Gstrointestinal disorders

A 2-year-old child is admitted through the emergency department with a suspected diagnosis of Hirschsprung's disease (aganglionic megacolon). The parent asks about treatment of the disease. What would be an appropriate response from the nurse?

"Initially the child will have a temporary colostomy; later a second operation removes the abnormal part of bowel and reattaches the normal bowel down to the rectum."

A client is scheduled to have a cholecystectomy. Which education should the nurse reinforce regarding the use of incentive spirometry? Select all that apply.

-It increases alveolar inflation. -It will promote lung expansion. -It will promote deep breathing.

A nurse is caring for a child who has been treated in the emergency department after ingesting drain cleaner. Which nursing interventions would be appropriate in this child care? (Select all that apply.)

-Observe vital signs for subtle changes. -Determine the child's ability to speak. -Observe for swelling of the tongue.

Which findings in a client with Crohn's disease indicate early signs of dehydration? Select all that apply.

-poor skin turgor -increased heart rate

The nurse is managing the care of a client with a gastrointestinal hemorrhage. Which task is appropriate to assign to a unlicensed assistive personnel (UAP)?

Check vital signs every 1 hour.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?

Relieving abdominal pain

A parent calls the clinic stating, "I think my child has ingested poison." Which action would help determine which poison was ingested?

Save all evidence of poison.

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 should the nurse suggest for this client?

acetaminophen

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

auscultate bowel sounds.

When assisting with development of a postoperative care plan for a client after gastric resection, which would be the priority?

nutritional needs

The nurse is presenting an in-service about peptic ulcers. When discussing risk factors, the nurse will include which factors? Select all that apply.

-alcohol abuse and smoking -chronic use of NSAIDs and physiologic stress

A client has just been diagnosed with hepatitis A. During assessment, which signs and/or symptoms would the nurse anticipate to find?

Anorexia, nausea, and vomiting.

The nurse is monitoring a client receiving paregoric to treat diarrhea for drug interactions. Which drugs can produce additive constipation when given with an opium preparation?

Anticholinergic drugs

A client takes 30 ml of magnesium hydroxide and aluminum hydroxide with simethicone by mouth 1 hour and 3 hours after each meal and at bedtime for treatment of a duodenal ulcer. Why does the client take this antacid so frequently?

It has a short duration of action.

The nurse is caring for an infant after a cleft lip and cleft palate repair. Which nursing intervention is a priority to prevent tissue infection after the repair?

Rinse the infant's mouth after each feeding.

A client with gastric cancer is scheduled for a gastric resection. What is the preoperative priority nursing care for this client?

correction of nutritional deficits

For a client who must undergo colon surgery, the physician orders preoperative cleansing enemas. The nurse anticipates administration of neomycin to this client to:

decrease the intestinal bacteria count.

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must stay alert for:

diaphoresis, vomiting, and diarrhea.

During the first few days of recovery from ostomy surgery for ulcerative colitis, what should be the priority of client care?

ostomy care

The physician orders morphine for a client who complains of postoperative abdominal pain. The nurse is monitoring the client and will anticipate administering morphine at what time?

Before the pain becomes severe

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's dusky-appearing stoma is related to which factor?

Blood supply to the stoma has been interrupted.

The nurse is caring for a client in the postoperative period who had an open colon resection. The nurse attempts to change the dressing but observes the protrusion of intestine through the wound. What is the priority nursing action at this time?

Cover the wound with a sterile dressing moistened with normal saline.

The nurse is caring for a client who is postoperative after abdominal surgery and reporting "gas pains." What action by the nurse can assist the client with alleviating the discomfort associated with gas?

Encourage the client to ambulate.

The nurse is reinforcing education for the parents of a child that has been diagnosed with celiac disease. To help promote a normal life for the child, which intervention should the nurse reinforce for the parents to use?

Introduce the child to a peer with celiac disease.

The nurse is assisting with the care of an infant following surgical repair of esophageal atresia and tracheoesophageal fistula. Which nursing intervention takes the highest priority during the first 24 hours following the surgical repair?

Monitor for excessive secretions.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

Positioning the client on the side with the knees flexed

The nurse cares for a client who is post-op bowel resection and has a nasogastric (NG) tube to low intermittent suction. Which care intervention should the nurse administer?

Provide meticulous mouth care as needed.

A client is scheduled for a laparoscopic cholecystectomy under general anesthesia. When the nurse asks the client what procedure the client will be having to compare with the informed consent, the client responds, "The doctor is going to take a piece of my liver out." What action should the nurse take at this time?

Request that the health care provider speak with the client before surgery to clarify the surgical procedure.

The client with a peptic ulcer is prescribed an antacid. After administering the medication, the nurse assesses the pH of which organ contents to determine effectiveness?

Stomach

A client reports right lower quadrant pain, nausea, vomiting, and a low-grade fever for the past 12 hours. The health care provider documents rebound tenderness, an elevated white blood cell count (WBC), and positive psoas sign. Based on these findings, what would the nurse suspect?

appendicitis

The nurse is caring for a client with an endotracheal tube who receives enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as residual volume. The purpose of the nurse's actions is to avoid:

aspiration.

A nurse is collecting data on a client with a history of constipation. Which data, obtained by the nurse, would indicate a risk factor for constipation?

diet high in cheese, lean meats, and pasta

A nurse is assigned to care for a client with peptic ulcer disease. Which finding will the nurse report immediately to the health care provider?

heart rate 126 bpm

The nurse is caring for a client that has taken an overdose of acetaminophen. For which initial complication should the nurse closely monitor the client?

hepatic damage

When planning care for a client with a small-bowel obstruction, which should the nurse consider to be the primary goal?

maintaining fluid balance

A nurse presents a client with the informed consent form for an abdominal paracentesis. The client asks the nurse what the procedure involves. The nurse should

notify the physician that the client doesn't understand the procedure.

A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should

wash their hands after touching the client.

A client with peptic ulcer disease is prescribed aluminum-magnesium complex. When teaching about this antacid preparation, the nurse should instruct the client to take it with:

water.

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse stresses the importance of which action?

Increasing fluid intake to prevent dehydration

A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention would the nurse use to determine if TPN is providing adequate nutrition?

Monitoring the client's weight every day

A nurse is preparing to perform complex abdominal wound care. Which action should the nurse take while performing this task?

Raise the bed to approximately waist level.

A client who is legally blind must undergo a colonoscopy. The nurse is helping the healthcare provider obtain informed consent. When obtaining informed consent from a client who is visually impaired, the nurse should take which step?

Read the consent form to the client and ask if there are any questions.

A child is diagnosed with acetaminophen poisoning. Which sign would the nurse expect when obtaining data from the client 12 to 24 hours after ingestion?

profuse sweating