NCLEX 10000 GI Disorders
The nurse is irrigating a client's colostomy. The client has abdominal cramping after receiving about 100 ml of the irrigating solution. The nurse should first: a) Remove the irrigation tube. b) Massage the abdomen gently. c) Stop the flow of solution. d) Reposition the client on to the right side.
Stop the flow of solution. Correct Explanation: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside.
A client has a suspected slow gastrointestinal bleed. Because of this, the nurse specifically instructs the nursing assistant to look for and report which of the following symptoms? a) Hypotension. b) Tarry stools. c) Bright red blood in the stools. d) Jaundice.
Tarry stools. Correct Explanation: A client with a suspected slow gastrointestinal bleed should be observed for tarry (black) stools, which indicate slow bleeding from an upper gastrointestinal site. The longer the blood remains in the system, the darker it becomes from the degradation of hemoglobin and release of iron.
A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which nursing observation indicates this client is ready to be discharged? a) The client walks in the hallway unassisted. b) The client is pain free. c) The client voids 500 mL of urine. d) The client tolerates eating a hamburger.
The client voids 500 mL of urine. Explanation: Urinary elimination in the first 8 hours postoperatively is a requirement before the client who has had an inguinal hernia repair can be discharged from same-day surgery.
The community health nurse develops a health education program about preventing the transmission of hepatitis B. The nurse evaluates that the teaching has been effective when the participants identify which activity to be high risk for acquiring hepatitis B? a) ingestion of contaminated seafood b) ingestion of large amounts of acetaminophen c) frequent use of marijuana d) sharing needles for drug use
sharing needles for drug use Correct Explanation: Sharing needles is associated with increased incidence of blood-borne diseases such as hepatitis B.
TPN is ordered for a client with Crohn's disease. The TPN solution is having an intended outcome when: a) the client does not have metabolic acidosis. b) the client is in a negative nitrogen balance. c) the client is hydrated. d) the client's nutritional needs are met.
the client's nutritional needs are met. Correct Explanation: The goal of TPN is to meet the client's nutritional needs
A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that: a) the client requires an antiviral agent. b) the client's infection may be caused by droplet transmission. c) enteric precautions must be continued. d) enteric precautions can be discontinued.
Correct response: enteric precautions must be continued. Explanation: The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route.
Which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting? a) Completing the admission history. b) Teaching about planned diagnostic tests. c) Maintaining hydration. d) Administering pain medication.
Administering pain medication. Correct Explanation: Administering pain medication would have the highest priority during the first hour after the client's admission. Completing the admission history can be done after the client's pain is controlled.
A client, age 82, is admitted to an acute care facility for treatment of an acute flare-up of a chronic GI condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the GI tract. Which age-related change increases the risk of anemia? a) Decrease in intestinal flora b) Dulling of nerve impulses c) Increase in bile secretion d) Atrophy of the gastric mucosa
Atrophy of the gastric mucosa Correct Explanation: Atrophy of the gastric mucosa reduces hydrochloric acid secretion; this, in turn, impairs absorption of iron and vitamin B12, increasing the risk of anemia as a person ages.
A client with acute pancreatitis has a blood pressure of 88/40 mm Hg, heart rate of 128 bpm, respirations of 28/min, and Grey Turner's sign. What prescription should the nurse implement first? a) Place an intravenous line. b) Position on the left side. c) Insert a nasogastric tube. d) Initiate intake/output record.
Correct response: Place an intravenous line. Explanation: Grey Turner's sign is a bluish discoloration in the flank area caused by retroperitoneal bleeding. The vital signs are showing hemodynamic instability. IV access should be obtained to provide immediate volume replacement.
A client who is scheduled for an open cholecystectomy has been smoking a pack of cigarettes a day for 20 years. For which postoperative complication is the client most at risk? a) atelectasis b) prolonged immobility c) deep vein thrombosis d) delayed wound healing
Correct response: atelectasis Explanation: The client who has a significant cigarette smoking history and an operative manipulation close to the diaphragm (the gallbladder is against the liver) is at increased risk for atelectasis and pneumonia. Postoperatively, this client will be reluctant to deep breathe because of pain, in addition to having residual lung damage from smoking. Therefore, the client is at greater-than-average risk for pulmonary complications.
A client reports abdominal pain and vomiting for 24 hours. The client's blood pressure is 98/48 mm Hg. The client is diagnosed with large-bowel obstruction. What is the priority nursing diagnosis for the client? a) Deficient knowledge b) Deficient fluid volume c) Acute pain d) Ineffective tissue perfusion
Deficient fluid volume Correct Explanation: Feces, fluid, and gas accumulate above a bowel obstruction. Then the absorption of fluids decreases and gastric secretions increase. This process leads to a loss of fluids and electrolytes in circulation. In addition the client has been vomiting for 24 hours and has a low blood pressure. Therefore, Deficient fluid volume is the priority diagnosis.
The client with chronic pancreatitis should be monitored closely for the development of which of the following disorders? a) Hepatitis. b) Irritable bowel syndrome. c) Cholelithiasis. d) Diabetes mellitus.
Diabetes mellitus. Correct Explanation: Clients with chronic pancreatitis are likely to develop diabetes as a result of the pancreatic fibrosis that occurs. The pancreas becomes unable to secrete insulin.
The client with chronic pancreatitis should be monitored closely for the development of which of the following disorders? a) Irritable bowel syndrome. b) Hepatitis. c) Diabetes mellitus. d) Cholelithiasis.
Diabetes mellitus. Correct Explanation: Clients with chronic pancreatitis are likely to develop diabetes as a result of the pancreatic fibrosis that occurs. The pancreas becomes unable to secrete insulin.
A client is in a metabolic acidosis from severe diarrhea. What assessment finding would be most concerning? a) Abdominal cramping b) Excoriated skin around the rectum c) Respiratory rate of 28 d) Irregular heart rate
Irregular heart rate Correct Explanation: Diarrhea causes a bicarbonate deficit. With loss of the relative alkalinity of the lower GI tract, the relative acidity of the upper GI tract predominates, leading to metabolic acidosis. The diarrhea would result in skin breakdown. Abdominal cramping would be anticipated. Kussmaul respirations are anticipated as a compensatory response. Irregular heart rate could be a sign of electrolyte imbalances and is most concerning.
A client has been prescribed propantheline as part of the treatment for a peptic ulcer. The nurse should assess the client for: a) Fatigue. b) Nausea. c) Urinary frequency. d) Hypotension.
Nausea. Correct Explanation: A common side effect of propantheline, an anticholinergic, is nausea. Other common side effects include blurred vision, dry mouth, vomiting, and urine retention.
A client is taking aluminum hydroxide tablets along with sucralfate daily 1 hour before meals. The nurse should instruct the client to do which of the following? a) Aluminum hydroxide and sucralfate are ineffective when used in combination. b) Sucralfate should be taken every 4 hours to be effective. c) Sucralfate and aluminum hydroxide should be taken early in the morning. d) Sucralfate should be taken on an empty stomach 1 hour before meals.
Sucralfate should be taken on an empty stomach 1 hour before meals. Explanation: Sucralfate is taken on an empty stomach at least 1 hour before meals and at bedtime to allow a protective coating to form over the ulcer before high levels of gastric acidity occur. It is not to be taken every 4 hours. Aluminum hydroxide and sucralfate are effective when prescribed together. Aluminum hydroxide should be taken for 2 hours before or after taking sucralfate, not at the same time.
A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care? a) Test all stools for occult blood. b) Prepare the client for a gastrostomy tube placement. c) Administer topical ointment to the rectal area to decrease bleeding. d) Administer morphine routinely, as ordered.
Test all stools for occult blood. Correct Explanation: Blood in the stools is one of the warning signs of colorectal cancer. The nurse should plan on checking all stools for both frank and occult blood.
A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage? a) There is a moderate amount of dry drainage on the outside of the dressing. b) The Hemovac drain isn't compressed; instead it's fully expanded. c) The client has been lying on his side for 2 hours with the drain positioned upward. d) The client has a nasogastric (NG) tube in place that drained 400 ml.
The Hemovac drain isn't compressed; instead it's fully expanded. Correct Explanation: The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage.
Which of the following interventions would be most appropriate for the nurse to recommend to a client to decrease discomfort from hemorrhoids? a) Decrease physical activity. b) Use warm sitz baths. c) Decrease fiber in the diet. d) Take laxatives to promote bowel movements.
Use warm sitz baths. Correct Explanation: Use of warm sitz baths can help relieve the rectal discomfort of hemorrhoids. Fiber in the diet should be increased to promote regular bowel movements.
A client has had an incisional cholecystectomy. Which of the following nursing interventions has the highest priority in postoperative care for this client? a) Using incentive spirometry every 2 hours while awake. b) Maintaining a weight-reduction diet. c) Promoting incisional healing. d) Performing leg exercises every shift.
Using incentive spirometry every 2 hours while awake. Correct Explanation: A major goal of postoperative care for the client who has had an incisional cholecystectomy is the prevention of respiratory complications. Because of the location of the incision, the client has a difficult time breathing deeply. Use of incentive spirometry promotes chest expansion and decreases atelectasis.
In caring for the client with hepatitis B, which situation would expose the nurse to the virus? a) disposing of syringes and needles without recapping b) a blood splash into the nurse's eyes c) touching the client's arm with ungloved hands while taking a blood pressure d) contact with fecal material
a blood splash into the nurse's eyes Correct Explanation: Hepatitis B virus is spread through contact with blood, body fluids contaminated with blood, and such body fluids as cerebrospinal, pleural, peritoneal, and synovial fluids; semen; and vaginal secretions. The risk of transmission of hepatitis B through feces is low.
The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which would be an indication that hepatic encephalopathy is developing? a) decreased mental status b) labored respirations c) decreased urine output d) elevated blood pressure
decreased mental status Explanation: The client should be monitored closely for changes in mental status. Ammonia has a toxic effect on central nervous system tissue and produces an altered level of consciousness, marked by drowsiness and irritability. If this process is unchecked, the client may lapse into coma.
The nurse is preparing a client for a paracentesis. The nurse should: a) initiate an IV line to administer sedatives. b) place the client on nothing-by-mouth (NPO) status 6 hours before the procedure. c) have the client void immediately before the procedure. d) place the client in a side-lying position.
have the client void immediately before the procedure. Correct Explanation: Immediately before a paracentesis, the client should empty the bladder to prevent perforation. The client will be placed in a high Fowler's position or seated on the side of the bed for the procedure. IV sedatives are not usually administered. The client does not need to be NPO
Metoclopramide is ordered as a premedication for a client about to undergo a gastroduodenoscopy. The expected therapeutic effect is: a) increased gastric pH. b) increased gastric emptying. c) inhibited respiratory secretions. d) reduced anxiety.
increased gastric emptying. Correct Explanation: Metoclopramide is an antiemetic given because of its gastric emptying ability, which is necessary in gastrointestinal procedures.
Which is a priority focus of care for a client experiencing an exacerbation of Crohn's disease? a) encouraging regular ambulation b) promoting bowel rest c) maintaining current weight d) decreasing episodes of rectal bleeding
promoting bowel rest Correct Explanation: 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
TPN is ordered for a client with Crohn's disease. The TPN solution is having an intended outcome when: a) the client is hydrated. b) the client's nutritional needs are met. c) the client does not have metabolic acidosis. d) the client is in a negative nitrogen balance.
the client's nutritional needs are met. Correct Explanation: The goal of TPN is to meet the client's nutritional needs. TPN is not used to treat metabolic acidosis; ketoacidosis can actually develop as a result of administering TPN. TPN is a hypertonic solution containing carbohydrates, amino acids, electrolytes, trace elements, and vitamins. It is not used to meet the hydration needs of clients. TPN is administered to provide a positive nitrogen balance.
Which of the following is included in a focused assessment of a client who has been diagnosed with hepatic cirrhosis? Select all that apply. a) Heart sounds. b) Current use of alcohol. c) Nutritional status. d) Mental status. e) Capillary refill time.
• Nutritional status. • Mental status. • Current use of alcohol. Correct Explanation: For the client with hepatic cirrhosis, it would be important to assess the client's current use of alcohol because alcohol consumption can have a significant impact on liver function and is, in fact, the major cause of cirrhosis. Continued use of alcohol further destroys liver cells and affects liver function. Assessing the client's nutritional status is also important because impaired nutrition develops in many clients due to gastrointestinal problems and the inability of the liver to metabolize nutrients. Mental status can be affected by the accumulation of ammonia in the blood, leading to hepatic coma if left untreated
Which of the following statements indicates that the client understands the home care of a colostomy? a) "I can expect to see some blood in my stool on occasion." b) "I can attach my colostomy pouch directly to my skin as long as it is not irritated." c) "I should be able to establish a regular pattern of elimination with my colostomy." d) "I can anticipate some pain around my stoma when I clean it."
"I should be able to establish a regular pattern of elimination with my colostomy." Explanation: Many colostomies, especially those located in the descending colon, can be regulated to evacuate on a schedule. All ostomy appliances should be applied using a peristomal skin barrier. There should be no pain associated with touching the stoma. After the immediate postoperative period, it is not normal for blood to be present in the stool. Bleeding should be reported to the client's health care provider.
A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. Based on the diagnosis of acute pancreatitis the nurse will provide which explanation for the prescribed interventions? a) "You are not allowed anything by mouth so that your pancreas can rest." b) "I will be starting antibiotic therapy once the blood cultures are obtained." c) "Activity is important, so you will be scheduled for physical therapy." d) "I can offer you ibuprofen for pain with a small sip of water."
"You are not allowed anything by mouth so that your pancreas can rest." Correct Explanation: The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Interventions include parenteral pain management preferably with an opioid, NPO status to decrease pancreatic activity, and bed rest to decrease body metabolism
Which diet would be most appropriate for the client with ulcerative colitis? a) high-calorie, low-protein b) high-protein, low-residue c) low-fat, high-fiber d) low-sodium, high-carbohydrate
high-protein, low-residue Correct Explanation: 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
A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: a) elevated blood urea nitrogen and creatinine levels and hyperglycemia. b) elevated liver enzymes and low serum protein level. c) subnormal serum glucose and elevated serum ammonia levels. d) subnormal clotting factors and platelet count.
subnormal serum glucose and elevated serum ammonia levels. Correct Explanation: In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness.
Which goal would be appropriate for a client with viral hepatitis? The client will: a) restrict activity to within the home to prevent disease transmission. b) demonstrate a decrease in fluid retention related to ascites. c) verbalize the importance of reporting bleeding gums or bloody stools. d) limit use of alcohol to two to three drinks per week.
Correct response: verbalize the importance of reporting bleeding gums or bloody stools. Explanation: The client should be able to verbalize the importance of reporting any bleeding tendencies that could be the result of a prolonged prothrombin time.
A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? a) Metabolic acidosis b) Respiratory alkalosis c) Respiratory acidosis d) Metabolic alkalosis
Metabolic alkalosis Correct Explanation: Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma biacarbonate concentration. The most common cuase of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and choloride ions. Gastric fluid has an acid pH, and loss of this acidic fluid increases the alkalinity of body fluids.
Which of the following interventions would be most appropriate for the nurse to recommend to a client to decrease discomfort from hemorrhoids? a) Use warm sitz baths. b) Decrease fiber in the diet. c) Take laxatives to promote bowel movements. d) Decrease physical activity.
Use warm sitz baths. Correct Explanation: Use of warm sitz baths can help relieve the rectal discomfort of hemorrhoids. F
A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test? a) "I'll take a laxative to clear my bowels before the test." b) "There is no need for special preparation before the test." c) "I'll avoid eating or drinking anything 6 to 8 hours before the test." d) "I'll drink full liquids the day before the test."
"I'll avoid eating or drinking anything 6 to 8 hours before the test." Correct Explanation: The client demonstrates understanding of a barium swallow when he states that he must refrain from eating or drinking for 6 to 8 hours before the test. No other preparation is needed
Following the formation of an ileal conduit, the nurse notes that the client's urinary drainage appliance contains pale yellow urine with large amounts of mucus. How should the nurse interpret these data? a) The mucus is caused by elevated levels of glucose in the urine. b) There is irritation of the stoma. c) The client is developing an infection of the urinary tract. d) These findings are normal for a client with an ileal conduit.
These findings are normal for a client with an ileal conduit. Correct Explanation: A segment of the terminal ileus is used to form the conduit that collects urine from the ureters. Hence, the client with an ileal conduit can be expected to excrete urine that contains mucus from this intestinal mucous membrane. Mucus production is not a result of infection or stomal irritation. Mucus production is not a result of glycosuria. There is no reason to expect to find glucose in the client's urine.
A client with a recent history of rectal bleeding is being prepared for a colonoscopy. Initially. The nurse knows that positioning the client lying on his/her left side with the knees bent is an appropriate intervention. The nurse recognizes that this position will: a) decrease the bleeding. b) allow for proper visualization of the small intestine. c) make the client more comfortable. d) allow proper visualization of the large intestine.
allow proper visualization of the large intestine. Correct Explanation: For a colonoscopy, the nurse initially should position the client on the left side with knees bent.
A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of: a) consuming a low-protein, high-fiber diet. b) taking only enteric-coated medications. c) increasing fluid intake to prevent dehydration. d) wearing an appliance pouch only at bedtime.
increasing fluid intake to prevent dehydration. Correct Explanation: Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake.
A client has had a nasogastric tube connected to low intermittent suction. The client is at risk for: a) confusion. b) edema. c) muscle cramping. d) tremors.
muscle cramping. Explanation: Muscle cramping is a sign of hypokalemia. Potassium is an electrolyte lost with nasogastric suctioning.
While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct? a) Submitting the incident report to the appropriate hospital administrator b) Making a copy of the incident report for the client c) Documenting the incident factually in her nurses' notes d) Notifying the physician of the incident and the client's condition
Making a copy of the incident report for the client Correct Explanation: A nurse shouldn't copy an incident report for anyone. An incident report is a confidential and privileged document available to agency personnel for risk-management activities. After completing the report, the nurse should submit it according to facility policy. The nurse should document the incident factually in the client's record and notify the physician of the incident and the client's condition. (
A client has a newly created colostomy. After participating in a teaching session with the nurse and receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which behavior suggests that the client is beginning to accept the change in body image? a) The client asks the spouse to leave the room. b) The client touches the altered body part. c) The client discusses care required for the colostomy. d) The client chooses the correct menu items suggested in the teaching.
The client touches the altered body part. Correct Explanation: By touching the altered body part, the client recognizes the body change and establishes that the change is real.
Which one of the following expected outcomes about nutrition would be appropriate for a client who has had a total gastrectomy for gastric cancer? The client will: a) Regain any weight lost within 4 weeks of the surgical procedure. b) Eat three full meals a day without experiencing gastric complications. c) Maintain adequate nutrition through oral or parenteral feedings. d) Learn to self-administer enteral feedings every 4 hours.
Maintain adequate nutrition through oral or parenteral feedings. Correct Explanation: An appropriate expected outcome is for the client to maintain nutrition either through oral or total parenteral feedings. Oral and total parenteral nutrition may also be used concurrently. It is not realistic to expect the client to regain weight loss within 4 weeks of surgery
A client is admitted to the hospital with a diagnosis of cholecystitis from cholelithiasis. The client has severe abdominal pain, nausea, and has vomited 120 mL. Based on these data, which nursing action would have the highest priority at this time? a) Restore fluid loss. b) Replace nutritional loss. c) Manage anxiety. d) Manage the pain.
Manage the pain. Correct Explanation: The priority for nursing care at this time is to decrease the client's severe abdominal pain. The pain, which is frequently accompanied by nausea and vomiting, is caused by biliary spasm. Opioid analgesics are given to relieve the severe pain and spasm of cholecystitis. Relief of pain may decrease nausea and vomiting and thereby decrease the client's likelihood of developing further complications, such as severe fluid loss and inadequate nutrition. There are no data to suggest that the client is anxious.
A nurse is providing postprocedure instructions for a client who is to undergo a esophagogastroduodenoscopy. The nurse should begin this process: a) in the preadmission area. b) immediately before discharge c) immediately following the procedure. d) before the procedure.
before the procedure. Explanation: A client who undergoes esophagogastroduodenoscopy receives sedation during the procedure, and his memory becomes impaired. Clients tend not to remember instructions provided after the procedure. The nurse's best course of action is to give the instructions prior to the client going to the procedure.
A barium enema is not prescribed as a diagnostic test for a client with diverticulitis, because a barium enema: a) would greatly increase the client's pain. b) is of minimal diagnostic value in diverticulitis. c) is too lengthy a procedure for the client to tolerate. d) can perforate an intestinal abscess.
can perforate an intestinal abscess. Correct Explanation: Barium enemas and colonoscopies are contraindicated in clients with acute diverticulitis because they can lead to perforation of the colon and peritonitis. A barium enema may be prescribed after the client has been treated with antibiotic therapy and the inflammation has subsided. A barium enema is diagnostic in diverticulitis. A barium enema could increase the client's pain; however, that is not a reason for excluding this test. The client may be able to tolerate the procedure, but the concern is the potential for perforation of the intestine
A physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should: a) store the specimen on ice. b) apply a solution to the stool specimen. c) take the specimen to the laboratory immediately. d) collect the specimen in a sterile container.
collect the specimen in a sterile container. Correct Explanation: The nurse should collect the stool specimen using sterile technique and a sterile stool container. The stool may be collected for 3 consecutive days.
The client has a nursing diagnosis of Constipation related to decreased mobility secondary to traction. A plan of care that incorporates which of the following breakfasts would be most helpful in reestablishing a normal bowel routine? a) An orange, raisin bran and milk, and wheat toast with butter. b) Corn flakes with sliced banana, milk, and English muffin and jelly. c) Eggs and bacon, buttered white toast, orange juice, and coffee. d) Orange juice, breakfast pastries (doughnut and Danish), and coffee.
An orange, raisin bran and milk, and wheat toast with butter. Correct Explanation: High-fiber foods provide bulk and decrease water absorption in the bowel. Whole grains and fruits (not juices, which often are strained) are recommended.
Which position would be appropriate for a client with severe ascites? a) Fowler's b) Sims c) reverse Trendelenburg d) side-lying
Fowler's Correct Explanation: Ascites can compromise the action of the diaphragm and increase the client's risk of respiratory problems. Ascites also greatly increases the risk of skin breakdown. Frequent position changes are important, but the preferred position is Fowler's. Placing the client in Fowler's position helps facilitate the client's breathing by relieving pressure on the diaphragm. The other positions do not relieve pressure on the diaphragm.
The client asks the nurse if surgery is needed to correct a hiatal hernia. Which reply by the nurse would be most accurate? a) "Surgery is not performed for this type of hernia." b) "Surgery is usually required, although medical treatment is attempted first." c) "Hiatal hernia symptoms can usually be successfully managed with diet modifications, medications, and lifestyle changes." d) "A minor surgical procedure to reduce the size of the diaphragmatic opening will probably be planned."
"Hiatal hernia symptoms can usually be successfully managed with diet modifications, medications, and lifestyle changes." Correct Explanation: Most clients can be treated successfully with a combination of diet restrictions, medications, weight control, and lifestyle modifications. Surgery to correct a hiatal hernia, which commonly produces complications, is performed only when medical therapy fails to control the symptoms.
The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Hypercalcemia
Metabolic alkalosis Correct Explanation: Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia
A client with a recent history of rectal bleeding is being prepared for a colonoscopy. Initially. The nurse knows that positioning the client lying on his/her left side with the knees bent is an appropriate intervention. The nurse recognizes that this position will: a) allow for proper visualization of the small intestine. b) make the client more comfortable. c) decrease the bleeding. d) allow proper visualization of the large intestine.
Correct response: allow proper visualization of the large intestine. Explanation: For a colonoscopy, the nurse initially should position the client on the left side with knees bent.
A surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member? a) Staff nurse b) Clinical educator c) Social worker d) Enterostomal nurse
Enterostomal nurse Correct Explanation: The surgeon should collaborate with the enterostomal nurse, who can address the client's concerns. The enterostomal nurse may schedule a visit with a client who has a colostomy to offer support to the client.
A client has vomited several times over the past 12 hours. The nurse should recognize the risk of what complication? a) Metabolic acidosis b) Respiratory alkalosis c) Respiratory acidosis d) Metabolic alkalosis
Metabolic alkalosis Correct Explanation: Vomiting results in loss of hydrochloric acid (HCl) and potassium from the stomach, leading to a reduction of chlorides and potassium in the blood and to metabolic alkalosis.
A client presents to the emergency department, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances? a) Metabolic alkalosis and hyperkalemia b) Metabolic acidosis and hyperkalemia c) Metabolic acidosis and hypokalemia d) Metabolic alkalosis and hypokalemia
Metabolic alkalosis and hypokalemia Correct Explanation: Gastric acid contains large amounts of potassium, chloride, and hydrogen ions. Excessive vomiting causes loss of these substances, which can lead to metabolic alkalosis and hypokalemia. Excessive vomiting doesn't cause metabolic acidosis or hyperkalemia
A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge? a) Hold his breath b) Pant like a dog c) Bear down as if having a bowel movement d) Take long, slow breaths
Take long, slow breaths Correct Explanation: During passage of the bougies used to dilate the esophagus, the client should take long, slow breaths to minimize the vomiting urge.
In the early postoperative period, the nurse notes a bright red, 3" × 5" (7.6 cm x 12.7 cm) area of drainage on the client's abdominal laparotomy dressing. What should be the nurse's first action in response to this observation? a) Take the client's vital signs. b) Change the dressing. c) Increase the IV flow rate. d) Ignore it because drainage is normal.
Take the client's vital signs. Correct Explanation: The sudden onset of bright red drainage of this magnitude needs to be further assessed. Assessing vital signs is an important nursing action to determine whether there have been any changes in the client's status. Additional steps would include reinforcing the dressing and notifying the health care provider (HCP).
As the nurse administers a tap water enema, the client begins to have abdominal cramping. Which of the following actions should the nurse implement first? a) Tell the client to hold the breath, and continue infusing the enema. b) Turn the client onto the back, and continue infusing the enema. c) Temporarily stop the infusion until the cramping subsides. d) Stop infusing the enema, and allow the client to evacuate the fluid.
Temporarily stop the infusion until the cramping subsides. Correct Explanation: When the client initially begins to report abdominal cramping during an enema, it is usually most appropriate to temporarily stop the infusion until the cramping subsides. If on resuming the flow of enema fluid the client continues to report cramping or inability to retain further fluid, the nurse should discontinue the enema
A client's nutritional status has been severely compromised through prolonged episodes of nausea and vomiting. Which of the following therapies will be the most effective in correcting nutritional deficits before surgery? a) I.V. infusion of normal saline solution at 125 ml/hour. b) High-protein between-meal nourishment four times a day. c) Continuous enteral feedings at 200 ml/hour. d) Total parenteral nutrition (TPN) for several days.
Total parenteral nutrition (TPN) for several days. Explanation: TPN bypasses the enteral route and provides total nutrition: protein, carbohydrates, fats, vitamins, minerals, and trace elements. The client is not able to tolerate oral feedings.
Which of the following expected outcomes would be most appropriate for a client with peptic ulcer disease? The client will: a) Understand the need to increase his exercise activity. b) Accept the need to inject himself with vitamin B12 for the rest of his life. c) Verbalize absence of epigastric pain. d) Eliminate stress from his life.
Verbalize absence of epigastric pain. Correct Explanation: A realistic goal for this client would be to gain relief from epigastric pain.
Which risk factor would most likely contribute to the development of a client's hiatal hernia? a) being 5 feet, 3 inches (160 cm) tall and weighing 190 lb (86.2 kg) b) using laxatives frequently c) having a sedentary desk job d) being 40 years old
being 5 feet, 3 inches (160 cm) tall and weighing 190 lb (86.2 kg) Correct Explanation: Any factor that increases intra-abdominal pressure, such as obesity, can contribute to the development of hiatal hernia.
A nurse is providing dietary instructions to a client with a history of pancreatitis. Which of the following instructions would be most appropriate? a) Maintain a high-fat, low-carbohydrate diet. b) Maintain a high-fat, high-carbohydrate diet. c) Maintain a low-carbohydrate, low-fat diet. d) Maintain a high-carbohydrate, low-fat diet.
Maintain a high-carbohydrate, low-fat diet. Explanation: A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet.
A client arrives to the emergency department with suspected appendicitis. The admitting nurse performs an assessment. Order the following steps according to the sequence in which they are performed. Use all of the options. 1 2 3 4 5 Percuss all four abdominal quadrants. Gently palpate all four quadrants, saving the painful area for last. Auscultate bowel sounds in all four quadrants. Inspect the abdomen, noting the shape, contours, and any visible peristalsis or pulsations. Obtain a health history.
Obtain a health history. Inspect the abdomen, noting the shape, contours, and any visible peristalsis or pulsations. Auscultate bowel sounds in all four quadrants. Percuss all four abdominal quadrants. Gently palpate all four quadrants, saving the painful area for last. Correct Explanation: The first step in the data collection process is to obtain a health history. Then, the nurse should visually inspect the abdomen. Of the three remaining steps, it is important to auscultate before percussing or palpating the client's abdomen. Touching or palpating the abdomen before listening may actually change the bowel sounds, leading to faulty data.
A nurse is caring for a client in the emergency department who is complaining of severe abdominal pain. The client is diagnosed with acute pancreatitis. Which laboratory value requires immediate intervention? a) Serum glucose level of 240 mg/dl (50 mmol/L) b) White blood cell (WBC) count of 18,000 mm3 (0.018 L) c) Troponin of 2.3 mcg/L d) Calcium level of 7.8 mg/dl (0.9 mmol/L)
Troponin of 2.3 mcg/L Correct response: Explanation: An elevated troponin level indicates myocardial damage and needs immediate further investigation.
When planning care for a client with a small-bowel obstruction, which of the following should the nurse consider to be the primary goal? a) Maintaining body weight b) Maintaining fluid balance c) Reporting pain relief d) Ambulating 4 times per day
Maintaining fluid balance Correct Explanation: Because a client with a small-bowel obstruction can't tolerate oral intake, fluid volume deficit may occur and can be life-threatening. Therefore, maintaining fluid balance is the primary goal
Two weeks before a client is scheduled for an ileostomy, the nurse should instruct the client to: a) report having a temperature above 99° F (37.2° C). b) stop taking drugs that will interfere with clotting (aspirin, ibuprofen). c) follow a low-residue diet. d) abstain from having sex.
stop taking drugs that will interfere with clotting (aspirin, ibuprofen). Correct Explanation: The nurse should instruct the client to stop taking drugs that would interfere with clotting, such as aspirin or ibuprofen.
A client is taking an antacid for treatment of a peptic ulcer. Which statement best indicates that the client understands how to correctly take the antacid? a) "I should take my antacid before I take my other medications." b) "My antacid will be most effective if I take it whenever I experience stomach pains." c) "It is best for me to take my antacid 1 to 3 hours after meals." d) "I need to decrease my intake of fluids so that I do not dilute the effects of my antacid."
"It is best for me to take my antacid 1 to 3 hours after meals." Correct Explanation: Antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an antacid is taken on an empty stomach, the duration of the drug's action is greatly decreased. Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the therapeutic action of the drug. Antacids should be administered about 2 hours after other medications to decrease the chance of drug interactions.
A client with cirrhosis has been referred to hospice care. Assessment data reveal a need to discuss nutrition with the client. What is the nurse's priority intervention? a) Discuss meals that include low-fat high-carbohydrate content. b) Discuss meals that have a high-fiber, high-protein content. c) Discuss the importance of eliminating caffeine in the diet. d) Discuss the importance of drinking at least 64 oz (1,920 mL) of water daily.
Discuss meals that include low-fat high-carbohydrate content. Explanation: In cirrhosis, the liver's metabolic function is compromised, increasing the client's need for carbohydrates and other energy sources for cellular metabolism. The nurse should limit the client's fat intake to prevent satiation and should restrict protein intake because a cirrhotic liver can't metabolize protein effectively. A client with cirrhosis may have increased edema as a result of reduced plasma albumin, so he should restrict fluid intake rather than drink 64 oz of water daily. Increasing fiber intake isn't a priority intervention for a client with cirrhosis. A client with cirrhosis doesn't need to eliminate caffeine from his diet.
A physician orders spironolactone, 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? a) Serum potassium level of 3.5 mEq/L b) Serum sodium level of 135 mEq/L c) Loss of 2.2 lb (1 kg) in 24 hours d) Blood pH of 7.25
Loss of 2.2 lb (1 kg) in 24 hours Correct Explanation: Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness.
While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct? a) Notifying the physician of the incident and the client's condition b) Submitting the incident report to the appropriate hospital administrator c) Making a copy of the incident report for the client d) Documenting the incident factually in her nurses' notes
Making a copy of the incident report for the client Correct Explanation: A nurse shouldn't copy an incident report for anyone. An incident report is a confidential and privileged document available to agency personnel for risk-management activities. After completing the report, the nurse should submit it according to facility policy. The nurse should document the incident factually in the client's record and notify the physician of the incident and the client's condition. (
