Review Practice Questions

The nurse is conducting a community presentation on the early detection of colon cancer. Which of the following should the nurse encourage members of the audience to report to their health care providers? Select all that apply. ■ 1. Fatigue. ■ 2. Unexplained weight loss with adequate nutritional intake. ■ 3. Rectal bleeding. ■ 4. Bowel changes. ■ 5. Positive fecal occult blood testing.

1, 2, 3, 4, 5. Colorectal cancer may be asymptomatic, or symptoms vary according to the location of the tumor and the extent of involvement. Fatigue, weight loss, and iron defi ciency anemia, even without rectal bleeding or bowel changes, should prompt investigation for colorectal cancer. Fecal occult blood testing commonly reveals evidence of carcinoma when the client is otherwise asymptomatic.

A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply. ■ 1. Preventing constipation. ■ 2. Administering lactulose (Cephulac). ■ 3. Monitoring coordination while walking. ■ 4. Checking the pupil reaction. ■ 5. Providing food and fl uids high in carbohydrate. ■ 6. Encouraging physical activity.

1, 2, 3, 4, 5. Constipation leads to increased ammonia production. Lactulose (Cephulac) is a hyperosmotic laxative that reduces blood ammonia by acidifying the colon contents, which retards diffusion of nonionic ammonia from the colon to the blood while promoting its migration from the blood to the colon. Hepatic encephalopathy is considered a toxic or metabolic condition that causes cerebral edema; it affects a person's coordination and pupil reaction to light and accommodation. Food and fluids high in carbohydrates should be given because the liver is not synthesizing and storing glucose. Because exercise produces ammonia as a byproduct of metabolism, physical activity should be limited, not encouraged.

The nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: Pulse 100; respiratory rate 22; and blood pressure 100/58. The nurse should prepare the client for which of the following? Select all that apply. ■ 1. Administration of intravenous Octreotide (Sandostatin). ■ 2. Endoscopy. ■ 3. Administration of a blood product. ■ 4. Minnesota tube insertion. ■ 5. Transjugular intrahepatic portosystemic shunt (TIPS) procedure. ■ 6. Immediate endotracheal intubation.

1, 2, 3. The management of bleeding esophageal varices involves endoscopic therapy and drug therapy with octreotide, vasopressin, nitroglycerin, or beta blockers to lower portal hypertension and decompress the varices. I.V. access is needed for octreotide and potential blood product administration due to blood loss or altered clotting factors. A patent airway should be maintained, but intubation is not needed for clients with adequate ventilation and oxygenation. Balloon tamponade is used if variceal hemorrhage cannot be controlled by endoscopy. A TIPS procedure may be considered after a second major bleed to redirect portal blood fl ow away from the varices.

A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for? Select all that apply. ■ 1. Projectile vomiting. ■ 2. Signifi cant abdominal distention. ■ 3. Copious diarrhea. ■ 4. Rapid onset of dehydration. ■ 5. Increased bowel sounds.

1, 4, 5. Signs and symptoms of intestinal obstructions in the small intestine may include projectile vomiting and rapidly developing dehydration and electrolyte imbalances. The client will also have increased bowel sounds, usually high-pitched and tinkling. The client would not normally have diarrhea and would have minimal abdominal distention. Pain is intermittent, being relieved by vomiting. Intestinal obstructions in the large intestine usually evolve slowly, produce persistent pain, and vomiting is less common. Clients with a large-intestine obstruction may develop obstipation and signifi cant abdominal distention.

Which of the following skin preparations would be best to apply around the client's colostomy? ■ 1. Karaya. ■ 2. Petroleum jelly. ■ 3. Cornstarch. ■ 4. Antiseptic cream.

1. Karaya and Stomahesive are both effective agents for protecting the skin around a colostomy. They keep the skin healthy and prevent skin irritation from stoma drainage. Petroleum jelly, cornstarch, and antiseptic creams do not protect the skin adequately and may prevent an adequate seal between the skin and the colostomy bag.

. The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which of the following would be an indication that hepatic encephalopathy is developing? ■ 1. Decreased mental status. ■ 2. Elevated blood pressure. ■ 3. Decreased urine output. ■ 4. Labored respirations.

1. 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. Increasing ammonia levels are not detected by changes in blood pressure, urine output, or respirations.

Which of the following should be included in the assessment of a client with diabetes mellitus who is experiencing a hypoglycemic reaction? Select all that apply: [ ] 1. Tremors [ ] 2. Nervousness [ ] 3. Extreme thirst [ ] 4. Flushed skin [ ] 5. Profuse perspiration [ ] 6. Constricted pupils

1. 2. 5. In hypoglycemia, the blood glucose levels fall, resulting in sympathetic nervous system responses such as sweating, tremors, and nervousness. Extreme thirst and flushed skin are clinical manifestations present in hyperglycemia. Dilated pupils are a sympathetic response.

23. The nurse should instruct a client with diabetes mellitus and the client's family about the clinical manifestations of diabetic ketoacidosis before discharge. Which of the following should be included? Select all that apply: [ ] 1. Dehydration [ ] 2. Shallow, labored respirations [ ] 3. Acetone breath [ ] 4. Tremors [ ] 5. Cold, clammy skin [ ] 6. Abdominal pain

1. 3. 6. In diabetic ketoacidosis (DKA), the body burns fats, which increases the amount of ketone bodies. An increase in ketone bodies causes acetone breath, which has a fruity odor. In DKA the respirations are deep but not labored. Other clinical manifestations of DKA include dehydration, abdominal pain, orthostatic hypotension, and tachycardia. DKA is a state of hyperglycemia. Tremulousness and cold, clammy skin are signs of hypoglycemia.

. A client with colon cancer is having a barium enema. The nurse should instruct the client to take which of the following after the procedure is completed? ■ 1. Laxative. ■ 2. Anticholinergic. ■ 3. Antacid. ■ 4. Demulcent.

1. After a barium enema, a laxative is ordinarily prescribed. This is done to promote elimination of the barium. Retained barium predisposes the client to constipation and fecal impaction. Anticholinergic drugs decrease gastrointestinal motility. Antacids decrease gastric acid secretion. Demulcents soothe mucous membranes of the gastrointestinal tract and are used to treat diarrhea.

Which of the following would be an expected outcome for a client who is recovering from an abdominal-perineal resection with a colostomy? The client will: ■ 1. Maintain a fl uid intake of 3,000 mL/day. ■ 2. Eliminate fi ber from the diet. ■ 3. Limit physical activity to light exercise. ■ 4. Accept that sexual activity will be diminished.

1. An expected outcome is that the client will maintain a fl uid intake of 3,000 mL/day unless contraindicated. There is no need to eliminate fi ber from the diet; the client can eat whatever foods are desired, avoiding those that are bothersome. Physical activity does not need to be limited to light exercise. The client can resume normal activities as tolerated, usually within 6 to 8 weeks. The client's sexual activity may be affected, but it does not need to be diminished.

The nurse instructs the client who has had a hemorrhoidectomy not to use sitz baths until at least 12 hours postoperatively to avoid inducing which of the following complications? ■ 1. Hemorrhage. ■ 2. Rectal spasm. ■ 3. Urine retention. ■ 4. Constipation.

1. Applying heat during the immediate postoperative period may cause hemorrhage at the surgical site. Moist heat may relieve rectal spasms after bowel movements. Urine retention caused by refl ex spasm may also be relieved by moist heat. Increasing fi ber and fl uid in the diet can help prevent

Which of the following positions would be appropriate for a client with severe ascites? ■ 1. Fowler's. ■ 2. Side-lying. ■ 3. Reverse Trendelenburg. ■ 4. Sims

1. 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 nurse is aware that the diagnostic tests typically ordered for acute diverticulitis do not include a barium enema. The reason for this is that a barium enema: ■ 1. Can perforate an intestinal abscess. ■ 2. Would greatly increase the client's pain. ■ 3. Is of minimal diagnostic value in diverticulitis. ■ 4. Is too lengthy a procedure for the client to tolerate.

1. 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 ordered after the client has been treated with antibiotic therapy and the infl ammation 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.

. The nurse is preparing a client for a paracentesis. The nurse should: ■ 1. Have the client void immediately before the procedure. ■ 2. Place the client in a side-lying position. ■ 3. Initiate an I.V. line to administer sedatives. ■ 4. Place the client on nothing-by-mouth (NPO) status 6 hours before the procedure.

1. 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. I.V. sedatives are not usually administered. The client does not need to be NPO.

24. Which of the following should the nurse include in the instructions given to a client with diabetes mellitus on how to prevent hypoglycemia? Eat a meal or snack every 4 to 5 hours while awake Have a family member learn to inject insulin if symptoms appear Increase insulin if moderate exercise is planned Ingest complex carbohydrates if symptoms appear

1. Meals or snacks every 4 to 5 hours while awake will maintain consistent blood sugar levels and should help to prevent hypoglycemia. Hypoglycemia is treated with injections of glucagon to raise the blood sugar level. Exercise burns calories so that less insulin is needed. Hypoglycemia is treated by ingesting simple carbohydrates.

The client with cirrhosis receives 100 mL of 25% serum albumin I.V. Which fi nding would best indicate that the albumin is having its desired effect? ■ 1. Increased urine output. ■ 2. Increased serum albumin level. ■ 3. Decreased anorexia. ■ 4. Increased ease of breathing.

1. Normal serum albumin is administered to reduce ascites. Hypoalbuminemia, a mechanism underlying ascites formation, results in decreased colloid osmotic pressure. Administering serum albumin increases the plasma colloid osmotic pressure, which causes fl uid to fl ow from the tissue space into the plasma. Increased urine output is the best indication that the albumin is having the desired effect. An increased serum albumin level and increased ease of breathing may indirectly imply that the administration of albumin is effective in relieving the ascites. However, it is not as direct an indicator as increased urine output. Anorexia is not affected by the administration of albumin.

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 signifi cance in causing an exacerbation of ulcerative colitis? ■ 1. A demanding and stressful job. ■ 2. Changing to a modifi ed 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 modifi ed vegetarian diet or an exercise program is an unlikely cause of the exacerbation.

The nurse administers fat emulsion solution during TPN as ordered based on the understanding that this type of solution: ■ 1. Provides essential fatty acids. ■ 2. Provides extra carbohydrates. ■ 3. Promotes effective metabolism of glucose. ■ 4. Maintains a normal body weight.

1. The administration of fat emulsion solution provides additional calories and essential fatty acids to meet the body's energy needs. Fatty acids are lipids, not carbohydrates. Fatty acids do not aid in the metabolism of glucose. Although they are necessary for meeting the complete nutritional needs of the client, fatty acids do not necessarily help a client maintain normal body weight.

TPN is ordered for a client with Crohn's disease. Which of the following indicate the TPN soloution is having an intended outcome? ■ 1. There is increased cell nutrition. ■ 2. The client does not have metabolic acidosis. ■ 3. The client is hydrated. ■ 4. The client is in a negative nitrogen balance.

1. 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.

A client with jaundice has pruritis and states that he has areas of irritation from scratching. What measures can the nurse discuss to prevent skin breakdown? Select all that apply. ■ 1. Avoid lotions containing calamine. ■ 2. Take baking soda baths. ■ 3. Keep nails short and clean. ■ 4. Rub with knuckles instead of nails. ■ 5. Massage skin with alcohol. ■ 6. Increase sodium intake in diet.

2, 3, 4. Baking soda baths can decrease pruritis. Keeping nails short and rubbing with knuckles can decrease breakdown when scratching cannot be resisted, such as during sleep. Calamine lotions help relieve itching. Alcohol will increase skin dryness. Sodium in the diet will increase edema and weaken skin integrity.

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. fl uid infusion rate hourly (even when using an I.V. fl uid 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 assesses the client's stoma during the initial postoperative period. Which of the following observations should be reported immediately to the physician? ■ 1. The stoma is slightly edematous. ■ 2. The stoma is dark red to purple. ■ 3. The stoma oozes a small amount of blood. ■ 4. The stoma does not expel stool.

2. A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing of blood are normal in the early postoperative period. The colostomy would typically not begin functioning until 2 to 4 days after surgery.

Which of the following statements about nasoenteric tubes is correct? ■ 1. The tube cannot be attached to suction. ■ 2. The tube contains a soft rubber bag fi lled with mercury. ■ 3. The tube is taped securely to the client's cheek after insertion. ■ 4. The tube can have its placement determined only by auscultation.

2. A nasoenteric tube has a small balloon at its tip that is weighted with mercury. The weight of the mercury helps advance the tube by gravity through the intestine. Nasoenteric tubes are attached to suction. A nasoenteric tube is not taped in position until it has reached the obstruction. Because the tube has a radiopaque strip, its progress through the intestinal tract can be followed by fl uoroscopy.

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 modifi ed 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.

. The client with colon cancer has an abdominal-perineal resection with a colostomy. Which of the following nursing interventions is most appropriate for this client in the postoperative period? ■ 1. Maintain the client in a semi-Fowler's position. ■ 2. Assist the client with warm sitz baths. ■ 3. Administer 30 mL of milk of magnesia to stimulate colostomy activity. ■ 4. Remove the ostomy pouch as needed so the stoma can be assessed.

2. Appropriate nursing interventions after an abdominal-perineal resection with a colostomy include assisting the client with warm sitz baths three to four times a day to clean the perineal incision. The client will be more comfortable assuming a side-lying position because of the perineal incision. It would be inappropriate to administer milk of magnesia to stimulate colostomy activity. Stool passage will begin as peristalsis returns. It is not necessary or desirable to change the ostomy pouch daily to assess the stoma. The ostomy pouch should be transparent to allow easy observation of the stoma and drainage.

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-fi ber. ■ 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.

. Which of the following interventions should the nurse include in the client's plan of care to prevent complications associated with TPN administered through a central line? ■ 1. Use a clean technique for all dressing changes. ■ 2. Tape all connections of the system. ■ 3. Encourage bed rest. ■ 4. Cover the insertion site with a moisture-proof dressing

2. Complications associated with administration of TPN through a central line include infection and air embolism. To prevent these complications, strict aseptic technique is used for all dressing changes, the insertion site is covered with an air-occlusive dressing, and all connections of the system are taped. Ambulation and activities of daily living are encouraged and not limited during the administration of TPN.

Which goal for the client's care should take priority during the fi rst 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 fi rst 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-infl ammatory drugs.

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 fl are-ups because they can decrease the incidence of bleeding." ■ 3. "Long-term use of steroids will prolong periods of remission."

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 benefi ts of short-term steroid therapy usually outweigh the potential adverse effects

. A client with infl ammatory bowel disease is receiving total parenteral nutrition (TPN). The basic component of the client's TPN solution is most likely to be: ■ 1. An isotonic dextrose solution. ■ 2. A hypertonic dextrose solution. ■ 3. A hypotonic dextrose solution. ■ 4. A colloidal dextrose solution.

2. The TPN solution is usually a hypertonic dextrose solution. The greater the concentration of dextrose in solution, the greater the tonicity. Hypertonic dextrose solutions are used to meet the body's calorie demands in a volume of fl uid that will not overload the cardiovascular system. An isotonic dextrose solution (e.g., 5% dextrose in water) or a hypotonic dextrose solution will not provide enough calories to meet metabolic needs. Colloids are plasma expanders and blood products and are not used in TPN.

The client with an intestinal obstruction continues to have acute pain even though the nasoenteric tube is patent and draining. Which action by the nurse would be most appropriate? ■ 1. Reassure the client that the nasoenteric tube is functioning. ■ 2. Assess the client for a rigid abdomen. ■ 3. Administer an opioid as ordered. ■ 4. Reposition the client on the left side.

2. The client's pain may be indicative of peritonitis, and the nurse should assess for signs and symptoms, such as a rigid abdomen, elevated temperature, and increasing pain. Reassuring the client is important, but accurate assessment of the client is essential. The full assessment should occur before pain relief measures are employed. Repositioning the client to the left side will not resolve the pain.

A client is to be discharged with a prescription for lactulose (Cephulac). The nurse teaches the client and the client's spouse how to administer this medication. Which of the following statements would indicate that the client has understood the information? ■ 1. "I'll take it with Maalox." ■ 2. "I'll mix it with apple juice." ■ 3. "I'll take it with a laxative." ■ 4. "I'll mix the crushed tablets in some gelatin."

2. The taste of lactulose (Cephulac) is a problem for some clients. Mixing it with fruit juice, water, or milk can make it more palatable. Lactulose should not be given with antacids, which may inhibit its action. Lactulose should not be taken with a laxative because diarrhea is an adverse effect of the drug. Lactulose comes in the form of syrup for oral or rectal administration.

19. The nurse conducts a health history for a client with type 1 diabetes mellitus. Which of the following client statements best describes the onset characteristics of this type of diabetes? "I was diagnosed during the fifth month of my pregnancy." "One day I passed out after I had terrible nausea, vomiting, and abdominal pain." "When I hit 40, I began to notice I was picking up weight and urinating more frequently." "My fasting blood sugars are always between 110 mg/dL and 126 mg/dL."

2. Type 1 diabetes mellitus usually has an acute onset with nausea, vomiting, and abdominal pain and is often diagnosed after the client becomes comatose with ketoacidosis. Diabetes mellitus diagnosed during pregnancy is classified as gestational diabetes. Type 2 diabetes mellitus has a gradual onset and usually occurs in clients over 30. Clients with consistent fasting blood sugar levels that are slightly over normal are classified as borderline diabetics with impaired glucose intolerance.

The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of aclient receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should do the following in order of what priority from fi rst to last? ■ 1. Change dressing per institutional policy. ■ 2. Culture drainage at insertion site. ■ 3. Notify physician. ■ 4. Position rolled towel under client's back, parallel to the spine.

3, 4, 2, 1. A potential complication of receiving TPN is leakage or catheter puncture; notify the physician immediately and prepare for changing of the catheter. If pneumothorax is suspected, position a rolled towel under the client's back. If there is drainage at the insertion site, culture the drainage and change the dressing using sterile technique.

After instructing a client with diverticulosis about appropriate self-care activities, which of the following client comments indicate effective teaching? Select all that apply. ■ 1. "With careful attention to my diet, my diverticulosis can be cured." ■ 2. "Using a cathartic laxative weekly is okay to control bowel movements." ■ 3. "I should follow a diet that's high in fi ber." ■ 4. "It is important for me to drink at least 2,000 mL of fl uid every day." ■ 5. "I should exercise regularly."

3, 4, 5. Clients who have diverticulosis should be instructed to maintain a diet high in fi ber and, unless contraindicated, should increase their fl uid intake to a minimum of 2,000 mL/day. Participating in a regular exercise program is also strongly encouraged. Diverticulosis can be controlled with treatment but cannot be cured. Clients should be instructed to avoid the regular use of cathartic laxatives. Bulk laxatives and stool softeners may be helpful to maintain regularity and decrease straining.

The nurse teaches the client who has had rectal surgery the proper timing for sitz baths. The nurse knows that the client has understood the teaching when the client states that it is most important to take a sitz bath: ■ 1. First thing each morning. ■ 2. As needed for discomfort. ■ 3. After a bowel movement. ■ 4. At bedtime.

3. Adequate cleaning of the anal area is diffi cult but essential. After rectal surgery, sitz baths assist in this process, so the client should take a sitz bath after a bowel movement. Other times are dictated by client comfort.

. The nurse is providing discharge instructions for a client with cirrhosis. Which of the following statements best indicates that the client has understood the teaching? ■ 1. "I should eat a high-protein, high-carbohydrate diet to provide energy." ■ 2. "It is safer for me to take acetaminophen (Tylenol) for pain instead of aspirin." ■ 3. "I should avoid constipation to decrease chances of bleeding." ■ 4. "If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured."

3. Clients with cirrhosis should be instructed to avoid constipation and straining at stool to prevent hemorrhage. The client with cirrhosis has bleeding tendencies because of the liver's inability to produce clotting factors. A low-protein and highcarbohydrate diet is recommended. Clients with cirrhosis should not take acetaminophen (Tylenol), which is potentially hepatotoxic. Aspirin also should be avoided if esophageal varices are present. Cirrhosis is a chronic disease.

The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate? ■ 1. Peripheral edema. ■ 2. Ascites. ■ 3. Anorexia. ■ 4. Jaundice.

3. Early clinical manifestations of cirrhosis are subtle and usually include gastrointestinal symptoms, such as anorexia, nausea, vomiting, and changes in bowel patterns. These changes are caused by the liver's altered ability to metabolize carbohydrates, proteins, and fats. Peripheral edema, ascites, and jaundice are later signs of liver failure and portal hypertension.

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 signifi cant depletion of the body's stores of sodium and potassium as well as fl uid. The client should be closely monitored for hypokalemia and hyponatremia. Ulcerative colitis does not place the client at risk for heart failure,

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, highprotein diet will worsen the client's symptoms.

. The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the physician of a decrease in which lab serum that is a potential precipitating factor for hepatic encephalopathy? ■ 1. Aldosterone. ■ 2. Creatinine. ■ 3. Potassium. ■ 4. Protein.

3. Hypokalemia is a precipitating factor in hepatic encephalopathy. A decrease in creatinine results from muscle atrophy; an increase in creatinine would indicate renal insuffi ciency. With liver dysfunction increased aldosterone levels are seen. A decrease in serum protein will decrease colloid osmotic pressure and promote edema

Which position would be best for the client in the early postoperative period after a hemorrhoidectomy? ■ 1. High Fowler's. ■ 2. Supine. ■ 3. Side-lying. ■ 4. Trendelenburg's.

3. Positioning in the early postoperative phase should avoid stress and pressure on the operative site. The prone and side-lying positions are ideal from a comfort perspective. A high Fowler's or supine position will place pressure on the operative site and is not recommended. There is no need for Trendelenburg's position.

Which of the following should the nurse interpret as an indication of a complication after the fi rst few days of TPN therapy? ■ 1. Glycosuria. ■ 2. A 1- to 2-pound weight gain. ■ 3. Decreased appetite. ■ 4. Elevated temperature.

4. An elevated temperature can be an indication of an infection at the insertion site or in the catheter. Vital signs should be taken every 2 to 4 hours after initiation of TPN therapy to detect early signs of complications. Glycosuria is to be expected during the fi rst few days of therapy until the pancreas adjusts by secreting more insulin. A gradual weight gain is to be expected as the client's nutritional status improves. Some clients experience a decreased appetite during TPN therapy.

Before abdominal surgery for an intestinal obstruction, the nurse monitors the client's urine output and fi nds that the total output for the past 2 hours was 35 mL. The nurse then assesses the client's total intake and output over the last 24 hours and notes that he had 2,000 mL of I.V. fl uid for intake, 500 mL of drainage from the nasogastric tube, and 700 mL of urine for a total output of 1,200 mL. This would indicate which of the following? ■ 1. Decreased renal function. ■ 2. Inadequate pain relief. ■ 3. Extension of the obstruction. ■ 4. Inadequate fl uid replacement.

4. Considering that there is usually 1 L of insensible fl uid loss, this client's output exceeds his intake (intake, 2,000 mL; output, 2,200 mL), indicating defi cient fl uid volume. The kidneys are concentrating urine in response to low circulating volume, as evidenced by a urine output of less than 30 mL/hour. This indicates that increased fl uid replacement is needed. Decreasing urine output can be a sign of decreased renal function, but the data provided suggest that the client is dehydrated. Pain does not affect urine output. There are no data to suggest that the obstruction has worsened.

26. The nurse is observing a staff member preparing to give a client in diabetic ketoacidosis 40 units of NPH insulin IV bolus. Which of the following interventions by the nurse is appropriate? Assist the staff member preparing the injection by rotating the vial of NPH insulin prior to drawing up the insulin Instruct the staff member to follow the NPH IV bolus with 5 to 10 units per hour in normal saline Ask the staff member to give the client the NPH insulin IV bolus for the experience Tell the staff member that only regular insulin may be administered intravenously

4. Only regular insulin, which is clear, may be administered intravenously.

The nurse should teach the client with diverticulitis to integrate which of the following into a daily routine at home? ■ 1. Using enemas to relieve constipation. ■ 2. Decreasing fl uid intake to increase the formed consistency of the stool. ■ 3. Eating a high-fi ber diet when symptomatic with diverticulitis. ■ 4. Refraining from straining and lifting activities.

Amswer 4.: Clients with diverticular disease should refrain from any activities, such as lifting, straining, or coughing, that increase intra-abdominal pressure and may precipitate an attack. Enemas are contraindicated because they increase intestinal pressure. Fluid intake should be increased, rather than decreased, to promote soft, formed stools. A low-fi ber diet is used when infl ammation is present.

A client with diverticulitis has developed peritonitis following diverticular rupture. The nurse should assess the client to determine which of the following? Select all that apply. ■ 1. Percuss the abdomen to note resonance and tympany. ■ 2. Percuss the liver to note lack of dullness. ■ 3. Monitor the vital signs for fever, tachypnea, and bradycardia. ■ 4. Assess presence of polyphagia and polydipsia. ■ 5. Auscultate bowel sounds to note frequency.

Answer: 1, 2, 5. Assessment during peritonitis will reveal fever, tachypnea, and tachycardia. The abdomen becomes rigid with rebound tenderness and there will be absent bowel sounds. Percussion will show resonance and tympany indicating paralytic ileus; loss of liver dullness may indicate free air in the abdomen. There is anorexia, nausea, and vomiting as peristalsis decreases.

A client is recovering from an abdominalperineal resection. Which of the following measures would most effectively promote wound healing after the perineal drains have been removed? ■ 1. Taking sitz baths. ■ 2. Taking daily showers. ■ 3. Applying warm, moist dressings to the area. ■ 4. Applying a protected heating pad to the area.

Answer: 1. Sitz baths are an effective way to clean the operative area after an abdominal-perineal resection. Sitz baths bring warmth to the area, improve circulation, and promote healing and cleanliness. Most clients fi nd them comfortable and relaxing. Between sitz baths, the area should be kept clean and dry. A shower will not adequately clean the perineal area. Moist dressings may promote wound contamination and delay healing. A heating pad applied to the area for longer than 20 minutes may cause excessive vasodilation, leading to congestion and discomfort.

When planning diet teaching for the client with a colostomy, the nurse should develop a plan that emphasizes which of the following dietary instructions? ■ 1. Foods containing roughage should not be eaten. ■ 2. Liquids are best limited to prevent diarrhea. ■ 3. Clients should experiment to find the diet that is best for them. ■ 4. A high-fi ber diet will produce a regular passage of stool.

Answer: 3. It is best to adjust the diet of a client with a colostomy in a manner that suits the client rather than trying special diets. Severe restriction of roughage is not recommended. The client is encouraged to drink 2 to 3 L of fl uid per day. A high-fi ber diet may produce loose stools.

Which of the following has been identifi ed as a potential risk factor for the development of colon cancer? ■ 1. Chronic constipation. ■ 2. Long-term use of laxatives. ■ 3. History of smoking. ■ 4. History of infl ammatory bowel disease

Answer: 4. A history of infl ammatory bowel disease is a risk factor for colon cancer. Other risk factors include age (older than 40 years), history of familial polyposis, colorectal polyps, and high-fat or low-fi ber diet.

A client with a Sengstaken-Blakemore tube has a sudden drop in SpO2 and increase in respiratory rate to 40 breaths/minute. The nurse should do which of the following in order from fi rst to last? 2. Remove the tube. 3. Defl ate the tube by cutting with bedside scissors. 4. Apply oxygen via face mask. 1. Affi rm airway obstruction by the tube

The nurse should fi rst assess the client to determine if the tube is obstructing the airway; assessment is done by assessing air fl ow. Once obstruction is established, the tube should be defl ated and then quickly removed. A set of scissors should always be at the bedside to allow for emergency defl ation of the balloon. Oxygen via face mask should then be applied once the tube is removed.

A client is admitted with a bowel obstruction. The client has nausea, vomiting, and crampy abdominal pain. The physician has written orders for the client to be up ad lib, to have narcotics for pain, to have a nasogastric tube inserted if needed,and for I.V. Ringer's Lactate and hyperalimentation fl uids. The nurse should do the following in order of

The nurse should fi rst help the client ambulate to try to induce peristalsis; this may be effective and require the least amount of invasive procedures. I.V. fl uid therapy can be done to correct fl uid and electrolyte imbalances (sodium and potassium), and normal saline or Ringer's Lactate to correct interstitial fl uid defi cit. Nasogastric (NG) decompression of G.I. tract to reduce gastric secretions and nasointestinal tubes may also be used. Hyperalimentation can be used to correct protein defi ciency from chronic obstruction, paralytic ileus, or infection.