GI questions from Evolve

A client has been advanced to a solid diet after undergoing a subtotal gastrectomy. The nurse caring for the client would perform which action to minimize the risk of dumping syndrome? 1.Remove fluids from the meal tray. 2.Give the client two large meals per day. 3.Ask the client to sit up for 1 hour after eating. 4.Provide concentrated, high-carbohydrate foods.

1.Remove fluids from the meal tray. Rationale: Factors to minimize dumping syndrome after gastric surgery include having the client lie down for at least 30 minutes after eating; giving small, frequent meals; having the client maintain a low Fowler's position while eating if possible; avoiding liquids with meals; and avoiding high-carbohydrate food sources. Antispasmodic medications also are prescribed as needed to delay gastric emptying.

The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy? 1.Restlessness 2.Complaints of fatigue 3.The presence of asterixis 4.Decreased serum ammonia levels

3.The presence of asterixis Rationale: Asterixis is a flapping tremor of the hand that is an early sign of hepatic encephalopathy. The exact cause of this disorder is not known, but abnormal ammonia metabolism may be implicated. Increased serum ammonia levels are thought to interfere with normal cerebral metabolism. Tremors and drowsiness also would be noted.

A client is experienced delayed gastric emptying. The nurse plans care, knowing that dysfunction of which structures is responsible for the client's symptoms? 1.Ileum 2.Jejunum 3.Pyloric sphincter 4.Cardiac sphincter

3.Pyloric sphincter Rationale: The pyloric sphincter joins the stomach and the duodenum and is responsible for proper gastric emptying. The ileum and jejunum are the two portions of the small intestine. The cardiac sphincter is another name for the lower esophageal sphincter, which joins the esophagus and the stomach.

The nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse will direct the assessment to look for which as a hallmark sign of this disorder? 1.Hypothermia 2.Epigastric pain radiating to the neck area 3.Severe abdominal pain relieved by vomiting 4.Severe abdominal pain that is unrelieved by vomiting

4.Severe abdominal pain that is unrelieved by vomiting Rationale: Nausea and vomiting are common presenting manifestations of acute pancreatitis. A hallmark symptom is severe abdominal pain that is not relieved by vomiting. The vomitus characteristically consists of gastric and duodenal contents. Fever also is a common sign but usually is mild, with temperatures less than 39° C. Epigastric pain radiating to the neck area is not a characteristic symptom.

The health care provider has determined that a client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D

1. Hepatitis A Rationale: Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? 1. Malaise 2. Dark stools 3. Weight gain 4. Left upper quadrant discomfort

1. Malaise Rationale: Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts. Test-Taking Strategy: Focus on the subject, expected assessment findings. Recalling the function of the liver will direct you to the correct option. Remember that fatigue and malaise are common.

The nurse is planning to teach a client with gastroesophageal reflux disease about substances to avoid. Which items should the nurse include on this list? Select all that apply. 1. Coffee 2. Chocolate 3. Peppermint 4. Nonfat milk 5. Fried chicken 6. Scrambled eggs

1. Coffee 2. Chocolate 3. Peppermint 5. Fried chicken Rationale: Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus will increase reflux and exacerbate the symptoms of gastroesophageal reflux disease (GERD) and therefore should be avoided. Aggravating substances include chocolate, coffee, fried or fatty foods, peppermint, carbonated beverages, and alcohol. Options 4 and 6 do not promote this effect. Test-Taking Strategy: Focus on the subject, substances that increase lower esophageal pressure. Use knowledge of the effect of various foods on LES pressure and GERD. However, if you are unsure, select the options that identify the most healthful food items.

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? 1.Sweating and pallor 2.Bradycardia and indigestion 3.Double vision and chest pain 4.Abdominal cramping and pain

1. Sweating and pallor Rationale: Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse monitors the client, knowing that this client is at risk for which vitamin deficiency? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin E

2. Vitamin B12 Rationale: Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of function of the parietal cells. The source of intrinsic factor is lost, which results in an inability to absorb vitamin B12. This leads to the development of pernicious anemia. The client is not at risk for vitamin A, C, or E deficiency.

A nurse is caring for a group of clients on the surgical nursing unit. The nurse anticipates that the client who underwent which procedure is most likely to have some long-term residual difficulty with absorption of nutrients? 1.Colectomy 2.Appendectomy 3.Ascending colostomy 4.Small bowel resection

4.Small bowel resection Rationale: The small intestine is responsible for the absorption of most nutrients. The client who has undergone removal of a segment of the small bowel is the one who has a decreased area with which to absorb nutrients. Decreased absorption is not a likely complication with the surgical procedures identified in options 1, 2, and 3.

A client experiencing chronic dumping syndrome makes the following comments to the nurse. Which one indicates the need for further teaching? 1."I eat at least three large meals each day." 2."I eat while lying in a semirecumbent position." 3."I have eliminated taking liquids with my meals." 4."I eat a high-protein, low- to moderate-carbohydrate diet."

1. "I eat at least three large meals each day." Rationale: Dumping syndrome describes a group of symptoms that occur after eating. It is believed to result from rapid dumping of gastric contents into the small intestine, which causes fluid to shift into the intestine. Signs and symptoms of dumping syndrome include diarrhea, abdominal distention, sweating, pallor, palpitations, and syncope. To manage this syndrome, clients are encouraged to decrease the amount of food taken at each sitting, eat in a semirecumbent position, eliminate ingesting fluids with meals, and avoid consumption of high-carbohydrate meals. Test-Taking Strategy: Focus on the client's diagnosis, and note the strategic words need for further teaching. These words indicate a negative event query and the need to select the incorrect statement. Remember that large meals and meals high in carbohydrates would cause increased dumping of glucose into the colon, causing increased fluid shifts.

A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. 1. Administer stool softeners as prescribed. 2. Instruct the client to limit fluid intake to avoid urinary retention. 3. Instruct the client to avoid activities that will initiate vasovagal responses. 4. Encourage a high-fiber diet to promote bowel movements without straining. 5. Apply cold packs to the anal-rectal area over the dressing until the packing is removed. 6. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding.

1. Administer stool softeners as prescribed. 4. Encourage a high-fiber diet to promote bowel movements without straining. 5. Apply cold packs to the anal-rectal area over the dressing until the packing is removed. Rationale: Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance of bleeding and incision rupture. Stool softeners and a high-fiber diet will help the client avoid straining, thereby reducing the chances of rupturing the incision. An ice pack will increase comfort and decrease bleeding. Options 2, 3, and 6 are incorrect interventions.

A client is experiencing blockage of the common bile duct. The nurse anticipates that the client's diet will be altered because the client will experience difficulty digesting which nutrient? 1.Fats 2.Proteins 3.Carbohydrates 4.Water-soluble vitamins

1.Fats Rationale: Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum. Bile acids or bile salts are produced by the liver to emulsify or break down fats. Options 2, 3, and 4 are incorrect.

The nurse is assessing for stoma prolapse in a client with a colostomy. What should the nurse observe if stoma prolapse occurs? 1.Protruding stoma 2.Sunken and hidden stoma 3.Narrowed and flattened stoma 4.Dark- and bluish-colored stoma

1.Protruding stoma Rationale: A prolapsed stoma is one in which the bowel protrudes through the stoma. A stoma retraction is characterized by sinking of the stoma. A stoma with a narrowed opening at the level of the skin or fascia is said to be stenosed. Ischemia of the stoma would be associated with a dusky or bluish color.

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? 1. Notify the health care provider (HCP). 2. Administer the prescribed pain medication. 3. Call and ask the operating room team to perform the surgery as soon as possible. 4. Reposition the client and apply a heating pad on the warm setting to the client's abdomen.

1. Notify the health care provider (HCP). Rationale: On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the HCP. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the HCP probably would perform the surgery earlier than the prescheduled time. Test-Taking Strategy: Note the strategic words most appropriate. Focus on the signs and symptoms in the question and consider the complications that can occur with appendicitis. Noting that the signs presented in the question indicate a complication will assist in directing you to the correct option.

The nurse has provided dietary instructions to a client with a diagnosis of peptic ulcer disease. Which statement, if made by the client, indicates an understanding of the dietary measures to take? 1."Baked foods such as chicken or fish are all right to eat." 2."Citrus fruits and raw vegetables need to be included in my daily diet." 3."I can drink beer so long as I consume only a moderate amount each day." 4."I can drink coffee or tea so long as I limit the amount to two cups daily."

1."Baked foods such as chicken or fish are all right to eat." Rationale: Dietary modifications for the client with peptic ulcer disease include eliminating foods that can cause irritation to the gastrointestinal (GI) tract. Items that should be eliminated or avoided include highly spiced foods, alcohol, caffeine, chocolate, and citrus fruits. Other foods may be taken according to the client's level of tolerance for that food.

The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which assessment question would most specifically elicit information regarding the pain that is associated with acute pancreatitis? 1."Does the pain in your stomach radiate to the back?" 2."Does the pain in your lower abdomen radiate to the hip?" 3."Does the pain in your lower abdomen radiate to your groin?" 4."Does the pain in your stomach radiate to your lower middle abdomen?"

1."Does the pain in your stomach radiate to the back?" Rationale: The pain that is associated with acute pancreatitis is often severe and is located in the epigastric region and radiates to the back. Options 2, 3, and 4 are incorrect because they are not specific for the pain experienced by the client with pancreatitis.

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client? 1."Take a deep breath when I tell you and hold it while I remove the tube." 2."Take a deep breath when I tell you and bear down while I remove the tube." 3."Take a deep breath when I tell you and slowly exhale while I remove the tube." 4."Take a deep breath when I tell you and breathe normally while I remove the tube."

1."Take a deep breath when I tell you and hold it while I remove the tube." Rationale: The client should take a deep breath because the client's airway will be temporarily obstructed during tube removal. The client is then told to hold the breath and the tube is withdrawn slowly and evenly over the course of 3 to 6 seconds (coil the tube around the hand while removing it) while the breath is held. Bearing down could inhibit the removal of the tube. Exhaling is not possible during removal because the airway is temporarily obstructed during removal. Breathing normally could result in aspiration of gastric secretions during inhalation. Test-Taking Strategy: Focus on the subject, the procedure for removal of a nasogastric tube, and attempt to visualize the process of tube removal to direct you to the correct option. Remember, holding the breath facilitates the process of removal.

Sulfasalazine (Azulfidine) is prescribed for a client with a diagnosis of ulcerative colitis, and the care unit nurse instructs the client about the medication. Which statement made by the client indicates a need for further instruction? 1."The medication will cause constipation." 2."I need to take the medication with meals." 3."I may have increased sensitivity to sunlight." 4."This medication should be taken as prescribed."

1."The medication will cause constipation." Rationale: Sulfasalazine is an anti-inflammatory sulfonamide. Constipation is not associated with this medication. It can cause photosensitivity, and the client should be instructed to avoid sun and ultraviolet light. It should be administered with meals, if possible, to prolong intestinal passage. The client needs to take the medication as prescribed and continue the full course of treatment even if symptoms are relieved.

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1.Administer antacids as prescribed. 2.Encourage coughing and deep breathing. 3.Administer anticholinergics as prescribed. 4.Give small, frequent high-calorie feedings. 5.Maintain the client in a supine and flat position. 6.Give opioid analgesics as prescribed for pain.

1.Administer antacids as prescribed. 2.Encourage coughing and deep breathing. 3.Administer anticholinergics as prescribed. 6.Give opioid analgesics as prescribed for pain. Rationale: The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication is prescribed. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress gastrointestinal secretions.

The nurse is reviewing the record of a client admitted to the nursing unit and notes that the client has a history of Laennec's cirrhosis. This type of cirrhosis is most commonly caused by which long-term condition? 1.Alcohol abuse 2.Cardiac disease 3.Exposure to chemicals 4.Obstruction to biliary ducts

1.Alcohol abuse Rationale: Laennec's cirrhosis results from long-term alcohol abuse. Cardiac cirrhosis most commonly is caused by long-term right-sided heart failure. Exposure to hepatotoxins, chemicals, or infections, or a metabolic disorder can cause postnecrotic cirrhosis. Biliary cirrhosis results from a decrease in bile flow and is most commonly caused by long-term obstruction of bile ducts.

A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? 1.Assessment of vital signs 2.Completion of abdominal examination 3.Insertion of the prescribed nasogastric tube 4.Thorough investigation of precipitating events

1.Assessment of vital signs Rationale: The priority nursing action is to assess the vital signs. This would indicate the amount of blood loss that has occurred and provide a baseline by which to monitor the progress of treatment. The client may be unable to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority. Insertion of a nasogastric tube is not the priority; in addition, the vital signs should be checked before performing this procedure. Test-Taking Strategy: Note the strategic word priority and use the ABCs—airway, breathing, and circulation. This will direct you to the correct option.

A client with viral hepatitis states, "I am so yellow." What is the most appropriate nursing action? 1.Assist the client in expressing feelings. 2.Restrict visitors until the jaundice subsides. 3.Perform most of the activities of daily living for the client. 4.Provide information to the client only when he or she requests it.

1.Assist the client in expressing feelings. Rationale: The client should be supported to explore feelings about the disease process and altered appearance so that appropriate interventions can be planned. Restricting visitors would reinforce the client's negative self-esteem. To assist the client in adapting to changes in appearance, it is important for the nurse to encourage participation in self-care to foster independence and self-esteem. The client should be encouraged to ask questions to clarify misconceptions, to learn ways to prevent the spread of hepatitis, to reduce fear, and to make appropriate decisions.

The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider? 1.Dark red drainage 2.Dark brown drainage 3.Green-tinged drainage 4.Light yellowish brown drainage

1.Dark red drainage Rationale: For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish brown color. The presence of bile may cause a green tinge. The health care provider (HCP) should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively. Test-Taking Strategy: Focus on the subject, the need to notify the HCP. Recall that bleeding is a concern in the postoperative client. This concept will direct you to the correct option.

Diphenoxylate hydrochloride with atropine sulfate (Lomotil) is prescribed for a client with ulcerative colitis. The nurse should monitor the client for which therapeutic effect of this medication? 1.Decreased diarrhea 2.Decreased cramping 3.Improved intestinal tone 4.Elimination of peristalsis

1.Decreased diarrhea Rationale: Diphenoxylate hydrochloride with atropine sulfate is an antidiarrheal product that decreases the frequency of defecation, usually by reducing the volume of liquid in the stools. Options 2, 3, and 4 are not associated therapeutic effects of this medication.

The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to note documented in the client's record? 1.Diarrhea 2.Chronic constipation 3.Constipation alternating with diarrhea 4.Stool constantly oozing from the rectum

1.Diarrhea Rationale: Crohn's disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options 2, 3, and 4 are not characteristics of Crohn's disease.

The nurse has been caring for a client who required a Sengstaken-Blakemore tube because other treatment measures for esophageal varices were unsuccessful. The health care provider arrives on the nursing unit and deflates the esophageal balloon. After deflation of the balloon, the nurse should monitor the client most closely for which complication? 1.Hematemesis 2.Bloody diarrhea 3.Swelling of the abdomen 4.An elevated temperature and a rise in blood pressure

1.Hematemesis Rationale: A Sengstaken-Blakemore tube may be inserted in a client with a diagnosis of cirrhosis and ruptured esophageal varices. It has both an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices, manifested as vomiting of blood (hematemesis). Options 2, 3, and 4 are unrelated to deflating the esophageal balloon.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment data should alert the nurse to this occurrence? 1.Inability to pass flatus 2.Loss of anal sphincter control 3.Severe, constant pain with rapid onset 4.Firm, nontender mass palpable at the lower right costal margin

1.Inability to pass flatus Rationale: An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually manifests as a more constant generalized discomfort. Option 4 is the description of the physical finding of liver enlargement. The liver may be enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction.

The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply. 1.Jaundice 2.Flu-like symptoms 3.Clay-colored stools 4.Dark or tea-colored urine 5.Elevated bilirubin levels

1.Jaundice 3.Clay-colored stools 4.Dark or tea-colored urine 5.Elevated bilirubin levels Rationale: There are three stages associated with viral hepatitis. The first (preicteric) stage includes flulike symptoms only. The second (icteric) stage includes the appearance of jaundice and associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay-colored stools. The third (posticteric) stage occurs when the jaundice decreases and the colors of the urine and stool return to normal.

The nurse is giving dietary instructions to a client who has a new colostomy. The nurse should encourage the client to eat foods representing which diet for the first 4 to 6 weeks postoperatively? 1.Low fiber 2.Low calorie 3.High protein 4.High carbohydrate

1.Low fiber Rationale: For the first 4 to 6 weeks after colostomy formation, the client should consume a low-fiber diet. After this period, the client should eat a high-carbohydrate, high-protein diet. The client also is instructed to add new foods, including those with fiber, one at a time to determine tolerance to that food.

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for this client? 1.Low-protein diet 2.High-protein diet 3.Moderate-fat diet 4.High-carbohydrate diet

1.Low-protein diet Rationale: Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. If the client has hepatic encephalopathy, a low-protein diet would be prescribed. Test-Taking Strategy: Focus on the subject, an elevated ammonia level. Recall the physiology of the liver to assist in answering. Also, note that the correct option and option 2 are opposite, which should provide you with the clue that one of these options is correct.

A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? 1.Lying recumbent following meals 2.Consuming small, frequent, bland meals 3.Raising the head of the bed on 6-inch blocks 4.Taking H2-receptor antagonist medication

1.Lying recumbent following meals Rationale: Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm where the esophagus usually is positioned. The client usually experiences pain from reflux caused by ingestion of irritating foods, lying flat following meals or at night, and eating large or fatty meals. Relief is obtained with the intake of small, frequent, and bland meals, use of H2-receptor antagonists and antacids, and elevation of the thorax following meals and during sleep.

The nurse is developing a plan of care for a client with cirrhosis and ascites. Which nursing actions should be included in the care plan for this client? Select all that apply. 1.Monitor daily weight. 2.Measure abdominal girth. 3.Monitor respiratory status. 4.Place the client in a supine position. 5.Assist the client with care as needed.

1.Monitor daily weight. 2.Measure abdominal girth. 3.Monitor respiratory status. 5.Assist the client with care as needed. Rationale: Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby impairing the client's breathing patterns. The client should be placed in a semi-Fowler's position with the arms supported on a pillow to allow for free diaphragm movement. The correct options identify appropriate nursing interventions to be included in the plan of care for the client with ascites.

A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? Select all that apply. 1.Orthopnea, dyspnea 2.Petechiae and ecchymosis 3.Inguinal or umbilical hernia 4.Poor body posture and balance 5.Abdominal distention and tenderness

1.Orthopnea, dyspnea 2.Petechiae and ecchymosis 3.Inguinal or umbilical hernia 5.Abdominal distention and tenderness Rationale: Excess fluid volume, related to the accumulation of fluid in the peritoneal cavity and dependent areas of the body, can occur in the client with cirrhosis. Ascites can cause physical problems because of the overdistended abdomen and resultant pressure on internal organs and vessels. These problems include respiratory difficulty, petechiae and ecchymoses, development of hernias, abdominal distention, and tenderness. Option 4 is unrelated to increased abdominal pressure.

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1.This is a normal, expected event. 2.The client is experiencing early signs of ischemic bowel. 3.The client should not have the nasogastric tube removed. 4.This indicates inadequate preoperative bowel preparation.

1.This is a normal, expected event. Rationale: As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect.

The nurse is preparing to teach a client with a new colostomy about how to perform a colostomy irrigation. Which information should the nurse include in the teaching plan? 1.Use 500 to 1000 mL of warm tap water. 2.Suspend the irrigant 36 inches above the stoma. 3.Insert the irrigation cone ½ inch into the stoma. 4.If cramping occurs, open the irrigation clamp farther.

1.Use 500 to 1000 mL of warm tap water. Rationale: The usual procedure for colostomy irrigation includes using 500 to 1000 mL of warm tap water. The solution is suspended 18 inches above the stoma. The cone is inserted 2 to 4 inches into the stoma but should never be forced. If cramping occurs, the client should decrease the flow rate of the irrigant as needed by closing the irrigation clamp.

A sexually active 20-year-old client has developed viral hepatitis. Which client statement indicates the need for further teaching? 1."I should avoid drinking alcohol." 2."I can go back to work right away." 3."My partner should get the vaccine." 4."A condom should be used for sexual intercourse."

2. "I can go back to work right away." Rationale: To prevent transmission of hepatitis, vaccination of the partner is advised. In addition, a condom is advised during sexual intercourse. Alcohol should be avoided because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that liver function has returned to normal. The client's activity is increased gradually, and the client should not return to work right away.

The nurse is teaching an older client about measures to prevent constipation. Which statement, if made by the client, indicates that further teaching is necessary about bowel elimination? 1."I walk 1 to 2 miles every day." 2."I need to decrease fiber in my diet." 3."I have a bowel movement every other day." 4."I drink six to eight glasses of water every day."

2. "I need to decrease fiber in my diet." Rationale: An older client has an increased tendency to experience constipation because of decreased stomach-emptying time and a lowered basal metabolic rate. Adequate dietary fiber is an important factor in aiding bowel function. Dietary fiber increases fecal weight and water content and accelerates the transit of fecal mass through the gastrointestinal tract. The retention of water by the fiber has the ability to soften stools and promote regularity. Fluid intake and exercise also facilitate bowel elimination.

A client is admitted to the hospital with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? 1. Select foods high in fat. 2. Increase intake of fluids, including juices. 3. Eat a good supper when anorexia is not as severe. 4. Eat less often, preferably only three large meals daily.

2. Increase intake of fluids, including juices. Rationale: Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important. Test-Taking Strategy: Focus on the subject, a diet for viral hepatitis. Think about the pathophysiology associated with hepatitis and focus on the client's complaints to direct you to the correct option.

A hospitalized client with liver disease has a dietary protein restriction. The nurse encourages intake of which complete proteins to maximize the availability of essential amino acids? 1.Nuts 2.Meats 3.Cereals 4.Vegetables

2. Meats Rationale: Complete proteins contain all of the essential amino acids, which are acids that the body cannot produce from other available sources. Complete proteins derive from animal sources, such as meat, cheese, milk, and eggs. Incomplete proteins can be found in fruits, vegetables, nuts, cereals, breads, and legumes.

A client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing the client's pain. What type of pain is consistent with this diagnosis? 1. Burning and aching, located in the left lower quadrant and radiating to the hip 2. Severe and unrelenting, located in the epigastric area and radiating to the back 3. Burning and aching, located in the epigastric area and radiating to the umbilicus 4. Severe and unrelenting, located in the left lower quadrant and radiating to the groin

2. Severe and unrelenting, located in the epigastric area and radiating to the back Rationale: The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back. The other options are incorrect. Test-Taking Strategy: Noting the word acute will assist in eliminating options 1 and 3 because they are comparable or alike. From the remaining options, recalling the anatomical location of the pancreas will direct you to the correct option.

The nurse is providing instructions to a client with a colostomy about measures to reduce the odor from the colostomy. Which statement, if made by the client, indicates an understanding of these measures? 1."I should be sure to eat at least one cucumber every day." 2."Beet greens, parsley, or yogurt will help to control the colostomy odor." 3."I will need to increase my egg intake and try to eat ½ to 1 egg per day." 4."Green vegetables such as spinach and broccoli will prevent odor, and I should eat these foods every day."

2."Beet greens, parsley, or yogurt will help to control the colostomy odor." Rationale: The client should be taught to include deodorizing foods in the diet such as beet greens, parsley, buttermilk, and yogurt. Spinach also may reduce odor, but it is a gas-forming food and should be avoided. Cucumbers, eggs, and broccoli also are gas-forming foods and should be avoided or limited by the client.

The ambulatory care nurse is providing instructions to a client who is scheduled for a small bowel biopsy. What should the nurse tell the client? 1.Clear liquids only are allowed on the day of the test. 2.A signed informed consent form will need to be obtained. 3.A tube will be inserted through the rectum to obtain the tissue sample. 4.A full liquid diet will need to be maintained for 48 hours after the procedure.

2.A signed informed consent form will need to be obtained. Rationale: A signed informed consent form is required for this procedure. The client is instructed to maintain a clear liquid diet for 24 to 48 hours before the biopsy and to withhold all food and fluids after the evening meal before the day of the scheduled biopsy. A small bowel biopsy involves removal of a tissue specimen from the small intestine for examination and aids in the diagnosis of diseases of the small intestine. A small biopsy tube is passed through the client's mouth and is monitored fluoroscopically until it reaches the desired location in the jejunum. A normal diet may be resumed after the procedure as soon as the gag reflex returns.

A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain, and appendicitis is suspected. Laboratory tests are performed, and the nurse notes that the client's white blood cell (WBC) count is elevated. On the basis of these findings, the nurse would question which health care provider's (HCP) prescriptions documented in the client's medical record? 1.Apply a cold pack to the abdomen. 2.Administer 30 mL of milk of magnesia (MOM). 3.Maintain nothing-by-mouth (nil per os [NPO]) status. 4.Initiate an intravenous (IV) line for the administration of IV fluids.

2.Administer 30 mL of milk of magnesia (MOM). Rationale: Appendicitis should be suspected in a client with an elevated WBC count complaining of acute right lower abdominal quadrant pain. Laxatives are never prescribed because if appendicitis is present, the effect of the laxative may cause a rupture with resultant peritonitis. Cold packs may be prescribed for comfort. The client would be NPO and given IV fluids in preparation for possible surgery.

The nurse provides dietary instructions to a client with a diagnosis of cholecystitis. Which food item identified by the client indicates an understanding of foods to avoid? 1.Fresh fruit 2.Brown gravy 3.Fresh vegetables 4.Poultry without skin

2.Brown gravy Rationale: The client with cholecystitis should decrease overall intake of dietary fat. Foods that should be avoided include sausage, gravies, fatty meats, fried foods, products made with cream, and desserts. Appropriate food choices include fruits and vegetables, fish, and poultry without skin.

A client with appendicitis is scheduled for an appendectomy. The nurse providing preoperative teaching for the client describes the location of the appendix by stating that it is attached to which part of the gastrointestinal system? 1.Ileum 2.Cecum 3.Rectum 4.Jejunum

2.Cecum Rationale: The appendix, sometimes referred to as the vermiform appendix, is attached to the apex of the cecum. The other locations listed are incorrect.

The nurse is providing dietary instructions to a client with a diagnosis of irritable bowel syndrome. The nurse determines that the client understands the instructions if the client states the need to avoid which food? 1.Rice 2.Corn 3.Broiled chicken 4.Cream of wheat

2.Corn Rationale: The client with irritable bowel should take in a diet that consists of 30g to 40 g of fiber daily because dietary fiber will help produce bulky soft stools and establish regular bowel habits. The client should also drink 8 to 10 glasses of fluid daily and chew food slowly to promote normal bowel function. Foods that are irritating to the intestines need to be avoided. Corn is high in fiber but can be very irritating to the intestines and should be avoided. The food items in the other options are acceptable to eat.

A nurse is caring for a hospitalized client who has been diagnosed with pancreatitis. The nurse checks the laboratory results form, anticipating that which enzyme will remain normal in the client? 1.Lipase 2.Lactase 3.Trypsin 4.Amylase

2.Lactase Rationale: Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Lipase, trypsin, and amylase are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively.

The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? 1.Leukopenia with a shift to the left 2.Leukocytosis with a shift to the left 3.Leukopenia with a shift to the right 4.Leukocytosis with a shift to the right

2.Leukocytosis with a shift to the left Rationale: Laboratory findings do not establish the diagnosis of appendicitis, but there is often an elevation of the white blood cell count (leukocytosis) with a shift to the left (an increased number of immature white blood cells). Options 1, 3, and 4 are incorrect because they are not associated findings in acute appenditis. Test-Taking Strategy: Focus on the subject, appendicitis. Knowledge that an inflammatory process causes an increase in the white blood cell count will assist in eliminating options 1 and 3. From the remaining options, it is necessary to understand the significance of a shift to the left.

The nurse is preparing to insert a nasogastric (NG) tube as prescribed for the purpose of stomach decompression. The nurse reviews the health care provider's (HCP) prescriptions and anticipates that the HCP will prescribe which type of suction pressure and control? 1.High and intermittent 2.Low and intermittent 3.High and continuous 4.Low and continuous

2.Low and intermittent Rationale: Gastric mucosa can be traumatized and pulled into the tube if the suction pressure is placed on high or if the suction is continuous. The suction should be set on low pressure and intermittent suction control.

A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention would be most appropriate? 1.Encourage foods that are high in protein. 2.Monitor for fluid and electrolyte imbalance. 3.Explain that high-fat diets usually are better tolerated. 4.Explain that most daily calories need to be consumed in the evening hours.

2.Monitor for fluid and electrolyte imbalance. Rationale: If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. It is important to explain to the client that most calories should be eaten in the morning hours because nausea is most common in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated.

A nurse is reviewing laboratory test results for a client with liver disease and notes that the client's albumin level is low. The nurse next assesses the client for which physiological effect of decreased circulating albumin? 1.Cerebral edema 2.Peripheral edema 3.Decreased clotting ability 4.Reflexive increase in total protein level

2.Peripheral edema Rationale: Albumin is responsible for maintaining the osmolality of the blood. When the albumin level is low, osmotic pressure is decreased, which in turn can lead to peripheral edema. The client will not experience cerebral edema. Clotting factors produced by the liver (not albumin) are responsible for coagulation. The total protein level may decrease if the albumin level is low.

After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication? 1.Stroke 2.Pernicious anemia 3.Bacterial meningitis 4.Peripheral arterial disease

2.Pernicious anemia Rationale: Billroth I surgery involves removing one half to two thirds of the stomach and reanastomosing the remaining segment of the stomach to the duodenum. With the loss of this much of the stomach, development of pernicious anemia is not uncommon. Pernicious anemia is a macrocytic anemia that most commonly is caused by the lack of intrinsic factor. During a Billroth I procedure, a large portion of the parietal cells, which are responsible for producing intrinsic factor (a necessary component for vitamin B12 absorption), are removed. In this anemia, the red cell is larger than usual and hence does not last as long in the circulation as normal red blood cells do, causing the client to have anemia with resultant fatigue. Vitamin B12 also is necessary for normal nerve function. Because of the lack of the necessary intrinsic factor, persons with pernicious anemia also experience paresthesias, impaired gait, and impaired balance. Although the symptoms could possibly indicate the other options listed, pernicious anemia is the most logical based on the surgery the client underwent.

A client with liver dysfunction is having difficulty with protein metabolism. The nurse checks the laboratory results, expecting that the results of which serum laboratory values will be elevated? 1.Lactase 2.Albumin 3.Ammonia 4.Lactic acid

3. Ammonia Rationale: During deamination of proteins in the liver, the amino group splits from the carbon-containing compound, which results in formation of ammonia and a carbon residue. The liver then converts the toxic ammonia substance into urea, which can be excreted by the kidneys. Clients with liver dysfunction may have high serum ammonia levels as a result. Options 1, 2, and 4 are incorrect.

The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography procedure. The nurse determines that the client needs further information if the client makes which statement? 1. "I know I must sign the consent form." 2. "I hope the throat spray keeps me from gagging." 3. "I'm glad I don't have to lie still for this procedure." 4. "I'm glad some IV medication will be given to relax me."

3. "I'm glad I don't have to lie still for this procedure." Rationale: The client does have to lie still for endoscopic retrograde cholangiopancreatography (ERCP), which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.

The nurse is caring for a client following a Billroth II procedure. Which postoperative prescription should the nurse question and verify? 1. Leg exercises 2. Early ambulation 3. Irrigating the nasogastric tube 4. Coughing and deep-breathing exercises

3. Irrigating the nasogastric tube Rationale: In a Billroth II procedure, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically prescribed by the health care provider. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions. Test-Taking Strategy: Note the words question and verify. Eliminate options 1, 2, and 4 because they are comparable or alike and are general postoperative measures. Also, consider the anatomical location of the surgical procedure to assist in directing you to the correct option.

The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? 1.Ambulate following a meal. 2.Eat high-carbohydrate foods. 3.Limit the fluids taken with meals. 4.Sit in a high Fowler's position during meals.

3. Limit the fluids taken with meals. Rationale: Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a Billroth II procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed. Test-Taking Strategy: Eliminate options 1 and 4 first because these measures are comparable or alike and will promote gastric emptying. From the remaining options, select the measure that will delay gastric emptying.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which symptom(s) of duodenal ulcer? 1.Weight loss 2.Nausea and vomiting 3.Pain relieved by food intake 4.Pain radiating down the right arm

3. Pain relieved by food intake Rationale: A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the mid-epigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer. Test-Taking Strategy: Eliminate options 1 and 2 because they are comparable or alike: if the client is vomiting, weight loss will occur. Next, think about the symptoms of duodenal and gastric ulcer. Choose the correct option over option 4, knowing that the pain does not radiate down the right arm and that a pattern of pain-food-relief occurs with duodenal ulcer.

A client is hospitalized with a diagnosis of viral hepatitis. To detect any difficulty in coping with this disease, the nurse should ask which question? 1."Do you have a fever?" 2."Are you losing weight?" 3."Have you enjoyed having visitors?" 4."Do you rest sometime during the day?"

3."Have you enjoyed having visitors?" Rationale: Clients with hepatitis may experience anxiety because of an anticipated change in lifestyle or fear of prognosis. They also may have a disturbance in body image related to the stigma of having a communicable disease or a change in appearance because of jaundice. The correct option relates to the client's possible feelings of not wanting to be seen by others because of altered appearance. Remember that the client with hepatitis is jaundiced.

The nurse is doing preoperative teaching with a client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which statement? 1."I will be able to pass stool by the rectum eventually." 2."The drainage from this type of ostomy will be formed." 3."I will need to drain the pouch regularly with a catheter." 4."I will need to wear a drainage bag for the rest of my life."

3."I will need to drain the pouch regularly with a catheter." Rationale: A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining to about three times a day, or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool from the rectum only if an ileal-anal pouch or anastomosis were created. This type of operation is a two-stage procedure.

A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, "I'm not sure I can avoid alcohol." What is the most appropriate nursing response? 1."I don't believe that." 2."Everything will be all right." 3."I'm not sure that I understand. Would you please explain?" 4."I think you should talk more with the health care provider (HCP) about this."

3."I'm not sure that I understand. Would you please explain?" Rationale: Explaining what is vague or clarifying the meaning of what has been said increases understanding for both the client and the nurse. Refusing to consider the client's ideas may cause the client to discontinue interaction with the nurse for fear of further rejection. False reassurance devalues the client's feelings. Placing the client's feelings on hold by referring him or her to the HCP for further information is a block to communication.

A health care provider (HCP) prescribes a Salem sump tube for gastrointestinal intubation. The nurse prepares for the insertion and obtains which item from the supply room? 1.A Dobbhoff weighted tube 2. A Sengstaken-Blakemore tube 3. A tube with a large lumen and an air vent 4. A tube with a single lumen that connects to suction

3.A tube with a large lumen and an air vent Rationale: A tube with a large lumen and an air vent is a Salem sump tube. A Dobbhoff weighted tube is a type of feeding tube. A Sengstaken-Blakemore tube is used to control bleeding in the esophagus. A tube with a single lumen is called a Levin tube.

The nurse is developing a teaching plan for a client with viral hepatitis. The nurse should plan to include which information in the teaching session? 1.The diet should be low in calories. 2.Meals should be large to conserve energy. 3.Activity should be limited to prevent fatigue. 4.Alcohol intake should be limited to 2 ounces per day.

3.Activity should be limited to prevent fatigue. Rationale: Rest is necessary for the client with hepatitis, and the client with viral hepatitis should limit activity to avoid fatigue. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per day. Alcohol is strictly forbidden.

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1.Dorsiflex the client's foot. 2.Measure the abdominal girth. 3.Ask the client to extend the arms. 4.Instruct the client to lean forward.

3.Ask the client to extend the arms. Rationale: Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect.

A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? 1.Call the surgeon to report the problem. 2.Reposition the NG tube to the proper location. 3.Check the suction device to make sure it is working. 4.Irrigate the NG tube with saline to remove the obstruction.

3.Check the suction device to make sure it is working. Rationale: After gastric surgery, the client will have an NG tube in place until bowel function returns. It is important for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse must ensure that the NG tube is attached to suction at the level prescribed and that the suction device is working correctly. The tip of the NG tube may be placed near the suture line. Because of this possibility, the nurse should never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned, the nurse should call the surgeon, who would do this repositioning under fluoroscopy.

The nurse checks the gastric residual of an unconscious client receiving nasogastric tube feedings continuously at 50 mL/hr. The nurse notes that the residual is 200 mL. The nurse determines that the client is experiencing which complication? 1.Air in the stomach 2.Too slow an infusion rate 3.Delayed gastric emptying 4.Early signs of peptic ulcer

3.Delayed gastric emptying Rationale: If the gastric residual is greater than 150 mL, the client may be experiencing delayed gastric emptying. If this occurs, the feeding is stopped, and the health care provider should be notified. The nurse should assess whether abdominal girth is enlarged and should auscultate bowel sounds to rule out intestinal obstruction. Some clients benefit from administration of metoclopramide (Reglan) to stimulate gastric emptying. Air in the stomach would be accompanied by abdominal distention and increased abdominal girth. The infusion rate cannot be too slow (option 2) if the client is not tolerating the rate. Early peptic ulcer could be detected by a Hematest-positive gastric aspirate. Additionally, agency procedures should be followed regarding gastric residuals.

The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client regarding the signs and symptoms associated with dumping syndrome. Which signs and symptoms, if identified by the client, would indicate an understanding of this potential complication after gastrointestinal (GI) surgery? 1.Hiccups and diarrhea 2.Constipation and fever 3.Diaphoresis and diarrhea 4.Fatigue and abdominal pain

3.Diaphoresis and diarrhea Rationale: Dumping syndrome occurs after gastric surgery because food is not held as long in the stomach and is dumped into the intestine as a hypertonic mass. This causes fluid to shift into the intestine, causing cardiovascular and GI symptoms. Symptoms can typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea. Options 1, 2, and 4 are incorrect and are not signs of dumping syndrome.

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? 1. Clamp the T-tube. 2. Irrigate the T-tube. 3. Document the findings. 4. Notify the health care provider.

3.Document the findings. Rationale: Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output. Test-Taking Strategy: Note the strategic words most appropriate. Options 1 and 2 can be eliminated because a T-tube is not irrigated and would not be clamped with this amount of drainage. From the remaining options, you must know normal expected findings following this surgical procedure.

A nurse has implemented a bowel maintenance program for an unconscious client. The nurse would evaluate the plan as best meeting the needs of the client if which method was successful in stimulating a bowel movement? 1.Fleet enema 2.Fecal disimpaction 3.Glycerin suppository 4.Soap solution enema (SSE)

3.Glycerin suppository Rationale: The least amount of invasiveness needed to produce a bowel movement is best. Use of glycerin suppositories is the least invasive method and usually stimulates bowel evacuation within a half-hour. Enemas may be needed on an every-other-day basis, but they are used cautiously (even if not contraindicated) because the Valsalva maneuver can increase intracranial pressure. Fecal disimpaction is done only when the client's rectum has become impacted from constipation as a result of inattention or failure of other measures. Stool softeners may be prescribed on a regular schedule for some clients to avoid hard, dry stools, but oral medication is not administered to an unconscious client.

A client has been diagnosed with gastroesophageal reflux disease (GERD). The nurse plans care, knowing that the client has dysfunction of which part of the digestive system? 1.Chief cells of the stomach 2.Parietal cells of the stomach 3.Lower esophageal sphincter (LES) 4.Upper esophageal sphincter (UES)

3.Lower esophageal sphincter (LES) Rationale: The LES is a functional sphincter that normally remains closed except when food or fluids are swallowed. If relaxation of this sphincter occurs, the client may experience symptoms of GERD. The chief cells of the stomach secrete pepsinogen, a precursor to pepsin, which helps to digest proteins. The parietal cells of the stomach secrete hydrochloric acid (gastric acid) and intrinsic factor. The UES is formed by the cricopharyngeus muscle attached to the cricoid cartilage.

The nurse is providing instructions to a client regarding measures to minimize the risk of dumping syndrome. The nurse should make which suggestion to the client? 1.Maintain a high-carbohydrate diet. 2.Increase fluid intake, particularly at meal time. 3.Maintain a low Fowler's position while eating. 4.Ambulate for at least 30 minutes following each meal.

3.Maintain a low Fowler's position while eating. Rationale: The client at risk for dumping syndrome should be instructed to maintain a low Fowler's position while eating and lie down for at least 30 minutes after eating. The client also should be told that small, frequent meals are best and to avoid liquids with meals. Avoiding high-carbohydrate food sources also will assist in minimizing dumping syndrome.

After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are normal. Which description best describes "normal bowel sounds"? 1.Waves of loud gurgles auscultated in all four quadrants 2. Low-pitched swishing auscultated in one or two quadrants 3.Relatively high-pitched clicks or gurgles auscultated in all four quadrants 4.Very high-pitched loud rushes auscultated especially in one or two quadrants

3.Relatively high-pitched clicks or gurgles auscultated in all four quadrants Rationale: Although frequency and intensity of bowel sounds vary depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds. Bowel sounds are very high-pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. Therefore, options 1, 2, and 4 are incorrect. Test-Taking Strategy: Note the strategic word best. Note the subject, techniques for abdominal assessment. Normally, bowel sounds are audible in all four quadrants, so options 2 and 4 can be eliminated. From the remaining options, use knowledge regarding normal findings to direct you to the correct option.

The nurse is caring for a client after abdominal surgery and creation of a colostomy. The nurse is assessing the client for a prolapsed stoma and should expect to note which observation if this is present? 1.A sunken and hidden stoma 2.A narrow and flattened stoma 3.A stoma that is dusky or bluish 4.A protrusion of the bowel with an elongated, swollen appearance of the stoma

4. A protrusion of the bowel with an elongated, swollen appearance of the stoma Rationale: A prolapsed stoma is one in which the bowel protrudes, causing an elongated and swollen appearance to the stoma. A retracted stoma is characterized by sinking of the stoma. A stoma with a narrow opening is described as being stenosed. Ischemia of the stoma would be associated with a dusky or bluish color.

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? 1.Bradycardia 2.Numbness in the legs 3.Nausea and vomiting 4.A rigid, boardlike abdomen

4. A rigid, boardlike abdomen Rationale: Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the mid-epigastric area and spreading over the abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding. Test-Taking Strategy: Focus on the subject, perforation. Option 2 can be eliminated easily because it is not related to perforation. Eliminate option 1 next because tachycardia rather than bradycardia would develop if perforation occurs. From the remaining options, note the strategic words most likely to help direct you to the correct option.

A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? 1. Monitoring the temperature 2. Monitoring complaints of heartburn 3. Giving warm gargles for a sore throat 4. Assessing for the return of the gag reflex

4. Assessing for the return of the gag reflex Rationale: The nurse places highest priority on assessing for return of the gag reflex. This assessment addresses the client's airway. The nurse also monitors the client's vital signs and for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client's airway is the priority. Test-Taking Strategy: Note the strategic words highest priority. Use the ABCs—airway, breathing, and circulation. The correct option addresses the airway.

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain? 1. Right lower quadrant, radiating to the back 2. Right lower quadrant, radiating to the umbilicus 3. Right upper quadrant, radiating to the left scapula and shoulder 4. Right upper quadrant, radiating to the right scapula and shoulder

4. Right upper quadrant, radiating to the right scapula and shoulder Rationale: During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula and shoulder. This is determined by the pattern of dermatomes in the body. The other options are incorrect. Test-Taking Strategy: Focus on the subject, the location of pain associated with cholecystitis. Recalling the anatomical location of the gallbladder will direct you to the correct option.

A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. In teaching the client about this condition, the nurse explains that the stomach lining is producing a decreased amount of intrinsic factor, so the client will need which medication? 1.An antacid 2.An antibiotic 3.Vitamin B6 injections 4.Vitamin B12 injections

4. Vitamin B12 injections Rationale: A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. An antacid and antibiotic may be prescribed for certain types of gastric ulcers. Vitamin B6 is not necessarily needed for pernicious anemia and can be taken orally.

A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week; however, he is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern that he will not be able to continue the tube feedings at home. Which nursing response is most appropriate at this time? 1."Do you want to stay here in this facility a few more days?" 2."Have you discussed your feelings with your health care provider?" 3."You need to talk to your health care provider about these findings." 4."Tell me more about your concerns with your diet after going home."

4."Tell me more about your concerns with your diet after going home." Rationale: A client often has fears about leaving the secure, cared-for environment of the health care facility. This client has a fear about not being able to care for himself at home and of not being able to handle the tube feedings at home. A therapeutic communication statement such as "Tell me more about..." often leads to valuable information about the client and the client's concerns. Options 1, 2, and 3 are nontherapeutic

A nurse is caring for a client on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, which nursing action is appropriate? 1.Document the findings. 2.Reassess the pH in 4 hours. 3.Instill 30 mL of sterile water. 4.Administer a dose of a prescribed antacid.

4.Administer a dose of a prescribed antacid. Rationale: The client on a mechanical ventilator who has a nasogastric tube in place should have the gastric pH monitored at the beginning of each shift or least every 12 hours. Because of the risk of stress ulcer formation, a pH lower than 5 (acidic) should be treated with prescribed antacids. If there is no prescription for the antacid, the health care provider should be notified. Documentation of the findings should be done after the administration of an antacid. Sterile water instillation is not an appropriate treatment.

A client with acute ulcerative colitis requests a snack. Which would be the most appropriate snack for this client? 1.Carrots and ranch dip 2.Whole-grain cereal and milk 3.A cup of popcorn and a cola drink 4.Applesauce and a graham cracker

4.Applesauce and a graham cracker Rationale: The diet for the client with ulcerative colitis should be low fiber (low residue). The nurse should avoid providing foods such as whole-wheat grains, nuts, and fresh fruits or vegetables. Typically, lactose-containing foods also are poorly tolerated. The client also should avoid caffeine, pepper, and alcohol.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The client has tolerated the tube being clamped every 2 hours for 1 hour. The health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube? 1.Checking for normal serum electrolyte levels 2.Checking for normal pH of the gastric aspirate 3.Checking for proper nasogastric tube placement 4.Checking for the presence of bowel sounds in all four quadrants

4.Checking for the presence of bowel sounds in all four quadrants Rationale: Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, pH of the gastric aspirate, and tube placement are important assessments for the client with a nasogastric tube in place, but would not assist in determining the readiness for removing the nasogastric tube. Test-Taking Strategy: Eliminate options 2 and 3 first because they are comparable or alike. Assessing the pH of the gastric aspirate is one method of assessing tube placement. From the remaining options, focus on the client's diagnosis to direct you to the correct option.

The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which initial sign, if noted in the client, indicates the presence of portal hypertension? 1.Weak pulse 2.Hypotension 3.Flat neck veins 4.Crackles on auscultation of the lungs

4.Crackles on auscultation of the lungs Rationale: Clinical signs and symptoms of portal hypertension are similar to those of heart failure and include jugular vein distention, lung crackles, and decreased perfusion to all organs. Initially the client may have hypertension, flushed skin, and a bounding pulse.

In performing a physical assessment of a client with a diagnosis of ulcerative colitis, the nurse should expect which finding? 1.Hypercalcemia 2.Fibrous stricture 3.Frothy, fatty stools 4.Decreased hemoglobin

4.Decreased hemoglobin Rationale: Ulcerative colitis is an inflammatory disease of the large colon. The signs and symptoms of ulcerative colitis include diarrhea with up to 10 to 20 liquid bloody stools per day, weight loss, anorexia, fatigue, increased white blood cell count, increased erythrocyte sedimentation rate, dehydration, hyponatremia, and hypokalemia, not hypercalcemia. Because of the loss of blood, clients with ulcerative colitis commonly have decreased hemoglobin and hematocrit levels. Strictures and fistulas are more commonly seen in Crohn's disease than in ulcerative colitis. Clients with ulcerative colitis have bloody diarrhea, not steatorrhea (fatty, frothy, foul-smelling stools).

The nurse is providing care for a client with a Sengstaken-Blakemore tube. The nurse suspects which diagnosis for this client? 1.Gastritis 2.Bowel obstruction 3.Small bowel tumor 4.Esophageal varices

4.Esophageal varices Rationale: A Sengstaken-Blakemore tube may be used in a client with a diagnosis of cirrhosis with ruptured esophageal varices if other treatment measures are unsuccessful. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could harm the client. This tube is not used in clients with the conditions noted in options 1, 2, or 3.

A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? 1.Folate deficiency 2.Malabsorption of fat 3.Intestinal obstruction 4.Fluid and electrolyte imbalance

4.Fluid and electrolyte imbalance Rationale: A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period. Test-Taking Strategy: Note the strategic words most frequent. Also note the subject, an ileostomy. Remember that ileostomy drainage is liquid, placing the client at risk for fluid and electrolyte imbalance.

A client with peptic ulcer disease states that stress frequently causes exacerbation of the disease. The nurse determines that which item mentioned by the client is most likely to be responsible for the exacerbation? 1.Sleeping 8 to 10 hours a night 2.Ability to work at home periodically 3.Eating five or six small meals per day 4.Frequent need to work overtime on short notice

4.Frequent need to work overtime on short notice Rationale: Psychological or emotional stressors that exacerbate peptic ulcer disease may be found either at home or in the workplace. Of the items listed, the frequent need to work overtime on short notice is potentially the most stressful because it is the item over which the client has the least control. An ability to work at home periodically is not necessarily stressful because it allows increased client control over timing and location of work. Adequate rest and proper dietary pattern (options 1 and 3) should alleviate symptoms, not worsen them.

A client with a diagnosis of stomach ulcer from gastric hyperacidity asks the nurse why the acid has not caused an ulcer in the small intestine as well. The nurse responds that the pH of intestinal contents is raised by bicarbonate, which is present in which area of the body? 1.Bile 2.Parietal cells 3.Liver enzymes 4.Pancreatic juice

4.Pancreatic juice Rationale: Pancreatic juice is rich is bicarbonate, which helps to neutralize the gastric acid in food entering the small intestine from the stomach. The duodenal papilla, which is an opening about 10 cm below the level of the pylorus, is responsible for carrying bile and pancreatic juices into the duodenum. Options 1, 2, and 3 are not substances rich in bicarbonate and are incorrect.

A client who has had a gastrectomy is not producing sufficient intrinsic factor. The nurse plans care, knowing that the client has lost the ability to absorb cyanocobalamin (vitamin B12) in which abdominal structure? 1.Colon 2.Stomach 3.Large intestine 4.Small intestine

4.Small intestine Rationale: Intrinsic factor is produced in the stomach but is used to aid in the absorption of vitamin B12 in the small intestine. This vitamin is not absorbed in the large intestine (options 1 and 3).

A client with spinal cord injury (SCI) is participating in a bowel retraining program. The nurse develops a plan that is based in part on the knowledge that defecation is normally a result of which phenomena? 1.Sufficiently low water content in the stool 2.Low intestinal roughage that promotes easier digestion 3.Constriction of the anal sphincter based on voluntary control 4.Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord

4.Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord Rationale: The principal reflex center for defecation is located in the parasympathetic center at the S1 to S4 level of the spinal cord. This center is most active after the first meal of the day. Other factors that contribute to satisfactory stool passage are sufficient fluid and roughage in the diet and the Valsalva maneuver (which is lost with SCI). During defecation, the anal sphincter relaxes.

The nurse obtains an admission history for a client with suspected peptic ulcer disease. Which client factor documented by the nurse would increase the risk for peptic ulcer disease? 1.Recently retired from a job 2.Significant other has a gastric ulcer 3.Occasionally drinks one cup of coffee in the morning 4.Takes nonsteroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis

4.Takes nonsteroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis Rationale: Risk factors for peptic ulcer disease include Helicobacter pylori infection, smoking (nicotine), chewing tobacco, corticosteroids, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), caffeine, alcohol, and stress. When an NSAID is taken as often as is typical for osteoarthritis, it will cause problems with the stomach. Certain medical conditions such as Crohn's disease, Zollinger-Ellison syndrome, and hepatic and biliary disease also can increase the risk for peptic ulcer disease by changing the amount of gastric and biliary acids produced. Recent retirement should decrease stress levels, rather than increase them. Ulcer disease in a first-degree relative also is associated with increased risk for an ulcer. A significant other is not a first-degree relative; therefore, no genetic connection is noted in this relationship. Although caffeinated drinks are a known risk factor for PUD, the option states that the client drinks one cup of coffee occasionally.