Med Surg 2 Exam 2

I should take a laxative, and my stool will then return to a normal color.

A client who has undergone barium enema is being readied for discharge. The nurse determines that the client has understood discharge instructions when the client states:

Provide frequent oral and nasal care on a regular basis.

A nurse is caring for a client with a Sengstaken-Blakemore tube. To prevent ulceration and necrosis of oral and nasal mucosa, the nurse should plan to:

Vitamin B12

A nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that this client is at risk for which vitamin deficiency?

The pH of the aspirate is 5.

A nurse is caring for a client with a nasogastric tube. Which observation is reliable in determining that the tube is correctly placed?

Inability to pass flatus

A nurse is caring for a client with acute pancreatitis and a history of alcoholism and is monitoring the client for complications. Which of the following data would be a sign of paralytic ileus?

4.0

A nurse is checking a client for the correct placement of a nasogastric (NG) tube. The nurse aspirates the client's stomach contents and checks their pH level. Which of the following pH values indicates the correct placement of the tube?

Drowsiness

A nurse is collecting admission data on the client with hepatitis. Which of the following findings would be a direct result of this client's condition

The transfer of digested food molecules from the GI tract into the bloodstream

A nurse is collecting data about how well a client with a gastrointestinal (GI) disorder is able to absorb food. While carrying out this function, the nurse recalls that absorption is best defined as:

Turkey and lettuce sandwich

A nurse is evaluating the effect of dietary counseling on the client with cholecystitis. The nurse determines that the client understands the instructions given if the client states that which food item is acceptable to include in the diet?

Sweating and pallor

A nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which of the following symptoms indicate this occurrence?

Protruding and swollen

A nurse is monitoring for stoma prolapse in a client with a colostomy. The nurse would observe which of the following appearances in the stoma if prolapse occurred

Personal history of ulcerative colitis or gastrointestinal (GI) polyps

A nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer. The nurse would plan to include which risk factor for colorectal cancer in the material?

My pain comes shortly after I eat, maybe a half hour or so later

A nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement, if made by the client, would support the diagnosis of gastric ulcer?

Pruritus

A nurse is collecting data on a client admitted to the hospital with hepatitis. Which data would indicate that the client may have liver damage?

Ask a member of the local ostomy club to visit with the client before discharge, Ask the enterostomal nurse specialist to consult with the client before discharge,Ask the client to begin doing one part of the ostomy care and increase tasks daily.

A client who has undergone a colostomy several days ago is reluctant to leave the hospital and has not yet looked at the ostomy site. Which measures are most likely to promote coping?

Smaller and more frequent meals should be eaten.

A client who has undergone a subtotal gastrectomy is being prepared for discharge. Which item concerning ongoing self-management should the nurse reinforce to the client?

Remain with the client and be silent.

A client is admitted to the hospital with a bowel obstruction secondary to a recurrent malignancy, and the health care provider plans to insert a Miller-Abbott tube. When the nurse tries to explain the procedure, the client interrupts the nurse and states, "I don't want to hear about that. Just let the doctor do it." Based on the client's statement, the nurse determines that the best action is to:

Fatigue

A client is admitted to the hospital with acute viral hepatitis. Which signs or symptoms would the nurse expect to note, based upon this diagnosis?

Increase intake of fluids.

A client is admitted to the hospital with viral hepatitis and is complaining of a loss of appetite. In order to provide adequate nutrition, the nurse encourages the client to:

A client with ulcerative colitis is to take sulfasalazine (Azulfidine). Which of the following instructions should the nurse provide for the client about taking this medication at home? Select all that apply. 1. Drink enough fluids to maintain a urine output of at least 1,200- 1,500 mL per day. 2. Discontinue therapy if symptoms of acute intolerance develop and notify the health care provider. 3. Stop taking the medication if the urine turns orange-yellow. 4. Avoid activities that require alertness. 5. If dose is missed, skip and continue with the next dose.

1, 2, 4. Sulfasalazine may cause dizziness and the nurse should caution the client to avoid driving or other activities that require alertness until response to medication is known. If symptoms of acute intolerance (cramping, acute abdominal pain, bloody diarrhea, fever, headache, rash) occur, the client should discontinue therapy and notify the health care provider immediately. Fluid intake should be sufficient to maintain a urine output of at least 1,200- 1,500 mL daily to prevent crystalluria and stone formation. The nurse can also inform the client that this medication may cause orange-yellow discoloration of urine and skin, which is not significant and does not require the client to stop taking the medication. The nurse should instruct the client to take missed doses as soon as remembered unless it is almost time for the next dose.

I just lost a family to gastrointestinal cancer."

A client is seen in the ambulatory care office for a routine examination. Which statement by the client would be important for the nurse to follow up?

A client with ulcerative colitis expresses serious concerns about her career as an attorney because of the effects of stress on ulcerative colitis. Which of the following nursing interventions will be most helpful to the client? 1. Review her current coping mechanisms and develop alternatives, if needed. 2. Suggest a less stressful career in which she would still use her education and experience. 3. Suggest that she ask her colleagues to help decrease her stress by giving her the easier cases. 4. Prepare family members for the fact that she will have to work part-time.

1. A client with ulcerative colitis need not curtail career goals. Self-care is the cornerstone of long-term management, and learning to cope with and modify stressors will enable the client to live with the disease. Giving up a desired career could discourage and even depress the client. Placing the responsibility for minimizing stressors at work in the hands of others leads to a feeling of loss of control and decreases the sense of responsibility needed for sound self-care. Working part-time rather than full-time is unnecessary.

A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors was most likely of greatest significance in causing an exacerbation of ulcerative colitis? 1. A demanding and stressful job. 2. Changing to a modified vegetarian diet. 3. Beginning a weight-training program. 4. Walking 2 miles every day.

1. Stressful and emotional events have been clearly linked to exacerbations of ulcerative colitis, although their role in the etiology of the disease has been disproved. A modified vegetarian diet or an exercise program is an unlikely cause of the exacerbation.

Which goal for the client's care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis? 1. Promoting self-care and independence. 2. Managing diarrhea. 3. Maintaining adequate nutrition. 4. Promoting rest and comfort.

2. Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and decreasing the frequency of stools is the first goal of treatment. The other goals are ongoing and will be best achieved by halting the exacerbation. The client may receive antidiarrheal agents, antispasmodic agents, bulk hydrophilic agents, or anti-inflammatory drugs.

When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistant? Select all that apply. 1. Assessing the client's bowel sounds. 2. Providing skin care following bowel movements. 3. Evaluating the client's response to antidiarrheal medications. 4. Maintaining intake and output records. 5. Obtaining the client's weight.

2, 4, 5. The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client's weight. Assessing the client's bowel sounds and evaluating the client's response to medication are registered nurse activities that cannot be delegated.

The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include? Select all that apply. 1. Monitoring vital signs once a shift. 2. Weighing the client daily. 3. Changing the central venous line dressing daily. 4. Monitoring the I.V. infusion rate hourly. 5. Taping all I.V. tubing connections securely.

2, 4, 5. When caring for a client who is receiving TPN, the nurse should plan to weigh the client daily, monitor the I.V. fluid infusion rate hourly (even when using an I.V. fluid pump), and securely tape all I.V. tubing connections to prevent disconnections. Vital signs should be monitored at least every 4 hours to facilitate early detection of complications. It is recommended that the I.V. dressing be changed once or twice per week or when it becomes soiled, loose, or wet.

The nurse is assigning clients for the evening shift. Which of the following clients are appropriate for the nurse to assign to a licensed practical nurse to provide client care? Select all that apply. 1. A client with Crohn's disease who is receiving total parenteral nutrition (TPN). 2. A client who underwent inguinal hernia repair surgery 3 hours ago. 3. A client with an intestinal obstruction who needs a Cantor tube inserted. 4. A client with diverticulitis who needs teaching about his take-home medications. 5. A client who is experiencing an exacerbation of his ulcerative colitis.

2, 5. The nurse should consider client needs and scope of practice when assigning staff to provide care. The client who is recovering from inguinal hernia repair surgery and the client who is experiencing an exacerbation of his ulcerative colitis are appropriate clients to assign to a licensed practical nurse as the care they require fall within the scope of practice for a licensed practical nurse. It is not within the scope of practice for the licensed practical nurse to administer TPN, insert nasoenteric tubes, or provide client teaching related to medications.

Which of the following should be a priority focus of care for a client experiencing an exacerbation of Crohn's disease? 1. Encouraging regular ambulation. 2. Promoting bowel rest. 3. Maintaining current weight. 4. Decreasing episodes of rectal bleeding.

2. A priority goal of care during an acute exacerbation of Crohn's disease is to promote bowel rest. This is accomplished through decreasing activity, encouraging rest, and initially placing client on nothing-by-mouth status while maintaining nutritional needs parenterally. Regular ambulation is important, but the priority is bowel rest. The client will probably lose some weight during the acute phase of the illness. Diarrhea is nonbloody in Crohn's disease, and episodes of rectal bleeding are not expected.

The client with ulcerative colitis is following orders for bed rest with bathroom privileges. When evaluating the effectiveness of this level of activity, the nurse should determine if the client has: 1. Conserved energy. 2. Reduced intestinal peristalsis. 3. Obtained needed rest. 4. Minimized stress.

2. Although modified bed rest does help conserve energy and promotes comfort, its primary purpose in this case is to help reduce the hypermotility of the colon. Remaining on bed rest does not by itself reduce stress, and if the client is having stress, the nurse can plan with the client to use strategies that will help the client manage the stress.

Which of the following diets would be most appropriate for the client with ulcerative colitis? 1. High-calorie, low-protein. 2. High-protein, low-residue. 3. Low-fat, high-fiber. 4. Low-sodium, high-carbohydrate.

2. Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid excess roughage. There is no need for clients with ulcerative colitis to follow low-sodium diets.

Occult blood

A client who has been prescribed indomethacin (Indocin) for gout is asked to provide a stool sample for guaiac testing. The nurse explains that the purpose of the test is to determine:

A client has been placed on long-term sulfasalazine (Azulfidine) therapy for treatment of his ulcerative colitis. The nurse should encourage the client to eat which of the following foods to help avoid the nutrient deficiencies that may develop as a result of this medication? 1. Citrus fruits. 2. Green, leafy vegetables. 3. Eggs. 4. Milk products.

2. In long-term sulfasalazine therapy, the client may develop folic acid deficiency. The client can take folic acid supplements, but the nurse should also encourage the client to increase the intake of folic acid in his diet. Green, leafy vegetables are a good source of folic acid. Citrus fruits, eggs, and milk products are not good sources of folic acid.

A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, and weak, thready pulses. The nurse should do which of the following first? 1. Encourage the client to drink at least 1,000 mL per day. 2. Provide parenteral rehydration therapy ordered by the physician. 3. Turn and reposition every 2 hours. 4. Monitor vital signs every shift.

2. Initially, the extracellular fluid (ECF) volume with isotonic I.V. fluids until adequate circulating blood volume and renal perfusion are achieved. Vital signs should be monitored as parenteral and oral rehydration are achieved. Oral fluid intake should be greater than 1,000 mL/ day. Turning and repositioning the client at regular intervals aids in the prevention of skin breakdown, but it is first necessary to rehydrate this client.

A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. The nurse shuld tell the client? 1. "Ulcerative colitis can be cured by the use of steroids." 2. "Steroids are used in severe flare-ups because they can decrease the incidence of bleeding." 3. "Long-term use of steroids will prolong periods of remission." 4.. "The side effects of steroids outweigh their benefits to clients with ulcerative colitis."

2. Steroids are effective in management of the acute symptoms of ulcerative colitis. Steroids do not cure ulcerative colitis, which is a chronic disease. Long-term use is not effective in prolonging the remission and is not advocated. Clients should be assessed carefully for side effects related to steroid therapy, but the benefits of short-term steroid therapy usually outweigh the potential adverse effects.

History of alcohol use, smoking, and weight loss

A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting. A gastric ulcer is suspected. Which of the following data would further support this diagnosis?

The physician prescribes sulfasalazine (Azulfidine) for the client with ulcerative colitis to continue taking at home. Which instruction should the nurse give the client about taking this medication? 1. Avoid taking it with food. 2. Take the total dose at bedtime. 3. Take it with a full glass (240 mL) of water. 4. Stop taking it if urine turns orange-yellow.

3. Adequate fluid intake of at least 8 glasses a day prevents crystalluria and stone formation during sulfasalazine therapy. Sulfasalazine can cause gastrointestinal distress and is best taken after meals and in equally divided doses. Sulfasalazine gives alkaline urine an orange-yellow color, but it is not necessary to stop the drug when this occurs.

A client's ulcerative colitis signs and symptoms have been present for longer than 1 week. The nurse should assess the client for signs and symptoms of which of the following complications? 1. Heart failure. 2. Deep vein thrombosis. 3. Hypokalemia. 4. Hypocalcemia.

3. Excessive diarrhea causes significant depletion of the body's stores of sodium and potassium as well as fluid. The client should be closely monitored for hypokalemia and hyponatremia. Ulcerative colitis does not place the client at risk for heart failure, deep vein thrombosis, or hypocalcemia.

A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 lb since the exacerbation of his ulcerative colitis. Which of the following will be most effective in helping the client meet his nutritional needs? 1. Continuous enteral feedings. 2. Following a high-calorie, high-protein diet. 3. Total parenteral nutrition (TPN). 4. Eating six small meals a day.

3. Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the bowel. To maintain the client's nutritional status, the client will be started on TPN. Enteral feedings or dividing the diet into six small meals does not allow the bowel to rest. A high-calorie, high-protein diet will worsen the client's symptoms.

A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for: 1. Hyperalbuminemia. 2. Thrombocytopenia. 3. Hypokalemia. 4. Hypercalcemia.

3. Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.

The aspirate from the tube has a pH of 7.45.

A client had a Miller-Abbott tube inserted 24 hours ago. The nurse is asked to check the client to determine whether the tube is in the appropriate location at this time. Which of the following findings would indicate adequate location of the tube?

A client who is experiencing an exacerbation of ulcerative colitis is receiving I.V. fluids that are to be infused at 125 mL/ hour. The I.V. tubing delivers 15 gtt/ mL. How quickly should the nurse infuse the fluids in drops per minute to infuse the fluids at the prescribed rate? ________________________ gtt/ minute.

31 gtt/ minute To administer I.V. fluids at 125 mL/ hour using tubing that has a drip factor of 15 gtt/ mL, the nurse should use the following formula: 125 mL/ 60 minutes × 15 gtt/ 1 mL = 31 gtt/ minute.

High-fiber diet

A client has asymptomatic diverticular disease. What type of diet should the nurse anticipate to be prescribed

Low fiber

A client has been diagnosed with acute gastroenteritis. Which of the following diets should the nurse anticipate would be prescribed for the client

The nurse has an order to administer sulfasalazine (Azulfidine) 2 g. The medication is available in 500-mg tablets. How many tablets should the nurse administer? ________________________ tablets.

4 tablets To administer 2 g sulfasalazine (Azulfidine), the nurse will need to administer 4 tablets.

A client who has ulcerative colitis says to the nurse, "I can't take this anymore! I'm constantly in pain, and I can't leave my room because I need to stay by the toilet. I don't know how to deal with this." Based on these comments, an appropriate nursing diagnosis for this client would be: 1. Impaired physical mobility related to fatigue. 2. Disturbed thought processes related to pain. 3. Social isolation related to chronic fatigue. 4. Ineffective coping related to chronic abdominal pain.

4. It is not uncommon for clients with ulcerative colitis to become apprehensive and upset about the frequency of stools and the presence of abdominal cramping. During these acute exacerbations, clients need emotional support and encouragement to verbalize their feelings about their chronic health concerns and assistance in developing effective coping methods. The client has not expressed feelings of fatigue or isolation or demonstrated disturbed thought processes.

"That is because the empty stomach sends signals to the brain to stimulate hunger."

A client has had extensive surgery on the gastrointestinal tract and has been started on parenteral nutrition (PN). The client tells the nurse, "I think I'm going crazy...I feel like I'm starving and yet that bag is supposed to be feeding me." The best response of the nurse would be:

Monitoring for the gag reflex

A client has just undergone a gastroscopy. Which action should be taken by the nurse as the essential post-procedure nursing intervention?

Checking for return of a gag reflex

A client has undergone esophagogastroduodenoscopy (EGD). The nurse places highest priority on which of the following items as part of the client's care plan?

What is your understanding of celiac disease?"

A client is admitted to an acute care facility with complications of celiac disease. Which question would be helpful initially in obtaining information for the nursing care plan?

Avoid eating or drinking after midnight before the test.

A client will undergo a barium swallow to confirm a diagnosis of a hiatal hernia. In preparation for the test, the nurse instructs the client to:

Difficulty swallowing both liquids and solids

A client with a possible hiatal hernia complains of frequent heartburn and regurgitation. Which sign or symptom would support this diagnosis?

Lying flat

A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse tells the client to avoid which position that could aggravate the pain?

Upright

A client with ascites is scheduled for a paracentesis. The nurse is assisting the health care provider in performing the procedure. Which of the following positions will the nurse assist the client to assume for this procedure?

Lying recumbent after meals

A client with hiatal hernia chronically experiences heartburn after meals. The nurse would teach the client to avoid which of the following, which is contraindicated with hiatal hernia?

Protect the gastric mucosa

A client with peptic ulcer disease has been prescribed misoprostol (Cytotec) and sucralfate (Carafate). The nurse teaches the client that these two medications will work primarily to:

Offer small, frequent meals

A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention would be appropriate

A tube with a larger lumen and an air vent

A health care provider asks the nurse to obtain a Salem Sump tube for gastric intubation. The nurse would correctly select which of the following tubes from the unit storage area?

Document the finding in the client's record.

A health care provider places a Miller-Abbott tube in a client who has a bowel obstruction. Six hours later, the nurse measures the length of the tube outside of the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action should the nurse take next?

Take and hold a deep breath.

A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. The LPN would instruct the client to do which of the following?

One day

A licensed practical nurse (LPN) is providing follow-up teaching after a client underwent an upper gastrointestinal (GI) series. The nurse reminds the client that the stools will remain white for approximately:

Eating low-fat or nonfat foods

A nurse documents that a client with a hiatal hernia is implementing effective health maintenance measures after the client reports doing which of the following

Low and intermittent

A nurse has assisted in the insertion of a Levin tube for gastrointestinal (GI) decompression. The nurse plans to set the suction to which of the following pressures?

Hematemesis

A nurse has been caring for a client with a Sengstaken-Blakemore tube. The health care provider arrives on the nursing unit and deflates the esophageal balloon. Following deflation of the balloon, the nurse should monitor the client most closely for which of the following

A decrease in sour eructation

A nurse has been reinforcing dietary teaching for a client with peptic ulcer disease who has a routine follow-up visit. Which behavior is the best indicator of a successful outcome for this client?

Resume full activity level within 1 week

A nurse has given the client with hepatitis instructions about postdischarge management during convalescence. The nurse determines that the client needs further teaching if the client states to:

Left Sims' position

A nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse assists the client to which of the following positions?

Esophageal varices

A nurse is assigned to care for a client with a Sengstaken-Blakemore tube. The nurse should suspect that the client has which diagnosis?

Learn measures such as biofeedback or progressive relaxation.

A nurse is assisting in planning stress management strategies for the client with irritable bowel syndrome. Which suggestion would the nurse give to the client?

High Fowler's position

A nurse is assisting with the insertion of a nasogastric tube into a client. The nurse places the client in which position for insertion?

Irrigating the nasogastric (NG) tube

A nurse is caring for a client after a Billroth II procedure. On review of the postoperative prescriptions, which of the following, if prescribed, would the nurse question and verify?

No oral intake of liquids or food

A nurse is caring for a client suspected of having appendicitis. Which of the following would the nurse anticipate will be prescribed for this client?

Apply disposable gloves,Lubricate the enema tube and insert it approximately 4 inches,Clamp the tubing if the client expresses discomfort during the procedure,Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C).

A nurse is preparing to administer an enema to an adult client. Choose the interventions that the nurse would perform for this procedure

Hold the feeding

A nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric tube. The nurse checks the residual and obtains an amount of 200 mL. The nurse would:

2

A nurse is preparing to perform an abdominal assessment on a client. The nurse places the client in which best position to perform the assessment? Refer to figure.

Eat anything as long as it does not aggravate or cause pain

A nurse is reinforcing dietary instructions to a client with peptic ulcer disease. The nurse encourages the client to:

Steatorrhea

A nurse is reviewing the health care record of a client with a diagnosis of chronic pancreatitis. Which data noted in the record indicate poor absorption of dietary fats?

Administer antacids, as prescribed,Encourage coughing and deep breathing,Administer anticholinergics, as prescribed

A nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Choose the interventions that the nurse would expect to be prescribed for the client.

Be sure to sleep with your head elevated in bed."

A nurse is teaching a client with a newly diagnosed hiatal hernia about measures to prevent recurrence of symptoms. Which statement would be included in the teaching?

Left Sims' position

A nurse is teaching the client about an upcoming colonoscopy procedure. The nurse would include in the instructions that the client will be placed in which of the following positions for the procedure?

Monitoring prothrombin and partial thromboplastin values

A nurse planning care for a client with hepatitis plans to meet the client's safety needs by:

Lie on the right side for 2 hours

A nurse provides instructions to a client after a liver biopsy. The nurse tells the client to:

The nizatidine (Axid) will cause me to produce less stomach acid."

A nurse provides medication instructions to a client with peptic ulcer disease. Which statement by the client indicates the best understanding of the medication therapy?

Regular monthly injections of vitamin B12 will prevent this complication

A nurse reinforces instructions to a client following a gastrectomy about the signs and symptoms of pernicious anemia, knowing that:

Maintaining a patent nasogastric (NG) tube

A nurse who is assisting in the care of a client within the first 24 hours following a total gastrectomy for gastric cancer should focus interventions on which of the following?

Take action to prevent dumping syndrome.

A nurse who is providing instructions to a client following gastric resection would include which of the following suggestions

Learn to use stress reduction techniques.

A nurse would include which of the following when reinforcing home care instructions for a client who has peptic ulcer disease?

This opioid will cause very deep sleep, which is what my husband needs."

Which statement by the spouse of a client with end-stage liver failure indicates the need for additional teaching by the multidisciplinary team regarding the management of pain?

A right side-lying position with a small pillow or folded towel under the puncture site

After a liver biopsy, the nurse places the client in which of the following positions?

Hemorrhage

After the deflation of the balloon of a client's Sengstaken-Blakemore tube, the nurse monitors the client closely for which esophageal complication

70 mcg/dL

An adult client with hepatic encephalopathy has a serum ammonia level of 120 mcg/dL and receives treatment with lactulose (Chronulac) syrup. The nurse determines that the client has the best and most optimal response if the level changes to which of the following after medication administration?

Requires the client to lie still for short intervals

An ultrasound of the gallbladder is scheduled for the client with a suspected diagnosis of cholecystitis. The nurse explains to the client that this test:

Evaluate absorption of the last feeding

Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. The nurse understands that the rationale for checking gastric residual volume before administering the tube feeding is to:

Hepatitis A

It has been determined that a client with hepatitis has contracted the infection from contaminated food. What type of hepatitis is this client most likely experiencing?

Hepatitis B vaccine

Of the following infection control methods, which would be the priority to include in the plan of care to specifically prevent hepatitis B in a client considered to be at high risk for exposure?

Limit the fluids taken with meals.

The nurse is providing discharge instructions to a client after gastrectomy. Which measure will the nurse instruct the client to follow to help prevent dumping syndrome?

Brush the client's teeth frequently. Use diluted mouthwash and water to rinse the mouth

The nurse observes that a client with a nasogastric tube connected to continuous gastric suction is mouth breathing, has dry mucous membranes, and has a foul breath odor. In planning care, which nursing intervention would be best to maintain the integrity of this client's oral mucosa?

Nasogastric

Treatment measures have been implemented for a client with bleeding esophageal varices and have been unsuccessful. The health care provider states that a Sengstaken-Blakemore tube will be used to control the resulting hemorrhage. The nurse prepares for insertion via which of the following routes?

History of the use of acetaminophen (Tylenol) for pain and discomfort

nurse is collecting data on a client with a diagnosis of peptic ulcer disease. Which of the following is least likely associated with this disease?

Position the client supine and flat

nurse is reviewing the health care provider's prescriptions written for a client admitted with acute pancreatitis. Which health care provider prescription would the nurse verify if noted on the client's chart?

Diarrhea

nurse is reviewing the record of a client with Crohn's disease. Which of the following stool characteristics would the nurse expect to see documented in the record