exam 5 GI Iggy ch 48-55

Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit? A. A 40 year old who needs administration of IV midazolam hydrochloride during an upper endoscopy. B. A 36 year old who needs teaching about an endoscopic retrograde cholangiopancreatography. C. A 46 year old who is admitted with abdominal cramping and diarrhea of unknown causes. D. A 32 year old with constipation who has received a laxative.

A 32 year old with constipation who has received a laxative. The LPN/LVN can best assist the RN by monitoring the client with constipation who has received a laxative.Assessment, IV hypnotic medication administration, and client teaching must be done by an RN.

A male client with a long history of ulcerative colitis experienced massive bleeding and had emergency surgery for creation of an ileostomy. He is very concerned that sexual intercourse with his wife will be impossible because of his new ileostomy pouch. How would the nurse respond? A. "A change in position may be what is needed for you to have intercourse with your wife." B. "You must get clearance from your primary health care provider before you attempt to have intercourse." C. "What has your wife said about your pouch system?" D. "Have you considered going to see a marriage counselor with your wife?"

A. "A change in position may be what is needed for you to have intercourse with your wife." The nurse tells the client who had an emergency ileostomy that a simple change in positioning during intercourse may alleviate apprehension and facilitate sexual relations with his wife. Suggesting marriage counseling may address the client's concerns, but it focuses on the wrong issue. The client has not stated that he has relationship problems. Asking the client what his wife has said about the pouch may address some of the client's concerns, but it similarly focuses on the wrong issue.

The nurse is teaching a family how to prevent the client's transmission of gastroenteritis at home. Which instructions will the nurse include in the health teaching? (Select all that apply.) A. "Clean and disinfect all bathrooms often to avoid stool exposure." b. "Everyone in the home should wash their hands for at least 30 seconds with an antibacterial soap using friction." C. "Contact the primary health care provider if GI symptoms last more than 3 days." D. "Wear a mask at home to prevent transmission of the disease." E. "Do not share dishes, glasses, and silverware among members of the family."

A. "Clean and disinfect all bathrooms often to avoid stool exposure." b. "Everyone in the home should wash their hands for at least 30 seconds with an antibacterial soap using friction." C. "Contact the primary health care provider if GI symptoms last more than 3 days." E. "Do not share dishes, glasses, and silverware among members of the family." All of these interventions are important to prevent the spread of gastroenteritis except there is no need to wear a mask because the disease is spread via the fecal-oral route rather than by droplets.

The nurse is teaching a group of clients on the complications of obesity that develop when weight is not controlled through diet and exercise. Which lifestyle change does the nurse emphasize? (Select all that apply.) A. "Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." B. "Begin a weight-training program for building muscle mass." C. "Liquid dietary supplements can be substituted safely for solid food." D. "Engage in moderate physical activity for at least 30 minutes each day." E. "Foods eaten away from home tend to be higher in fat than foods made at home." F. "Eat a variety of foods, especially grain products, vegetables, and fruits."

A. "Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." D. "Engage in moderate physical activity for at least 30 minutes each day." E. "Foods eaten away from home tend to be higher in fat than foods made at home." F. "Eat a variety of foods, especially grain products, vegetables, and fruits." Lifestyle changes the nurse emphasizes include consuming a diet that is moderate in salt and sugar and low in fats and cholesterol, and moderate physical activity for at least 30 minutes each day. Eating a variety of foods, especially grain products, vegetables, and fruits, helps people achieve weight loss. These are foods that "burn" more calories as they are metabolized. Many foods eaten away from home tend to be higher in fat than foods prepared at home.A weight-training program for building muscle mass does not need to be included in a weight loss program. Muscle weighs more and tends to increase weight in people who weight-train. Liquid dietary supplements cannot safely be substituted for solid food while attempting to lose weight. These types of liquid diets should be carefully supervised by a health care provider with special education in weight management.

The nurse is caring for a client who has been diagnosed with esophageal cancer. The client appears anxious, and asks the nurse, "Does this mean I am going to die?". Which nursing response is appropriate? (Select all that apply.) A. "Let me sit with you for awhile and we can discuss how you are feeling about this." B. "You can beat this disease if you just put your mind to it." C. "No, surgery can cure you." D. "It sounds like death frightens you." E. "Let me call the hospital chaplain to talk with you."

A. "Let me sit with you for awhile and we can discuss how you are feeling about this." D. "It sounds like death frightens you." Acknowledging that death may frighten the client, and offering to talk about how the client is feeling, are therapeutic nursing interventions. Telling the client that surgery is curative, and promising the client can beat the disease, are nontherapeutic responses that provide false hope. Although talking with the chaplain at a later time may be requested by the client, the immediate need is to allow the client to express feelings to the nurse.

The family of a client who has hepatic encephalopathy asks why the client is restricted to moderate amounts of dietary protein and has to take lactulose. What is an appropriate response by the nurse? A. "These interventions help to reduce the ammonia level." B. "These interventions help to prevent heart failure." C. "These interventions help the client's jaundice improve." D. "These interventions help to prevent nausea and vomiting."

A. "These interventions help to reduce the ammonia level." The client's high ammonia level has caused encephalopathy which can become so severe that it causes death. These interventions help to reduce ammonia in the body so that this condition does not worsen.

The nurse is performing a health assessment on a client with obesity who states, "I have tried many diets in an effort to lose weight, but have been unsuccessful." How does the nurse assess whether the client's response to stress is related to the client's obesity? A. "What do you usually do that helps to relieve stress?" B. "What is it about your size that causes you to feel uncomfortable?" C. "Do you usually use alcohol or drugs when you feel stressed?" D. "Do you have a history of mental health concerns?"

A. "What do you usually do that helps to relieve stress?" The appropriate way to assess the client's response to stress is to ask an open-ended type of question because it cannot be answered with a "yes" or "no." From that answer, the nurse can better determine if the client eats in response to stress. Asking the client about mental health problems may cause the client to feel uncomfortable with the assessment and shut down. This subject can be more gently introduced later, if needed, based on the nurse's initial assessment. More effective methods can be used to determine the client's alcohol and drug habits. Having the client tell you what makes him or her uncomfortable about size will only cause the client to restate the obvious. It does not determine the effect that stress has on the client.

While working in the outpatient procedure unit, the RN is assigned to four clients. Which client will the nurse assess first? A. A 51 year old who just had an endoscopic retrograde cholangiopancreatography (ERCP). B. A 58 year old who has just arrived for a sigmoidoscopy. C. A 60 year old with questions about an endoscopic ultrasound examination. D. A 54 year old who is ready for discharge following a colonoscopy.

A. A 51 year old who just had an endoscopic retrograde cholangiopancreatography (ERCP). ERCP requires conscious sedation, so the client needs immediate assessment of respiratory and cardiovascular status. The endoscopic procedure and nursing care for a client having an ERCP are similar to those for the EGD procedure, except that the endoscope is advanced farther into the duodenum and into the biliary tract. A 54-year-old client being discharged after a colonoscopy, a 58-year-old client who is going to have a sigmoidoscopy, and a 60-year-old client with questions about an endoscopic ultrasound examination are not at risk for depressed respiratory status. They can all be seen following the client who just had an ERCP.

An RN receives the change-of-shift report about these four clients. Which client will the nurse assess first? A. A 75 year old with dementia on nasogastric feedings with a respiratory rate of 38 breaths/min B. A 50 year old receiving total parenteral nutrition (TPN) with a blood glucose (BG) level of 300 mg/dL (16.7 mmol/L) C. A 30 year old admitted 2 hours ago with malnutrition associated with malabsorption syndrome D. A 45 year old who had gastric bypass surgery and is reporting severe incisional pain

A. A 75 year old with dementia on nasogastric feedings with a respiratory rate of 38 breaths/min The nurse first assesses the client with dementia who has a respiratory rate of 38 breaths/min. This client needs immediate respiratory assessment and interventions. Aspiration is a major complication in clients receiving tube feedings, especially in clients with an altered level of consciousness. The client with malnutrition associated with malabsorption syndrome, the client with incisional pain from gastric bypass surgery, and the client receiving TPN with a BG of 300 mg/dL (16.7 mmol/L) all need assessments and/or interventions by the RN, but maintaining respiratory function in the client with tachypnea is the highest priority.

The nurse is instructing a client with recently diagnosed diverticular disease about diet. What food does the nurse suggest the client include? A. A slice of 5-grain bread B. Strawberries (1 cup [160 g]) C. Tomato (1 medium) D. Chuck steak patty (6 ounces [170 g])

A. A slice of 5-grain bread The nurse suggests to the client with recently diagnosed diverticular disease to include a slice of 5-grain bread in the diet. Whole-grain breads are recommended to be included in the diet of clients with diverticular disease because cellulose and hemicellulose types of fiber are found in them. Dietary fat would be reduced in clients with diverticular disease. If the client wants to eat beef, it must be of a leaner cut. Foods containing seeds, such as strawberries, must be avoided. Tomatoes would also be avoided unless the seeds are removed. The seeds may block diverticula in the patient and present problems leading to diverticulitis.

The nurse is assessing an alert client who had abdominal surgery yesterday. Which assessment method will the nurse use to most accurately determine whether peristalsis has resumed? A. Ask if the client has passed flatus (gas) within the previous 12 to 24 hours. B. Perform auscultation with the diaphragm of the stethoscope. C. Listen for bowel sounds in all abdominal quadrants. D. Count the number of bowel sounds in each abdominal quadrant over 1 minute.

A. Ask if the client has passed flatus (gas) within the previous 12 to 24 hours. The best and most reliable method for assessing the return of peristalsis following abdominal surgery is the client's report of passing flatus within the past 8 hours or stool within the past 12 hours. Although auscultation and counting the number of sounds can help to assess for bowel activity, it is not the most reliable method.

The nurse is caring for a client who had a Whipple surgical procedure yesterday. For what serum laboratory test results would the nurse want to monitor frequently and carefully? A. Blood glucose B. Blood urea nitrogen C. Phosphorus D. Platelet count

A. Blood glucose During a Whipple procedure, most or all of the pancreas is manipulated, stressed, and possibly removed. Therefore, the client is at risk for hyperglycemia or hypoglycemia and blood glucose would need careful monitoring with a possible need for treatment.

A client with ulcerative colitis (UC) is prescribed sulfasalazine and corticosteroid therapy. As the disease improves, what change does the nurse expect in the client's medication regimen? A. Corticosteroid therapy will be tapered. B. Corticosteroid therapy will be stopped. C. Sulfasalazine will be stopped. D. Sulfasalazine will be tapered.

A. Corticosteroid therapy will be tapered. The nurse expects that corticosteroid therapy will be tapered as the UC improves in the client who was taking both sulfasalazine and corticosteroids. Once clinical improvement has been established, corticosteroids are tapered over a 2- to 3-month period.Stopping corticosteroid therapy abruptly is unsafe—steroids must be gradually decreased in patients. Usually the amount that they have been taking dictates how quickly or slowly they can be stopped. Sulfasalazine therapy will be taken on a long-term basis. It may be increased or decreased, depending on the patient's symptoms, but will likely never be stopped. These decisions are made over a long period of therapy.

While undergoing radiation treatment for oral cancer, a client develops xerostomia. What collaborative resource does the nurse suggest for this client's care? A. Dentist B. Occupational therapist C. Speech therapist D. Psychiatrist

A. Dentist Xerostomia is the subjective feeling of oral dryness. It is a long-term effect of radiation therapy and requires ongoing oral care such as the use of saliva substitutes and follow-up dental visits. Occupational therapists, psychiatrists, and speech therapists are not the appropriate resource for a client with xerostomia.

The nurse is reviewing laboratory results of a client recently admitted with a diagnosis of acute pancreatitis. Which values would the nurse expect to be elevated? (Select all that apply.) A. Elastase B. Amylase C. Glucose D. Lipase E. Trypsin F. Calcium

A. Elastase B. Amylase C. Glucose D. Lipase E. Trypsin The client who has acute pancreatitis experiences elevation of all pancreatic enzymes and glucose. The serum calcium level is usually decreased (rather than elevated) because the release of fatty acids combined with available calcium.

When caring for a client with portal hypertension, the nurse assesses for which potential complications? (Select all that apply.) A. Esophageal varices B. Ascites C. Hematuria D. Hemorrhoids E. Fever

A. Esophageal varices B. Ascites D. Hemorrhoids Potential complications of portal hypertension include esophageal varices, ascites, and hemorrhoids. Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid).Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.

The nurse is caring for a client with peptic ulcer disease who has been vomiting profusely at home before coming to the emergency department. For which vital sign change will the nurse expect for this client? A. Hypotension B. Tachypnea C. Oxygen desaturation D. Bradycardia

A. Hypotension The client who is vomiting profusely is losing fluids from the body causing dehydration. A client who is dehydrated has hypovolemia resulting in hypotension and tachycardia.

The nurse is caring for a client who has been diagnosed with cirrhosis. Which laboratory result(s) would the nurse expect for this client? (Select all that apply.) A. Increased serum bilirubin B. Increased lactate dehydrogenase C. Decreased serum albumin D. Increased serum alanine aminotransferase E. Increased aspartate aminotransferase F. Increased serum ammonia

A. Increased serum bilirubin B. Increased lactate dehydrogenase C. Decreased serum albumin D. Increased serum alanine aminotransferase E. Increased aspartate aminotransferase F. Increased serum ammonia Cirrhosis is a chronic disease in which the liver progressively degenerates. As a result, liver enzymes and bilirubin increase. Additionally, the liver is unable to synthesize protein leading to decreased serum albumin. Elevated serum ammonia results from the inability of the liver to detoxify protein by-products.

A client with obesity has been taking orlistat as prescribed for 4 weeks but has only lost 10 lb (4.5 kg). The health care provider doubles the dosage and asks the nurse to provide further teaching. What behavioral change does the nurse include in the teaching plan? (Select all that apply.) A. Keep a daily food diary. B. Set daily reasonable goals for eating. C. Increase exercise. D. Identify emotional and situational factors that stimulate eating. E. Identify a healthy individual that can be role-modeled.

A. Keep a daily food diary. B. Set daily reasonable goals for eating. C. Increase exercise. D. Identify emotional and situational factors that stimulate eating. Techniques the nurse includes in the teaching plan are keeping a record of foods eaten (food diary) (to look at daily trends), identifying emotional and situational factors that stimulate eating (which can be modified after identification), and increasing exercise (to burn calories). Setting daily reasonable goals helps the client focus on how to be healthy now instead of setting unreasonable future goals that cause the client to give up if not quickly achieved.The client should not look to role-model other people, as what works for them may not work for the client. The client should focus on his or her own behaviors in order to identify trends and make reasonable changes.

The nurse is caring for a client who recently had an external percutaneous transhepatic biliary catheter placed for severe biliary obstruction. What is the nurse's priority intervention when caring for this client? A. Keeping the biliary drainage bag below the level of the catheter-insertion site B. Checking the client's blood glucose frequently to monitor for diabetes C. Managing pain with continuous opioid patient-controlled analgesia (PCA) D. Capping the catheter if it starts to leak around the insertion site

A. Keeping the biliary drainage bag below the level of the catheter-insertion site The client who has an external percutaneous transhepatic biliary catheter drains by gravity and therefore needs to have the drainage bag placed lower that the catheter-insertion site. The catheter is not capped if jaundice or leakage around the catheter site occurs. Opioids are not needed while the client has the catheter; however, if it is in place for an extended period of time, it needs to be changed.

The nurse is reviewing medications that can be used for female clients who have constipation-predominant irritable bowel syndrome (IBS). Which drugs are available for this health problem? (Select all that apply.) A. Lubiprostone B. Cetuximab C. 5-fluorouracil D. Psyllium hydrophilic mucilloid E. Linaclotide

A. Lubiprostone D. Psyllium hydrophilic mucilloid E. Linaclotide Cetuximab and 5-fluorouracil are chemotherapeutic drugs used for clients who have colorectal cancer. The other drugs are available for female clients who have constipation-predominant IBS.

Which nursing care activity for an undernourished client does the nurse safely delegate to an assistive personnel (AP)? A. Measuring current height and weight B. Determining body mass index (BMI) C. Estimating body fat using skinfold measurements D. Completing the Mini Nutritional Assessment

A. Measuring current height and weight Determining height and weight is the only activity that the nurse can safely delegated to an AP. The nurse is responsible for completing the Mini Nutritional Assessment, determining the client's BMI, and estimating body fat using skinfold measurements, as these assessments fall within the scope of practice of a registered nurse.

The nurse is caring for a client who was recently diagnosed with Helicobacter pylori infection. Which drugs does the nurse and anticipate would be used for this client to manage the infection? (Select all that apply.) A. Metronidazole B. Lansoprazole C. Azithromycin D. Tetracycline E. Hydroxychloroquine

A. Metronidazole B. Lansoprazole D. Tetracycline Most clients who have this type of infection are prescribed to take a proton pump inhibitor, such as lansoprazole, and two antimicrobial drugs, such as metronidazole and tetracycline. Clarithromycin and amoxicillin may be used as alternative antibiotics.

The nurse is teaching a client with a newly created colostomy about foods to limit or avoid because of flatulence or odors. Which foods should be avoided? (Select all that apply.) A. Mushrooms B. Peas C. Onions D. Broccoli E. Buttermilk F. Yogurt

A. Mushrooms B. Peas C. Onions D. Broccoli Foods the patient with a newly created colostomy needs to limit or avoid because of flatulence or odors include: broccoli, mushrooms, onions, and peas. Buttermilk will help prevent odors. Yogurt can help prevent flatus.

The nurse is caring for a client who states that her mother had "gallbladder problems" and wonders if she is at risk for this disorder. What major risk factor places women most at risk for gallbladder disease? A. Obesity B. Birth control pills C. Infertility D. Advanced age

A. Obesity Obese women who are middle age and have had multiple children are at the highest risk for gallbladder disease, although it can occur in anyone.

The nurse is caring for a client who reports stomach pain and heartburn. Which assessment finding is most significant suggesting the client's ulcer is duodenal and not gastric? A. Pain occurs 1½ to 3 hours after a meal, usually at night. B. The client is a man older than 50 years. C. Pain is worsened by the ingestion of food. D. The client has a malnourished appearance.

A. Pain occurs 1½ to 3 hours after a meal, usually at night. A key symptom of duodenal ulcers is that pain usually awakens the client between 1:00 a.m. and 2:00 a.m. (0100 and 0200) and occurs 1½ to 3 hours after a meal. Pain that is worsened with ingestion of food and a malnourished appearance are key features of gastric ulcers. A male over 50 years is a finding that could apply to either type of ulcer.

Which practice does the nurse include when teaching a client about proper oral hygiene? A. Perform self-examination of the mouth every week, and report any unusual findings. B. Brush the teeth daily and floss as needed. C. Wear dentures that fit a bit loosely for movement when chewing. D. Use mouthwash with alcohol unless lesions are present.

A. Perform self-examination of the mouth every week, and report any unusual findings. The nurse will teach the client that proper oral care involves self-examination of the mouth every week and to report any unusual findings to the Health Care Provider.Clients need to brush teeth and floss every day—not just as needed. Clients are taught to avoid contact with agents that may cause inflammation of the mouth (such as, alcohol-based mouthwashes). Dentures should fit snugly, not loosely.

A 67-year-old male client with no surgical history reports pain in the inguinal area that occurs when he coughs. A bulge that can be pushed back into the abdomen is found in his inguinal area. What type of hernia does he have? A. Reducible B. Strangulated C. Incarcerated D. Femoral

A. Reducible The hernia is reducible because its contents can be pushed back into the abdominal cavity. Femoral hernias tend to occur more frequently in obese and pregnant women. A hernia is considered to be strangulated when the blood supply to the herniated segment of the bowel is cut off. An incarcerated or irreducible hernia cannot be reduced or placed back into the abdominal cavity. Any hernia that is not reducible requires immediate surgical evaluation.

The nurse is teaching a client how to maintain effective oral health. Which measure does the nurse include in the teaching plan? (Select all that apply.) A. Regular dental checkups. B. Eating a balanced diet. C. Use of mouthwashes containing alcohol. D. Managing stress as much as possible. E. Ensuring that dentures are slightly loose-fitting.

A. Regular dental checkups. B. Eating a balanced diet. D. Managing stress as much as possible. Regular dental checkups are important, so potential problems can be prevented or attended to promptly. Stress suppresses the immune system, which can increase the client's risk for infections such as Candida albicans. Eating a balanced diet can reduce the risk for dental caries and infections such as C. albicans or stomatitis.Mouthwashes that contain alcohol may irritate tissues and cause inflammation, and should be avoided. Dentures must be in good repair and need to fit properly, not loosely.

A client is admitted to the emergency department with possible acute pancreatitis. What is the nurse's priority assessment at this time? A. Respiratory assessment B. Cardiovascular assessment C. Abdominal assessment D. Pain intensity assessment

A. Respiratory assessment As for any client, the nurse would want to continually assess for airway, breathing, and circulation. Clients who have acute pancreatitis often develop pleural infusions, atelectasis, or pneumonia. Necrotizing hemorrhagic pancreatitis places the client at risk for acute respiratory distress syndrome (ARDS).

When assessing a client with hepatitis B, the nurse anticipates which assessment findings? (Select all that apply.) A. Right upper quadrant tenderness B. Itching C. Recent influenza infection D. Brown stool E. Tea-colored urine

A. Right upper quadrant tenderness B. Itching E. Tea-colored urine Assessment findings the nurse expects to find in a client with hepatitis B include brown, tea-, or cola-colored urine; right upper quadrant pain due to inflammation of the liver; and itching, irritating skin caused by deposits of bilirubin on the skin secondary to high bilirubin levels and jaundice. Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored, not typically brown.

A client returns to the unit after having an exploratory abdominal laparotomy. How does the nurse position this client after being situated in bed? A. Semi-Fowler B. Lateral Sims' (side-lying) C. High Fowler D. Supine

A. Semi-Fowler The nurse places the postoperative abdominal laparotomy client in the semi-Fowler position in bed. The client is maintained in this position to facilitate the drainage of peritoneal contents into the lower region of the abdominal cavity after an abdominal laparotomy. This position also helps increase lung expansion.High-Fowler position would be too high for the client postoperatively. It would place strain on the abdominal incision(s), and, if the client was still drowsy from anesthesia, this position would not enhance the client's ability to rest. Sims' position does not promote drainage to the lower abdomen. The supine position does not facilitate drainage to the abdomen or increased lung expansion. The client would be more likely to develop complications (wound drainage stasis and atelectasis) in the supine position.

The nurse is caring for a client who has an enterocutaneous fistula. For what complications will the nurse monitor? (Select all that apply.) A. Skin breakdown B. Hyperkalemia C. Malnutrition D. Hypernatremia E. Dehydration F. Bowel obstruction

A. Skin breakdown C. Malnutrition E. Dehydration The client has an abnormal tunneling between the small intestines and the skin causing spillage of the GI contents onto the skin. Enzymes in the intestines can break down skin and underlying tissues. The intestinal contents are also rich in fluids and electrolytes, especially potassium, such that the client would likely develop hypokalemia rather than hyperkalemia. Loss of fluids could lead to dehydration if the client is not carefully monitored and managed.

The nurse teaches the client who has cirrhosis about foods and other substances that should be avoided to prevent worsening of the disease. Which substance(s) will the nurse include in that health teaching? (Select all that apply.) A. Smoking B. Alcohol C. Illicit drugs D. Acetaminophen E. Sodium E. Protein

A. Smoking B. Alcohol C. Illicit drugs D. Acetaminophen Protein and sodium should be moderately restricted but not completely avoided. The other substances can worsen the disease process, especially drugs and alcohol which are normally metabolized by the liver.

Which factor does the nurse identify that places a client at risk for gastrointestinal (GI) problems? (Select all that apply.) A. Smoking a half-pack of cigarettes per day B. Taking nonsteroidal anti-inflammatory drugs (NSAIDs) C. Financial concerns D. Eating a high-fiber diet E. Use of herbal preparations

A. Smoking a half-pack of cigarettes per day B. Taking nonsteroidal anti-inflammatory drugs (NSAIDs) C. Financial concerns E. Use of herbal preparations Smoking or any tobacco use places a client in a higher-risk category for GI problems. Financial concerns can also influence the risk for GI problems; clients may not be able to afford to seek care or treatment and may put off seeking help. Some herbal preparations contribute to GI problems, such as Ayurvedic herbs, which can affect appetite, absorption, and elimination. NSAIDs can predispose clients to peptic ulcer disease or GI bleeding.High-fiber diets are generally believed to be healthy for most clients.

A client who has undergone a bariatric surgical procedure is recuperating after surgery. Which nursing intervention most effectively prevents a client injury during repositioning? A. Using a weight-rated extra-wide bed for the client B. Administering pain medication C. Monitoring skinfold areas and keeping them clean and dry D. Making sure not to move the client's nasogastric (NG) tube

A. Using a weight-rated extra-wide bed for the client The most effective way to reposition a postoperative bariatric client and prevent injury is to use a special weight-related extra wide bed. This will allow adequate room for repositioning the client comfortably without causing the bed rails to touch his or her body, causing pressure and injury. Pain medication and monitoring skinfold areas will not prevent injury to the client that might occur during repositioning. Not moving the client's NG tube will prevent disruption of the suture line, but will not prevent repositioning injuries.

The nurse is preparing to instruct a client with chronic pancreatitis who is to begin taking pancrelipase. Which instruction does the nurse include when teaching the client about this medication? A. Wipe your lips after taking pancrelipase. B. Take pancrelipase before meals. C. Administer pancrelipase before taking an antacid. D. Chew tablets before swallowing.

A. Wipe your lips after taking pancrelipase. The nurse will instruct the client to wipe the lips after taking pancrelipase. Pancrelipase is a pancreatic enzyme used for enzyme replacement for clients with chronic pancreatitis. To avoid skin irritation and breakdown from residual enzymes, the lips should be wiped. Pancrelipase should be administered after, and not before, antacids or histamine2 blockers are taken. It should not be chewed to minimize oral irritation and allow the drug to be released more slowly. It should be taken with meals and snacks, and not before, and followed with a glass of water.

The nurse is teaching a group of clients with irritable bowel syndrome (IBS) about complementary and alternative therapies. What does the nurse suggest as possible treatment modalities? (Select all that apply.) A. Yoga B. Acupuncture C. Peppermint oil capsules D. Decreasing physical activities E. Meditation

A. Yoga B. Acupuncture C. Peppermint oil capsules E. Meditation Possible treatment modalities the nurse suggests for a client with IBS include: acupuncture, meditation, peppermint oil capsules, and yoga. Acupuncture is recommended as a complementary therapy for IBS. Meditation, yoga, and other relaxation techniques help many patients manage stress and their IBS symptoms. Research has shown that peppermint oil capsules may be effective in reducing symptoms of IBS. Regular exercise is important for managing stress and promoting bowel elimination.

The nurse is teaching a client with Crohn disease about managing the disease with the adalimumab Which instruction does the nurse emphasize to the client? A. "Do not take the medication if you are allergic to foods with fatty acids." B. "Avoid large crowds and anyone who is sick." C. "Monitor your blood pressure and report any significant decrease in it." D. "Expect difficulty with wound healing while you are taking this drug."

B. "Avoid large crowds and anyone who is sick." The nurse emphasizes that the client taking adalimumab for Crohn disease needs to avoid being around large crowds to prevent developing an infection. Adalimumab (Humira), a biological response modifier (BRM), also known as a monoclonal antibody drug, has been approved for use in Crohn disease when other drugs have been ineffective. BRMs are approved for refractory (not responsive to other therapies) cases. These drugs cause immunosuppression and should be used with caution. Clients must be taught to report any signs of a beginning infection, including a cold, and to also avoid others who are sick. The client would not take the medication if he or she is allergic to certain proteins. Although immune suppression may occur to some degree, the client would not experience difficulty with wound healing while taking adalimumab. Also, the client would not experience a decrease in blood pressure from taking this drug.

The nurse is teaching a client about dietary methods to help manage exacerbations (flare-ups) of diverticulitis. What does the nurse advise the client? A. "Maintain a high-fiber diet to prevent the development of hemorrhoids that frequently accompany this condition." B. "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." C. "Make sure you consume a high-fiber diet while diverticulitis is active. When inflammation resolves, consume a low-fiber diet." D. "Be sure to maintain an exclusively low-fiber diet to prevent pain on defecation."

B. "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." The nurse teaches the client that the most effective way to manage diverticulitis is to consume a low-fiber diet while inflammation is present, followed by a high-fiber diet once the inflammation has subsided. Neither an exclusively low-fiber diet nor an exclusively high-fiber diet will effectively manage diverticulitis. A high-fiber diet while diverticulitis is active will only worsen the disease and its symptoms.

The nurse is teaching a client with irritable bowel syndrome (IBS) who has frequent constipation. Which statement by the client shows an accurate understanding of the nurse's teaching? A. "Maintaining a low-fiber diet will manage my constipation." B. "I need to go for a walk every day if possible." C. "Limiting the amount of fluid that I drink with meals is very important." D. "A cup of caffeinated coffee with cream & sugar at dinner is OK for me."

B. "I need to go for a walk every day if possible." The client statement, "I need to go for a walk every evening," shows that the client accurately understands the nurse's teaching plan to treat IBS. Walking every day is an excellent exercise for promoting intestinal motility. Increased ambulation is part of the management plan for IBS, along with increased fluids and fiber and avoiding caffeinated beverages.

The nurse is teaching a preoperative client who is scheduled for a laparoscopic cholecystectomy ("lap chole"). What statement by the client indicates a need for further teaching? A. "I will likely need oral pain medications for the first few days after my surgery." B. "I should only be hospitalized for 2 to 3 days after my surgery." C. "I will probably not be at risk for complications from this surgery." D. "I should be able to go back to work in the next week or so."

B. "I should only be hospitalized for 2 to 3 days after my surgery." A "lap chole" surgery has many advantages over the open traditional surgical method, including a short hospital stay, usually same-day surgery, minimal risk for complications, and the ability to achieve pain control by using oral analgesics.

A client has been newly diagnosed with ulcerative colitis (UC). What does the nurse teach the client about diet and lifestyle choices? A. "Raw vegetables and high-fiber foods may help to diminish your symptoms." B. "Lactose-containing foods should be reduced or eliminated from your diet." C. "Drinking carbonated beverages will help with your abdominal distress." D. "It's OK to smoke cigarettes, but you should limit them to ½ pack per day."

B. "Lactose-containing foods should be reduced or eliminated from your diet." The nurse teaches the newly diagnosed client with ulcerative colitis that lactose-containing foods are often poorly tolerated and need to be reduced or eliminated from the diet. Carbonated beverages are GI stimulants that can cause discomfort and must be used rarely or completely eliminated from the diet. Cigarette smoking is a stimulant that can cause GI distress symptoms. Nurses would never advise patients that any amount of cigarette smoking is "OK." Raw vegetables and high-fiber foods can cause GI symptoms in patients with UC.

Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? A. "The scars on my liver create problems with blood circulation." B. "My liver is scarred, but the cells can regenerate themselves and repair the damage." C. "Because of the scars on my liver, blood clotting and blood pressure are affected." D. "Cirrhosis is a chronic disease that has scarred my liver."

B. "My liver is scarred, but the cells can regenerate themselves and repair the damage." The client's statement that, although his liver is scarred, the cells can regenerate and repair the damage indicates that further instruction is needed. Although cells and tissues will attempt to regenerate, destroyed liver cells will result in permanent scarring and irreparable damage.

A client is preparing to undergo a stool DNA (sDNA) test to screen for colon cancer. What preprocedure teaching does the nurse provide? A. "Do not eat or drink anything for 12 hours before the test." B. "No special preparation is needed prior to completing this test." C. "Give yourself tap water enemas until the fluid returns are clear." D. "Begin a clear liquid diet at least 24 hours before the test."

B. "No special preparation is needed prior to completing this test." The nurse will teach the client that no special preparation is needed prior to completing the Cologuard test. Cologuard is a home screening test that the client can perform at any time, with no traditional bowel cleaning preparation or fasting necessary.

A client with peptic ulcer disease (PUD) asks the nurse whether licorice and slippery elm might be useful in managing the disease. What is the nurse's best response? A. "No, they probably won't be useful. You should use only prescription medications in your treatment plan." B. "These herbs could be helpful. However, you should talk with your primary health care provider before adding them to your treatment regimen." C. "No, herbs are not useful for managing this disease. You can use any type of over-the-counter drugs though. They have been shown to be safe." D. "Yes, these are known to be effective in managing this disease but make sure you research the herbs thoroughly before taking them."

B. "These herbs could be helpful. However, you should talk with your primary health care provider before adding them to your treatment regimen." The nurse's best response is that although licorice and slippery elm may be helpful in managing PUD, the client must consult his or her primary health care provider before making a change in the treatment regimen. Alternative therapies may or may not be helpful in managing PUD. The client should not use over-the-counter medications without first discussing it with his or her primary health care provider.

A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? A. Assist the client to assume a position of comfort. B. Administer opioid analgesic medication. C. Do not administer food or fluids by mouth. D. Measure intake and output every shift.

B. Administer opioid analgesic medication. Pain relief is the highest priority for the client with acute pancreatitis. Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority.

A client has a nasogastric tube (NGT) connected to low continuous suction. What is the nurse's priority to ensure client safety? A. Assess for peristalsis at least once every 8 to 12 hours. B. Assess placement of the NGT for placement every 4 hours. C. Measure the gastric drainage every 8 to12 hours and document. D. Monitor the nasal skin and membranes around the tube for irritation.

B. Assess placement of the NGT for placement every 4 hours. Assessing the NGT for placement every 4 hours can help prevent aspiration which could lead to pneumonia. The other actions are appropriate for some clients, checking tube placement is the priority for care.

The nurse is preparing to administer natalizumab for a client who has Crohn disease (CD). What is the most important client assessment for the nurse to perform before giving this drug? A. Skin integrity B. Body temperature C. Peripheral pulses D. Breath sounds

B. Body temperature Because this drug may cause a deadly infection that affects the brain (progressive multifocal leukencephalopathy [PML]), the nurse would want to ensure that the client does not have any type of infection. Assessing body temperature is one way to determine the presence of infection.

The nurse is teaching a client and family about home care following a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. Which client finding would the nurse teach the family to report to the primary health care provider immediately? A. Decreased ascitic fluid B. Changes in consciousness or behavior C. Fatigue and weakness D. Decreased pulse rate

B. Changes in consciousness or behavior Although serious complications of the TIPS are not common, the client needs to be monitored for hepatic encephalopathy. This complication is manifested by changes in consciousness, mental status, and/or behavior. A decreased pulse rate and ascitic fluid are expected and clients with cirrhosis are usually fatigued and weak.

A client has undergone the Whipple procedure (radical pancreaticoduodenectomy) for pancreatic cancer. Which nursing actions would the nurse implement to prevent potential complications? (Select all that apply.) A. Ensure that drainage color is clear. B. Check blood glucose often. C. Place the client in the supine position. D. Check bowel sounds and stools. E. Monitor mental status.

B. Check blood glucose often. To prevent potential complications after a Whipple procedure, the nurse would check the client's glucose often to monitor for diabetes mellitus. Bowels sounds and stools would be checked to monitor for bowel obstruction. A change in mental status or level of consciousness could be indicative of hemorrhage.Clear, colorless, bile-tinged drainage or frank blood with increased output may indicate disruption or leakage of a site of anastomosis but is not a precautionary action for the nurse to implement. The client should be placed in semi-Fowler and not supine position to reduce tension on the suture line and the anastomosis site and to optimize lung expansion.

The nurse and the registered dietitian nutritionist are planning sample diet menus for a client who is experiencing dumping syndrome. Which sample meal is most appropriate for this client? A. Liver, bacon, and onions B. Chicken and white rice C. Chicken salad on whole wheat bread D. Green vegetable salad with buttermilk ranch dressing

B. Chicken and white rice Chicken and rice is the most appropriate sample meal for this client. It is the only selection suitable for the client who is experiencing dumping syndrome because it contains high protein without the addition of milk or wheat products. The client with dumping syndrome should not have much mayonnaise, onions, or buttermilk ranch dressing. Buttermilk dressing is made from milk products. The client may have whole wheat bread only in very limited amounts.

The nurse is reinforcing teaching provided by the registered dietitian nutritionist about dietary restrictions needed for a client who has a new ileostomy. Although each client can tolerate different foods, what food would the nurse suggest that the client avoid? A. Potatoes B. Corn C. Bread D. Green beans

B. Corn The client should avoid gas-forming foods like cabbage and foods that contain indigestible fiber such as nuts and corn.

The nurse is assessing an older client who has had frequent vomiting and diarrhea for the last 24 hours. Which vital sign change would be of most concern to the nurse? A. Increased oxygen saturation B. Decreased blood pressure C. Increased temperature D. Decreased pulse rate

B. Decreased blood pressure Older clients are most at risk for dehydration from loss of fluids. Older clients who have dehydration usually have an increased pulse and decreased blood pressure (BP). When BP decreases, the client is at risk for orthostatic hypotension which can cause dizziness and subsequent falls. The client may also experience an elevated temperature, but this change is less common in older adults when compared to their younger counterparts.

The nurse is teaching an older adult client. Which gastrointestinal problem does the nurse discuss that takes place during the normal aging process? A. Increased peristalsis B. Decreased hydrochloric acid levels C. Increased liver size D. Excess lipase production

B. Decreased hydrochloric acid levels In older adults, decreased hydrochloric acid levels (hypochlorhydria) results from atrophy of the gastric mucosa.A decrease in lipase production results from calcification of pancreatic vessels. A decrease in the number and size of hepatic cells leads to decreased liver weight and mass. Peristalsis decreases, and nerve impulses are dulled.

The nurse is caring for a client who just had a paracentesis. Which client finding indicates that the procedure was effective? A. Increased blood pressure B. Decreased weight C. Increased pulse D. Decreased pain

B. Decreased weight A paracentesis is performed to remove ascitic fluid from the abdomen. Therefore, the client should weigh less after the procedure than before. Blood pressure should decrease due to less fluid volume and the pulse rate may not be affected. The client may report less abdominal discomfort or ease in breathing, but pain is not a common problem for cirrhotic clients.

An older adult with severe rheumatoid arthritis in the upper extremities is undernourished. What does the nurse anticipate may be a contributing factor? A. Inadequate income to purchase sufficient food B. Diminishing ability to manipulate eating utensils C. A decrease in appetite D. Metabolic requirements that are increased due to immobility

B. Diminishing ability to manipulate eating utensils The client's severe rheumatoid arthritis in the hands and arms would produce a decrease in the client's ability to manipulate utensils. No evidence suggests that the client is experiencing a decrease in appetite or is financially unable to purchase adequate food. No evidence suggests that the client is immobile. Metabolic requirements would decrease, not increase, with less mobility.

The nurse is monitoring a client who is receiving an intravenous fat emulsion (IVFE) nutritional supplement. What action does the nurse take after reviewing the client's laboratory report, and seeing an increase in triglycerides? (Select all that apply.) A. Document the findings and continues to monitor. B. Discontinue the IVFE infusion. C. Slow the rate of flow of the IVFE infusion. D. Offer small bites of oral foods. E. Notify the health care provider.

B. Discontinue the IVFE infusion. E. Notify the health care provider. If a client receiving an IVFE nutritional supplement develops fever, increased triglycerides, clotting problems, or symptoms of multi-system organ failure, the nurse must discontinue the IVFE and notify the HCP. These symptoms may indicate fat overload syndrome, especially in a critically ill patient.Only documenting the findings and continuing to monitor could have serious repercussions for this client. Slowing the rate of flow of the IVFE infusion, or offering small bites of oral foods, can also present a serious safety risk.

The nurse is assessing a client who is diagnosed as having Hepatitis A and asks how someone gets this disease. What is the most likely cause of the client's Hepatitis A? A. Being exposed to blood or blood products B. Eating contaminated food or water C. Having unprotected sex D. Sharing needles for illicit drugs

B. Eating contaminated food or water Hepatitis A is transmitted through the fecal-oral route rather than via blood. Therefore, contaminated food or water with Escherichia coli or other microbes can cause this liver infection.

A client with a family history of colorectal cancer (CRC) regularly sees a primary health care provider for early detection of any signs of cancer. Which laboratory result may be an indication of CRC in this client? A. Decrease in liver function test results B. Elevated carcinoembryonic antigen C. Negative test for occult blood D. Elevated hemoglobin levels

B. Elevated carcinoembryonic antigen Carcinoembryonic antigen may be elevated in many patients diagnosed with CRC. Liver involvement may or may not occur in CRC. Hemoglobin will likely be decreased with CRC, not increased. An occult blood test is not reliable to affirm or rule out CRC.

The nurse is assessing a client who is suspected of having early gastric cancer. What signs and symptoms would the nurse expect? (Select all that apply.) A. Fatigue B. Feeling of fullness C. Dyspepsia D. Weakness E. Weight loss F. Nausea and vomiting

B. Feeling of fullness C. Dyspepsia The client who has early gastric cancer usually has no or few signs and symptoms, but may have dyspepsia and a feeling of fullness. More distressing changes are manifested when the cancer becomes more advanced.

The nurse is teaching a group of senior citizens in a residential facility about how to prevent gastrointestinal (GI) infectious outbreaks, such as norovirus. What information will the nurse include as a priority intervention for the group? A. Keeping at least 6 feet apart B. Handwashing and hand sanitizing C. Avoiding group dining D. Cooking all food and boiling water

B. Handwashing and hand sanitizing GI infections like norovirus are typically transmitted via the fecal-oral route. Therefore, handwashing and using hand sanitizers frequently is the best method to promote health and prevent infection.

The nurse is caring for a client who has a gastric ulcer. For which potentially life-threatening complication would the nurse monitor for this client? A. Hypokalemia B. Hemorrhage C. Nausea and vomiting D. Infection

B. Hemorrhage Clients who have gastric ulcers are particularly at risk for upper GI bleeding, or hemorrhage. They may also experience nausea and vomiting causing dehydration. However, hemorrhage is most serious.

A client developed gastroenteritis while traveling outside the country. What is the most likely cause of the client's symptoms? A. Overcooked food B. Ingestion of parasites in the water C. Insufficient vaccinations D. Bacteria on the patient's hands

B. Ingestion of parasites in the water The likely cause of gastroenteritis when a client travels outside the country is ingestion of water that is infested with parasites. Bacteria on the client's hands will not produce gastroenteritis unless food or water is contaminated with the bacteria. Insufficient vaccinations may cause other disease processes, but not gastroenteritis. Undercooked, not overcooked, food may produce gastroenteritis.

The nurse and health care provider are discussing a client who has pernicious anemia. The nurse anticipates that the client has which deficiency? A. Hydrochloric acid B. Intrinsic factor C. Glucagon D. Pepsinogen

B. Intrinsic factor Intrinsic cells are produced by the parietal cells in the stomach. This substance facilitates the absorption of vitamin B12. Absence of intrinsic factor causes pernicious anemia.Glucagon, which is produced by the alpha cells in the pancreas, is essential for the regulation of metabolism. Parietal cells secrete hydrochloric acid, but this does not facilitate the absorption of vitamin B12. Pepsinogen is secreted by the chief cells; pepsinogen is a precursor to pepsin, a digestive enzyme.

A client with oral cancer who is to have a radical neck dissection reports being depressed. What is the nurse's priority response? A. Suggest seeking support from a community group. B. Listen to the client's concerns. C. Explain the grieving process. D. Reassure that it is normal to feel depressed about the diagnosis.

B. Listen to the client's concerns. The nurse's priority response is to listen to the client and allow him or her to process feelings. After the client has processed feelings, he or she is more open to learning about the normalcy of feeling depressed about this diagnosis, understanding the grieving process, and considering referral to a community group of clients undergoing a similar experience.

The nurse is caring for a client admitted with a long-term diagnosis of ulcerative colitis (UC). For what potentially life-threatening complication would the nurse monitor? A. Chronic kidney disease B. Lower gastrointestinal (GI) bleeding C. Metabolic acidosis D. Hyperkalemia

B. Lower gastrointestinal (GI) bleeding The client who has UC is at most risk for lower GI bleeding due to inflammation and diarrhea. The client with UC is also at risk for hypokalemia and metabolic alkalosis as a result of losing intestinal contents through diarrhea.

The nurse is caring for a client diagnosed with aphthous ulcers. Which food will the nurse recommend that the client avoid? (Select all that apply.) A. Apples B. Pasta C. Baked potato D. Nuts E. Cheese

B. Pasta C. Baked potato D. Nuts E. Cheese Aphthous ulcers (canker sores) are small, shallow lesions that develop on the soft tissues in the mouth or at the base of the gums. The nurse tells the client that certain foods such as cheese, nuts, potatoes, and foods containing gluten (like pasta) may trigger allergic responses that cause aphthous ulcers and should be avoided. Apples and bananas are not acidic and do not trigger allergic responses that cause aphthous ulcers.

A client is being observed after a routine sigmoidoscopy with a tissue biopsy. Which assessment finding will the nurse report to the health care provider? A. Flatulence B. Rectal bleeding C. Mild abdominal pain D. Borborygmi

B. Rectal bleeding Bleeding is a possible complication following a sigmoidoscopy. It must be reported immediately to the health care provider.Mild abdominal pain (usually gas pain) and flatulence are expected findings after a sigmoidoscopy. Borborygmi may be heard, especially if the client is hungry if they have followed a clear liquid diet prep before the procedure.

A client who is receiving total enteral nutrition exhibits acute confusion and shallow breathing and says, "I feel weak." As the client begin to experience a seizure, how does the nurse interpret this client's signs and symptoms? A. Abdominal distention is present. B. Refeeding syndrome may be occurring. C. Severe hyperglycemia is present. D. The enteral tube is dislodged.

B. Refeeding syndrome may be occurring. Refeeding syndrome is a syndrome consisting of metabolic disturbances that occur as a result of reinstitution of nutrition to clients who are starved, severely malnourished, or metabolically stressed due to severe illness. Symptoms of refeeding syndrome include heart failure, peripheral edema, rhabdomyolysis, seizures, and hemolysis. If the enteral tube becomes misplaced or dislodged, the client may develop aspiration pneumonia displayed by increased temperature, increased pulse, dehydration, diminished breath sounds, and shortness of breath. Abdominal distention is most frequently accompanied by nausea and vomiting. In refeeding syndrome, insulin secretion decreases in response to the physiologic changes in the body, so hyperglycemia is not present. When refeeding begins, insulin production resumes and the cells take up glucose and electrolytes from the bloodstream, thus depleting serum levels, resulting in hypoglycemia.

The nurse is caring for a client who is diagnosed with a perforated duodenal ulcer. Which assessment finding would the nurse expect? A. Positive McBurney point B. Rigid, board-like and tender abdomen C. Nausea and profuse vomiting D. Absent bowel sounds in all four quadrants

B. Rigid, board-like and tender abdomen Perforation allows intestinal contents to escape into the peritoneal cavity causing peritonitis. The classic assessment finding for a client who has peritonitis is a rigid, board-like abdomen that is tender or painful.

An older client with a 2-day history of myalgia, nausea, vomiting, and diarrhea is admitted to the medical-surgical unit with a diagnosis of gastroenteritis. Which primary health care provider request does the nurse implement first? A. Obtain a stool specimen for culture and sensitivity. B. Start an IV solution of 5% dextrose in 0.45 normal saline. C. Draw blood for a complete blood count and serum electrolytes. D. Administer acetaminophen 650 mg rectally.

B. Start an IV solution of 5% dextrose in 0.45 normal saline. The request the nurse implements first is to start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr. Although the dextrose 5% in 0.45% sodium chloride is hypertonic in the IV bag, once it is infused, the glucose is rapidly metabolized and the fluid is really hypotonic. Fluid therapy is the focus of treatment for clients with gastroenteritis. Older clients are at increased risk for the complications of dehydration such as hypovolemia and acute kidney failure. Acetaminophen 650 mg should be administered rectally soon, and blood draws and stool specimen collection would also be implemented soon, but prevention and treatment of dehydration are the priorities for this client.

When caring for a client with Laennec cirrhosis, which of these findings does the nurse expect to find on assessment? (Select all that apply.) A. Elevated magnesium B. Swollen abdomen C. Prolonged partial thromboplastin time D. Elevated amylase level E. Currant jelly stool F. Icterus of skin

B. Swollen abdomen C. Prolonged partial thromboplastin time F. Icterus of skin Clients with Laennec cirrhosis have damaged clotting factors, so prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The client with cirrhosis may develop ascites, or fluid in the abdominal cavity.Elevated magnesium is not related to cirrhosis. Amylase is typically elevated in pancreatitis. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. The client with cirrhosis may develop hypocalcemia and/or hypokalemia. It is also consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase.

The nurse obtains assessment data on a client who had bariatric surgery today. Which finding does the nurse report to the surgeon immediately? A. Reports pain of "6" on 0-10 scale when being repositioned. B. Urine output total is 15 mL for the past 2 hours. C. Skin under the panniculus is excoriated. D. Bowel sounds are not audible in all quadrants.

B. Urine output total is 15 mL for the past 2 hours. The nurse reports a urine output total of 15 mL for the past 2 hours. Normal urine output needs to be at least 30 mL/hr. Oliguria (scant urine output) may indicate severe postoperative complications such as anastomotic leaks or acute kidney failure.Inaudible bowel sounds would typically require intervention, but on the day of surgery, absent bowel sounds are an expected finding. The other findings, excoriated skin under the panniculus and subjective reports of pain, may require nursing interventions, but do not require an immediate report to the surgeon.

A client who has undergone surgery and completed radiation therapy to treat oral cancer reports persistent dry mouth. What will the nurse teach this client about managing this symptom? A. This condition is common but is temporary. B. Use saliva substitutes, especially when eating dry foods. C. This indicates a complication of therapy. D. Use lozenges and hard candies to prevent dry mouth.

B. Use saliva substitutes, especially when eating dry foods. Xerostomia is a common effect of oral irradiation. Clients should be advised to use saliva substitutes. The condition is common, but often permanent. Lozenges and hard candies are not as effective as saliva substitutes. Dry mouth is a side effect of therapy, not a symptom of complications. Taking frequent sips of water is the preferred method of treating xerostomia during radiation therapy.

The nurse is teaching a client about dietary choices to prevent dumping syndrome after gastric bypass surgery. Which statement by the client indicates a need for further teaching? A. "I cannot drink alcohol at all." B. "I will need to avoid sweetened fruit juice beverages." C. "I can eat ice cream in moderation." D. "It is okay to have a serving of sugar-free pudding."

C. "I can eat ice cream in moderation." A need for further teaching about dietary changes related to dumping syndrome is indicated when the client says that ice cream can be eaten in moderation. Milk products such as ice cream must be eliminated from the diet of a patient with dumping syndrome.

The Certified Wound, Ostomy, and Continence Nurse (CWOCN) is teaching a client with colorectal cancer how to care for a newly created colostomy. Which statement by the client indicates a correct understanding of the necessary self-management skills? A. "If I have any leakage, I'll put a towel over it." B. "I can put aspirin tablets in the pouch in order to reduce odor" C. "I will apply a nonalcoholic skin sealant and let it dry before applying the bag." D. "I will have my spouse change the bag for me."

C. "I will apply a nonalcoholic skin sealant and let it dry before applying the bag." The nurse would teach the client and family to apply a skin sealant (preferably without alcohol) and allow it to dry before application of the appliance (colostomy bag) to facilitate less painful removal of the tape or adhesive. It is not realistic that the spouse will always change the patient's bag and does not reflect correct understanding of self-management skills. A towel is not an acceptable or effective way to cope with leakage. Putting an aspirin in the pouch will not reduce odor and can lead to ulcers in the stoma.offers reassurance and is a "pat" statement, making it nontherapeutic. "Why" questions place patients on the defense and are not therapeutic because they close the conversation.

The nurse is teaching an older client how to prevent a stool impaction that can obstruct the intestines. Which statement by the client indicates a need for further teaching? A. "I will drink lots of fluids every day, especially water." B. "I will increase my exercise, especially walking, every day." C. "I will be sure to take a laxative every night to keep my bowels moving." D. "I will try to eat more high-fiber foods, such as raw vegetables and whole grains."

C. "I will be sure to take a laxative every night to keep my bowels moving." All of these statements are correct except that the client should not take laxatives because they can decrease the tone of the abdominal muscles.

The nurse is teaching a client who has undergone a hemorrhoidectomy about a follow-up plan of care. Which statement by the client demonstrates a correct understanding of the nurse's instructions? A. "I will take laxatives after the surgery to 'keep things moving?'." B. "To help with the pain, I'll apply ice to the surgical area." C. "I will need to eat a diet high in fiber, including raw vegetables." D. "Limiting my fluids will help me with constipation."

C. "I will need to eat a diet high in fiber, including raw vegetables." The statement that shows that the hemorrhoidectomy patient correctly understands the nurse's instruction is, "I will need to eat a diet high in fiber." A diet high in fiber serves as a natural stool softener and will prevent irritation to hemorrhoids caused by painful bowel movements. Laxatives are discouraged because they can be habit-forming and decrease abdominal muscle tone. Increased amounts of fluids are needed to prevent constipation. Moist heat (sitz baths) will be more effective with postoperative discomfort than cold applications.

A male client is scheduled for a minimally invasive inguinal hernia repair (MIIHR). Which statement by the client indicates a need for further teaching about this procedure? A. "I may have trouble urinating immediately after the surgery." B. "My chances of having complications after this procedure are slim." C. "I will need to stay in the hospital overnight." D. "I will not eat after midnight the day of the surgery."

C. "I will need to stay in the hospital overnight." A need for further teaching about MIIHR is when the patient says, "I will need to stay in the hospital overnight." Usually, the patient is discharged 3 to 5 hours after MIIHR surgery.Male patients who have difficulty urinating after the procedure would be encouraged to force fluids and to assume a natural position when voiding. Patients undergoing MIIHR surgery must be NPO after midnight before the surgery. Most patients who have MIIHR surgery have an uneventful recovery.

A male client's sister was recently diagnosed with colorectal cancer (CRC), and his brother died of CRC 5 years ago. The client asks whether he will inherit the disease. How would the nurse respond? A. "Have you asked your primary health care provider about your chances ?" B. "It is hard to know what can predispose a person to develop a certain disease." C. "The only way to know whether you are predisposed to CRC is by genetic testing." D. "No. Just because they both had CRC doesn't mean that you will have it, too."

C. "The only way to know whether you are predisposed to CRC is by genetic testing." The nurse's best response to the client who asks if he will inherit CRC is "the only way to know whether you are predisposed to CRC is by genetic testing." Genetic testing is the only definitive way to determine whether the patient has a predisposition to develop CRC.

A client is preparing to have a hepatobiliary scan (HIDA scan). What health teaching would the nurse include about what the client can expect during the test? A. "This test measures how inflamed your gallbladder and liver may be." B. "You may eat and drink as much as you'd like before you have this test." C. "You will have to lie still for some time while the camera is very close to your body." D. "I need to know if you are allergic to shellfish because the contrast will be iodine-based."

C. "You will have to lie still for some time while the camera is very close to your body." The HIDA scan requires the injection of radioactive medium which is given about 20 minutes before a large camera is positioned very close to the body. The camera moves to assess for biliary flow and to determine if any obstruction is present.

Which action by the nurse would most likely help to relieve symptoms associated with ascites? A. Monitoring serum albumin levels B. Lowering the head of the bed C. Administering oxygen therapy D. Administering intravenous fluids

C. Administering oxygen therapy The best action by the nurse caring for a client with ascites is to elevate the head of the bed and provide supplemental oxygen. The enlarged abdomen of ascites limits respiratory excursion. Fowler position will increase excursion and reduce shortness of breath.Monitoring serum albumin levels will detect anticipated decreased levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.

How does the nurse accurately calculate a client's body mass index (BMI)? A. BMI = weight (lb)/height (in inches)2 B. BMI = weight (kg)/height (in meters) C. BMI = weight (kg)/height (in meters)2 D. BMI = weight (lb)/height (in meters)

C. BMI = weight (kg)/height (in meters)2 The correct formula to accurately calculate a client's body mass index (BMI) is: BMI = weight (kg)/height (in meters)2.

A client reports ongoing episodes of "heartburn." Which food will the nurse recommend that the client eliminate from the diet? A. Steak B. Carrots C. Chocolate D. Popcorn

C. Chocolate Foods that decrease esophageal sphincter pressure, such as fatty foods, caffeine, and chocolate, should be avoided. Steak, carrots, and popcorn do not decrease esophageal sphincter pressure.

A client receiving total parenteral nutrition (TPN) exhibits symptoms of heart failure (CHF) and pulmonary edema. Which complication of TPN does the nurse recognize that the client is experiencing? A. Potassium imbalance B. Fluid volume deficit C. Fluid volume overload D. Calcium imbalance

C. Fluid volume overload This client is most likely experiencing fluid volume overload. Heart failure and pulmonary edema are symptoms of this condition.Calcium imbalance, fluid volume deficit, and potassium imbalance do not manifest with heart failure and pulmonary edema. The nurse tells the client to expect loose stools, abdominal cramps, and nausea. These are side effects unique to orlistat (Xenical).Dry mouth, constipation, and insomnia are not side effects of orlistat. Insomnia, dry mouth, blurred vision, palpitations, constipation, and restlessness are all side effects of short-term therapy drugs such as phentermine (Adipex-P), diethylpropion (Tenuate), and phendimetrazine (Bontril).

What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? A. Drink only bottled water and avoid ice. B. Avoid sharing the bathroom with the client. C. Members of the household must not share toothbrushes. D. The client must not consume alcohol.

C. Members of the household must not share toothbrushes. The nurse teaches the family of a client with hepatitis C that toothbrushes, razors, towels, and any other items may spread blood and body fluids and must not be shared. The client should not consume alcohol, but abstention will not prevent spread of the virus. The client may share a bathroom if he or she is continent. To prevent hepatitis A when traveling to foreign countries, bottled water should be consumed and ice made from tap water needs to be avoided.

When providing community education, the nurse emphasizes that which group needs to receive immunization for hepatitis B? A. Clients who work with shellfish. B. Clients with elevations of aspartate aminotransferase and alanine aminotransferase. C. Men who engage in sex with men. D. Clients traveling to a third-world country.

C. Men who engage in sex with men. Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity. Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A. Hepatitis B is not of concern, unless the client is exposed to blood and body fluids during travel. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B.

The nurse is caring for a client with peptic ulcer disease who has been vomiting profusely at home before coming to the emergency department. For which acid-base imbalance will the nurse expect for this client? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic alkalosis D. Metabolic acidosis

C. Metabolic alkalosis Gastric contents are rich in acid (hydrogen and chloride ions). When this fluid is lost through vomiting, the client has less acid causing an alkalotic state.

The nurse is assessing a very thin client who has come to the emergency department with acute abdominal pain. Upon assessment, visible peristaltic movements are noted. What is the appropriate nursing action? A. Prepare to administer antibiotics as prescribed. B. Report finding to the health care provider. C. Monitor laboratory values for possible pancreatitis. D. Toilet quickly as diarrhea is imminent.

C. Monitor laboratory values for possible pancreatitis. The nurse will report the finding to the health care provider, as it is possible that the client has an obstruction. Peristaltic movements are rarely seen except in thin clients.Acute diarrhea does not cause visible peristaltic movements. Pancreatitis is not characterized by visible peristaltic movement. The client likely has an obstruction, not an infection.

A young adult man says that he cannot stay on a diet because of trouble finding one that will incorporate his food preferences. How does the nurse most effectively plan nutritional care for this client? A. Calculates his body mass index (BMI). B. Measures his accurate height and weight measurements. C. Obtains a 24-hour recall (diary) of his food intake. D. Records a 24-hour diary of his physical activities.

C. Obtains a 24-hour recall (diary) of his food intake. The most effective way to plan nutritional care for a client is to obtain a 24-hour recall of food intake. This will determine the client's food preferences and eating patterns so that they can be incorporated into the diet. Although calculating a BMI and measuring height and weight are important parts of a nutritional assessment, they do not address the issue of the client's food preferences. Keeping an activity diary will also not reveal any information related to the client's food preferences.

A client who had a Whipple surgical procedure develops an internal fistula between the pancreas and stomach. For which complication would the nurse monitor? A. Cirrhosis B. Crohn disease C. Peritonitis D. Peptic ulcer disease

C. Peritonitis Leakage of pancreatic enzymes, bile, and/or gastric secretions into the abdomen (peritoneal cavity) often causes peritonitis, which requires IV antibiotic therapy to manage.

When caring for a client with oral cancer who has developed stomatitis as a complication of radiation and chemotherapy, which action does the nurse delegate to the assistive personnel (AP)? A. Instruct how to use nystatin oral rinses. B. Assist with making appropriate dietary choices that do not irritate tissues. C. Provide oral care using a soft toothbrush. D. Inspect the oral mucosa for evidence of oral candidiasis.

C. Provide oral care using a soft toothbrush. Providing oral care using a soft toothbrush for a client with oral lesions is an appropriate assignment for an AP. Assessments, client teaching, and assisting clients with oral problems in making appropriate dietary choices are the responsibilities of licensed nursing staff.

The nurse is providing instructions to a client with a history of stomatitis. Which instructions does the nurse include in the teaching plan? A. Encourage the client to eat acidic foods to decrease bacteria. B. Mouth care should be performed twice daily at the maximum. C. Rinse the mouth frequently with warm saline or sodium bicarbonate. D. Use a medium-bristled toothbrush for oral care.

C. Rinse the mouth frequently with warm saline or sodium bicarbonate. Rinsing the mouth frequently with warm saline or sodium bicarbonate or a combination of the two decreases inflammation and pain. Acidic foods increase inflammation and should be avoided. Mouth care should be done after each meal and as often as needed, at the minimum of twice daily. If stomatitis is not controlled, mouth care may have to be done every 2 hours or more frequently. A soft toothbrush, not medium-bristled one, needs to be used for oral care.

Which food does the nurse teach a client undergoing chemotherapy with secondary stomatitis to avoid? A. Broiled fish B. Ice cream C. Salted pretzels D. Scrambled eggs

C. Salted pretzels Salty foods like pretzels can further irritate ulcers in the client's mouth, causing pain. Cool or cold foods and foods high in protein, such as fish, eggs, and ice cream, may be included in the diet of the client with stomatitis.

The nurse is caring for a client who had an anterior-posterior surgical resection for colorectal cancer this morning. What will the nurse anticipate as the client's priority problem at this time? A. Intestinal obstruction B. Nausea and vomiting C. Severe pain D. Constipation

C. Severe pain The surgical incisions are in the perineal area and are very painful due to the number of nerves in that region of the body. Pain control is the biggest challenge for the nurse and health care team to promote client comfort.

The community nurse is discussing risk factors for esophageal cancer with a group of clients. Which client behavior requires further teaching? A. Eats a small snack each night before bedtime. B. Walks at the shopping mall three times weekly. C. Smokes 1/3 of a pack of cigarettes daily. D. Elevates pillows at night.

C. Smokes 1/3 of a pack of cigarettes daily. Tobacco use is one of the primary risk factors for esophageal cancer. This client behavior requires teaching about lifestyle risks that could increase the risk for esophageal cancer.Other reported client behaviors are acceptable and do not increase risk for esophageal cancer.

The nurse finds a client vomiting coffee-ground emesis. On assessment, the client has a blood pressure of 100/74 mm Hg, is acutely confused, and has a weak and thready pulse. Which intervention is the nurse's first priority? A. Administer antianxiety medication. B. Initiate enteral nutrition. C. Start intravenous (IV) fluids. D. Administer histamine (H2) antagonist.

C. Start intravenous (IV) fluids. The nurse's first priority is to administer intravenous (IV) fluids. Administering IV fluids is necessary to treat the hypovolemia caused by acute gastrointestinal (GI) bleeding.

The nurse is planning health teaching about omeprazole for a client who has acute gastritis. What would the nurse include in the health teaching? A. Crushing the drug and mixing in applesauce B. Avoiding alcohol while taking this drug C. Taking the drug 30 minutes before a meal D. Taking the drug when the client has gastric pain

C. Taking the drug 30 minutes before a meal This drug is a proton pump inhibitor and is activated by the presence of food in the stomach. Therefore, it should be taken before a meal.

The nurse is teaching a client with gallbladder disease about diet modification. Which meal would the nurse suggest to the client? A. Sausage and scrambled eggs B. Steak and french fries C. Turkey sandwich on wheat bread D. Fried chicken and mashed potatoes

C. Turkey sandwich on wheat bread Turkey is an appropriate low-fat selection for this client. High fiber, from the wheat bread, also helps reduce the risk. Typically, diets high in fat, high in calories, low in fiber, and high in refined white carbohydrates place clients at higher risk for developing gallstones.Steak, french fries, fried chicken and mashed potatoes, and sausage are too fatty. Eggs are too high in cholesterol for a client with gallbladder disease.

A hospitalized client with ongoing abdominal tenderness reports an increase in generalized abdominal pain today. Which assessment technique will the nurse perform? (Select all that apply.) A. Percuss to determine size of liver and spleen. B. Auscultate beginning in the RLQ. C. Visually observe for contour and symmetry. D. Ask for a pain scale rating on a scale of 0-10. E. Deeply palpate the area of tenderness.

C. Visually observe for contour and symmetry. D. Ask for a pain scale rating on a scale of 0-10. The abdominal assessment is performed in the order of inspection, auscultation, percussion, and palpation. The nurse will visually observe the abdomen for contour and symmetry, auscultate beginning in the RUQ (not the RLQ), lightly palpate for any large masses or areas of tenderness, ask the client to rate the pain level on a 0-10 scale, and document the findings.The nurse will not perform deep palpation nor percussion, as the health care provider conducts this portion of the examination.

Based on nutritional screening findings and assessments, which client does the nurse identify that meets criteria for surgical treatment of obesity? A. Woman with a BMI of 38, weight 50% above ideal body weight B. Man with a body mass index (BMI) of 40, weight 75% above ideal body weight C. Woman with a BMI of 42, weight 100% above ideal body weight D. Man with a BMI of 41, weight 80% above ideal body weight

C. Woman with a BMI of 42, weight 100% above ideal body weight The client who will be most successful with surgical intervention is the client with a BMI of 40 or more and a weight 100% above the ideal body weight. The other clients do not have a high enough BMI-to-weight ratio to be considered for surgical intervention.

After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? A. Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL (13.1 mmol/L). B. Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain. C. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. D. Middle-age client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography.

C. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. The nurse would first assess the young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. Airway and breathing are the two most important criteria the nurse will use to determine which client to assess first. The dyspneic client is at greatest risk for rapid deterioration and requires immediate assessment and intervention. Acute respiratory distress syndrome is a possible complication of acute pancreatitis.The client with cholecystitis and the client with an elevated temperature will require further assessment and intervention, but these are not medical emergencies requiring the nurse's immediate attention. The older adult client's glucose level will require intervention but, again, is not a medical emergency.

The nurse is caring for a client who has cirrhosis of the liver. The client's latest laboratory testing shows a prolonged prothrombin time. For what assessment finding would the nurse monitor: A. deep vein thrombosis. B. jaundice. C. hematemesis. D. pressure injury.

C. hematemesis. The client who has cirrhosis is at risk for bleeding due to decreased production of prothrombin by the liver. Portal hypertension that occurs in clients with cirrhosis causes esophageal blood veins to become fragile, distended, and tortuous. Therefore, these veins tend to bleed as evidenced by either hematemesis or melena.

The nurse is teaching a client about caring for a new ileostomy. What information is most important to include? A. "After surgery, output from your ileostomy may be a loose, dark-green liquid with some blood present." B. "Remember that you must wear a pouch system at all times." C. "Notify the primary health care provider if output from your stoma has a sweetish odor." D. "Call your primary health care provider if your stoma has a bluish or pale look."

D. "Call your primary health care provider if your stoma has a bluish or pale look." It is most important for the nurse to tell the client with a new ileostomy to call the primary health care provider if the stoma has a bluish or pale look. If the stoma has a bluish, pale, or dark look, its blood supply may be compromised and the primary health care provider must be notified immediately.

A client who developed viral gastroenteritis with vomiting and diarrhea is scheduled to be seen in the clinic the following day. What intervention would the nurse recommend for the client to do? A. "Avoid all solid foods to allow complete bowel rest." B. "Take an over-the-counter antidiarrheal medication." C. "Contact your primary health care provider for an antibiotic medication." D. "Consume extra fluids to replace fluid losses."

D. "Consume extra fluids to replace fluid losses." The nurse tells the client to drink extra fluids to replace fluid lost through vomiting and diarrhea. It is not necessary to stop all solid food intake. Antidiarrheal medications are used if diarrhea is severe. Antibiotics are used if the infection is bacterial.

The home health nurse is teaching a client about the care of a new colostomy. Which statement by the client demonstrates a correct understanding of the health teaching? A. "If the skin around the stoma is red or scratched, it will heal soon." B. "I need to strive for a very tight fit when applying the barrier around the stoma." C. "A dark or purplish-looking stoma is normal and would not concern me." D. "I need to check for leakage underneath my colostomy."

D. "I need to check for leakage underneath my colostomy." The client's statement, "I need to check for leakage underneath my colostomy" shows that the patient correctly understands the instructions about how to care for a new colostomy. The pouch system must be checked frequently for evidence of leakage to prevent excoriation. A purplish stoma is indicative of ischemia and necrosis. Redness or scratched skin around the stoma must be reported to prevent it from beginning to break down. An overly tight fit may lead to necrosis of the stoma.

The nurse is teaching a client how to prevent recurrent chronic gastritis symptoms before discharge. Which statement by the client demonstrates a correct understanding of the nurse's instruction? A. "I will need to take vitamin B12 shots for the rest of my life." B. "I should eat small meals about six times a day." C. "It is okay to continue to drink coffee in the morning when I get to work." D. "I should avoid alcohol and tobacco of any type."

D. "I should avoid alcohol and tobacco of any type." The client's statement that he or she needs to avoid alcohol and tobacco shows that the client correctly understands the nurse's instructions. The client also needs to eliminate caffeine from the diet. The client will need to take vitamin B12 shots only if he or she has pernicious anemia. The client would also not eat six small meals daily. This practice may actually stimulate gastric acid secretion.

The nurse is assessing a client who reports having a history of gastroesophageal reflux disease (GERD). Which assessment finding does the nurse report to the primary health care provider? A. "My family likes to eat small meals every 3 to 4 hours throughout the day." B. "When I buy meat, I ask for the leanest cut that is available." C. "I quit smoking 6 months ago." D. "Sometimes I wake up gasping for air in the middle of the night."

D. "Sometimes I wake up gasping for air in the middle of the night." Gasping for air upon waking in the middle of the night can be a sign of sleep apnea; the nurse must report this finding to the primary health care provider. Often patients who have one condition (sleep apnea or GERD) also experience the other. Quitting smoking 6 months ago, eating small meals, and eating lean meats are favorable findings that do not need to be reported.

The nurse is preparing to provide health teaching for a client who is starting sulfasalazine. Which statement by the client indicates a need for further teaching? A. "I'll let my primary health care provider know if the drug upsets my stomach." B. "I will be sure to take a folic acid supplement while on this drug." C. "I will follow up with getting labs done to check my blood counts." D. "This drug can make me dehydrated because I'm already on a diuretic."

D. "This drug can make me dehydrated because I'm already on a diuretic." Sulfasalazine can cause nausea and vomiting, and can interfere with folic acid absorption. In high doses, it can also cause anemia and agranulocytosis, so blood work would be important for ongoing monitoring. However, the drug does not cause dehydration.

The nurse is providing teaching on ways to promote bowel health and disease prevention. Which statement will the nurse include in this teaching? A. "You should start colorectal cancer screening when you are over 70 years of age." B. "You only need to have regular colonoscopies if there is colorectal cancer in your family.' C. "If you perform fecal occult blood tests every 5 years, you don't need a colonoscopy." D. "You should have a colonoscopy every 10 years starting at 45 years of age."

D. "You should have a colonoscopy every 10 years starting at 45 years of age." The American Cancer Society recommends that for individuals of average risk for colorectal cancer (CRC), a colonoscopy every 10 years or flexible sigmoidoscopy every 5 years is adequate. The screening should begin for adults of 45 years of age or older unless individuals are at high risk for CRC.

When preparing a client to undergo paracentesis, which action is necessary to reduce potential injury as a result of the procedure? A. Assist the provider to insert a trocar catheter into the abdomen. B. Position the client with the head of the bed flat. C. Encourage the client to take deep breaths and cough. D. Ask the client to void prior to the procedure.

D. Ask the client to void prior to the procedure. To avoid injury to the bladder during a paracentesis, the client would be asked to void prior to the procedure. Taking deep breaths and coughing does not prevent complications or injury as a result of paracentesis. Clients would be positioned with the head of the bed elevated. The trocar catheter is used to drain the ascetic fluid and does not reduce the risk of damage to the bladder.

An older adult client is at risk for undernutrition. Which nursing intervention is appropriate to ensure optimum nutritional intake? A. Administering antiemetics and analgesics after meals B. Reminding APs to allow the client to remain in bed during meals C. Turning on the television during meals to provide distraction D. Assisting the client with toileting and oral care prior to meals

D. Assisting the client with toileting and oral care prior to meals The appropriate intervention to ensure optimum nutritional intake in an older adult client at risk for undernutrition is to assist the client with toileting and oral care prior to meals for comfort and to prevent these from distracting clients from meals.Antiemetics and analgesics should be provided prior to meals. Clients need to be free from distractions while eating. When possible, clients are placed in chairs for eating.

It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication? A. Right shoulder pain B. Bone marrow suppression C. Polyuria D. Bleeding

D. Bleeding A potential complication of hepatic artery embolization for hepatic cancer is bleeding. Prompt detection of hemorrhage is the priority.Discomfort such as right shoulder pain may be present, but the priority is to assess for hemorrhage. The nurse must assess for signs of shock, not polyuria. Embolization does not suppress the bone marrow. If chemotherapy or immune modulators is used, the nurse then assesses for bone marrow suppression.

The nurse is monitoring a client with gastric cancer for signs and symptoms of upper gastrointestinal bleeding. Which change in vital signs would the nurse expect? A. Temperature from 97.9° to 98.9° F (36.6° to 37.2° C) B. Respiratory rate from 24 to 20 breaths/min C. Apical pulse from 80 to 72 beats/min D. Blood pressure from 140/90 to 110/70 mm Hg

D. Blood pressure from 140/90 to 110/70 mm Hg A decrease in blood pressure from 140/90 to 110/70 indicates that the client has hypovolemia from loss of body fluid (in this case, blood).

A client who has colorectal cancer is scheduled for a colostomy. Which referral is initially the most important for this client? A. Home health nursing agency B. Social worker D. Certified Wound, Ostomy, and Continence Nurse (CWOCN) D. Hospital chaplain

D. Certified Wound, Ostomy, and Continence Nurse (CWOCN) A CWOCN (or an enterostomal therapist) will be of greatest value to the client with colorectal cancer because the client is scheduled to receive a colostomy. The client is newly diagnosed, so it is not yet known whether home health nursing will be needed. A referral to hospice may be helpful for a terminally ill client. Referral to a chaplain may be helpful later in the process of adjusting to the disease.

Which client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) clinic? A. Client admitted with nausea, abdominal pain, and abdominal distention. B. Client who needs discharge teaching after an endoscopic retrograde cholangiopancreatography (ERCP). C. Client with epigastric pain who needs conscious sedation during endoscopy. D. Client who has had laxatives administered and needs monitoring before a colonoscopy.

D. Client who has had laxatives administered and needs monitoring before a colonoscopy. The client who needs laxatives administered and effectiveness monitored before a colonoscopy is the least complicated client. This client would be assigned to the float nurse who would have the experience and education to adequately care for this client.Discharge instructions following an ERCP, assessment of an admitted acutely ill client, and monitoring a client who is receiving conscious sedation is accomplished best by a nurse with experience in caring for adults with acute GI problems.

The nurse is caring for a client who was recently diagnosed with Laennec cirrhosis. What is the nurse's priority assessment during client care? A. Cardiovascular assessment B. Abdominal assessment, including bowel sounds C. Respiratory assessment D. Cognitive and neurologic assessment

D. Cognitive and neurologic assessment The type of cirrhosis that this client has is caused by alcoholism. Withdrawal from alcohol can cause cognitive and neurologic changes, such as confusion and delirium tremens (DTs).

A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client? A. Has the client lie in a supine position with legs straight and arms above the head. B. Assesses the following sequence: inspection, palpation, percussion, auscultation. C. Palpates any bulging mass very gently and documents findings. D. Examines the RUQ of the abdomen last following all other assessment techniques.

D. Examines the RUQ of the abdomen last following all other assessment techniques. If the client reports pain in the RUQ, the nurse examines this area last. This sequence prevents the client from tensing abdominal muscles because of the pain, which would make the assessment difficult. The sequence for examining the abdomen is inspection, auscultation, percussion, and then palpation. This sequence prevents the increase in intestinal activity and bowel sounds caused by palpation and percussion. The client would be positioned supine with the knees bent while keeping the arms at the sides to prevent tensing of the abdominal muscles. If a bulging, pulsating mass is present during assessment of the abdomen, the nurse must never touch the area because the client may have an abdominal aortic aneurysm, a life-threatening problem. The nurse would notify the health care provider of this finding immediately!

The nurse is recovering a client who had an esophagogastroduodenoscopy (EGD). What assessment would the nurse perform before determining if the client can have fluids to drink? A. Bowel sounds B. Orientation C. Presence of bruit D. Gag reflex

D. Gag reflex The nurse would check for the return of the client's gag reflex before allowing the client to drink or eat to prevent aspiration.

The nurse is caring for a client who had a liver transplant last week. For which complication will the nurse teach the client and family to monitor? A. Acute kidney injury B. Hypertension C. Pulmonary edema D. Infection

D. Infection The client is at the most risk for rejection of the transplant which can be the result of an infection if not identified and managed effectively. Therefore, the nurse would teach the client and family to report cough, fever, skin redness, and other signs of infection.

A client has recently developed acute sialadenitis. Which intervention does the nurse include in this client's care? A. Request a prescription for an opioid to manage pain. B. Restrict fluids. C. Apply cold compresses. D. Massage the salivary gland.

D. Massage the salivary gland. Sialadenitis is inflammation of a salivary gland. The salivary gland is massaged to stimulate the flow of saliva. This is done by milking the edematous gland with the fingertips toward the ductal opening. To promote the flow of saliva, warm (not cold) compresses are applied to the affected salivary gland. Pain from this condition is managed with NSAIDs, not opioids. Hydration promotes salivary flow.

A client with an intestinal obstruction has pain that changes from a "colicky" intermittent type to constant discomfort. After a complete assessment, what action would the nurse plan implement at this time? A. Change the nasogastric suction level from "intermittent" to "continuous." B. Administer medication for pain based on the client's pain level. C. Position the client in a semi- or high-Fowler position. D. Prepare the client for emergency surgery in collaboration with the health team.

D. Prepare the client for emergency surgery in collaboration with the health team. The appropriate nursing action for a client with intestinal obstruction whose pain changes from "colicky" intermittent type to constant discomfort is to prepare surgery because this change is most likely indicative of perforation or peritonitis and will require immediate surgical intervention.vPain medication may mask the client's symptoms but will not address the root cause. A change in the nasogastric suction rate will not resolve the cause of the client's pain and could be particularly ineffective if a nonvented tube is in use.

A client has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the client about this therapy, the nurse advises the client not to mix enzyme preparations with foods containing which element? A. High fat B. High fiber C. Carbohydrates D. Protein

D. Protein The nurse tells the client not to mix enzyme preparations with foods containing protein because the enzymes will dissolve the food into a watery substance. Pancreatic-enzyme replacement therapy (PERT) is the standard of care to prevent malnutrition, malabsorption, and excessive weight loss. Pancrelipase is usually prescribed in capsule or tablet form and contains varying amounts of amylase, lipase, and protease. No evidence suggests that enzyme preparations should not be mixed with carbohydrates, food with highfat content, and food with high-fiber content.

An older adult client needs additional dietary protein, but refuses to drink the prescribed liquid protein supplements. Which nursing intervention helps the client to increase protein intake? A. Keeping a food and fluid intake diary for at least 3 days B. Administering the liquid supplement with routine medications C. Giving a glucose polymer modular supplement D. Providing protein modular supplements in the form of puddings

D. Providing protein modular supplements in the form of puddings The appropriate intervention to increase the client's protein intake is to provide protein modular supplements in the form of puddings. This would increase the client's protein intake in a format other than a liquid supplement. Administering the liquid supplement with routine medications will not be effective because the client has already refused to drink the supplements. Glucose polymer modular supplements will increase the client's calorie intake but not protein intake. A food and fluid diary will provide information about the client's typical intake pattern, but will not increase protein intake.

How would the home care nurse best modify the client's home environment to manage side effects of lactulose? A. Obtains a walker for the client. B. Rearranges furniture to declutter the home. C. Removes throw rugs to prevent falls. D. Requests a bedside commode for the client.

D. Requests a bedside commode for the client. The home care nurse would modify the client's home environment to manage side effects of lactulose by making a bedside commode available to the client. Lactulose therapy increases the frequency of stools. A bedside commode is especially necessary if the client has difficulty reaching the toilet.

The nurse collaborates with the registered dietitian nutritionist in providing teaching for a client who has ascites from cirrhosis. What daily dietary restriction would the nurse include in the health teaching? A. Calcium B. Potassium C. Magnesium D. Sodium

D. Sodium Mild to moderate sodium restriction is often tried as the first intervention to decrease body fluid retention, including ascites.

A client is admitted to the hospital with right lower quadrant abdominal pain, nausea, and vomiting. What assessment would the nurse monitor to identify a potentially life-threatening complication based on the client's condition? A. Intake and output B. Electrolyte values C. Abdominal assessment D. Vital signs

D. Vital signs The client most likely has appendicitis which can result in perforation of the appendix and peritonitis. If this complication occurs, the client would develop tachycardia and a fever. Therefore, the nurse would monitor for changes in vital signs.