Med Surg CH 60-62

In assessing for the presence of asterixis, the nurse instructs the patient to perform which action?

"Extend your arm, flex your wrist upward, and extend your fingers."

The nurse incorporates which information into the teaching plan for the patient with severe esophageal varices who is scheduled for transjugular intrahepatic portal systemic shunt (TIPS) insertion?

"You will receive sedation, but the procedure may still be painful."

The nurse is caring for a patient who is being discharged from the hospital after an attack of acute pancreatitus. Which discharge instructions will the nurse provide for the patient to help prevent a recurrence? (select all)

A. ""Take a 20-minute walk at least 5 days a week." B. "Attend local Alcoholics Anonymous (AA) meetings weekly." D. "Use olive oil when you cook rather than margarine or butter." E. "Stay away from milk and airy products that contain lactose." G. "Use Tylenol (acetaminophen) rather than Motrin (ibuprofen) for pain."

The nurse is caring for a postoperative patient who complains of pain in the shoulder blades following laparoscopic cholecystectomy surgery. Which direction will the nurse give to the nursing assistant to help relieve the client's pain?

A. "Ambulate the patient in the hallway."

The nurse is caring for a client who wishes to avoid getting traveler's diarrhea on his upcoming trip. Which recommendation will the nurse offer the client?

A. "Do not ask for ice in soft drinks." B. "Use bottle water to brush your teeth." C. "Boil water for at least one minute before drinking." D. " Do not eat salads with lettuce, spinach or cut up fruit." G. " Do not drink bottled water if the seal on the bottle has been broken."

The nurse is caring for a patient with end-stage pancreatic cancer. The patient asks the nurse, "Why is this happening to me?" Which is the nurse's best response?

A. "I don't know. I wish I had the answer for you but I don't."

The patient with obstructive jaundice asks the nurse why his skin is so itchy. Which is the nurse's best response?

A. "The itching is caused by the accumulation of bile salts in the skin."

Which is the nurse's best response to the patient receiving lactulose who reports ecperiencing several soft stools daily?

A. "This is the expected response to the medication"

The nurse reviews a health teaching for a client with Crohn's disease. Which instructions will the nurse provide for the client?

A. "You should have a colonoscopy every few years."

The nurse recognizes which patient as being at greatest risk of developing hepatitis B?

A. A college student who has had several sexual partners

In assessing a patient, the nurse correlates Kehr's sign with which finding?

A. Abdominal pain referred to the right shoulder

Which clinical sign would alert the nurse to the presence of possible liver trauma?

A. Abdominal pain reffered to the right shoulder

The nurse monitors for which clinical manifestation as indicative of a serious side effect of ribavirin (Virazole)?

A. Anemia

The nurse is caring for a client who has undergone an incision and drainage of an anorectal abscess. Which nursing intervention will the nurse include in the client's plan of care?

A. Assisting the client with sitz baths several times daily

The nurse monitors for which clinical manifestation in the patient with a decreased fecal urobilinoegen concentration?

A. Clay-colored stools

The nurse correlates which action to the administration of vasopressin for the patient with bleeding esophageal varices?

A. Constriction of preportal splanchnic arterioles

The postanesthesia care unit nurse is caring for a patient who has just undergone an open Whipple procedure. The patient has multiple tubes and drains in place after the surgery. Which will the nurse assess first?

A. Endotracheal tube with 40% FiO2

The nurse monitors what laboratory data in the patient reporting seven loose stools in the 12 hours after receiving lactulose?

A. Hypokalemia

The nurse is teaching the patient with a history of cholelithiasis to select menu items for dinner. Which selections made by the patient indicates the the nurse's teachings were effective?

A. Lasagna, tossed salad with Italian dressing, 2% milk

Which medication does the nurse prepare to administer for the patient who is experiencing transplant rejection?

A. Methylprednisolone (Solu-Medrol)

The nurse conducts a physical assessment for a client with abdominal pain. Which finding leads the nurse to suspect appendicitis?

A. Positive obturator and iliopsoas muscle test

The nurse is caring for a client with Crohn's disease and colonic strictures. Which assessment finding indicates to the nurse that a dangerous complication has developed?

A. The client's abdomen is distended

The nurse is caring for a female patient with cholelithiasis. Which assessment findings from the patient's history and physical examination may have contributed to the development of the condition? (select all)

A. The patient's BMI is 46 D. The patient gave birth to twins 2 months ago E. The patient has a history of metabolic syndrome. G. The patient's glycosylated hemoglobin level is 15%

The nurse includes which information in the teaching plan for the patient with viral hepatitis? (select all that apply)

B. "Avoid all medications unless prescribed by physician" D. "Increase intake of carbohydrates" E. "Do not share razors or nail clippers"

Which statement by the patient with alcohol induced cirrhosis indicates the need for further teaching?

B. "I need to avoid protein in my diet"

The nurse is caring for a client with perineal excoriation caused by diarrhea from acute gastroenteritis. Which client statement indicates that additional teaching about perineal care is needed?

B. "I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel."

The nurse is providing discharge teaching for a patient who has undergone laparoscopic cholecystectomy surgery. Which statement by the patient indicates understanding of the instructions?

B. "I will have a low-fat diet with small, frequent meals."

The nurse provides discharge teaching for a client who was hopitalized for salmonella food poisoning. Which client statement indicates that additional teaching is needed?

B. "I will take the ciprofloxacin (Cipro) until the diarrhea has resolved."

A patient admitted with hepatitis A is tearful and states that her boyfriend will not visit her. Which response by the nurse is most therapeutic?

B. "Let's discuss strategies to deal with this"

A patient who underwent liver transplantation 2 weeks ago reports a temperature of 101 degrees and right flank pain. Which would be the nurse's best response?

B. "You may be rejecting the transplanted liver and should go to the hospital immediately"

For the patient diagnosed with hepatitis A asking how the infection may have been contracted, which response by the nurse is correct?

B. "You may have been exposed through contaminated shellfish"

The nurse is caring for a client who reports that he cannot sleep because of severe itching around his rectum at night. Which is the appropriate recommendation by the nurse?

B. "You should wash your bed linens and pajamas twice a week and clean the toilet seats every day."

The nurse has completed the teaching session for a client with a new colostomy. Which feedback statement by the nurse is the most appropriate?

B. "You were able to clean the stoma well today. Now you do need practice putting on the appliance."

The nurse is caring for a client who had ileostomy surgery 10 days ago. The client verbalizes concerns that they effluent has not becomed formed and is still liquid green. Which is the nurse's best response?

B. "Your stools will become firmer over the next few weeks as your body gets used to the ileostomy."

The nurse recognizes that fetor hepaticus is consistant with which assessment finding?

B. A fruity or musty breath odor

The nurse correlates which rationale for a protien-restricted diet in the patient with portal-systemic encephalopathy (PSE)?

B. A low protein diet will help reduce the amount of ammonia in the blood

The nurse correlates which data in the patient's history as a predisposing factor for Laennec's cirrhosis?

B. Alcohol abuse

The nurse is caring for a patient who has undergone surgery to drain a pancreatic abscess with placement of a pancreatic drainage tube. Which nursing intervention will prevent complications from this procedure?

B. Applying a skin barrier around the drainage tube site.

Prior to calling the health care provider, which is the nurse's priority action for the patient with an increase in abdominal girth after undergoing a portal-systemic shunting procedure?

B. Assessing blood pressure

The nurse correlates which findings in the patient with chronic persistant hepatitis?

B. Asymptomatic

The nurse monitors for which complication in the patient with end-stage cirrhosis who develops severe vomiting?

B. Bleeding esophageal varices

The nurse is caring for a client who is having approximately 20 foul-smelling stools/day. Laboratory Gram stain testing indicates the presence of white blood cells (WBCs) and red blood cells (RBCs) in the stool. Which organisms does the nurse expect to see in the culture report?

B. Campylobacter jejuni

Which clinical manifestation would support the nurse's assessment of venous congestion in the patient admitted with cirrhosis and an enlarged liver?

B. Crackles on auscultation

A patient with an esophagogastric tube suddenly experiences acute respiratory distress. Which is the nurse's first action?

B. Cutting the balloon ports and remove the tube

Which laboratory findings does the nurse recognizes as a potential complication of liver disease?

B. Elevated prothrombin time and international normalized ratio (INR)

Which laboratory data does the nurse correlate with advanced disease in the patient with cirrhosis?

B. Elevated serum ammonia level

The nurse is caring for an older client with salmonella food poisoning. Which is the priority action of the nurse?

B. Maintaining IV fluids

The nurse is caring for a patient with acute pancreatitis. Which nursing intervention will best reduce discomfort for the patient?

B. Maintaining NPO status for the patient with IV fluids.

Which nursing intervention is a priority for the patient who has just undergone a paracentesis?

B. Maintaining bedrest

For the patient with cirrhosis, which nursing intervention would be most effective in controlling fluid accumulation in the abdominal cavity?

B. Providing a low-sodium diet

In reveiwing patient charts, which finding by the nurse correlates with an increased risk for developing hepatorenal syndrome secondary to cirrhosis?

B. Taking acetaminophen for pain

The nurse is caring for a client with diarrhea who has just been diagnnosed with Clostridium difficile infection. Which nursing actions will help prevent the spread of infection to others? (Select all that apply?

B. Washing hands thoroughly with antibacterial soap and water before and after caring for the client C. Placing the client in a private room with contact isolation precautions E. Ensuring that visitors and family members do not share eating utensils or dishes F. Keeping a separate blood pressure blood pressure cuff, stethoscope and thermometer in the room for use with only the client G. Cleaning non-disposible equipment with bleach or disinfectant solution before use with other clients

The nurse is caring for a client who has acute viral gastroenteritis. Which dietary instruction will the nurse provide to the client?

C. "Drink Gatorade if you do not like the taste of Pedialyte."

Which statement by the patient with liver cancer scheduled for a hepatic arterial infusion of chemotherapy indicates that teaching was effective?

C. "I am glad I will have fewer side effects to this procedure"

Which statement made by a patient traveling to a nonindustrialized country indicates the need for further teaching regarding the prevention of viral hepatitis?

C. "I should eat plenty of fresh fruit"

The nurse is caring for a patient with chronic pancreatitis. Which statement by the patient indicates that additional teaching is needed?

C. "I will avoid simple carbohydrates and concentrated sweets."

The nurse is caring for a client with severe ulcerative colitis who has been prescribed adalimumab (Humira). Which client statement indicates that additional teaching about the medication is needed?

C. "I will get the chickenpox vaccine this year."

The nurse is preparing a client with diverticulitis for discharge from the hospital. Which statement by the client indicates that additional teaching is needed?

C. "I will take a senna laxative at bedtime to avoid becoming constipated."

The nurse is providing discharge teaching for a patient who will be receiving pancreatic enzyme replacement at home. Which statement by the patient indicates that additional teaching is needed?

C. "I will take the enzymes immediately after I have a meal or snack."

In completing preoperative teaching for a patient scheduled for liver transplantation, the patient states that he is scared that the procedure will not work. Which is the nurse's best response?

C. "It is expected the you have some anxiety before the surgery"

The nurse is caring for a teenage girl with a new ileostomy. She tells the nurse tearfully that she cannot go to the prom with an ostomy. Which is the nurse's best response?

C. "Lets talk to the enterostomal therapist (ET) about options for ostomy supplies and dress styles so that you can look beautiful for the prom."

The nurse is caring for a client who is taking diphenoxylate hydrochloride and atropine sulfate (Lomotil) for gastrooenteritis. Which finding will the nurse report to the client's health care provider right away?

C. Abdominal pain and bloating

The nurse is caring for a patient who had undergone a Whipple procedure 2 days previously. The nurse notes that the patient's hands and feet are endematous, and urine output has decreased from the previous day. Which intervention will the nurse expect to do for the patient?

C. Adding additional amino acids to the client's total parental nutrition (TPN) solution

The nurse correlates decreased hepatic synthesis of which substance in the patient who develops ascites?

C. Albumin

A patient with a history of alcohol abuse is diagnosed with liver cancer. Which community resource is best for providing information about living with liver cancer?

C. American liver foundation

The nurse monitors for which clinical manifestation as a potential complication of surgical bypass shunting?

C. Decreased urinary output

The nurse is caring for a patient who has just been diagnosed with end-stage pancreatic cancer. The nurse assess the client's emotional response to the diagnosis. Which is the nurse's initial action for the assessment?

C. Determining if the patient feels like talking about his or her feelings.

The nurse is caring for a patient who has just undergone traditional cholecystectomy surgery and has a Jackson-Pratt (JP) drain in place. The nurse notes that there is serosanguineous drainage present in the drain. Which is the nurse's priority action?

C. Document the finding's in the patient's chart

The nurse is caring for a patient who has undergone traditional cholecystectomy surgery earlier in the day. The nurse notes that there is approximately 150 mL of serosanguineous drainage present in the T-tube drain. Which is the nurse's priority action?

C. Gently milking the T-tube drain tubing to maintain patency.

The nurse monitors for which serologic marker in the patient who is a carrier of chronic hepatitis?

C. HBsAg antibodies

Which clinical finding does the nurse expect to observe in the patient who had just undergone a peritoneovenous shunt placement?

C. Increased blood pressure

The nurse recognizes which patient as at greatest risk for the development of carcinoma of the liver?

C. Older adult patient with a history of cirrhosis

The nurse is caring for a client who has had a total colectomy with an ileoanal reservoir. Which is the priority nursing intervention for the client?

C. Providing careful perineal care after each stool

Which laboratory result will the nurse expect to find in a patient with pancreatitis?

C. Serum amylase, 625 IU/L

A client is brought to the emergency department with an abrupt onset of vomiting, abdominal cramping, and diarrhea 2 hours after eating food at a picnic. Which of the following infections agents does the nurse suspect as the probable cause?

C. Staphylococcus aureus

The nurse is preparing to begin teaching the client about how to care for his new ileostomy. Which consideration is the highest priority for the nurse when planning teaching for this client?

C. Starting the teaching when the client is ready to look at the stoma

The nurse has completed teaching about dietary recommendations for a client with diverticulitis. Which notion will the nurse include in the client's chart about the client's response to the teaching?

C. The client identified and verbalized understanding of five dietary recommendations for diverticulitis.

The nurse is caring for a client who is hospitalized with an exacerbation of Crohn's disease. What does the nurse expect to find during physical assessment?

C. The client's bowel sounds are hyperactive in all quadrants.

The nurse is caring for a client with Giardia lamblia infection. Which assessment finding indicates to the nurse that the client has developed a dangerous complication from the infection?

C. The client's tongue is smooth and bright red in color

The nurse is caring for a patient with acute pancreatitis. The patient is to receive dicyclomine (Bentyl), 20 mg IM, every 6 hours. Which assessment finding leads the nurse to clarify the order with the patient's physician?

C. The nurse does not hear any bowel sounds in the patient's abdomen.

The nurse is caring for a patient with a T-tube placed 3 days ago. Which assessment finding indicates to the nurse that the procedure was successful?

C. The patient had a soft, brown, formed stool this morning.

The nurse is caring for a patient with cholecystitis. Which assessment finding indicates to the nurse that the condition is chronic rather than acute?

C. The patient has clay-colored stools and dark amber urine.

The nurse is caring for a patient with cholecystitis. The patient is a poor historian and is unable to tell the nurse when the symptoms started. Which assessment finding indicates to the nurse that the condition is chronic rather than acute?

C. The patient has light-colored stoolls and dark amber urine.

The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the highest priority?

C> Heart rate and rhythm

The nurse is providing discharge information for a patient who will be going home with a T-tube following cholecystectomy surgery. Which statement by the patient indicates the need for additional teaching?

D. "I will irrigate the T-tube with normal saline if the drainage appears too slow"

The nurse is teaching the client how to care for a new ileostomy. Which client statement indicated that additional teaching is needed?

D. "I will keep some extra ostomy supplies in the glove compartment of my car."

The client asks the nurse how to avoid becoming ill will salmonella infection again. Which are appropriate responses from the nurse? (Select all that apply)

D. "Wash your hands before and after using the bathroom." E. "Use separate cutting boards for raw meats and vegetables." F. "Avoid eating eggs that are sunny side up or undercooked." G. "Make sure that all juices and milk are pasteurized before drinking."

The nurse is caring for a client who recently underwent total colectomy and placement of a continent ileostomy. Which instruction will the nurse include in the teaching plan for the client?

D. "You can add a few drops of deodorant solution inside the pouch to minimize odor."

The nurse helps a client with diverticular disease choose appropriate dinner options for a low-residue diet. Which menu selections are most appropriate?

D. Baked fish with steamed asparagus, dinner roll with butter, glass of apple juice

The nurse is caring for a client who is taking mesalamine (5-aminosalicylic acid) (Asacol, Rowasa) for ulcerative colitis. The client cannot swallow the pill and asks the nurse to crush it. What is the nurse's appropriate action?

D. Contact the client's physician to request an order for Rowasa enemas instead

The nurse is caring for a client who is recovering from food poisoning. The nurse tells the client about which foods to eat when he feels hungry again. Which client selection indicates that additional teaching is needed?

D. Cup of cottage cheese and a slice of orange

Which finding alerts the nurse to presence of hepatomegaly?

D. Dullness percussed over the liver

The nurse is caring for a client with Crohn's disease who has developed a fistula. Which nursing intervention is the highest priority?

D. Encouraging the client to consume a diet high in protein and calories

The nurse is caring for a patient with acute pancreatitis. During the physical assessment, the nurse notes the presence of Turner's sign. Which is the nurse's priority action?

D. Ensuring that the patient has a patent large-bore IV site.

Which laboratory finding does the nurse anticipate to note for a female client with an exacerbation of ulcerative colitis?

D. Erythrocyte sedimentation rate (ESR), 55 mm/hr

Which finding in the patient receiving an infusion of vasopressin to treat bleeding esophageal varices indicates to the nurse a serious adverse effect of the drug?

D. Midternal chest pain

The nurse uses which measurement technique in assessing abdominal girth?

D. Obtainting the measurement at the end of exhalation

The nurse is caring for a client who has food poisoning that may be the result of Clostridium botulinum infection. Which is the priority nursing assessment for this client?

D. Oxygen saturation and respiratory rate

The nurse conducts a physical assessment for a client with anorexia and sever abdominal pain. The nurse notes that the abdomen is rigid and the client's temperature is 101.1 F (38.4 C). Which condition does the nurse suspect based on this information?

D. Perforated gastric ulcer with peritonitis

The patient with end stage cirrhosis presents with gastrointestinal (GI) bleeding, combativeness, and confusion. The nurse recognizes these as complications of which disorder?

D. Portal-systemic encephalopathy

Which nursing intervention is the priority in the patient being treated for bleeding esophageal varices with an esophagogastric tube?

D. Suctioning the oral cavity of secretions

The nurse is caring for an adult patient with possible cholecystitis. Which laboratory findings lead the nurse to beleive that this diagnosis is correct? (select all)

E. WBC count, 13,000/mm3 F. Alanine aminotransferase (ALT), 66 IU/L G. Alkaline phosphatase (ALP), 106 U/L

The nurse monitors the patient 1 hour postparacentesis for which complication?

Hypovolemia