment finding will the nurse expect in the client after the procedure? Fever Abdominal distention Abdominal cramps Rectal bleeding

Abdominal cramps After the procedure, clients are maintained on bed rest until fully alert. Some clients have abdominal cramps caused by increased peristalsis stimulated by the air insufflated into the bowel during the procedure. Fever, rectal bleeding, and abdominal distention are symptoms of bowel perforation and should be immediately reported to the health care provider.

A client is scheduled for a flexible sigmoidoscopy. Which preparation will the nurse instruct the client to complete before the procedure? Administer tap water enemas until liquid from rectum is clear. Take oral laxatives for 2 days before the procedure. Maintain liquid diet for 3 days before the procedure. Avoid aspirin products a week before the procedure.

Administer tap water enemas until liquid from rectum is clear

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects the client's stools to have which description? Bright red Clay-colored Coffee-ground-like Black and tarry

Black and tarry Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes on the blood. Vomitus associated with upper GI tract bleeding commonly is described as coffee-ground-like. Clay-colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract bleeding.

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects the client's stools to have which description? Clay-colored Black and tarry Coffee-ground-like Bright red

Black and tarry Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes on the blood. Vomitus associated with upper GI tract bleeding commonly is described as coffee-ground-like. Clay-colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract bleeding.

A client reports a history of bleeding hemorrhoids to the nurse. Which observation supports the client's statement? Black tarry stool Hard, dry stool Blood streaks on stool Dark red stool

Blood streaks on stool

Which of the following would a nurse expect to assess in a client with peritonitis? Deep slow respirations Board-like abdomen Decreased pulse rate Hyperactive bowel sounds

Board-like abdomen

Which of the following would a nurse expect to assess in a client with peritonitis? Hyperactive bowel sounds Board-like abdomen Deep slow respirations Decreased pulse rate

Board-like abdomen

Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis? Chancre Lichen planus Leukoplakia Actinic cheilitis

Chancre

A client is at risk for emphysema. When reviewing information about the condition with the client, which would the nurse emphasize as the most important risk factor for emphysema? Infectious agents Cigarette smoking Air pollution Allergens

Cigarette smoking

A young adult with cystic fibrosis is admitted to the hospital for an acute airway exacerbation. Aggressive treatment is indicated. What is the first action by the nurse? Collects sputum for culture and sensitivity Gives oral pancreatic enzymes with meals Administers vancomycin intravenously Provides nebulized tobramycin (TOBI)

Collects sputum for culture and sensitivity Aggressive therapy for cystic fibrosis involves airway clearance and antibiotics, such as vancomycin and tobramycin, which will be prescribed based on sputum cultures. Sputum must be obtained prior to antibiotic therapy so results will not be skewed. Administering oral pancreatic enzymes with meals will be a lesser priority.

The nurse is providing preoperative care for a client with gastric cancer who is having a resection. What is the nursing management priority for this client? Teaching about radiation treatment Correcting nutritional deficits Preventing deep vein thrombosis (DVT) Discharge planning

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

What information should the nurse include in the teaching plan for a client being treated for diverticulosis? Avoid unprocessed bran in the diet Use laxatives or enemas at least once a week Drink at least 8 to 10 large glasses of fluid every day Avoid daily exercise; indulge only in mild activity

Drink at least 8 to 10 large glasses of fluid every day

Cancer of the esophagus is most often diagnosed by which of the following? X-ray Barium swallow Esophagogastroduodenoscopy (EGD) with biopsy and brushings Fluoroscopy

Esophagogastroduodenoscopy (EGD) with biopsy and brushings

The nurse has instructed the client to use a peak flow meter. The nurse evaluates client learning as satisfactory when the client Records in a diary the number achieved after one breath Inhales deeply and holds the breath Exhales hard and fast with a single blow Sits in a straight-back chair and leans forward

Exhales hard and fast with a single blow

The nurse assesses a patient who recently had a nasoenteric intubation. Symptoms of oliguria, lethargy, and tachycardia in the patient would indicate to the nurse what common complication? Fluid volume deficit A cardiac dysrhythmia Mucous membrane irritation Pulmonary complications

Fluid volume deficit Symptoms of fluid volume deficit include dry skin and mucous membranes, decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate.

A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate? Gastroesophageal reflux disease Esophageal cancer Peptic ulcer disease Diverticulitis

Gastroesophageal reflux disease

Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the: The patient cannot experience the deprivational stress of not swallowing. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. Digestive process occurs more rapidly as a result of the feedings not having to pass through the esophagus. Feedings can be administered with the patient in the recumbent position.

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration.

The following appears on the medical record of a male patient receiving parenteral nutrition: WBC: 6500/cu mm Potassium 4.3 mEq/L Magnesium 2.0 mg/dL Calcium 8.8 mg/dL Glucose 190 mg/dL Which finding would alert the nurse to a problem? Glucose level White blood cell count Potassium level Magnesium level

Glucose level hyperglycemia is a potential complication of parenteral nutrition

A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, labored breathing, and appears to be confused. Which complication has the client most likely developed? Penetration Pyloric obstruction Perforation Hemorrhage

Hemorrhage

The nurse is cautiously assessing a client admitted with peptic ulcer disease because the most common complication that occurs in 10% to 20% of clients is: Intractable ulcer Pyloric obstruction Perforation Hemorrhage

Hemorrhage Hemorrhage, the most common complication, occurs in 10% to 20% of clients with peptic ulcers. Bleeding may be manifested by hematemesis or melena. Perforation is erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. Intractable ulcer refers to one that is hard to treat, relieve, or cure. Pyloric obstruction, also called gastric outlet obstruction (GOO), occurs when the area distal to the pyloric sphincter becomes scarred and stenosed from spasm or edema or from scar tissue that forms when an ulcer alternately heals and breaks down.

A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, labored breathing, and appears to be confused. Which complication has the client most likely developed? Pyloric obstruction Penetration Hemorrhage Perforation

Hemorrhage Signs of hemorrhage following surgery include cool skin, confusion, increased heart rate, labored breathing, and blood in the stool. Signs of penetration and perforation are severe abdominal pain, rigid and tender abdomen, vomiting, elevated temperature, and increased heart rate. Indicators of pyloric obstruction are nausea, vomiting, distended abdomen, and abdominal pain.

A client diagnosed with asthma is preparing for discharge. The nurse is educating the client on the proper use of a peak flow meter. The nurse instructs the client to complete which action? Move the indicator to the top of the numbered scale. Sit down while completing a peak flow reading. Take and record peak flow readings three times daily. If coughing occurs during the procedure, repeat it.

If coughing occurs during the procedure, repeat it.

A client is reporting problems with constipation. What dietary suggestion can the nurse inform the client may help facilitate the passage of stool? Increase dietary fiber. Increase the carbohydrate content of the diet. Increase dietary protein such as lean meats. Increase dietary fat consumption.

Increase dietary fiber.

Gastrin has which of the following effects on gastrointestinal (GI) motility? Contraction of the ileocecal sphincter Relaxation of gastroesophageal sphincter Increased motility of the stomach Relaxation of the colon

Increased motility of the stomach

Gastrin has which of the following effects on gastrointestinal (GI) motility? Contraction of the ileocecal sphincter Relaxation of gastroesophageal sphincter Relaxation of the colon Increased motility of the stomach

Increased motility of the stomach

Which measure may increase complications for a client with COPD? Administration of antibiotics Administration of antitussive agents Decreased oxygen supply Increased oxygen supply

Increased oxygen supply

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, what would the nurse stress the importance of? Wearing an appliance pouch only at bedtime Consuming a low-protein, high-fiber diet Increasing fluid intake to prevent dehydration Taking only enteric-coated medications

Increasing fluid intake to prevent dehydration Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The nurse should teach the client to wear a collection appliance at all times because ileostomy drainage is incontinent, to avoid high-fiber foods because they may irritate the intestines, and to avoid enteric-coated medications because the body can't absorb them after an ileostomy.

A nursing student understands the importance of the psychosocial aspects of disease processes. When working with a patient with COPD, the student would rank which of the following nursing diagnoses as the MOST important when analyzing the psychosocial effects? Activity intolerance related to fatigue Disturbed sleep pattern related to cough High risk for ineffective therapeutic regimen management related to lack of knowledge Ineffective coping related to anxiety

Ineffective coping related to anxiety

A nursing student is taking a pathophysiology examination. Which of the following factors would the student correctly identify as contributing to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Choose all that apply. Mucus secretions that block airways Decreased numbers of goblet cells Inflamed airways that obstruct airflow Dry airways that obstruct airflow Overinflated alveoli that impair gas exchange

Inflamed airways that obstruct airflow Mucus secretions that block airways Overinflated alveoli that impair gas exchange

Which of the following is the key underlying feature of asthma? Chest tightness Productive cough Shortness of breath Inflammation

Inflammation

A nursing student is caring for a client with gastritis. Which of the following would the student recognize as a common cause of gastritis? Choose all that apply. Ingestion of strong acids DASH diet Irritating foods Overuse of aspirin Participation in highly competitive sports

Ingestion of strong acids Irritating foods Overuse of aspirin Acute gastritis is often caused by dietary indiscretion-a person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, and radiation therapy. A more severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. A DASH diet is an acronym for Dietary Approaches to Stop Hypertension, which would not cause gastritis. Participation in competitive sports also would not cause gastritis.

When assisting with the plan of care for a client receiving tube feedings, which of the following would the nurse include to reduce the client's risk for aspiration? Administering 15 to 30 mL of water every 4 hours. Keeping the client in a semi-Fowler's position at all times. Aspirating for residual contents every 4 to 8 hours. Giving the feedings at room temperature.

Keeping the client in a semi-Fowler's position at all times. With continuous tube feedings, the nurse needs to keep the client in a semi-Fowler's position at all times to reduce regurgitation and the risk for aspiration. Aspirating for residual contents helps to ensure adequate nutrition and prevent overfeeding. Administering 15 to 30 mL of water every 4 hours helps to maintain tube patency. Giving the feedings at room temperature reduces the risk for diarrhea.

While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure? Sigmoid colon Spleen Liver Appendix

Liver

Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following? Low protein Iron restriction Low residue Calorie restriction

Low residue Oral fluids and a low-residue, high-protein, high-calorie diet with supplemental vitamin therapy and iron replacement are prescribed to meet the nutritional needs, reduce inflammation, and control pain and diarrhea.

What part of the GI tract begins the digestion of food? Esophagus Mouth Stomach Duodenum

Mouth Food that contains starch undergoes partial digestion in the mouth when it mixes with the enzyme salivary amylase, which the salivary glands secrete. Food that contains starch undergoes partial digestion in the mouth.

The nurse is working with clients with digestive tract disorders. Which of the following organs does the nurse realize has effects as an exocrine gland and an endocrine gland? Gallbladder Stomach Liver Pancreas

Pancreas

The nurse is conducting a community education class on gastritis. The nurse includes that chronic gastritis caused by Helicobacter pylori is implicated in which disease/condition? Systemic infection Pernicious anemia Colostomy Peptic ulcers

Peptic ulcers

A client is in the hospital for the treatment of peptic ulcer disease. The client reports vomiting and a sudden severe pain in the abdomen. The nurse then assesses a board-like abdomen. What does the nurse suspect these symptoms indicate? Perforation of the peptic ulcer A reaction to the medication given for the ulcer Ineffective treatment for the peptic ulcer Gastric penetration

Perforation of the peptic ulcer

A client with a diagnosis of acute appendicitis is awaiting surgical intervention. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and board-like. What complication does the nurse determine may be occurring at this time? Peritonitis Accumulation of gas Constipation Paralytic ileus

Peritonitis Lack of bowel motility typically accompanies peritonitis. The abdomen feels rigid and board-like as it distends with gas and intestinal contents. Bowel sounds typically are absent. The diagnosis of acute appendicitis correlates with the symptoms of rupture of the appendix and peritonitis. A paralytic ileus and gas alone do not produce these symptoms.

A nurse is interviewing a client about past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer? Weight gain Duodenal ulcers Hemorrhoids Polyps

Polyps Colorectal polyps are common with colon cancer. Duodenal ulcers and hemorrhoids aren't preexisting conditions of colorectal cancer. Weight loss — not gain — is an indication of colorectal cancer.

A client is scheduled for a barium enema later in the day. Which actions will the nurse take to prepare the client on the morning of the test? Select all that apply. Administer anti-anxiety medication before the test Give only oral laxatives Provide a low-residue breakfast Maintain nothing by mouth until after the test Provide cleansing enemas until clear

Provide cleansing enemas until clear Maintain nothing by mouth until after the test

Which of the following is the most successful treatment for gastric cancer? Chemotherapy Palliation Removal of the tumor Radiation

Removal of the tumor There is no successful treatment for gastric carcinoma except removal of the tumor. If the tumor can be removed while it is still localized to the stomach, the patient may be cured. If the tumor has spread beyond the area that can be excised, cure is less likely.

The nurse observes the physician palpating the abdomen of a client that is suspected of having acute appendicitis. When the abdomen is pressed in the left lower quadrant the client complains of pain on the right side. What does the nurse understand this assessment technique is referred to? Rebound pain Rovsing sign Cremasteric reflex Referred pain

Rovsing sign

A client is admitted with a gastrointestinal bleed. What client symptom may indicate a peptic ulcer perforation to the nurse? Soft abdomen Bradycardia Sudden, severe upper abdominal pain Hypertension

Sudden, severe upper abdominal pain

A client who has undergone colostomy surgery is experiencing constipation. Which intervention should a nurse consider for such a client? Instruct the client to avoid prune or apple juice Instruct the client to keep a record of food intake Suggest fluid intake of at least 2 L/day Assist the client regarding the correct diet or to minimize food intake

Suggest fluid intake of at least 2 L/day The nurse should suggest a fluid intake of at least 2 L/day to help the client avoid constipation. The nurse should also offer prune or apple juice because they promote elimination. The nurse should encourage the client to eat regular meals. Dieting or fasting can decrease stool volume and slow elimination. The nurse should instruct the client to keep a record of food intake in case of diarrhea, because this helps identify specific foods that irritate the gastrointestinal tract.

A client who has undergone colostomy surgery is experiencing constipation. Which intervention should a nurse consider for such a client? Instruct the client to keep a record of food intake Assist the client regarding the correct diet or to minimize food intake Suggest fluid intake of at least 2 L/day Instruct the client to avoid prune or apple juice

Suggest fluid intake of at least 2 L/day The nurse should suggest a fluid intake of at least 2 L/day to help the client avoid constipation. The nurse should also offer prune or apple juice because they promote elimination. The nurse should encourage the client to eat regular meals. Dieting or fasting can decrease stool volume and slow elimination. The nurse should instruct the client to keep a record of food intake in case of diarrhea, because this helps identify specific foods that irritate the gastrointestinal tract.

The nurse is preparing to examine the abdomen of a client who reports a change in bowel pattern. The nurse would place the client in which position? Knee-chest Lithotomy Left Sim's lateral Supine with knees flexed

Supine with knees flexed When examining the abdomen, the client lies supine with knees flexed. This position assists in relaxing the abdominal muscles. The lithotomy position commonly is used for a female pelvic examination and to examine the rectum. The knee-chest position can be used for a variety of examinations, most commonly the anus and rectum. The left Sim's lateral position may be used to assess the rectum or vagina and to administer an enema.

A client has been diagnosed with Zenker's diverticulum. What treatment does the nurse include in the client education? Surgical removal of the diverticulum A low-residue diet Chemotherapeutic agents Radiation therapy

Surgical removal of the diverticulum

Specific disease processes and ingestion of certain foods and medications may change the appearance of the stool. If blood is shed in sufficient quantities into the upper gastrointestinal (GI) tract, it produces which change in the stool appearance? Tarry-black Bright red Blood-streaked Dark brown

Tarry-black

A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor? The client may eat a light meal before either test. The ultrasonography should be scheduled before the GI procedure. Both tests need to be done before breakfast. The upper GI should be scheduled before the ultrasonography.

The ultrasonography should be scheduled before the GI procedure.

The nurse is assigned to care for a patient in the ICU who is diagnosed with status asthmaticus. Why does the nurse include fluid intake as being an important aspect of the plan of care? (Select all that apply.) To relieve bronchospasm To facilitate expectoration To combat dehydration To loosen secretions To assist with the effectiveness of the corticosteroids

To loosen secretions To facilitate expectoration To combat dehydration

A client is demonstrating symptoms of a tumor in the small bowel. About which diagnostic test will the nurse anticipate teaching the client? Ultrasound of the abdomen Upper GI series with small bowel follow-through Abdominal flat plate x-ray Barium enema

Upper GI series with small bowel follow-through

The nurse is assessing a client for constipation. Which review should the nurse conduct first to identify the cause of constipation? Activity levels Current medications Usual pattern of elimination Alcohol consumption

Usual pattern of elimination Constipation has many possible causes and assessing the client's usual pattern of elimination is the first step in identifying the cause. The nurse should obtain a description of the bowel elimination pattern, asking about the frequency, overall appearance and consistency of stool, blood in the stool, pain, and effort necessary to pass stool. It is also essential for the nurse to review the client's current medications, diet, and activity levels.

A client is admitted to the emergency department with reports right lower quadrant pain. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the health care provider immediately? White blood cell (WBC) count 22.8/mm3 Hematocrit 42% Serum sodium 135 mEq/L Serum potassium 4.2 mEq/L

White blood cell (WBC) count 22.8/mm3

The nurse prepares a client for a barium enema. The nurse should place the client on which diet prior to the procedure? nothing by mouth (NPO) 2 days prior soft diet 1 day prior high-fiber diet 1 to 2 days prior clear liquids day before

clear liquids day before The nurse should place the client on clear liquids the evening before the procedure, a low-residue diet 1 to 2 days before the test, and NPO at midnight in preparation for the barium enema.

A nurse providing care to a patient who is receiving nasogastric tube feedings finds that the tube is clogged. Which of the following is no longer considered appropriate to use to unclog the tube? Cranberry juice Air insufflation Digestive enzyme mixed with warm water Commercial enzyme product

cranberry juice

A client reports severe pain and bleeding while having a bowel movement. Upon inspection, the health care provider notes a linear tear in the anal canal tissue. The client is diagnosed with a: hemorrhoid. fissure. pilonidal cyst. fistula.

fissure. An anal fissure (fissure in ano) is a linear tear in the anal canal tissue. An anal fistula (fistula in ano) is a tract that forms in the anal canal. Hemorrhoids are dilated veins outside or inside the anal sphincter. A pilonidal sinus is an infection in the hair follicles in the sacrococcygeal area above the anus.

The nurse determines one or two bowel sounds in 2 minutes should be documented as normal. hypoactive. absent. hyperactive.

hypoactive Hypoactive bowel sound is the description given to auscultation of one to two bowel sounds in 2 minutes. Normal bowel sounds are heard every 5 to 20 seconds. Hyperactive bowel sounds occur when 5 or 6 sounds are heard in less than 30 seconds. The nurse records that bowel sounds are absent when no sound is heard in 3 to 5 minutes.

A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should: instruct the client to drink at least 2 L of fluid daily. administer anxiolytics, as ordered, to control anxiety. administer pain medication as ordered. maintain the client on bed rest.

instruct the client to drink at least 2 L of fluid daily.

The nurse teaches an unlicensed caregiver about bathing clients who are receiving tube feedings. The most significant complication related to continuous tube feedings is the disturbance in the sequence of intestinal and hepatic metabolism. interruption in fat metabolism and lipoprotein synthesis. potential risk for aspiration. interruption of GI integrity.

potential risk for aspiration. Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the client receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis.

An older adult client in a long-term care facility is concerned about bowel regularity. During a client education session, the nurse reinforces the medically acceptable definition of "regularity." What is the actual measurement of "regular"? two bowel movements daily one bowel movement daily stool consistency and client comfort one bowel movement every other day

stool consistency and client comfort

A client has received a diagnosis of oral cancer. During client education, the client expresses dismay at not having recognized any early signs or symptoms of the disease. The nurse tells the client that in early stages of this disease: symptoms include oral bleeding. symptoms include mouth pain. there are usually no symptoms. symptoms include oral numbness.

there are usually no symptoms.

The client describes a test previously completed to detect a small bowel obstruction prior to admission to the hospital. The client states that the test involved insertion of a tube through the nose and lasted over 6 hours. The nurse determines which test name should be documented? abdominal ultrasound upper GI enteroclysis magnetic resonance imaging positron emission tomography

upper GI enteroclysis

A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when he: wants the head of the bed raised to a 90-degree level. sits in tripod position. uses the sternocleidomastoid muscles. has a pulse oximetry reading of 93%.

uses the sternocleidomastoid muscles.