Gastrointestinal System

A client who is prescribed a 2-gram sodium diet asks for juice. How should the nurse respond? 1 "I suggest you have pear nectar." 2 "I suggest you have tomato juice." 3 "Juice is not permitted on a low-sodium diet." 4 "Juice between meals is not calculated into your diet.

1 "I suggest you have pear nectar."

Which reported clinical manifestations would the nurse expect from a client with ulcerative colitis? Select all that apply. One, some, or all responses may be correct. 1 Fever 2 Diarrhea 3 Gain in weight 4 Spitting up blood 5 Abdominal cramps

1 Fever 2 Diarrhea 5 Abdominal cramps

The nurse assesses a client with the diagnosis of an intestinal obstruction in the descending colon. When auscultating the mid-abdomen, which type of sound would the nurse expect to hear? 1 Tympany 2 Borborygmi 3 Abdominal bruit 4 Pleural friction rub

2 Borborygmi

A client is admitted to the hospital with a diagnosis of intestinal obstruction and has an intestinal tube inserted. As prescribed, the nurse instills 30 mL of normal saline into the tube to maintain patency. Which action would the nurse take next? 1 Add 30 mL to the gastric output on the intake and output record. 2 Record 30 mL as intake in the intake and output record. 3 Recognize that the amount instilled equals insensible losses. 4 Identify that the amount is insignificant and does not need to be documented.

2 Record 30 mL as intake in the intake and output record.

A client had surgery for a perforated appendix with localized peritonitis. In which position would the nurse place this client? 1 Sims 2 Semi-Fowler 3 Trendelenburg 4 Dorsal recumbent

2 Semi-Fowler

A client who previously signed a consent form for a liver biopsy reconsiders and decides not to have the procedure. How would the nurse respond? 1 "Why did you sign the consent form originally?" 2 "I can understand why you changed your mind." 3 "Can you tell me your reasons for refusing the procedure?" 4 "You must be afraid about something concerning the procedure."

3 "Can you tell me your reasons for refusing the procedure?"

The nurse is caring for a client with a 25-year history of excessive alcohol use. Which assessment finding is consistent with the client's history? 1 Signs of liver infection 2 A low blood ammonia level 3 A small liver with a rough surface 4 An elevated temperature and a generalized rash

3 A small liver with a rough surface Scar tissue that forms as cirrhosis progresses causes the liver tissue to contract, making the liver small with a rough surface; little lumps are formed as scar tissue pulls the liver at certain points. The client has cirrhosis, not a liver infection. The liver converts ammonia to urea; therefore, the blood ammonia level increases, not decreases, when the liver fails. A high fever and a generalized rash are adaptations of an infection, not cirrhosis of the liver.

The nurse understands that research demonstrates that malnutrition occurs in as many as 50% of hospitalized clients. The nurse would assess a postoperative client with anorexia for which sign of malnutrition? 1 Dependent edema 2 Spoon-shaped nails 3 Loose, decayed teeth 4 Delayed wound healing

4 Delayed wound healing

An older adult client who is accustomed to taking enemas periodically to avoid constipation is admitted to a long-term care facility and is bedbound. Which nursing action would be included in the initial plan of care to prevent the client from developing constipation? 1 Arrange to have enemas prescribed for the client. 2 Obtain a prescription for a daily laxative for the client. 3 Place a commode by the bedside to facilitate defecation. 4 Offer a large glass of prune juice with warm water each morning.

4 Offer a large glass of prune juice with warm water each morning.

A client consumes 4 ounces of apple juice, 6 ounces of tea, and 8 ounces of chicken broth. How many mL of fluid will the nurse document the client ingested? Record your answer using a whole number. _____ mL

540

A client with carcinoma of the colon is scheduled for an abdominoperineal resection. What would preparation for the surgery include? 1 Medications to promote diuresis 2 Fluid restriction to 1 L daily 3 Antibiotics to reduce intestinal bacteria 4 Abdominal exercises to facilitate recovery

3 Antibiotics to reduce intestinal bacteria