Gastrointestinal System (HESI)
A client who had surgery for a resection of the colon and the formation of a colostomy is to be discharged in several days. What is a primary nursing intervention for this client?
Determine the client's ability to care for the colostomy. (Rationale: The client's feelings, knowledge, and skills concerning caring for the colostomy must be assessed before discharge. )
A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching has been understood when the client makes what statements? (Select all that apply.)
"I should drink eight glasses of water every day." "I can include bran muffins in my breakfast daily." "I will walk every day as part of my exercise regimen." (Rationale:At least eight glasses of fluid keeps the feces soft, which prevents constipation. Whole grains such as bran muffins are high in roughage, which prevents constipation. Walking increases intestinal motility, which helps prevent constipation.)
A client has a colostomy as a result of surgery for cancer of the colon. Which nurse's statement will most effectively minimize the client's stress the first time self-irrigation is to be done?
"I'll draw the curtain and assemble all the equipment. Would you like me to stay, or do you prefer to try it yourself and call me if you need help?" (Rationale: Drawing the curtain protects the client's privacy, and the client can make decisions about care; independence is encouraged, and nursing assistance is offered.)
Prednisone (Meticorten) is prescribed for a client with an exacerbation of colitis. Before administering the first dose, the nurse teaches the client that:
Although the medication decreases intestinal inflammation, it will not cure the colitis. (Rationale:Prednisone inhibits phagocytosis and suppresses other clinical phenomena of inflammation; this is a symptomatic treatment that is not curative. )
For the last three days, the client has expressed a complete lack of interest in food. How should the nurse document this in the client's record?
Anorexia (Rationale:Anorexia refers to loss of appetite. Apathy refers to lack of concern or emotion. Aphasia is the absence of or inability to provide communication through speech. Adactyly refers to the absence of digits on the hands or feet. )
An underweight client has autoimmune hemolytic anemia that has been unresponsive to corticosteroids, and a splenectomy is scheduled. For what complication should the nurse assess the client in the immediate postoperative period?
Hemorrhage (Rationale: A client is at risk for hemorrhage because of the vascularity of the spleen. )
A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea?
High osmolarity of the feedings. (Rationale:The increased osmolarity (concentration) of many formulas draws fluid into the intestinal tract, which can cause diarrhea; such feedings may need to be diluted initially until the client develops tolerance. )
A client has a paracentesis during which 1500 mL of fluid is removed. The nurse should monitor the client carefully for:
Hypovolemic shock (Rationale: Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemia and compensatory tachycardia. )
A client is scheduled to begin chemotherapy two weeks after the client had surgery for colon cancer. The nurse explains to the client that the delay in instituting drug therapy is planned because the chemotherapy:
Interferes with cell growth and delays wound healing. (Rationale:Chemotherapeutic agents can attack healthy as well as malignant cells; they generally interfere with protein synthesis and cell division in all rapidly dividing cells, including those regenerating traumatized tissue (as in wound healing), bone marrow, and cutaneous and alimentary tract epithelial tissue)
The nurse is caring for a client one hour after the client had esophageal surgery. The assessment that is the priority for this client is:
Respiratory Assessment (Rationale: Because of the trauma of surgery and the proximity of the esophagus to the trachea, respiratory assessments become the priority.)
When teaching a client how to prevent constipation, the nurse evaluates that the dietary teaching is understood when the client states that the preferred breakfast cereal is:
Shredded Wheat (Rationale: Shredded Wheat contains 5.5 grams of fiber per serving, which is more than the other choices)
The nurse identifies that a client who had extensive abdominal surgery appears depressed. The most appropriate nursing action is:
Talking with the client and encouraging exploration of feelings. (Rationale:The nurse must first explore the client's feelings; an honest discussion with emphasis on concerns helps promote adjustment)
