Test 5 -- GI Questions

A nurse cares for a client who has obstructive jaundice. The client asks, Why is my skin so itchy? How should the nurse respond? a. Bile salts accumulate in the skin and cause the itching. b. Toxins released from an inflamed gallbladder lead to itching. c. Itching is caused by the release of calcium into the skin. d. Itching is caused by a hypersensitivity reaction.

A In obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excess bile salts to accumulate on the skin. This leads to itching, or pruritus. The other statements are not accurate.

A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse instructs the client and family about the signs of potential complications, which include what problems? (Select all that apply.) a. Cholangitis b. Pancreatitis c. Perforation d. Renal lithiasis e. sepsis

A, B,C,E

A nurse cares for a client who presents with tachycardia and prostration related to biliary colic. Which actions should the nurse take? (Select all that apply.) a. Contact the provider immediately. b. Lower the head of the bed. c. Decrease intravenous fluids. d. Ask the client to bear down e. Administer prescribed opioids.

A,B

The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common causes for which the nurse assesses in these clients? (Select all that apply.) a. Colon cancer b. Diverticulitis c. Inflammatory bowel disease d. Peptic ulcer disease e. Pernicious anemia

A,B,C,D

An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? (Select all that apply.) a. Hypertension b. Tachycardia c. Flushed skin d. Confusion e. Shallow respirations

B,D

A nurse assesses a client who is recovering from a Whipple procedure. Which clinical manifestations alert the nurse to a complication from this procedure? (Select all that apply.) a. Clay-colored stools b. Substernal chest pain c. Shortness of breath d. Lack of bowel sounds or flatus e. Urine output of 20 mL/6 hr

B, C, D, E Myocardial infarction (chest pain), pulmonary embolism (shortness of breath), adynamic ileus (lack of bowel sounds or flatus), and renal failure (urine output of 20 mL/6 hr) are just some of the complications for which the nurse must assess the client after the Whipple procedure. Clay-colored stools are associated with cholecystitis and are not a complication of a Whipple procedure.

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? (Select all that apply.) a. Do not allow the client to eat between meals. b. Make sure the client receives a protein shake. c. Do not allow caffeine-containing beverages. d. Make sure the foods are bland with little spice .e. Do not allow high-carbohydrate food items.

B,C,D

The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to what organ dysfunctions? (Select all that apply.) a. Alanine aminotransferase: biliary system b. Ammonia: liver . Amylase: liver d. Lipase: pancreas e. Urine urobilinogen: stomach

B,D

A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially causing complications of this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)

B,E,F

A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Take a 20-minute walk at least 5 days each week. b. Attend local Alcoholics Anonymous (AA) meetings weekly. c. Choose whole grains rather than foods with simple sugars. d. Use cooking spray when you cook rather than margarine or butter. e. Stay away from milk and dairy products that contain lactose.f. We can talk to your doctor about a prescription for nicotine patches.

BDF

A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.) a. Apply lotion to the clients dry skin areas. b. Use a basin with warm water to bathe the client. c. For the clients oral care, use a soft toothbrush. d. Provide clippers so the client can trim the fingernails. e. Bathe with antibacterial and water-based soaps.

a,c,d

A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B? a. A 20-year-old college student who has had several sexual partners b. A 46-year-old woman who takes acetaminophen daily for headaches c. A 63-year-old businessman who travels frequently across the country d. An 82-year-old woman who recently ate raw shellfish for dinner

a. A 20-year-old college student who has had several sexual partners

A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge? a. Do you have a one- or two-story home? b. Can you check your own pulse rate? c. Do you have any alcohol in your home? d. Can you prepare your own meals?

a. Do you have a one- or two-story home? A client recovering from chronic pancreatitis should be limited to one floor until strength and activity increase. The client will need a bathroom on the same floor for frequent defecation. Assessing pulse rate and preparation of meals is not specific to chronic pancreatitis. Although the client should be encouraged to stop drinking alcoholic beverages, asking about alcohol availability is not adequate to assess this clients safety.

A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to urgently contact the health care provider? a. Drainage from a fistula b. Absent bowel sounds c. Pain at the incision site d. Nasogastric (NG) tube drainage

a. Drainage from a fistula

A nurse cares for a client with end-stage pancreatic cancer. The client asks, Why is this happening to me? How should the nurse respond? a. I dont know. I wish I had an answer for you, but I dont. b. Its important to keep a positive attitude for your family right now .c. Scientists have not determined why cancer develops in certain people .d. I think that this is a trial so you can become a better person because of it.

a. I dont know. I wish I had an answer for you, but I dont

A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone! Which action should the nurse take? a. Instruct the client to sit in as upright a position as possible. b. Add humidity to the oxygen and encourage the client to wear it. c. Document the clients refusal, and call the health care provider. d. Contact the provider to request an extra dose of the clients diuretic.

a. Instruct the client to sit in as upright a position as possible.

A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? a. Its a good thing I love orange and cherry gelatin. b. My spouse will be here to drive me home. c. I should refrigerate the GoLYTELY before use. d. I will buy a case of Gatorade before the prep.

a. Its a good thing I love orange and cherry gelatin.

To promote comfort after a colonoscopy, in what position does the nurse place the client? a. Left lateral b. Prone c. Right lateral d. Supine

a. Left lateral

A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 18 to 14 breaths/min d. A decrease in the clients weight by 6 kg

a. Urine output via indwelling urinary catheter is 20 mL/hr

A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus). Which statement should the nurse include in this clients discharge education? a. Use a pill organizer to ensure you take this medication as prescribed. b. Transient muscle aching is a common side effect of this medication. c. Follow up with your provider in 1 week to test your blood for toxicity. d. Take your radial pulse for 1 minute prior to taking this medication.

a. Use a pill organizer to ensure you take this medication as prescribed.

A nurse cares for a client who is prescribed patient-controlled analgesia (PCA) after a cholecystectomy. The client states, When I wake up I am in pain. Which action should the nurse take? a. Administer intravenous morphine while the client sleeps. b. Encourage the client to use the PCA pump upon awakening. c. Contact the provider and request a different analgesic. d. Ask a family member to initiate the PCA pump for the client.

b. Encourage the client to use the PCA pump upon awakening.

An emergency room nurse assesses a client after a motor vehicle crash. The nurse notices a steering wheel mark across the clients chest. Which action should the nurse take? a. Ask the client where in the car he or she was sitting during the crash. b. Assess the client by gently palpating the abdomen for tenderness. c. Notify the laboratory to draw blood for blood type and crossmatch. d. Place the client on the stretcher in reverse Trendelenburg position.

b. Assess the client by gently palpating the abdomen for tenderness.

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best? a. Allow the client cool liquids only. b. Assess the clients gag reflex. c. Remind the client to remain NPO. d. Tell the client to wait 4 hours.

b. Assess the clients gag reflex.

A nurse cares for a client who is scheduled for a paracentesis. Which intervention should the nurse delegate to an unlicensed assistive personnel (UAP)? a. Have the client sign the informed consent form. b. Assist the client to void before the procedure. c. Help the client lie flat in bed on the right side. d. Get the client into a chair after the procedure.

b. Assist the client to void before the procedure.

A client who has been taking antibiotics reports severe, watery diarrhea. About which test does the nurse teach the client? a. Colonoscopy b. Enzyme-linked immunosorbent assay (ELISA) toxin A+B c. Ova and parasites d. Stool culture

b. Enzyme-linked immunosorbent assay (ELISA) toxin A+B Clients taking antibiotics are at risk for Clostridium difficile infection. The most common test for this disorder is a stool sample for ELISA toxin A+B. Colonoscopy, ova and parasites, and stool culture are not warranted at this time.

After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I cannot drink any alcohol at all anymore. b. I need to avoid protein in my diet. c. I should not take over-the-counter medications. d. I should eat small, frequent, balanced meals.

b. I need to avoid protein in my diet.

A nurse obtains a clients health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this client? a. I drink two glasses of red wine each week. b. I take a lot of Tylenol for my arthritis pain. c. I have a cousin who died of liver cancer. d. I got a hepatitis vaccine before traveling.

b. I take a lot of Tylenol for my arthritis pain.

After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. Drinking at least 2 liters of water each day is suggested b. I will decrease the amount of fatty foods in my diet. c. Drinking fluids with my meals will increase bloating. d. I will avoid concentrated sweets and simple carbohydrates.

b. I will decrease the amount of fatty foods in my diet.

A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic in appearance, and the family expresses distress that the client is receiving little dietary protein. How should the nurse respond? a. A low-protein diet will help the liver rest and will restore liver function. b. Less protein in the diet will help prevent confusion associated with liver failure. c. Increasing dietary protein will help the client gain weight and muscle mass. d. Low dietary protein is needed to prevent fluid from leaking into the abdomen

b. Less protein in the diet will help prevent confusion associated with liver failure.

The student nurse studying the gastrointestinal system understands that chyme refers to what? a. Hormones that reduce gastric acidity b. Liquefied food ready for digestion c. Nutrients after being absorbed d. Secretions that help digest food

b. Liquefied food ready for digestion

The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ? a. Kidneys b. Liver c. Spleen d. Stomach

b. Liver Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting proteins. The other organs are not related to this issue.

A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this clients plan of care to reduce discomfort? a. Administer morphine sulfate intravenously every 4 hours as needed. b. Maintain nothing by mouth (NPO) and administer intravenous fluids. c. Provide small, frequent feedings with no concentrated sweets. d. Place the client in semi-Fowlers position with the head of bed elevated.

b. Maintain nothing by mouth (NPO) and administer intravenous fluids. The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.

A nurse cares for a client who is recovering from an open Whipple procedure. Which action should the nurse take? a. Clamp the nasogastric tube. b. Place the client in semi-Fowlers position. c. Assess vital signs once every shift. d. Provide oral rehydration.

b. Place the client in semi-Fowlers position.

A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the client daily.

b. Provide a low-sodium diet.

A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, I am experiencing right flank pain and have a temperature of 101 F. How should the nurse respond? a. The anti-rejection drugs you are taking make you susceptible to infection. b. You should go to the hospital immediately to have your new liver checked out. c. You should take an additional dose of cyclosporine today. d. Take acetaminophen (Tylenol) every 4 hours until you feel better.

b. You should go to the hospital immediately to have your new liver checked out.

A nurse assesses clients at a community health center. Which client is at highest risk for pancreatic cancer? a. A 32-year-old with hypothyroidism b. A 44-year-old with cholelithiasis c. A 50-year-old who has the BRCA2 gene mutation d. A 68-year-old who is of African-American ethnicity

c. A 50-year-old who has the BRCA2 gene mutation Mutations in both the BRCA2 and p16 genes increase the risk for developing pancreatic cancer in a small number of cases. The other factors do not appear to be linked to increased risk.

A nurse prepares to assess the emotional state of a client with end-stage pancreatic cancer. Which action should the nurse take first? a. Bring the client to a quiet room for privacy. b. Pull up a chair and sit next to the clients bed. c. Determine whether the client feels like talking about his or her feelings. d. Review the health care providers notes about the prognosis for the client.

c. Determine whether the client feels like talking about his or her feelings.

After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the clients understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for additional teaching? a. I should drink bottled water during my travels. b. I will not eat off anothers plate or share utensils. c. I should eat plenty of fresh fruits and vegetables. d. I will wash my hands frequently and thoroughly.

c. I should eat plenty of fresh fruits and vegetables.

A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best? a. Ask the client to call back if this happens again today. b. Instruct the client to go to the emergency department. c. Remind the client that a small amount of bleeding is possible. d. Tell the client to come in to the clinic this afternoon.

c. Remind the client that a small amount of bleeding is possible.

A nurse assesses clients on the medical-surgical unit. Which client should the nurse identify as at high risk for pancreatic cancer? a. A 26-year-old with a body mass index of 21 b. A 33-year-old who frequently eats sushi c. A 48-year-old who often drinks wine d. A 66-year-old who smokes cigarettes

d. A 66-year-old who smokes cigarettes

A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first? a. Sedate the client to prevent tube dislodgement. b. Maintain balloon pressure at 15 and 20 mm Hg. c. Irrigate the gastric lumen with normal saline. d. Assess the client for airway patency.

d. Assess the client for airway patency.

A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect? a. Nausea and vomiting b. Frontal headache c. Vertigo and syncope d. Mid-sternal chest pain

d. Mid-sternal chest pain

A nurse is examining a client reporting right upper quadrant (RUQ) abdominal pain. What technique should the nurse use to assess this clients abdomen? a. Auscultate after palpating. b. Avoid any palpation. c. Palpate the RUQ first .d. Palpate the RUQ last.

d. Palpate the RUQ last.

A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important? a. Ask the client about recent exposure to illness. b. Assess the clients stool for obvious food particles. c. Include the date and time on the specimen container. d. Put on gloves prior to collecting the sample.

d. Put on gloves prior to collecting the sample.

After teaching a client who has a history of cholelithiasis, the nurse assesses the clients understanding. Which menu selection made by the client indicates the client clearly understands the dietary teaching? a. Lasagna, tossed salad with Italian dressing, and low-fat milk b. Grilled cheese sandwich, tomato soup, and coffee with cream c. Cream of potato soup, Caesar salad with chicken, and a diet cola d. Roasted chicken breast, baked potato with chives, and orange juice

d. Roasted chicken breast, baked potato with chives, and orange juice Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, low-fat milk, grilled cheese, cream, and cream of potato soup all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.

The nurse is aware of the 2014 American Cancer Society Screening Guidelines for colon cancer, which include which testing modalities for people over the age of 50? (Select all that apply.) a. Colonoscopy every 10 years b. Colonoscopy every 5 years c. Computed tomography (CT) colonography every 5 years d. Double-contrast barium enema every 10 years e. Flexible sigmoidoscopy every 10 years

A,C

A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Oxygen therapy b. Prone position c. Feet elevated on pillows d. Daily weights e. Physical therapy

A,C,D

The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.) a. Decreased hydrochloric acid production b. Diminished sensation that can lead to constipation c. Fat not digested as well in older adultsd. Increased peristalsis in the large intestine e. Pancreatic vessels become calcified

A,B,C,E

A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this laboratory result? (Select all that apply.) a. How frequently do you drink alcohol? b. Have you ever had sex with a man? c. Do you have a family history of cancer?d. Have you ever worked as a plumber? e. Were you previously incarcerated?

A,B,E

An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.) a. Policies related to consistent use of Standard Precautions b. Hepatitis vaccination mandate for workers in high-risk areas c. Implementation of a needleless system for intravenous therapy d. Number of sharps used in client care reduced where possible e. Postexposure prophylaxis provided in a timely manner

A,C,D,E

A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) a. Registered dietitian b. Nursing assistant c. Clinical pharmacist d. Certified herbalist e. Health care provider

A,C,E,

A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as contributors to this clients condition? (Select all that apply. a. Body mass index of 46 b. Vegetarian diet c. Drinking 4 ounces of red wine nightly d. Pregnant with twins e. History of metabolic syndromef. Glycosylated hemoglobin level of 15%

A,D,F

A nurse cares for a client who is recovering from laparoscopic cholecystectomy surgery. The client reports pain in the shoulder blades. How should the nurse respond? a. Ambulating in the hallway twice a day will help. b. I will apply a cold compress to the painful area on your back. c. Drinking a warm beverage can relieve this referred pain. d. You should cough and deep breathe every hour.

a. Ambulating in the hallway twice a day will help

A client scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best? a. Ask the client about shellfish allergies. b. Document this information on the chart. c. Ensure that the client has a ride home. d. Instruct the client on bowel preparation.

a. Ask the client about shellfish allergies.

A nurse cares for a client with hepatitis C. The clients brother states, I do not want to contract this infection, so I will not go into his hospital room. How should the nurse respond? a. If you wear a gown and gloves, you will not get this virus. b. Viral hepatitis is not spread through casual contact. c. This virus is only transmitted through a fecal specimen. d. I can give you an update on your brothers status from here.

b. Viral hepatitis is not spread through casual contact.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of carcinoma of the liver? a. A 22-year-old with a history of blunt liver trauma b. A 48-year-old with a history of diabetes mellitus c. A 66-year-old who has a history of cirrhosis d. An 82-year-old who has chronic malnutrition

c. A 66-year-old who has a history of cirrhosis

A nurse cares for a client with acute pancreatitis. The client states, I am hungry. How should the nurse reply? a. Is your stomach rumbling or do you have bowel sounds? b. I need to check your gag reflex before you can eat. c. Have you passed any flatus or moved your bowels? d. You will not be able to eat until the pain subsides.

c. Have you passed any flatus or moved your bowels? Paralytic ileus is a common complication of acute pancreatitis. The client should not eat until this has resolved. Bowel sounds and decreased pain are not reliable indicators of peristalsis. Instead, the nurse should assess for passage of flatus or bowel movement.

A nurse cares for a client who has chronic cirrhosis from substance abuse. The client states, All of my family hates me. How should the nurse respond? a. You should make peace with your family. b. This is not unusual. My family hates me too. c. I will help you identify a support system. d. You must attend Alcoholics Anonymous.

c. I will help you identify a support system.

A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute? a. Temperature of 100.1 F (37.8 C) b. Positive Murphys sign c. Light-colored stools d. Upper abdominal pain after eating

c. Light-colored stools Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen equally with both chronic and acute cholecystitis

A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The clients respiratory rate is 8 breaths/min. What action by the nurse is best? a. Administer naloxone (Narcan). b. Call the Rapid Response Team. c. Provide physical stimulation. d. Ventilate with a bag-valve-mask.

c. Provide physical stimulation. For an EGD, clients are given mild sedation but should still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurses first action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for Versed. The Rapid Response Team is not needed at this point. The client does not need manual ventilation.

After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. The capsules can be opened and the powder sprinkled on applesauce if needed. b. I will wipe my lips carefully after I drink the enzyme preparation. c. The best time to take the enzymes is immediately after I have a meal or a snack. d. I will not mix the enzyme powder with food or liquids that contain protein.

c. The best time to take the enzymes is immediately after I have a meal or a snack. The enzymes should be taken immediately before eating meals or snacks. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. Protein items will be dissolved by the enzymes if they are mixed together.

After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. Some medications have been known to cause hepatitis A. b. I may have been exposed when we ate shrimp last weekend. c. I was infected with hepatitis A through a recent blood transfusion. d. My infection with Epstein-Barr virus can co-infect me with hepatitis A.

b. I may have been exposed when we ate shrimp last weekend.

A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority? a. Auscultate for bowel sounds. b. Notify the provider immediately. c. Order an abdominal flat-plate x-ray. d. Palpate the mass and measure its size.

b. Notify the provider immediately.

A nurse assesses a client who is recovering from an open Whipple procedure. Which action should the nurse perform first? a. Assess the clients endotracheal tube with 40% FiO2. b. Insert an indwelling Foley catheter to gravity drainage. c. Place the clients nasogastric tube to low intermittent suction d. Start lactated Ringers solution through an intravenous catheter.

a. Assess the clients endotracheal tube with 40% FiO2. Using the ABCs, airway and oxygenation status should always be assessed first, so checking the endotracheal tube is the first action. Next, the nurse should start the IV line (circulation). After that, the Foley catheter can be inserted and the nasogastric tube can be set.

An older client has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? a. Changes in your liver cause drugs to be metabolized differently. b. Perhaps you dont need as high a dose of the drug as before. c. Stomach muscles atrophy with age and you digest more slowly. d. Your body probably cant tolerate as much medication anymore.

a. Changes in your liver cause drugs to be metabolized differently.