Gastrointestinal Disorders
The nurse prepares to administer morning medications to a client with hepatitis. The client's medications are listed below. Which medication will the nurse withhold? 1. Lamivudine 150 mg orally twice daily 2. Acetaminophen 650 mg orally every day 3. Vitamin B₁₂ one capsule twice daily 4. Phytonadione 5 mg IM once daily
2. Acetaminophen is contraindicated in clients with liver disorders. The medication should be withheld, and the healthcare provider should be contacted regarding this medication. Lamivudine is an antiviral used to treat hepatitis B; B₁₂ is a vitamin supplement used to treat anemia associated with hepatitis; and phytonadione, a form of vitamin K, is used to prevent bleeding when the liver is not functioning properly and does not produce adequate amounts of clotting factors to support clotting.
A client who takes famotidine for gastritis asks the home care nurse which medication is best to take for a headache. Which over-the-counter medication will the nurse suggest for this client? 1. Acetylsalicylic acid 2. Acetaminophen 3. Ibuprofen 4. Naproxen
2. The client is taking famotidine, a histamine-2 receptor antagonist. This implies the client has a disorder characterized by gastrointestinal (GI) irritation. The only medication among the answer choices that is not irritating to the GI tract is acetaminophen. The other medications could aggravate an already existing GI problem.
The nurse will expect to prepare a client for which test to aid in diagnosing a hiatal hernia? 1. Colonoscopy 2. Lower gastrointestinal (GI) series 3. Barium swallow 4. Abdominal x-ray series
3. A barium swallow with fluoroscopy shows the position of the stomach in relation to the diaphragm, which is pertinent in diagnosing a hiatal hernia. A colonoscopy and a lower GI series show disorders of the intestine. An abdominal x-ray series would show structural defects but not necessarily a hiatal hernia, unless it is sliding or rolling at the time of the x-ray.
A client has just been given a prescription for diphenoxylate hydrochloride-atropine sulfate. Which information will the nurse provide about the use of this medication? 1. Drooling is a side effect of this medication 2. Irritability is an adverse effect of the medication 3. This medication can be habit-forming 4. Finish all of the medicine as prescribed
3. Diphenoxylate hydrochrolide-atropine sulfate is an antidiarrheal. This client should not exceed the recommended dose of this medication because it may be habit-forming. Because this medication is an antidiarrheal, it should not be taken until it is finished. Side effects of the medication include dry mouth and drowsiness, not drooling or irritability.
The nurse is caring for a client with alcohol-related acute pancreatitis. Which intervention is most appropriate to reduce the exacerbation of pain? 1. Lying supine 2. Taking aspirin 3. Eating low-fat foods 4. Abstaining from alcohol
4. Abstaining from alcohol is imperative to reduce injury to the pancreas; in fact, it may be enough to completely control pain. Lying supine usually aggravates the pain because it stretches the abdominal muscles. Taking aspirin can cause bleeding in hemorrhagic pancreatitis. During an attack of acute pancreatitis, the client usually is not allowed to ingest anything orally.
The nurse is reviewing laboratory results for a client with peritonitis. Which result will the nurse expect to observe? 1. Partial thromboplastin time (PTT) longer than 100 seconds 2. Hemoglobin level below 10 g/dL (100 g/L) 3. Potassium level above 5.5 mEq/L (5.5 mmol/L) 4. White blood cell (WBC) count above 15,000/µL (15 ✕ 10⁹/L)
4. Because of infection, the client's WBC count would be elevated. A PTT longer than 100 seconds may suggest disseminated intravascular coagulation, a serious complication of septic shock. A hemoglobin level below 10 mg/dL (100 g/L) may occur from hemorrhage. A potassium level above 5.5 mEq/L (5.5 mmol/L) may suggest renal failure.
When providing discharge education for a client with ulcerative colitis, the nurse emphasizes the importance of regular examinations. Which statement by the client indicates a proper understanding of the instructions? 1. "People who have ulcerative colitis tend to have more problems with their teeth than those with other GI problems." 2. "I should report any rectal bleeding to my healthcare provider because this could indicate I have developed an ulcer." 3. "My healthcare provider needs to see me frequently because my chance of developing appendicitis is higher." 4. "I will need to have routine screenings because having ulcerative colitis places me at risk for colon cancer."
4. Clients with chronic ulcerative colitis, granulomas, and familial polyposis have an increased risk of developing colon cancer. Clients with ulcerative colitis do not have an increased risk of developing the other disorders.
When counseling a client in the ways to prevent cholecystitis, which guideline is appropriate for the nurse to include? 1. Eat low-protein foods. 2. Eat high-fat, high-cholesterol foods. 3. Limit exercise to 10 minutes per day. 4. Keep weight proportional to height.
4. Obesity is a known cause of gallstones, and maintaining a recommended weight helps to protect against cholecystitis. Excessive dietary intake of cholesterol is associated with the development of gallstones in many people. Dietary protein is not implicated in cholecystitis. Liquid protein and low-calorie diets (with rapid weight loss of more than 5 lb [2.3 kg] per week) are implicated as the cause of some cases of cholecystitis. Regular exercise (30 minutes/three times per week) may help to reduce weight and improve fat metabolism.
The nurse is completing the intake record for a client with chronic pancreatitis. The client has the intake during the previous 8 hours listed below. Intake: 4 oz apple juice 1/2 cup fruit-flavored gelatin 6 oz water 500 mL 0.45% sodium chloride IV How many milliliters will the nurse record as the client's intake? Record your answer using a whole number.
920 mL. Fluid intake for this client includes 4 oz (120 mL) apple juice, 1/2 cup (120 mL) fruit-flavored gelatin, 6 oz (180 mL) water, and 500mL 0.45% sodium chloride IV for a total of 920 mL.
A client with irritable bowel syndrome (IBS) is reporting pain. The nurse will expect to administer which medication to help alleviate the underlying cause of the client's pain? 1. Acetaminophen 2. Morphine sulfate 3. Prednisone 4. Docustate sodium
3. The pain of IBS is caused by inflammation, which steroids can reduce. Acetaminophen has little effect on the pain, and opiates will not treat its underlying cause. Stool softeners are not necessary.
To reduce occurrence of dumping syndrome, which action will the nurse instruct a client to take? 1. Sip fluids while eating meals. 2. Consume three meals daily. 3. Rest after meals for 20 to 30 minutes. 4. Eat high-carbohydrate, low-fat foods.
3. To reduce occurrences of dumping syndrome, clients should be taught to lie down for 20 to 30 minutes after eating; take fluids between meals only; eat smaller amounts more frequently in a semi-recumbent position; follow a low-carbohydrate diet, with high-protein and moderate-fat foods; and avoid sweets.
The nurse is planning care for a client following a gastric resection. Which item is the nurse's priority? 1. Body image 2. Nutritional needs 3. Skin care 4. Spiritual needs
2. After gastric resection, a client may require total parenteral nutrition or jejunostomy tube (J-tube) feedings to maintain adequate nutritional status. Body image is not much of a problem for this client because clothing can cover the incision site. Wound care of the incision site is necessary to prevent infection; otherwise, the skin should not be affected. Spiritual needs may be a concern, depending on the client, and should be addressed as the client demonstrates readiness to share concerns.
The nurse is caring for a client during the initial days following ostomy surgery for ulcerative colitis. Which area of care is the nurse's priority? 1. Body image 2. Ostomy care 3. Sexual concerns 4. Skin care
2. Although all of these are concerns the nurse should address, it is crucial that the client is able to safely manage the ostomy before discharge.
The nurse is caring for a client who has undergone an open surgical procedure for hiatal hernia repair. Which nursing intervention is priority? 1. Turn and reposition the client. 2. Encourage incentive spirometer use. 3. Palpate the bladder for distention. 4. Administer pain medications.
2. Although all of these are concerns the nurse should address, it is crucial the client use the incentive spirometer to maintain lung expansion and prevent atelectasis.
Which nursing intervention is priority when caring for a client with esophageal varices? 1. Recognizing hemorrhage 2. Controlling blood pressure 3. Encouraging nutritional intake 4. Provide education about varices
1. Recognizing the rupture of esophageal varices, or hemorrhage, is the focus of nursing care because the client could succumb to this quickly. Controlling blood pressure is also important because it helps reduce the risk of variceal rupture. It is also important to educate the client on what varices are and what foods the client should avoid, such as spicy foods.
A client with a liver disorder is having an invasive procedure. It is priority for the nurse to review which of the client's laboratory tests? 1. Coagulation studies 2. Liver enzyme levels 3. Serum chemistries 4. White blood cell count
1. The liver produces coagulation factors. If the liver is affected negatively, production of these factors may be altered, placing the client at risk for hemorrhage. The other laboratory tests should be monitored as well, but the results may not necessarily relate to the safety of the procedure.
After a laparoscopic cholecystectomy, a client reports abdominal pain. The nurse prepares to administer morphine sulfate 2 mg. The label on the morphine vial reads 10 mg/mL. How many milliliters will the nurse administer to the client? Record your answer using one decimal place.
0.2 mL. This formula is used to calculate drug dosages: Dose on hand / Quantity on hand = Dose desired / x In this example, the formula for calculating the amount of morphine is as follows: 10 mg / mL = 2 mg / x x = 0.2 mL
The nurse is preparing to obtain a stool sample from a client admitted with suspected hepatitis. Which precaution(s) will the nurse take when caring for this client? Select all that apply. 1. Wear gloves 2. Perform hand hygiene 3. Wear a gown 4. Wear a mask 5. Wear a high-filtration mask 6. Use of an alcohol-based hand sanitizer
1, 2, 3, 6. Hepatitis transmission occurs via the fecal-oral route, exposure to infected blood feces and urine, and through the ingestion of contaminated food or liquids. To collect a specimen when the type of hepatitis is unknown, the nurse should take these precautions: wear gloves and a gown, perform meticulous hand washing, and use an alcohol-based hand sanitizer to reduce the possibility of spreading infection. A mask and goggles are not needed unless there is the possibility of splashing (e.g., when performing gastric lavage; flushing G-tubes or catheters; suctioning; and when working with clients who are vomiting, have explosive diarrhea, or are vomiting/coughing up blood).
Which finding(s) will the nurse expect when assessing a client admitted with suspected appendicitis? Select all that apply. 1. Loss of appetite 2. Nausea and vomiting 3. Sudden cessation of pain 4. Yellow pigment to the skin 5. Right lower quadrant pain 6. Abdominal rigidity and tenderness
1, 2, 5. The pain begins in the periumbilical region and then shifts to the lower right quadrant (McBurney's point) and becomes steady. The pain may range from moderate to severe. Other signs and symptoms include anorexia, nausea, and vomiting. Sudden cessation of the pain indicates rupture of the appendix and requires surgery. Yellow-pigmented skin (jaundice) is a sign of hepatitis or liver failure/cirrhosis. Abdominal rigidity and tenderness are signs of peritonitis.
A client is brought to the emergency room with suspected cholecystitis. Which finding(s) is characteristic of this diagnosis? Select all that apply. 1. Epigastric pain radiating to the back 2. Indigestion after eating fatty foods 3. Blood-tinged emesis 4. Abdominal distention 5. Itching and dry skin.
1, 2. Cholecystitis has characteristic symptoms of epigastric pain radiating to the back and indigestion after eating fatty foods. Hematemesis, or blood in the vomit, may be a symptom of cirrhosis, gastritis, or peptic ulcer disease but is not associated with cholecystitis. Itching, dry skin is associated with pancreatic cancer. Abdominal bloating is associated with irritable bowel syndrome.
Which finding(s) in a client with Crohn's disease indicates early signs of dehydration? Select all that apply. 1. Poor skin turgor 2. Decreased creatinine 3. Low specific gravity 4. Elevated blood pressure 5. Increased heart rate 6. Bradypnea
1, 5. Signs and symptoms of dehydration include poor skin turgor, increased heart rate, concentrated urine, and decreased blood pressure. Other signs are dry skin and mouth, sunken eyes, and lethargy. Decreased creatinine level and bradypnea are not early signs of dehydration.
Several children at a day care center have been infected with the hepatitis A virus. Which instruction will the nurse include when educating the day care staff? 1. Hand washing after diaper changes 2. Isolation of the sick children 3. Using masks during contact with children 4. Sterilization of all eating utensils
1. Children in day care centers are at risk of hepatitis A infection, which is transmitted via the fecal-oral route due to poor hand hygiene practices and sanitation. Isolation of sick children, use of masks during contact, and sterilization of all eating utensils would not be useful in breaking the chain of infection.
The nurse provides education to a teenage client and parents about Crohn's disease and the dietary changes needed. Which statement by the parents indicates an accurate understanding of the child's dietary needs? 1. "We will need to include plenty of calories in our child's diet." 2. "We will need to make certain our child's food is gluten-free." 3. "We will only give our child foods that are low in sodium." 4. "We will be sure to provide foods high in fiber for our child."
1. Crohn's disease is an inflammatory bowel disease that causes diarrhea with subsequent weight loss and malnutrition. A high-calorie, nutritious diet helps replenish nutrients that are lost through the affected bowel. A gluten-free diet is appropriate for a client with celiac disease, not Crohn's disease. A client with Crohn's disease does not need to restrict dietary sodium but should avoid high-fiber foods during a flare-up of the disease, because these foods can contribute to bowel irritation.
The nurse assesses a client with ascites from liver cirrhosis who is taking spironolactone. Which finding indicates to the nurse the client is responding well to the medication? 1. Decrease in abdominal circumference 2. Increase in urine output to 50 mL/hour 3. Serum potassium level of 5.8 mEq/L (5.8 mmol/L) 4. Improvement in breathing pattern
1. In clients with ascites, spironolactone is used to reduce ascites and portal hypertension that causes the ascites. The medication helps to reduce the accumulation of fluid in the abdominal region and other regions of the body, which would be indicated by a decrease in abdominal circumference. Spironolactone is a potassium sparing diuretic, which can cause potassium levels to rise dramatically in clients, so this should be monitored. Elevation of serum potassium levels above the normal range should be reported. Increased urine output is an expected finding but does not indicate how well the client's ascites is responding to the medication. Breathing pattern is also not an indicator of the client's response to spironolactone.
A client with cirrhosis is prescribed lactulose 2 tablespoons orally every day, so start if indicated by the client's lab results or signs and symptoms. Which finding indicates to the nurse a need to administer the medication? 1. Increasing confusion 2. Potassium level 5.6 mEq/dL (5.6 mmol/L) 3. Blood pressure 158/94 mm Hg 4. Increase in ascites
1. Lactulose is given when the client's ammonia level is elevated. The only sign of elevation in the ammonia levels is increasing confusion, which can indicate hepatic encephalopathy. Elevation in blood pressure and potassium level is not an indicator of elevated ammonia, nor is an increase in ascites.
A client with colon cancer asks the nurse, "Why am I getting radiation therapy before surgery?" Which response by the nurse is most appropriate? 1. "It helps reduce the size of the tumor." 2. "It eliminates the malignant cells." 3. "The chances of curing the cancer are improved." 4. "The therapy helps to heal the bowel after surgery."
1. Radiation therapy is used to treat colon cancer before surgery to reduce the size of the tumor, making it easier to resect. Radiation therapy cannot eliminate the malignant cells (though it helps define tumor margins), is not curative, and could slow postoperative healing.
A client with osteoarthritis is admitted to the hospital with peptic ulcer disease. Which finding(s) will the nurse expect to assess in this client? Select all that apply. 1. Localized, colicky periumbilical pain 2. History of nonsteroidal anti-inflammatory drug (NSAID) use 3. Epigastric pain relieved by antacids 4. Tachycardia 5. Nausea 6. Weight loss 7. Low-grade fever
2, 3, 5, 6. Peptic ulcer disease is characterized by nausea, hematemesis, melena, weight loss, and left-sided epigastric pain—occurring 1 to 2 hours after eating—that is relieved with antacids. NSAID use is also associated with peptic ulcer disease. Appendicitis begins with generalized or localized colicky periumbilical or epigastric pain, followed by anorexia, nausea, a few episodes of vomiting, low-grade fever, and tachycardia.
The nurse assesses a client with colon cancer. Which finding(s) will the nurse report immediately to the healthcare provider? Select all that apply. 1. Change in bowel habits 2. A palpable abdominal mass 3. Fecal smears in client's underwear 4. Reports of rectal bleeding 5. Diarrhea and constipation 6. Abdominal swelling and tenderness
2, 3, 6. A mass is not usually palpable in the abdomen unless this is an advanced case. The fecal smearing is a sign of incontinence caused by loss of sphincter control/tone or diarrhea. Abdominal swelling would not be expected with colon cancer and thus may be a sign of another gastrointestinal (GI) problem. The key signs and symptoms of colon cancer are: change in bowel habits and shape of stools; abdominal pain (bloating, gas, cramps), diarrhea, and constipation; bloody stools or rectal bleeding; and weight loss from GI irritation.
A client undergoes a barium swallow fluoroscopy that confirms gastroesophageal reflux disease (GERD). Based on this diagnosis, the nurse will instruct the client to take which action(s)? Select all that apply. 1. Follow a high-fat, low-fiber diet. 2. Avoid caffeine and carbonated beverages. 3. Sleep with the head of the bed flat. 4. Stop smoking. 5. Take antacids 1 hour after meals and at bedtime. 6. Limit alcohol consumption to one drink per day.
2, 4, 5. The nurse should instruct the client with GERD to follow a low-fat, high-fiber diet. Caffeine, carbonated beverages, alcohol, and smoking should be avoided because they aggravate GERD. In addition, the client should take antacids as prescribed (typically 1 hour after meals and at bedtime). Lying down with the head of the bed elevated, not flat, reduces intra-abdominal pressure, thereby reducing the symptoms of GERD.
The nurse is caring for a client with acute pancreatitis. The nurse knows it is most important to monitor the client closely for which complication? 1. Increased appetite 2. Vomiting 3. Hypoglycemia 4. Pain.
2. Acute pancreatitis is commonly associated with fluid isolation and accumulation in the bowel secondary to ileus or peripancreatic edema. Fluid and electrolyte loss from vomiting is the primary concern. A client with acute pancreatitis may have increased pain on eating and is unlikely to demonstrate an increased appetite. A client with acute pancreatitis is at risk for hyperglycemia, not hypoglycemia. Although pain is an important concern, it is less significant than vomiting.
The nurse is reviewing data in a client's chart suspected to have cholecystitis. Which test result will help confirm a diagnosis of cholecystitis? 1. Results of a colonoscopy 2. Results of an abdominal ultrasound 3. Results of barium swallow 4. Results of endoscopy
2. An abdominal ultrasound can show whether the gallbladder is enlarged, gallstones are present, the gallbladder wall is thickened, or distention of the gallbladder lumen is present. A colonoscopy looks at the inner surface of the colon. A barium swallow looks at the stomach and the duodenum. Endoscopy looks at the esophagus, stomach, and duodenum.
A client with gastric caner is scheduled for a gastric resection. Preoperative, which nursing intervention is priority for this client? 1. Discharge planning 2. Correction of nutritional deficits 3. Prevention of deep vein thrombosis 4. Instruction regarding radiation treatment
2. Clients with gastric cancer commonly have nutritional deficits and may be cachectic. Discharge planning before surgery is important, but correcting the nutritional deficit is the priority. Prevention of deep vein thrombosis also is not the priority before surgery, though it assumes greater importance after surgery. At present, radiation therapy has not been proven effective for gastric cancer, and teaching about it preoperatively would not be appropriate.
A client is prescribed 1 g of neomycin sulfate orally every hour times 4 doses followed by 1 g orally every 4 hours for the remaining balance of the 24 days. Neomycin sulfate tablets are available in 500 mg per tablet. How many tablets will the nurse administer the client for each dose? Record your answer using a whole number.
2. First, convert from g to mg. 1 g to mg: 1,000 mg = 1 g, therefore the prescription is for 1,000 mg of neomycin. Then use this formula for calculating the number of tablets to administer: Desired dose / Form on hand = Dose 1000 mg / 500 mg = 2 tablets
Oral lactulose is prescribed for a client with a hepatic disorder, and the nurse provides instructions to the client regarding this medication. Which statement by the client indicates a correct understanding of the instructions? 1. "Increasing my fluid intake will make the medication work better." 2. "I should remain close to the restroom when I take the medication." 3. "I need to include more high-fiber foods in my diet." 4. "I should call my healthcare provider immediately if I start having nausea."
2. Lactulose retains ammonia in the colon and promotes increased peristalsis and bowel evacuation, expelling ammonia from the colon. Therefore, the client should remain close to the restroom when taking the medication. It should be taken with water or juice to aid in softening the stool. An increased fluid intake and a high-fiber diet would promote defecation but is unrelated to the medication and why it is being given to this client. Nausea is a side effect and the client should be instructed to drink cola and eat unsalted crackers or dry toast. It is not necessary to notify the healthcare provider should nausea occur.
The nurse obtains data from a client admitted with a diagnosis of cirrhosis and ascites. The client is lethargic and confused. Which action will the nurse take? 1. Elevate the head of the bed. 2. Notify the healthcare provider. 3. Reorient to time, place, and circumstance. 4. Apply 2 L of oxygen via nasal cannula.
2. Notify the healthcare provider for changes in the level of consciousness (observe for behavioral or personality changes, increased confusion, stupor, lethargy, hallucinations, and neuromuscular dysfunction), which indicate hepatic encephalopathy due to increased ammonia levels. Ammonia is a byproduct of the metabolism of nitrogen-containing compounds and is neurotoxic. Elevating the head of the bed would not improve confusion and lethargy and may be appropriate if the client was semiconscious. Reorientation would not improve the confusion, and although O₂ may also be needed, it would not fix the problem (elevated ammonia and possible swollen brain).
A client diagnosed with peptic ulcer disease is prescribed ranitidine. The client asks the nurse, "What is the action of ranitidine?" Which response by the nurse is appropriate? 1. "It neutralizes stomach acid." 2. "It reduces acid secretions." 3. "It stimulates gastrin release." 4. "It protects the mucosal barrier."
2. Ranitidine is a histamine-2 receptor antagonist, which reduces acid secretions by inhibiting gastrin secretion. Antacids neutralize acid, and mucosal barrier fortifiers protect the mucosal barrier.
Which intervention will the nurse provide for a client admitted with a perforated gastric ulcer? 1. Administration of antacids 2. Fluid and electrolyte replacement 3. Removal of nasogastric (NG) tube 4. Histamine-2 (H₂) receptor antagonist administration
2. The client should be treated with fluid and electrolyte replacement, blood products, and antibiotics. NG tube suctioning may also be performed to prevent further spillage of stomach contents into the peritoneal cavity. Antacids and H₂ receptor antagonists are not helpful in this situation.
The nurse is caring for a client immediately after a liver biopsy. Which finding indicates to the nurse the client is experiencing a post-procedure complication? 1. Abdominal cramping 2. Weak, rapid pulse 3. Onset of vomiting 4. Temperature of 100.1ºF (37.8ºC)
2. The liver is so vascular that taking a biopsy would cause the client to hemorrhage. Hemorrhage may be hidden, frank, or slow; therefore, monitor the dressing for visible bleeding and monitor the client's vital signs (changes in pulse rate, quality, and rhythm and a drop in blood pressure). The client may experience some discomfort but typically not cramping. Nausea and vomiting may be present and infection may occur, but not immediately after the procedure.
A client is prescribed carmustine. Which nursing intervention is appropriate when caring for this client? 1. Allow the client to hold the medication in the hand. 2. Give an antiemetic before giving carmustine. 3. Monitor the client's electrolyte levels daily. 4. Apply a heart monitor to assess cardiac function.
2. The nurse would give an antiemetic before administering carmustine to reduce nausea. The medication should not touch skin because it may stain the skin brown. The nurse should monitor the client's liver, renal, and pulmonary function tests. Electrolytes should be monitored when taking cisplatin. Cardiac function should be monitored when taking doxorubicin.
A client had a gastroscopy while under anesthesia. Before resuming the client's oral fluid intake, which action will the nurse take first? 1. Listen for bowel sounds. 2. Determine whether the client can talk. 3. Check for a gag reflex. 4. Determine the client's mental status.
3. After a gastroscopy, the nurse should check for the presence of a gag reflex before giving oral fluids. This step is essential to prevent aspiration. The presence of bowel sounds, the ability to speak, and mental status within normal limits would not ensure the presence of a gag reflex.
A client with acute pancreatitis is admitted to the hospital. Which healthcare provider prescription will the nurse question? 1. Start a normal saline (0.9% NaCl) IV to run at 100 mL/hour. 2. Give meperidine 4 mg IM every 6 hours PRN pain. 3. Monitor blood glucose levels every 6 hours. 4. Connect NG tube to low intermittent suction.
2. The use of meperidine in the treatment of clients with pancreatitis and other biliary disorders is contraindicated because it causes spasms of the sphincter of Oddi. Morphine is one of the medications of choice used to treat pain associated with biliary disorders. IV fluids are given to prevent fluid volume deficit. Blood glucose monitoring is indicated because the pancreas is responsible for the release of insulin that is needed for glucose metabolism; when inflamed the organ does not function normally. Connecting the NG tube to low intermittent suction is indicated for very ill clients or for those with vomiting that is intractable.
Which symptoms reported by a client leads to the nurse to suspect gastric cancer? 1. Abdominal cramping 2. Constant hunger 3. Feeling of fullness 4. Weight gain
3. The client with gastric cancer may report a feeling of fullness in the stomach but not enough to seek medical care. Abdominal cramping is not associated with gastric cancer. Anorexia and weight loss (not increased hunger or weight gain) are common symptoms of gastric cancer.
Which intervention(s) will the nurse perform when caring for a client with acute gastritis? Select all that apply. 1. Maintain bed rest. 2. Prepare for gastric resection. 3. Monitor laboratory values. 4. Administer parenteral nutrition. 5. Assess for changes in abdominal status. 6. Administer antispasmodics as prescribed.
3, 5. The nurse will monitor lab values for changes in hematocrit, hemoglobin, and electrolytes. The nurse will also assess for changes in abdominal status, which includes increased tenderness, distention, pain, bowel sounds, etc. Gastric resection is an option only when serious erosion has occurred. Antispasmodics are for irritable bowel syndrome. Bed rest is not necessary unless the client is unstable, and neither is parenteral nutrition.
A client is suspected of having gastric cancer. The nurse will expect to prepare the client for which diagnostic test? 1. Barium enema 2. Colonoscopy 3. Gastroscopy 4. Serum chemistry levels
3. A gastroscopy allows direct visualization of the tumor. A barium enema or colonoscopy would help to diagnose colon cancer. Serum chemistry levels do not contribute data useful to the assessment of gastric cancer.
The nurse is providing discharge education for a client treated for acute diverticulitis. Which statement by the client indicates the client understands the discharge instructions? 1. "I will reduce my fluid intake." 2. "I will decrease the fiber in my diet." 3. "I will take all of my antibiotics." 4. "I will exercise to increase my intra-abdominal pressure."
3. Antibiotics are used to reduce inflammation. The client with acute diverticulitis typically is not allowed anything orally until the acute episode subsides. Parenteral fluids are given until the client feels better; then it is recommended the client drink eight 8-ounce (237 mL) glasses of water per day and gradually increase fiber in the diet to improve intestinal motility. During the acute phase, activities that increase intra-abdominal pressure should be avoided to decrease pain and the chance of intestinal obstruction.
Which intervention will the nurse expect to perform while caring for a client with acute pancreatitis? 1. Institute transmission-based precautions. 2. Administer sedatives to control anxiety. 3. Withhold oral intake as prescribed. 4. Encourage the client to ambulate.
3. Clients admitted with pancreatitis are acutely ill and should be NPO on admission. Maintain NPO status as prescribed by the healthcare provider. Transmission-based precautions are not indicated because this is not an infectious process spread by contact with body fluids or by airborne or direct contact modes of transmission. Administer morphine or hydromorphone for pain relief, not sedatives. During acute pancreatitis, the client is on bed rest and not encouraged to ambulate.
While caring for a client with cirrhosis, the nurse reviews the laboratory data in the client's chart. Which data will the nurse report immediately to the primary healthcare provider? 1. White blood cells (WBC) 12,800 mm³ (12.8 ✕ 10⁹/L) 2. Red blood cells (RBC) 5.3 mm³ (5.03 ✕ 10¹²/L) 3. Prothrombin time (PT) 18 seconds 4. Total bilirubin 0.6 mg/dL (10.26 µmol/L)
3. Clotting factors may not be produced normally when a client has cirrhosis, increasing the potential for bleeding. PT measures the time required for a fibrin clot to form and is normally 11 to 13.5 seconds. The WBC count can be elevated in acute cirrhosis but is not always altered. The total bilirubin level would be elevated in cirrhosis of the liver. The elevation of bilirubin levels is what causes jaundice. The RBC count is not abnormal.
The nurse is caring for a client diagnosed with hepatitis A. Which client statement indicates the nurse's education about hepatitis A was effective? 1. "I will wear a mask all of the time." 2. "I should keep my door closed." 3. "I should wash my hands frequently." 4. "I will save part of my sandwich for my wife."
3. Hepatitis A is transmitted through the fecal-oral route, so frequent hand washing, especially after elimination, helps prevent transmission. It is not necessary to wear a mask or keep the door closed. Sharing food allows for viral transmission.
The nurse administers lactulose to a client with cirrhosis. Which assessment finding indicates to the nurse the medication is effective? 1. Four or more loose stools in 24 hours 2. Serum sodium level of 135 mEq/L (135 mmol/L) 3. Improvement in mental status 4. Reduction in abdominal ascites
3. Lactulose, used to treat portal-systemic encephalopathy in clients with cirrhosis, works by acidifying colonic contents and trapping ammonia in the colon. The laxative action of lactulose assists in expelling the ammonia from the colon. This leads to a reduction in serum ammonia levels and improvements in mental and cardiac status. Lactulose causes diarrhea as a side effect and is expected—but it is not the intended effect of the medication. Adverse effects of lactulose are increased serum sodium and decreased serum potassium levels. Abdominal ascites is not affected by this medication.
The nurse is caring for a client with chronic pancreatitis. Which response by the client indicates discharge education has been effective? 1. "I will eat a low-carbohydrate diet." 2. "I can have an occasional glass of wine." 3. "I will take pancreatic enzymes with each meal." 4. "I will take pancreatic enzymes before breakfast and at bedtime."
3. Oral pancreatic enzymes are taken with each meal to aid digestion and control steatorrhea. The client should adhere to a low-fat (not low-carbohydrate) diet. The client should eliminate alcohol from the diet completely, as it would continue to cause pancreatic damage.
The nurse admits a client with Crohn's disease who is experiencing an exacerbation. Which intervention is the nurse's priority? 1. Maintain current weight 2. Encouraging ambulation 3. Promoting bowel rest 4. Providing mouth care
3. Promoting bowel rest is the priority during an acute exacerbation. This is accomplished by decreasing the activity and initially putting the client on nothing-by-mouth (NPO) status. Weight loss may occur and providing mouth care may be indicated, but the priority is bowel rest.
The nurse receives shift report on a client who underwent a bowel resection 2 days ago and reports sudden onset of pain unrelieved by medications. The client's abdomen is rigid and bowel sounds are absent. Which action will the nurse take next? 1. Administer an increased dosage of pain medication. 2. Perform an in-depth abdominal assessment. 3. Obtain a complete set of vital signs. 4. Notify the client's primary healthcare provider.
3. The client is exhibiting signs of peritonitis. The nurse needs a set of vital signs to make sure the client is not going into shock from hidden bleeding before calling the healthcare provider. An in-depth abdominal assessment is not necessary based on the client's current status. Once the vital signs are gathered, then the healthcare provider should be notified. The client is already receiving pain medication, and is not relieving the pain. The nurse would assess for complications before increasing the medication dosage.
A client who underwent a colon resection 1 week ago calls the nurse and says, "My incision is wide open on one side and something is poking out of it." Which instruction is priority for the nurse to give this client? 1. "Drive to the nearest emergency department to be evaluated by a healthcare provider." 2. "Wrap an ace bandage around your abdomen and monitor for bleeding." 3. "Place wax paper over the wound and call an ambulance immediately." 4. "Apply petroleum jelly gauze over the wound and come to the office."
3. The client is experiencing wound evisceration (occurs 5 to 7 days after surgery). The nurse should instruct the client to cover the wound with wax paper to maintain moisture of the internal organs and call 911 for ambulance transport to the hospital. Petroleum products, an elastic bandage, and driving to the hospital are contraindicated in the care of this client.
The nurse interviews a client presenting to the clinic with reports of nausea, dark urine, weight loss, and fatigue for the past 2 weeks. Which additional information will the nurse gather from this client related to the presenting symptoms? 1. Presence of anorexia 2. 24-hour dietary history 3. Number and color of stools 4. Use of over-the-counter medications
3. Weight loss, nausea, fatigue, and dark urine lasting 2 weeks or more are signs of hepatitis. The nurse should question the client about the presence of clay-colored stools. This additional symptom would prompt the nurse to look at the eyes for the presence of a yellow sclera (jaundice). A 24-hour diet history is not appropriate in a case in which the nausea has been ongoing for 2 weeks but is useful in cases in which nausea and vomiting have just started. A client who has nausea does not eat as much as he or she normally would if not nauseated. Asking about loss of appetite does not add to what the nurse already knows in the presenting report. Use of over-the-counter medications is not related to the client's presenting symptoms.
The nurse is educating a 52-year-old client on cancer screenings. The nurse emphasizes the client needs which diagnostic test annually after age 50 years to screen for colon cancer? 1. Abdominal computed tomography (CT) scan 2. Abdominal x-ray 3. Colonoscopy 4. Fecal occult blood test
4. Annual screenings for colon cancer using fecal occult blood tests beginning at age 50 years are recommended. Surface blood vessels of polyps and cancers are fragile and often bleed with the passage of stools, so a fecal occult blood test should be performed annually. CT scan and abdominal x-ray can help establish tumor size and metastasis. A colonoscopy can help locate a tumor as well as polyps and can be used for screenings every 10 years.
Which instruction will the nurse give to a client with pancreatitis during discharge education? 1. Consume high-fat meals. 2. Consume low-calorie meals. 3. Limit daily intake of alcohol. 4. Avoid beverages that contain caffeine.
4. Caffeine must be avoided because it is a stimulant, which would further irritate the pancreas. A client with pancreatitis must avoid all alcohol because chronic alcohol use is one of the causes of pancreatitis. The diet should be low in fat and high in calories, especially from carbohydrates.
The nurse is providing discharge instructions to a client with chronic cholecystitis. Which response by the client indicates the education has been effective? 1. "I need to rest more during the day." 2. "I should avoid taking antacids for heartburn." 3. "I should increase the fat intake in my diet." 4." I will take my anticholinergic medications as prescribed."
4. Conservative therapy for chronic cholecystitis includes weight reduction by increasing physical activity, a low-fat diet, antacid use to treat dyspepsia, and anticholinergic use to relax smooth muscles and reduce ductal tone and spasm, thereby reducing pain.
Which manifestations reported by a client will lead the nurse to suspect Crohn's disease affecting the small intestine? 1. Nausea accompanied by vomiting 2. Weight gain and fluid retention 3. Diarrhea alternating with constipation 4. Stools that have an oily consistency
4. Excessive amounts of fat in the feces due to malabsorption can occur with Crohn's disease. Weight loss (not weight gain) due to malabsorption is common. Nausea, vomiting, diarrhea, and constipation are symptoms of many different GI disorders. Fluid loss (not fluid retention) occurs with Crohn's disease due to diarrhea.
A client is brought to the emergency room with severe nausea, vomiting, and diarrhea for 36 hours. The client is admitted for gastroenteritis. Which action will the nurse take first? 1. Initiate NPO status for the client. 2. Encourage sips of an electrolyte-replacement drink. 3. Administer promethazine 25 mg orally. 4. Insert an IV and give fluids as prescribed.
4. First, the nurse would start an IV and administer fluids to restore the client's fluid imbalance. An antiemetic, such as promethazine, can be given to control nausea and vomiting. The nurse would make the client NPO until 2 to 3 hours after the nausea and vomiting subsided. Sips of an electrolyte-replacement drink can be offered after the antiemetic to increase the chances of the client keeping the fluids down.
Which nursing intervention is priority during the immediate postoperative care of a client who has undergone gastric surgery? 1. Monitor gastric pH. 2. Assess bowel sounds. 3. Provide nutritional support. 4. Monitor for hemorrhage.
4. Hemorrhage is a postoperative complication detected by monitoring vital signs, abdominal dressings, and nasogastric tube drainage for bleeding. Monitor the postoperative client closely for signs and symptoms of hemorrhage, such as bright red blood in the nasogastric tube suction, tachycardia, or a drop in blood pressure. Monitoring gastric pH helps to evaluate the need for histamine-2 receptor antagonists but is not a priority. Bowel sounds may not return for up to 72 hours postoperatively. Providing nutritional support is not an immediate priority.
The nurse assesses a client at the clinic for follow-up after being treated in the hospital for pancreatitis. When assessing the client, which finding will the nurse immediately report to the healthcare provider? 1. Dry, itchy, and scaly skin 2. Abdomen bloated but non-tender 3. Greenish-yellow bruise over the IV site 4. Shortness of breath with minimal exertion
4. In pancreatitis, the nurse should watch for signs and symptoms of worsening of the condition: shortness of breath with minimal exertion; respiratory failure and tachycardia (signs of hypocalcemia and hypomagnesemia); and acute changes in abdominal symptoms/size. The other findings are expected and are not a reason to be alarmed.
The nurse provides discharge education to a client with Crohn's disease. Which long-term symptom management instruction will the nurse include in the teaching? 1. "Increase your intake of fiber and take a probiotic daily." 2. "Join a support group and exercise three times a day." 3. "Take your multivitamin and corticosteroid for a year." 4. "Keep a food diary and eat small, frequent meals."
4. Keeping a food diary to determine foods that produce or aggravate symptoms and eating small, frequent meals help to manage symptom flare-ups long term. Managing stress with exercise can increase the time between flare-ups; however, joining a support group may not help to manage symptoms. Increased fiber, fatty foods, dairy products, alcohol, smoking, and caffeine can aggravate symptoms. Probiotics have not shown any benefit with the management of Crohn's disease symptoms. Steroids are not for long-term use. Short-term (3 to 4 months) steroid therapy is used with immune suppressants to induce disease remission until immune suppressant therapy can maintain the disease in remission. A multivitamin does not help to manage symptoms.
When talking with a client, which finding leads the nurse to suspect the client is at risk for developing chronic gastritis? 1. The client consumes an occasional glass of wine with dinner 2. The client is finishing a 7-day course of amoxicillin for an infection 3. The client is 28 years old with a history of gallbladder disease 4. The client is taking naproxen three times a day for a sports injury
4. Overuse of non-steroidal anti-inflammatory drugs (such as naproxen), alcohol overuse, and bacterial colonization with Helicobacter pylori in the gastrointestinal tract can lead to chronic atrophic gastritis. Conditions that allow reflux of bile acids into the stomach can also cause gastritis. Chronic gastritis can occur at any age but is more common in older adults; antibiotics, occasional alcohol consumption, and gallbladder disease are not causes of gastritis.
The nurse is caring for a client who just underwent bowel resection and has a nasogastric (NG) tube connected to low intermittent suction. Which nursing intervention will the nurse include in the plan of care? 1. Flush the NG with saline once per shift 2. Offer ice chips to moisturize the mouth. 3. Secure the suction tubing to the bed rail. 4. Provide meticulous mouth care as needed.
4. Provide mouth care for clients who are receiving enteral or parenteral feedings or NPO and are not able to perform for themselves. The NG tube should not be flushed once per shift; the healthcare provider's prescription would determine the frequency of flushing if prescribed. A client who is on gastric suctioning should be NPO. Avoid securing the suction tubing to the bed rail; doing so may cause the NG tube to become dislodged if the bedrail is let down.
The nurse is assigned to care for a client with peptic ulcer disease. Which finding will the nurse report immediately to the primary healthcare provider? 1. Black, tarry stools 2. Abdominal pain 3. Loss of appetite 4. Tachycardia
4. Pulse rate is a cardiovascular system assessment and tachycardia is an indicator of hidden bleeding, as well as a compensatory mechanism when a client is in the early stage of shock. Loss of appetite can occur from a number of factors and is not something to be alarmed about. Abdominal pain and black, tarry stools are expected with peptic ulcer disease. As blood from the gastrointestinal tract passes through the intestines, bacterial action causes it to become black and tarry colored.
Which instruction is most appropriate for the nurse to give a client reporting cramping abdominal pain, vomiting, and the inability to pass gas and stool 5 days after undergoing open abdominal surgery to remove an intestinal mass? 1. "Add additional fiber and fluids to your diet." 2. "Eat dried prunes to help you have a bowel movement." 3. "Sip on clear liquids until the vomiting subsides." 4. "Go to the emergency department for evaluation."
4. The client is exhibiting symptoms of an intestinal obstruction. The nurse should advise the client to go to the emergency department for evaluation of the symptoms, especially when this occurs after open abdominal surgery (inflammation of the colon and scar tissue development are causes of intestinal obstruction). Signs and symptoms of an intestinal obstruction include abdominal distention, nausea, vomiting, diarrhea, cramping abdominal pain, and inability to pass gas and stool. Consuming foods that are high in indigestible fiber (such as bran cereal, lettuce, apricots, raisins, dried prunes, brown rice, and fresh peeled apples) promotes regular bowel movements and the passage of gas. The client in this case is vomiting; therefore, offering this advice, as well as the advice to sip on clear liquids, is not appropriate.
A client recently diagnosed with colon cancer tells the nurse, "I am having trouble sleeping because of thoughts of how life will change after surgery." Which action will the nurse take in this situation? 1. Request a chaplain to come and talk to the client. 2. Refer the client to a cancer support group. 3. Discuss the client's remarks with the charge nurse. 4. Encourage the client to discuss personal feelings.
4. The client is having trouble sleeping because of concerns about life changes. The client may be experiencing anxiety and powerlessness. Encouraging the client to verbalize feelings helps the nurse to determine how to assist the client and may reduce the client's anxiety. The other options do not directly address the client's comments and concerns.
A recently admitted client suspected of having peritonitis is requesting a glass of water to drink. What is the best response by the nurse? 1. "I can give you small amounts of water frequently." 2. "You are getting your fluids intravenously." 3. "I will check with your healthcare provider." 4. "It would not be safe to give you anything to drink."
4. The client with peritonitis commonly is not allowed anything orally until the source of the peritonitis is confirmed and treated. IV fluids are given to maintain hydration and hemodynamic stability and to replace electrolytes; however, saying, "You are getting your fluids intravenously" does not explain to the client why oral fluids are not permitted. Checking with the healthcare provider is not necessary.
The nurse will place a client with appendicitis in which position to help relieve pain? 1. Prone position 2. Supine position 3. Side-lying position 4. Fowler's Position
4. The nurse should place the client in the Fowler's position with a pillow at the knees. Lying still with the legs drawn up toward the chest helps relieve tension on the abdominal muscles, which helps to reduce the amount of discomfort felt. Lying flat or sitting may increase the amount of pain experienced.
The nurse is caring for an adult client prescribed phytonadione. Which nursing action is priority? 1. Monitor the client's sclera for signs of jaundice. 2. Assess the client's electrolyte levels closely. 3. Educate the client on dietary restrictions. 4. Get liver function tests before giving the first dose.
4. The nurse would obtain liver function tests, platelet count, prothrombin time (PT), and international normalized ratio (INR) before starting therapy to have a baseline. The nurse would monitor newborn clients for jaundice. There is not a need to assess electrolyte levels. There are no dietary restrictions for phytonadione.
Which nursing intervention is priority when providing care for a client following an appendectomy for an appendix that spontaneously ruptured? 1. Monitoring for pain 2. Encouraging oral intake of fluids 3. Providing discharge education 4. Monitoring for peritonitis
4. The priority of care is to monitor for peritonitis, or inflammation of the peritoneal cavity. Peritonitis is caused by appendix rupture and invasion of bacteria, which could be lethal. Postoperative pain management is not a priority because this is not life-threatening. The nurse should encourage oral intake; however, it is not a priority. Discharge education is important, but management should focus on minimizing complications and recognizing when they may be occurring for rapid intervention.
The nurse provides home care instructions to a client with a diagnosis of hiatal hernia. Which statement made by the client indicates a proper understanding of the instructions? 1. "I will drink carbonated cola beverages with my meals." 2. "I will be sure to lie down immediately after eating." 3. "I should eat three large, high-carbohydrate meals each day." 4. "I will sleep with my head elevated about 3 to 4 inches."
4. With a hiatal hernia, sleeping with the head of the bed elevated 30 degrees (about 3 to 4 inches [7.5 to 10cm]) prevents stomach acids from refluxing into the esophagus. Carbonated beverages would create gas and belching (eructation), causing an increase in intra-abdominal pressure, which would irritate the herniated area. Lying down immediately after eating leads to the reflux of stomach acids, causing irritation. Clients with hiatal hernia should eat small meals.
