Saunders GI unit 1
The nurse has provided dietary instructions to a client with a diagnosis of peptic ulcer disease. Which client statement indicates that education was effective?
"Baked foods such as chicken or fish are all right to eat."
The nurse is providing instructions to a client with a colostomy about measures to reduce the odor from the colostomy. Which client statement indicates that the educational session was effective?
"Beet greens, parsley, or yogurt will help to control the colostomy odor."
The registered nurse is precepting a new nurse who is caring for a client with pernicious anemia as a result of gastrectomy. Which statement made by the new nurse indicates understanding of this diagnosis?
"Decreased production of intrinsic factor by the stomach affects absorption of vitamin B12 in the small intestine."
The nurse is reviewing the record of a client admitted to the nursing unit and notes that the client has a history of Laënnec's cirrhosis. Which question related to the client's history would be most important to ask?
"Do you abuse alcohol?"
The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which assessment question would most specifically elicit information regarding the pain that is associated with acute pancreatitis?
"Does the pain in your stomach radiate to your back?"
A client with viral hepatitis is having difficulty coping with the disorder. Which question by the nurse is the most appropriate in identifying the client's coping problem?
"Have you enjoyed having visitors?"
The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement?
"I am glad I don't have to lie still for this procedure"
The health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis?
"I ate shellfish about 2 weeks ago at a local restaurant."
A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching?
"I can go back to work right away."
The nurse has given instructions to a client with hepatitis about postdischarge management during convalescence. The nurse determines that further teaching is needed if the client makes which statement?
"I can resume a full activity level within 1 week." The client with hepatitis is easily fatigued and may require several weeks to resume a full activity level. It is important for the client to get adequate rest so that the liver can heal. The client should avoid hepatotoxic substances such as aspirin and alcohol. The client should take in a high-carbohydrate and low-fat diet. Vitamin K may be prescribed for prolonged clotting times.
A client experiencing chronic dumping syndrome makes the following comments to the nurse. Which one indicates the need for further teaching?
"I eat at least 3 large meals each day."
The nurse is teaching an older client about measures to prevent constipation. Which statement by the client indicates a need for further teaching?
"I need to decrease fiber in my diet."
The nurse is teaching the postgastrectomy client about measures to prevent dumping syndrome. Which statement by the client indicates a need for further teaching?
"I need to drink liquids with meals." The client with dumping syndrome should avoid drinking liquids with meals. The client should be placed on a high-protein, moderate-fat, high-calorie diet and should lie down after eating. The client should avoid concentrated sweets, and frequent small meals are encouraged.
The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching?
"I need to limit my intake of dietary fiber."
The nurse is caring for a client with gastroesophageal reflux disease (GERD) and provides client education on measures to decrease GERD. Which statement made by the client indicates a need for further teaching?
"I plan to have a snack 1 hour before going to bed."
The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction?
"I should increase the fiber in my diet."
A client is resuming a diet after hemigastrectomy, and the nurse provides dietary instructions. Which statement by the client indicates a need for further teaching?
"I will drink plenty of liquids with meals."
A home care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home care management instructions to the client. Which client statement indicates a need for further instruction?
"I will take acetaminophen if I get a headache." Acetaminophen is avoided because it can cause fatal liver damage in the client with cirrhosis. Adequate rest and nutrition are important. The client's weight should be monitored on a regular basis. The diet should supply sufficient carbohydrates with a total daily calorie intake of 2000 to 3000.
A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, "I'm not sure I can avoid alcohol." What is the most appropriate nursing response?
"I'm not sure that I understand. Would you please explain?"
The nurse is performing an assessment on a client with suspected acute pancreatitis. Which complaint made by the client supports the diagnosis?
"I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting."
The nurse is completing an admission assessment for a client with suspected esophageal cancer. Which statement made by the client indicates the presence of a risk factor for esophageal cancer?
"I've been smoking for 20 years now."
The nurse has given postprocedure instructions to a client who has undergone a colonoscopy. Which statement by the client indicates the need for further teaching?
"It is all right to drive once I've been home for an hour or so." The client should not drive for several hours after discharge because of the sedative medications used during the procedure. Important decisions also should be delayed for at least 12 to 24 hours for the same reason. The client may experience gas, bloating, or abdominal tenderness for a short while after the procedure, and this is normal. The client should resume intake slowly and progress as tolerated.
The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client on the signs and symptoms associated with dumping syndrome. Which client statement indicates that teaching was effective?
"It will cause diaphoresis and diarrhea."
The client with a small bowel obstruction asks the nurse to explain the purpose of the nasogastric tube attached to continuous gastric suction. The nurse determines that teaching has been effective if the client makes which statement?
"It will help to remove gas and fluids from my stomach and intestine." Treatment of intestinal obstruction is directed toward decompression of the intestine by removal of gas and fluid. Nasogastric tubes may be used to decompress the stomach and bowel. Continuous gastric suction does not provide nourishment. The purpose of tracheal suctioning (not gastric suctioning) is to remove excess mucus that has led to congestion. Although gastric contents may be sent for laboratory analysis, it is not the main purpose for continuous gastric suction.
The nurse is performing an admission assessment on a client who has been admitted to the hospital with a diagnosis of suspected gastric ulcer. The nurse is asking the client questions about pain. Which client statement supports the diagnosis of gastric ulcer?
"My pain comes shortly after I eat, maybe a half-hour or so later." Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be exacerbated by intake of food. The pain occurs 30 to 60 minutes after a meal and rarely occurs at night. Duodenal ulcer pain is usually located to the right of the epigastrium. The pain associated with a duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the client at night.
A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week; however, he is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern that he will not be able to continue the tube feedings at home. Which nursing response is most appropriate at this time?
"Tell me more about your concerns with your diet after going home."
Sulfasalazine is prescribed for a client with a diagnosis of ulcerative colitis, and the nurse instructs the client about the medication. Which statement made by the client indicates a need for further teaching?
"The medication will cause constipation."
The nurse teaches a preoperative client about the use of a nasogastric (NG) tube for the planned surgery. Which statement indicates to the nurse that the client understands when the tube can be removed in the postoperative period?
"When my bowels begin to function again, and I begin to pass gas." NG tubes are discontinued when normal function returns to the gastrointestinal (GI) tract. Food would not be administered unless bowel function returns. The tube will be removed before GI healing. Although the health care provider (HCP) determines when the NG tube will be removed, it does not determine effectiveness of teaching and the need for the NG tube.
The nurse is caring for a postoperative client who has just returned from surgery for creation of a colostomy. The nurse inspects the colostomy stoma and recognizes that which is a normal assessment finding for this client?
A brick-red color
A client has a large, deep duodenal ulcer diagnosed by endoscopy. Which sign or symptom indicative of a complication should the nurse look for during the client's postprocedure assessment?
A rigid, boardlike abdomen The client with a large, deep duodenal ulcer is at risk for perforation of the ulcer. If this occurs, the client will experience sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which then becomes rigid and boardlike. Tachycardia, not bradycardia, may occur as hypovolemic shock develops. Nausea and vomiting may not occur if the pyloric sphincter is intact. Numbness in the legs is not an associated finding.
The ambulatory care nurse is providing instructions to a client who is scheduled for a small bowel biopsy. What should the nurse tell the client?
A signed informed consent form will need to be obtained.
The nurse is caring for a client after abdominal surgery and creation of a colostomy. The nurse is assessing the client for a prolapsed stoma and should expect to note which observation if this is present?
A stoma that is elongated with a swollen appearance
A health care provider (HCP) prescribes a Salem sump tube for gastrointestinal intubation. Which item should the nurse obtain from the supply room?
A tube with a large lumen and an air vent
The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which finding should the nurse interpret as a sign or symptom of portal hypertension?
Abdominal distention
A client seen in the ambulatory care clinic has ascites and slight jaundice. The nurse should assess the client for a history of chronic use of which medication?
Acetaminophen Acetaminophen is a potentially hepatotoxic medication. Use of this medication and other hepatotoxic agents should be investigated whenever a client presents with signs and symptoms compatible with liver disease (such as ascites and jaundice). Hepatotoxicity is not an adverse effect of the medications identified in the remaining options.
The nurse is developing a teaching plan for a client with viral hepatitis. The nurse should plan to include which information in the teaching session?
Activity should be limited to prevent fatigue.
A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain, and appendicitis is suspected. Laboratory tests are performed, and the nurse notes that the client's white blood cell (WBC) count is elevated. On the basis of these findings, the nurse should question which health care provider (HCP) prescription documented in the client's medical record?
Administer 30 mL of milk of magnesia (MOM).
The nurse is caring for a client on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, the nurse should take which action?
Administer a dose of a prescribed antacid.
A client with a gastric ulcer is prescribed both magnesium hydroxide and cimetidine twice daily. How should the nurse schedule the medications for administration?
Administer each dose of cimetidine 1 hour prior to the administration of magnesium hydroxide. Antacids, such as magnesium hydroxide, can decrease absorption of cimetidine. At least 1 hour should separate administration of an antacid and cimetidine. The remaining options are incorrect.
A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply.
Administer stool softeners as prescribed Encourage a high-fiber diet to promote bowel movements without straining Apply cold packs to the anal rectal area over the dressing until the packing is removed
A client with ulcerative colitis has a prescription to begin a salicylate compound medication to reduce inflammation. What instruction should the nurse give the client regarding when to take this medication?
After meals Salicylate compounds, such as sulfasalazine, act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and increase fluid intake throughout the day. The medication needs to be taken after meals to reduce gastrointestinal irritation. The other options are incorrect and could cause gastric irritation.
The nurse has taught the client with chronic pancreatitis about risk factor modification to reduce the incidence of recurrences. The nurse determines that teaching was effective if the client states that it will be necessary to control which factor?
Alcohol intake Chronic pancreatitis is aggravated by continued alcohol intake. Each of the other options is not specifically associated with pancreatitis.
A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client?
Applesauce and a graham cracker
A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain. Appendicitis is suspected, and appropriate laboratory tests are performed. The emergency department nurse reviews the test results and notes that the client's white blood cell (WBC) count is elevated. The nurse also reviews the prescriptions from the health care provider (HCP). The nurse should contact the HCP to question which prescription if noted in the client's record?
Apply a heating pad to the lower abdomen for comfort. Appendicitis should be suspected in a client with an elevated WBC count who is complaining of acute right lower quadrant abdominal pain. A semi Fowler's position is maintained for comfort. The client would be on NPO status and given IV fluids in preparation for possible surgery. Heat should never be applied to the abdomen because this may increase circulation to the appendix, potentially leading to increased inflammation and perforation.
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis (is a tremor of the hand when the wrist is extended) How should the nurse assess for its presence?
Ask the client to extend the arms.
A client is scheduled for an upper gastrointestinal (GI) endoscopy. Which assessment is essential to include in the plan of care following the procedure?
Assessing for the presence of the gag reflex Following the procedure, the client remains NPO (nothing by mouth) until the gag reflex returns, which is usually in 1 to 2 hours. The remaining options are not specific assessments related to this procedure.
A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan?
Assessing for the return of the gag reflex
A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client?
Assessment of vital signs
A client with viral hepatitis states, "I am so yellow." What is the most appropriate nursing action?
Assist the client in expressing feelings.
The nurse is performing discharge teaching for a client with chronic pancreatitis. Which information should the nurse include?
Avoid caffeine because it may aggravate symptoms.
A client is readmitted to the hospital with dehydration after surgery for creation of an ileostomy. The nurse assesses that the client has lost 3 lb of weight, has poor skin turgor, and has concentrated urine. The nurse interprets the client's clinical picture as correlating most closely with recent intake of which medication, which is contraindicated for the ileostomy client?
Biscodyl The client with an ileostomy is prone to dehydration because of the location of the ostomy in the gastrointestinal tract and should not take laxatives. Laxatives will compound the potential risk for the client. These clients are at risk for deficiencies of folate, iron, and cyanocobalamin and should receive them as supplements if necessary.
The nurse is giving instructions to a client with cholecystitis about food to exclude from the diet. Which food item identified by the client indicates that the educational session was successful?
Brown gravy
A client with appendicitis is scheduled for an appendectomy. The nurse providing preoperative teaching for the client describes the location of the appendix by stating that it is attached to which part of the gastrointestinal (GI) system?
Cecum The appendix, sometimes referred to as the vermiform appendix, is attached to the apex of the cecum. The other locations listed are incorrect.
A Penrose drain is in place on the first postoperative day in a client who has undergone a cholecystectomy procedure. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?
Change the dressing. Serosanguinous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is usually removed within 48 hours. A sterile dressing covers the site and should be changed if wet to prevent infection and skin excoriation. Although the nurse would continue to monitor the drainage, the most appropriate intervention is to change the dressing. The HCP does not need to be notified.
A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially?
Check the suction device to make sure it is working.
The nurse is providing dietary instructions to a client hospitalized for pancreatitis. Which food should the nurse instruct the client to avoid?
Chili The client with pancreatitis needs to avoid alcohol, coffee and tea, spicy foods, and heavy meals, which stimulate pancreatic secretions, producing attacks of pancreatitis. The client is instructed in the benefit of eating small, frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates.
A client receiving a cleansing enema complains of pain and cramping. The nurse should take which corrective action?
Clamp the tubing for 30 seconds, and restart the flow at a slower rate.
The nurse should instruct a client with an ileostomy to include which action as part of essential care of the stoma?
Cleanse the peristomal skin meticulously. The peristomal skin must receive meticulous cleansing because ileostomy drainage has more enzymes and is more caustic to the skin than colostomy drainage. The area below the ileostomy may be massaged as needed if the ileostomy becomes blocked by high-fiber foods. Foods such as nuts and those with seeds will pass through the ileostomy. The client should be taught that these foods will remain undigested. Fluid intake should be at least 6 to 8 glasses of water per day to prevent dehydration.
The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply.
Coffee Chocolate Peppermint Friend Chicken
The nurse is caring for a client prescribed enteral feeding via a newly inserted nasogastric (NG) tube. Before initiating the enteral feeding, the nurse should perform which action first?
Confirm NG placement by x-ray study. Before initiating enteral feedings via a newly inserted NG tube, the placement of the tube is confirmed by x-ray. If the tube is not in the stomach, the client is at risk for aspiration. Formulas are administered at room temperature, not at 103°F. To prevent aspiration while administering a tube feeding, the nurse should place the client in an upright sitting position or elevate the head of the bed at least 30 degrees. Although an important action, it is not the priority. Priming the enteral feeding tube is important prior to initiating the feedings; however, it is not the priority action.
The nurse should incorporate which in the dietary plan to ensure optimal nutrition for the client during the acute phase of hepatitis? Select all that apply.
Consume multiple small meals throughout the day. Allow the client to select foods that are most appealing. Eliminate fatty foods from the meal trays until nausea subsides. Because the client with hepatitis experiences general malaise, small, more frequent meals are better tolerated than large meals, with breakfast being the best tolerated meal of the day. Self-selection of foods may enhance appetite over randomly selected foods. Fatty foods can exacerbate nausea and need to be avoided during the acute phase. The diseased liver may be unable to metabolize large amounts of protein at this time. The client should receive a diet high in carbohydrates to assist with meeting increased caloric needs. Anorexia typically increases as the day goes on.
The nurse is providing dietary instructions to a client with a diagnosis of irritable bowel syndrome. The nurse determines that education was effective if the client states the need to avoid which food?
Corn
The nurse is caring for a client with biliary obstruction. The nurse interprets that obstruction of which passage is related to the client's condition?
Cystic duct The gallbladder receives bile from the liver through the cystic duct. The liver collects bile in the canaliculi, from which bile flows into the right and left hepatic ducts and then into the common hepatic duct. From there, the bile can be transported for storage in the gallbladder through the cystic duct, or it can flow directly into the duodenum by way of the common bile duct.
The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)?
Dark red drainage
Diphenoxylate hydrochloride with atropine sulfate is prescribed for a client with ulcerative colitis. The nurse should monitor the client for which therapeutic effect of this medication?
Decreased diarrhea
The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis?
Decreased hemoglobin
The nurse checks the gastric residual of an unconscious client receiving nasogastric tube feedings continuously at 50 mL/hr. The nurse notes that the residual is 250 mL at 0800 and 300 mL at 0900. The nurse determines that the client is experiencing which complication?
Delayed gastric emptying
A client who has a gastrostomy tube for feeding refuses to participate in the plan of care, will not make eye contact, and does not speak to the family or visitors. The nurse interprets that the client is using which coping mechanism?
Distancing Distancing is an unwillingness or inability to discuss events. Self-control is demonstrated by stoicism and hiding feelings. Problem solving involves making plans and verbalizing what will be done. Accepting responsibility places the responsibility for a situation on oneself.
The nurse is caring for a client postoperatively after creation of a colostomy. What is an appropriate potential client problem?
Disturbed body image Disturbed body image for a client who is postoperative after creation of a colostomy relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). There are no data in the question to support sexual dysfunction or fear. Imbalanced nutrition: less (not more) than body requirements is the more likely client problem.
The nurse is caring for a client who has just returned from the operating room after the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is appropriate based on this assessment?
Document the amount and characteristics of the drainage. During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Applying ice or pressure to the stoma site are inappropriate actions. Notifying the HCP is unnecessary because this is an expected finding.
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?
Document the findings
The nurse is caring for a client with pancreatitis. Which finding should the nurse expect to note when reviewing the client's laboratory results?
Elevated level of amylase The serum level of amylase, an enzyme produced by the pancreas, increases with pancreatitis. Amylase normally is responsible for carbohydrate digestion. Pepsin is produced by the stomach and is used in protein digestion. Lactase and enterokinase are enzymes produced by the small intestine; lactase splits lactose into galactose and fructose, and enterokinase activates trypsin.
The nurse is reviewing the results of serum laboratory studies for a client admitted for suspected hepatitis. Which laboratory finding is most associated with hepatitis, requiring the nurse to contact the health care provider?
Elevated serum bilirubin level Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and ESR. However, ESR is a nonspecific test that indicates the presence of inflammation somewhere in the body. The hemoglobin concentration is unrelated to this diagnosis. An elevated BUN level may indicate renal dysfunction.
The nurse is caring for a client with acute pancreatitis. Which finding should the nurse expect to note when reviewing the laboratory results?
Elevated serum lipase level The serum lipase level is elevated in the presence of pancreatic cell injury. Serum trypsin and amylase levels are also elevated in pancreatic injury. Although bilirubin can be elevated in the client with pancreatitis, it is secondary to the hepatobiliary obstructive process.
The nurse is caring for a hospitalized client with pancreatitis. Which findings should the nurse look for and expect to note when reviewing the laboratory results? Select all that apply.
Elevated trypsin level Elevated lipase level Elevated amylase level Lipase, trypsin, and amylase are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively. Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Sucrase is produced in the small intestine and converts sucrose into glucose and fructose.
The nurse is preparing to administer an intermittent enteral feeding though a nasogastric (NG) tube. Which priority assessment should the nurse perform?
Evaluate absorption of the last feeding. All stomach contents are aspirated and measured before a tube feeding is administered. This procedure measures the gastric residual. The gastric residual is assessed to confirm whether undigested formula from a previous feeding remains, thereby evaluating absorption of the last feeding. It is important to assess gastric residual because administration of an enteral feeding to a full stomach could result in overdistention, predisposing the client to regurgitation and possible aspiration. The remaining options do not relate to the purpose of assessing residual.
A client with cirrhosis complicated by ascites is admitted to the hospital. The client reports a 10-lb weight gain over the past 1½ weeks. The client has edema of the feet and ankles, and his abdomen is distended, taut, and shiny with striae. Which client problem is most appropriate at this time?
Excessive body fluid volume
A client with chronic pancreatitis needs information on dietary modification to manage the health problem. Which item in the diet should the nurse teach the client to limit?
Fat The client with chronic pancreatitis should limit fat in the diet and also take in small meals, which will reduce the amount of carbohydrates and protein that the client must digest at any one time. The client does not need to limit water-soluble vitamins in the diet.
A client is admitted to the hospital with acute viral hepatitis. Which sign or symptom should the nurse expect to note based on this diagnosis?
Fatigue Common manifestations of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider angiomas—small, dilated blood vessels—are commonly seen in cirrhosis of the liver.
The nurse manager is providing an educational session to nursing staff members about the phases of viral hepatitis. The nurse manager tells the staff that which clinical manifestation(s) are primary characteristics of the preicteric phase?
Fatigue, anorexia, and nausea In the preicteric phase, the client has nonspecific complaints of fatigue, anorexia, nausea, cough, and joint pain. The remaining options are clinical manifestations that occur in the icteric phase. In the posticteric phase, jaundice decreases, the color of urine and stool returns to normal, and the client's appetite improves.
The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply.
Fever Complaints of indigestion Pain in the upper right quadrant after fatty meal
A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?
Fluid and electrolyte imbalance
A client with peptic ulcer disease states that stress frequently causes exacerbation of the disease. The nurse determines that which item mentioned by the client is most likely to be responsible for the exacerbation?
Frequent need to work overtime on short notice
The nurse is reviewing the health care provider's prescriptions written for a client admitted to the hospital with acute pancreatitis. Which prescription requires follow-up by the nurse?
Full liquid diet The client with acute pancreatitis is placed on NPO (nothing by mouth) status to decrease the activity of the pancreas, which occurs with oral intake. Pain management for acute pancreatitis typically begins with the administration of opioids by patient-controlled analgesia. Medications such as morphine or hydromorphone are typically used. Nasogastric tube insertion is done to provide suction of secretions and administer medications as necessary.
The nurse is caring for a client admitted with severe weight loss due to dieting. Based on the data provided, which condition should the nurse suspect is occurring in this client?
Gluconeogenesis Gluconeogenesis is the production of glucose for energy from protein and fat stores in the body. This can occur with extreme dieting and also with diabetes mellitus. Glycogenolysis is the production of glucose from glycogen stores in the liver. Lactic acidosis occurs with excess production of lactic acid resulting from anaerobic metabolism. The body normally burns glucose for energy.
The nurse has implemented a bowel maintenance program for an unconscious client. The nurse would evaluate the plan as best meeting the needs of the client if which method was successful in stimulating a bowel movement?
Glycerin suppository
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply.
Gray-blue color at the flank Abdominal guarding and tenderness Left upper quadrant pain with radiation to the back
The nurse is caring for a client who is receiving bolus feedings via a nasogastric tube. As the nurse is finishing the feeding, the client asks for the bed to be positioned flat for sleep. The nurse understands that which is the appropriate position for this client at this time?
Head of bed elevated 30 to 45 degrees, with the client in the right lateral position for 60 minutes Aspiration is a possible complication associated with nasogastric tube feeding. The head of the bed is elevated 30 to 45 degrees for 60 minutes after a bolus tube feeding to prevent vomiting and aspiration. The right lateral position uses gravity to facilitate gastric emptying and thus prevent vomiting. The flat supine position is to be avoided for the first 30 minutes after a tube feeding.
The nurse has been caring for a client who required a Sengstaken-Blakemore tube because other treatment measures for esophageal varices were unsuccessful. The health care provider (HCP) arrives on the nursing unit and deflates the esophageal balloon. Which assessment finding by the nurse is the most important and should be reported to the HCP immediately?
Hematemesis (vomiting blood)
The nurse is assigned to care for a client with a Sengstaken-Blakemore tube. Which laboratory result is most focused on evaluating the effectiveness of this tube?
Hemoglobin A Sengstaken-Blakemore tube may be used in a client with a diagnosis of cirrhosis with ruptured esophageal varices if other treatment measures are unsuccessful. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could harm the client. Evaluation of the client's hemoglobin level trends will determine if the tube is effective. Sodium, creatinine, and ammonia levels are not related to monitoring for blood loss.
The medication history of a client with peptic ulcer disease reveals intermittent use of several medications. The nurse would teach the client that which of these medications are not a part of the treatment plan because of its irritating effects on the lining of the gastrointestinal tract?
Ibuprofen Ibuprofen is a nonsteroidal antiinflammatory drug that typically is irritating to the lining of the gastrointestinal tract and should be avoided by clients with a history of peptic ulcer disease. The other medications listed are frequently used to treat peptic ulcer disease. Nizatidine is an H2-receptor antagonist that reduces the secretion of gastric acid. Sucralfate coats the surface of an ulcer to promote healing. Omeprazole is a proton pump inhibitor that blocks transport of hydrogen ions into the lumen of the gastrointestinal tract.
The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence?
Inability to pass flatus
The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment data would alert the nurse to this occurrence?
Inability to pass flatus An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of anal sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. A firm, palpable mass at the right costal margin describes the physical finding of liver enlargement, which is usually associated with cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, this is not a sign of paralytic ileus or intestinal obstruction.
A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?
Increase intake of fluids, including juices
The nurse is caring for a client with altered protein metabolism as a result of liver dysfunction. Which finding should the nurse expect to note when reviewing the client's laboratory results?
Increased ammonia level During deamination of proteins in the liver, the amino group splits from the carbon-containing compound, which results in formation of ammonia and a carbon residue. The liver then converts the toxic ammonia substance into urea, which can be excreted by the kidneys. Clients with liver dysfunction may have high serum ammonia levels as a result. The remaining options are incorrect.
The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, should the nurse question?
Indomethacin Indomethacin is a nonsteroidal antiinflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Digoxin is a cardiac medication. Furosemide is a loop diuretic. Propranolol hydrochloride is a beta-adrenergic blocking agent. Digoxin, furosemide, and propranolol are not contraindicated in clients with gastric disorders.
The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify?
Irrigating the nasogastric tube
The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply.
Jaundice Clay-colored stools Elevated bilirubin levels Dark or tea-colored urine
The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis?
Leukocytosis with a shift to the left
The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome?
Limit the fluids taken with meals.
The nurse is caring for an older client. The nurse should anticipate that medication dosages will be further adjusted if the client has dysfunction of which organ?
Liver
The nurse is assisting a client with Crohn's disease to ambulate to the bathroom. After the client has a bowel movement, the nurse should assess the stool for which characteristic that is expected with this disease?
Loose, watery stool Crohn's disease is characterized by nonbloody diarrhea of usually not more than 4 or 5 stools daily. Over time, the episodes of diarrhea increase in frequency, duration, and severity. Options 1, 2, and 4 are not characteristics of the stool in Crohn's disease.
The nurse is caring for a client who is prescribed a nasogastric (NG) tube for the purpose of stomach decompression. The nurse should anticipate a health care provider prescription for which type of suction?
Low and intermittent Gastric mucosa can be traumatized and pulled into the tube if the suction pressure is placed on high or if the suction is continuous. The suction should be set on low pressure and intermittent suction control.
The nurse is caring for a client with common bile duct obstruction. The nurse should anticipate that the health care provider (HCP) will prescribe which diet for this client?
Low fat Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum. Bile acids or bile salts are produced by the liver to emulsify or break down fats. The diets listed in the remaining options are incorrect.
A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse determines that education about positioning to reduce pain was effective if the client avoids which action?
Lying flat The pain of pancreatitis is aggravated by lying supine or walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation will intensify the irritation of the posterior peritoneal wall with these positions or movements. Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) will alleviate some of the pain associated with pancreatitis. The fetal position (with the legs drawn up to the chest) may decrease the abdominal pain of pancreatitis.
A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia?
Lying recumbent following meals
The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply.
Maintain NPO (nothing by mouth) status. Encourage coughing and deep breathing. Give hydromorphone intravenously as prescribed for pain.
The nurse is providing instructions to a client regarding measures to minimize the risk of dumping syndrome. The nurse should make which suggestion to the client?
Maintain a low Fowler's position while eating.
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?
Malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify)
A hospitalized client with liver disease has a dietary protein restriction. The nurse encourages intake of which source of complete proteins to maximize the availability of essential amino acids?
Meats Complete proteins contain all of the essential amino acids, which are acids that the body cannot produce from other available sources. Complete proteins derive from animal sources, such as meat, cheese, milk, and eggs. Incomplete proteins can be found in fruits, vegetables, nuts, cereals, breads, and legumes.
Cholestyramine resin is prescribed for a client with an elevated serum cholesterol level. The nurse should instruct the client to take the medication in which way?
Mixed with fruit juice This medication binds with bile salts in the intestines to form a compound that is excreted in the feces. The client should be instructed to mix the medication with 3 to 6 ounces of water, milk, fruit juice, or soup. It should be administered before meals. It is not administered via rectal suppository.
The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions should be included in the care plan for this client? Select all that apply.
Monitor daily weight. Measure abdominal girth. Monitor respiratory status. Assist the client with care as needed.
A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention is appropriate?
Monitor for fluid and electrolyte imbalance.
The nurse is caring for a client with acute pancreatitis. Which medications should the nurse expect to be prescribed for treatment of this problem? Select all that apply.
Morphine Dicyclomine Pantoprazole Acetazolamide Medications used to treat acute pancreatitis include pain medications such as morphine, antispasmodics such as dicyclomine, proton pump inhibitors such as pantoprazole, and acetazolamide to decrease the volume and bicarbonate concentration of pancreatic secretions. Insulin is used in chronic pancreatitis to treat diabetes mellitus or hyperglycemia if needed, and pancreatic enzyme products are used for replacement of pancreatic enzymes.
A client is admitted to the hospital with a diagnosis of acute diverticulitis. What should the nurse expect to be prescribed for this client?
NPO (nothing by mouth) status
The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply.
Nut Liver Lentils
A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? Select all that apply.
Orthopnea and dyspnea Petechiae and ecchymosis Inguinal or umbilical hernia Abdominal distention and tenderness Excess fluid volume, related to the accumulation of fluid in the peritoneal cavity and dependent areas of the body, can occur in the client with cirrhosis. Ascites can cause physical problems because of the overdistended abdomen and resultant pressure on internal organs and vessels. These problems include respiratory difficulty, petechiae and ecchymosis, development of hernias, and abdominal distention and tenderness. Poor body posture and balance are unrelated to increased abdominal pressure.
The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which sign(s)/symptom(s) of duodenal ulcer?
Pain relieved by food intake
The nurse is assessing a client with a duodenal ulcer. The nurse interprets that which sign or symptom is most consistent with the typical presentation of duodenal ulcer?
Pain that is relieved by food intake The most typical finding with duodenal ulcer is pain that is relieved by food intake. The pain is often described as a burning, heavy, sharp, or "hunger pang" pain that often localizes in the midepigastric area. It does not radiate down the right arm. The client with duodenal ulcer does not usually experience weight loss or nausea and vomiting; these symptoms are more typical in the client with a gastric ulcer.
The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels?
Palpating for peripheral edema Albumin is responsible for maintaining the osmolality of the blood. When there is a low albumin level, there is decreased osmotic pressure, which in turn can lead to peripheral edema. The remaining options are incorrect and are not associated with a low albumin level.
A client with a diagnosis of stomach ulcer from gastric hyperacidity asks the nurse why the acid has not caused an ulcer in the small intestine as well. The nurse responds that the pH of intestinal contents is raised by bicarbonate, which is present in which area of the body?
Pancreatic juice Pancreatic juice is rich is bicarbonate, which helps to neutralize the gastric acid in food entering the small intestine from the stomach. The duodenal papilla, which is an opening about 10 cm below the level of the pylorus, is responsible for carrying bile and pancreatic juices into the duodenum. Bile, parietal cells, and liver enzymes are not substances rich in bicarbonate and are incorrect.
The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client?
Pasta with sauce
The nurse is assessing a client with liver disease for signs and symptoms of low albumin. Which sign or symptom should the nurse expect to note?
Peripheral edema Albumin is responsible for maintaining the osmolality of the blood. When the albumin level is low, osmotic pressure is decreased, which in turn can lead to peripheral edema. Weight loss is not a sign or symptom for hypoalbuminemia. Capillary refill of 5 seconds is a delayed filling time but is not associated with decreased albumin levels. Clotting factors produced by the liver (not albumin) are responsible for coagulation, and lack of clotting factors can result in bleeding from old puncture sites. The total protein level may decrease if the albumin level is low.
After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication?
Pernicious anemia
The nurse is assisting a health care provider (HCP) with the insertion of a Miller-Abbott tube. The nurse understands that the procedure places the client at risk for aspiration and should therefore implement which action to decrease this risk?
Place the client in a semi Fowler's to high Fowler's position. The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine, as in correcting a bowel obstruction. Initial insertion of the tube is an HCP responsibility. The tube is inserted with the balloon deflated in a manner similar to the proper procedure for inserting a nasogastric tube. The client is usually given water to drink to facilitate passage of the tube through the nasopharynx and esophagus. A semi Fowler's to high Fowler's position decreases the risk of aspiration if vomiting occurs. A Valsalva maneuver is not helpful and is not used if the impulse to gag occurs.
The nurse is caring for a client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which food?
Pork Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin. Other good sources include peanuts, asparagus, and whole-grain and enriched cereals.
A client who has undergone creation of a colostomy has a concern about body image. What action by the client indicates the most significant progress toward identified goals?
Practicing proper cutting of the ostomy appliance The client is expected to have body image disturbance after colostomy. The client progresses through normal grieving stages to adjust to this change. The client demonstrates the greatest degree of acceptance when he or she participates in the actual colostomy care. Each incorrect option represents an interest in colostomy care but is a passive activity. The correct option shows the client participating in self-care.
A client with cirrhosis is beginning to show signs of hepatic encephalopathy. The nurse should plan a dietary consultation to limit the amount of which ingredient in the client's diet?
Protein Ammonia is formed as a product of protein metabolism. Clients with hepatic encephalopathy have a high serum ammonia level, which is responsible for the symptoms of encephalopathy. Limiting protein intake will prevent further elevation in the serum ammonia level and prevent further deterioration of the client's mental status. It is not necessary to limit calories, minerals, or carbohydrates.
A client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which actions should the nurse plan to promote client safety? Select all that apply.
Provide the client with a soft toothbrush. Instruct the client to use an electric razor. Monitor all secretions for frank or occult blood.
The nurse has inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts to slowly advance the NG tube with each swallow. The client begins to cough, gag, and choke. Which actions should the nurse take that will result in proper tube insertion and promote client relaxation? Select all that apply.
Pull the tube back slightly. Instruct the client to breathe slowly. Assist the client to take sips of water. Check the back of the pharynx using a tongue blade and flashlight. As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx and obstruct the airway, pulling the tube back slightly will remove it from the larynx; advancing the tube might position it in the trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Slow breathing helps the client relax, which reduces the gag response. The nurse should check the back of the client's throat to note whether the tube has coiled. The tube may be advanced after the client relaxes.
The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider?
Purple discoloration of the stoma
The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, should the nurse report to the health care provider (HCP)?
Rebound tenderness Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the HCP.
A client who has been advanced to a solid diet after undergoing a subtotal gastrectomy. What is the appropriate nursing intervention in preventing dumping syndrome?
Remove fluids from the meal tray.
The nurse assists a health care provider in performing a liver biopsy. After the procedure, the nurse should place the client in which position?
Right side To splint and provide pressure at the puncture site, the client is kept on the right side for a minimum of 2 hours after a liver biopsy. Therefore, the remaining positions are incorrect.
The nurse is caring for a group of clients on the surgical nursing unit. The nurse anticipates that the client who underwent which procedure is most likely to have some long-term residual difficulty with absorption of nutrients?
Small bowel resection The small intestine is responsible for the absorption of most nutrients. The client who has undergone removal of a segment of the small bowel is the one who has a decreased area with which to absorb nutrients. Decreased absorption is not a likely complication with the surgical procedures identified in the remaining options.
The nurse is caring for a client with spinal cord injury (SCI) who is participating in a bowel retraining program. What should the nurse anticipate to promote during the bowel retraining program?
Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord The principal reflex center for defecation is located in the parasympathetic center at the S1 to S4 level of the spinal cord. This center is most active after the first meal of the day. Other factors that contribute to satisfactory stool passage are sufficient fluid and roughage in the diet and the Valsalva maneuver (which is lost with SCI). During defecation, the anal sphincter relaxes.
The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence?
Sweating and pallor
The nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which client factor documented by the nurse would increase the risk for PUD?
Takes nonsteroidal antiinflammatory drugs (NSAIDs) for osteoarthritis
The nurse is evaluating the plan of care for a client with peptic ulcer disease (PUD) who is experiencing acute pain. The nurse determines that the expected outcomes have been met if the nursing assessment reveals which result?
The client has eliminated any irritating foods from the diet. Expected outcomes for the client with PUD who is experiencing pain include elimination of irritating foods from the diet, effectiveness of prescribed medications to eliminate pain, self-reporting of absence of pain with medication, and an ability to sleep through the night without pain. The client who continues to be awakened by pain requires further modification of medication therapy, which may include adjustment of timing of histamine H2-receptor antagonist administration or an additional dose of antacid before the time when pain usually awakens the client.
Lactulose is prescribed for a hospitalized client with a diagnosis of hepatic encephalopathy. Which assessment finding indicates that the client is responding to this medication therapy as anticipated?
The fecal pH is acidic. Lactulose is an osmotic laxative used to decrease ammonia levels, which are elevated in hepatic encephalopathy. The desired effect is 2 or 3 soft stools per day with an acid fecal pH. Lactulose creates an acid environment in the bowel, resulting in a fall of the colon's pH from 7 to 5. This causes ammonia to leave the circulatory system and move into the colon for excretion. Diarrhea may indicate excessive administration of the medication. Vomiting and ability to tolerate a full diet do not determine that a desired effect has occurred.
A client is admitted to the hospital with a diagnosis of acute pancreatitis. Which would the nurse expect the client to report about the pain?
The pain usually increases after vomiting. Pain with acute pancreatitis usually increases after vomiting because of an increase in intraductal pressure caused by retching, which leads to further obstruction of the outflow of pancreatic secretions. The pain is a steady and intense epigastric pain that radiates to the client's back and flank. The pain may lessen when the client sits up or bends forward. Eating exacerbates the pain by stimulating the secretion of enzymes.
Pancreatin is prescribed for a client with postgastrectomy syndrome. Which assessment finding would indicate a therapeutic effect of this medication?
The stool is less fatty and decreases in frequency. Pancreatin aids in the digestion of protein, carbohydrate, and fat in the gastrointestinal tract. It is used to treat steatorrhea associated with postgastrectomy syndrome after bowel resection. The nurse should record the number of stools per day and the stool consistency to monitor the effectiveness of this enzyme therapy. If it is effective, the stools should become less frequent and less fatty. The remaining options are not indications of a therapeutic effect of the medication.
The nurse is obtaining a health history for a client with chronic pancreatitis. The health history is most likely to include which as a most common causative factor in this client's disorder?
The use of Alcohol Chronic pancreatitis occurs most often in alcoholics. Abstinence from alcohol is important to prevent the client from developing chronic pancreatitis. Clients usually experience malabsorption with weight loss. Chemical exposure is associated with cancer of the pancreas. Pain will not be relieved with food or antacids.
A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?
This is a normal, expected event.
The nurse is preparing to teach a client with a new colostomy about how to perform a colostomy irrigation. Which information should the nurse include in the teaching plan?
Use 500 to 1000 mL of warm tap water.
A client with gastric hypersecretion is scheduled for surgery. The nurse teaches the client that the procedure will lessen the stomach's production of acid by altering which structure?
Vagus nerve Vagotomy is a procedure that can reduce innervation to the stomach, thereby reducing the production of gastric acid. The portal vein drains venous blood from the stomach. The celiac artery brings arterial blood to the stomach. The pyloric valve separates the stomach from the duodenum. The pyloric valve may undergo surgical repair if it becomes stenosed; this procedure is known as pyloroplasty.
The nurse is caring for a client with pernicious anemia. Which prescription by the health care provider (HCP) should the nurse anticipate?
Vitamin B12 Pernicious anemia is caused by a deficiency of vitamin B12. Treatment consists of administration of high doses of oral vitamin B12. Monthly injections of vitamin B12 can also be administered but are less comfortable when compared to oral administration. Thiamine is most often prescribed for the client with alcoholism, folic acid is prescribed for folic acid deficiency, and vitamin B6 is ordered when there is pyridoxine deficiency.
A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that in this disorder because the stomach lining produces a decreased amount of a substance known as the intrinsic factor, the client will need which medication?
Vitamin B12 injections A lack of the intrinsic factor needed to absorb vitamin B12 is a feature of pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Vitamin B6 is not specifically lacking in pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers.
The nurse should anticipate that the health care provider (HCP) will prescribe which treatment for a client with pernicious anemia?
Vitamin B12 injections A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Iron is used for anemia that results from a lack of iron. Blood transfusions are not needed for pernicious anemia because a lack of red blood cells is not the problem. Gastric tube feedings will not replace vitamin B12. Vitamin B12 needs to be given by injection to ensure absorption.
The nurse is caring for a client admitted to the hospital with suspected acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis?
WBC count of 18,000 mm3 (18 × 109/L) Laboratory findings do not establish the diagnosis of appendicitis, but there is often a moderate elevation of the WBC count (leukocytosis) to 10,000 to 18,000 mm3 (10 to 18 × 109/L) with an increased number of immature WBCs. An inflammatory process causes a rise in the WBC count. A rise to 26,000 mm3 (26 × 109/L) may indicate a perforated appendix (greater than 20,000 mm3 [20 × 109/L]).
After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding?
Waves of loud gurgles auscultated in all 4 quadrants
The nurse is caring for a client who had a subtotal gastrectomy. The nurse should assess the client for which signs and symptoms of dumping syndrome?
Weakness, diaphoresis, and diarrhea Dumping syndrome occurs after gastric surgery because food is not held long enough in the stomach and is "dumped" into the small intestine as a hypertonic mass. This causes fluid to shift into the intestines, causing cardiovascular and gastrointestinal symptoms. Signs and symptoms typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea.
A client is experiencing blockage of the common bile duct. Which food selection made by the client indicates the need for further teaching?
Whole milk Bile acids or bile salts are produced by the liver to emulsify or break down fats. Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum, thus preventing breakdown of fatty intake. Knowledge of this should direct you to the option of whole milk. Dairy products, such as whole milk, ice cream, butter, and cheese, are high in cholesterol and fat and should be avoided.
A client with a new colostomy is concerned about the odor from stool in the ostomy drainage bag. The nurse should teach the client to include which food in the diet to reduce odor?
Yogurt The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas-forming food as well. Broccoli, cucumbers, and eggs are gas-forming foods.
A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse should anticipate a prescription from the health care provider for which type of diet for this client?
a low fiber diet
The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer?
a rigid boardlike abdomen
The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy?
asterixis (arm/wrist bird flap tremor)
The nurse is caring for a client with a low thrombin level as a result of liver dysfunction. Based on this finding it is most important for the nurse to monitor the client for signs and symptoms of which potential complication?
bleeding
The nurse is giving dietary instructions to a client who has a new colostomy. The nurse should encourage the client to eat foods representing which diet for the first 4 to 6 weeks postoperatively?
low fiber Rationale: For the first 4 to 6 weeks after colostomy formation, the client should consume a low-fiber diet. After this period, the client should eat a high-carbohydrate, high-protein diet. The client also is instructed to add new foods, including those with fiber, one at a time to determine tolerance to that food.