Gastrointestinal

A client has a Jackson-Pratt drainage tube in place the first day after surgical repair of a ruptured diverticulum. The client asks the nurse the purpose of the drain. What should the nurse tell the client? "The drainage tube is used to prevent:

infection in the peritoneal cavity."

A client's stools are light gray in color. What additional information should the nurse obtain from the client? Select all that apply.

intolerance to fatty foods fever jaundice

A client is in a metabolic acidosis from severe diarrhea. What assessment finding would be most concerning?

irregular heart rate

A physician orders spironolactone, 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?

loss of 2.2 lb (1 kg) in 24 hours

The nurse should assess the client with severe diarrhea for which acid-base imbalance?

metabolic acidosis

A client in the emergency department reports that they have been vomiting excessively for the past 2 days. The client's arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?

metabolic alkalosis

The nurse is assessing a client who has been admitted to the hospital with chest pain. The client has been taking simvastatin 40 mg daily for 3 years. The nurse notes that the client has yellow sclerae and a dark skin color. The client tells the nurse that urine is getting darker. The nurse should:

notify the health care provider.

A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention?

oxygen saturation (SaO2) of 89%

After gastric resection surgery, which signs alert the nurse to the development of a leaking anastomosis?

pain, fever, and abdominal rigidity

Which condition is most likely to have a nursing diagnosis of fluid volume deficit?

pancreatitis

A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these findings, the nurse should further assess the client for which complication?

peritonitis

A client with advanced cirrhosis has a prothrombin time (PT) of 15 seconds, compared with a control time of 11 seconds. The nurse expects to administer

phytonadione

A client with pancreatitis returns from an endoscopic retrograde cholangiopancreatography (ERCP). Which assessment would be of most concern to the nurse?

poor gag reflex

Which factor puts an older adult at the greatest risk for impaired wound healing after abdominal surgery?

poorly controlled diabetes

Which client requires immediate nursing intervention? The client who

presents with a rigid, boardlike abdomen.

After a gastrectomy, the client has a nasogastric (NG) tube in place. The tube is used to:

prevent excessive pressure on suture lines.

The nurse administers fat emulsion solution during TPN to a malnourished client. What should the nurse tell the client about the purpose of this solution? Fat emulsion solution:

provides essential fatty acids.

The client with cirrhosis who has ascites receives 100 mL of 25% serum albumin I.V. Which finding would best indicate that the albumin is having its desired effect?

reduced ascites

A client with pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate?

reserving an antecubital site for a peripherally inserted central catheter (PICC)

A client with colon cancer has developed ascites. The nurse should conduct a focused assessment for which additional signs and symptoms? Select all that apply.

respiratory distress fluid and electrolyte imbalance

A client with nausea, vomiting, and abdominal cramps and distention is admitted to the healthcare facility. Which test result is most significant?

serum potassium level of [3 mEq/L (3.0 mmol/L)]

A nurse is assessing a client who underwent esophagogastroduodenoscopy (EGD) for postoperative complications. Which sign or symptom would indicate a potential complication of this procedure?

severe abdominal pain

A client is admitted with severe abdominal pains and the diagnosis of acute pancreatitis. The nurse should develop a plan of care during the acute phase of pancreatitis that will involve interventions to manage:

severe pain.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds the client very difficult to arouse. The diagnostic information which best explains the client's behavior is

subnormal serum glucose and elevated serum ammonia levels.

A client with appendicitis is experiencing excruciating abdominal pain. An abdominal X-ray film reveals intraperitoneal air. What should the nurse prepare the client for?

surgery

The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable over the last 24 hours, with most recent temperature 98.6°F (37°C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16 breaths/minute, and heart rate (HR) 78 bpm, but these signs are now changing. Which set of vital signs indicates that the nurse should contact the health care provider (HCP)?

temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24 breaths/min

The nurse's assignment consists of four clients. From highest to lowest priority, in which order should the nurse assess the clients after receiving morning report? All options must be used.

the client with cirrhosis who became confused and disoriented during the night the client with acute pancreatitis who is requesting pain medication the client who is 1 day postoperative following a cholecystectomy and has a t-tube inserted the client with hepatitis B who has questions about discharge instructions

A nurse is caring for a client in the emergency department who is complaining of severe abdominal pain. The client is diagnosed with acute pancreatitis. Which laboratory value requires immediate intervention?

troponin of 2.3 mcg/L

Diphenoxylate/atropine has been prescribed to treat a client's diarrhea. The nurse should teach the client to report:

urine retention.

What intervention will minimize the risk for diarrhea in a client receiving enteral tube feedings?

using strict aseptic technique when preparing the formula

During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy. Which vitamin would be affected by this?

vitamin K

A physician prescribes several drugs for a client admitted to the emergency department with Laennec's cirrhosis. Which drug order should the nurse question?

warfarin

The nurse is assessing a client diagnosed with liver cancer. What findings are consistent with this diagnosis? Select all that apply.

weight gain decrease in appetite palpable enlarged liver ascites fluid wave

Which finding is the best indication that the goals for total parenteral nutrition (TPN) are being achieved for the client?

weight gain of 0.5 lb/day (0.2 kg/day)

Before a cancer client receiving total parenteral nutrition resumes a normal diet, the nurse teaches them about dietary sources of minerals. Which foods are good sources of zinc?

whole grains and meats

Pancreatic enzyme replacements are prescribed for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect?

with each meal and snack

The nurse is providing discharge instructions for a client with cirrhosis. Which statement best indicates that the client has understood the teaching?

"I should avoid constipation to decrease chances of bleeding."

A client had a resection of the terminal ileum 3 years ago. While obtaining a health history and physical assessment, the nurse finds that the client has weakness, shortness of breath, and a sore tongue. Which additional information from the client indicates a need for client teaching?

"I take a vitamin B12 tablet every day."

A nurse is performing discharge teaching with a client who had a total gastrectomy. Which statement indicates the need for further teaching?

"I will have to take vitamin B12 shots up to 1 year after surgery."

A client who is recovering from a subtotal gastrectomy experiences dumping syndrome and is to eat six small meals a day. The client asks the nurse, "When will I be able to eat three meals a day again like I used to?" Which response by the nurse is most appropriate?

"Most clients can resume their normal meal patterns in about 6 to 12 months."

A nurse preceptor is working with a student nurse who is administering medications. Which statement by the student indicates an understanding of the action of an antacid?

"The action occurs in the stomach by increasing the pH of the stomach contents and decreasing pepsin activity."

The client who has been hospitalized with pancreatitis does not drink alcohol because of religious convictions. The client becomes upset when the health care provider (HCP) persists in asking about alcohol intake. What should the nurse tell the client about the reason for these questions?

"There is a strong link between alcohol use and acute pancreatitis."

A nurse is caring for a client who recently had a bowel resection. The client has a hemoglobin level of 8 g/dl and HCT of 30%. Dextrose 5% in half-normal saline solution (D5½NS) is infusing through a triple-lumen central catheter at 125 ml/hour. The healthcare provider 's orders include•gentamicin 80 mg intravenous piggyback in 50 ml D5W over 30 minutes•ranitidine 50 mg intravenous in 50 ml D5W piggyback over 30 minutes•one unit of 250 ml of packed red blood cells (RBCs) over 3 hours•nasogastric tube flushes with 30 ml of normal saline solution every 2 hoursHow many milliliters would the nurse document as the total intake for the 8-hour shift? Record your answer as a whole number.

1470

The nurse has an order to administer 2 oz of lactulose to a client who has cirrhosis. How many milliliters of lactulose should the nurse administer? Record your answer using a whole number.

60

A client returns from the operating room after undergoing extensive abdominal surgery. The client is receiving 1,000 ml of lactated Ringer's solution via a central line infusion. The health care provider orders the intravenous fluid to be infused at 125 ml/hour and additional intravenous fluids based on total output of the last hour. The drip factor of the tubing is 15 gtt/ml and the output for the previous hour was 75 ml via Foley catheter, 50 ml via nasogastric tube, and 10 ml via Jackson Pratt tube. For how many drops (gtt) per minute would the nurse set the intravenous flow rate to deliver the correct amount of fluid? Record your answer as a whole number.

65

Which health promotion activity should the nurse to suggest that the client with cirrhosis add to the daily routine at home?

Abstain from drinking alcohol.

A nurse is caring for a client who has had gastric bypass surgery. The health care provider encourages the client to increase mobility as soon as possible. The nurse notes edema to the right leg with skin color changes to the right lower extremity. The client reports pain at the incision site as 3 on a 0- to 10-point scale and pain to the right calf as 7 on a 0- to 10-point scale. The nurse reports the findings to the health care provider and suspects that the client has a deep vein thrombosis. Which intervention should the nurse include in the plan of care? Select all that apply.

Administer heparin infusion. Elevate the right lower extremity. Ambulate as tolerated.

A client with cirrhosis is receiving lactulose. The nurse notes the client is more confused and has asterixis. What should the nurse do next?

Assess for gastrointestinal (GI) bleeding.

The nurse is preparing to initiate enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube. What interventions will the nurse include in the client's plan of care? Select all that apply.

Change tubing and bag every 24 hours. Ensure patency of the tube prior to enteral feedings.

A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which action should the nurse take?

Clear the client's airway.

A client has been hospitalized with pancreatitis for 3 days. The nurse assesses the client and documents the accompanying results. The nurse realizes these findings are a manifestation of what sign?

Cullen's sign

To reduce the risk of dumping syndrome, what should the nurse teach the client to do?

Decrease the carbohydrate content of meals.

The client has been prescribed one unit of blood to transfuse over 4 hours. In what order will the nurse perform each action? Place each option in order from first action to last. All options must be used.

Determine that informed consent has been collected and documented. Ensure patent 20 to 24 guage IV catheter is in place. Prime a micron filter-equipped Y-type I.V. with normal saline Use a two-person verification process to match client and blood product. Obtain baseline vital signs and reinforce prior teaching about symptoms of reaction. Begin transfusion at 2ml/minute for first 15 minutes and monitor the client.

Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the client appears to be having difficulty breathing. What should the nurse do first?

Determine whether the tube is obstructing the airway.

The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable for the past 24 hours, but the client now has a temperature of 101.1 degrees F (38.4 degrees C), a heart rate of 116 beats/min, and a respiratory rate of 26 breaths/min. Using SBAR communication, which of the following recommendations should the nurse make when calling the health care provider? Select all that apply.

Draw stat blood cultures x 2. Draw CBC, CRP, ESR, and UA with culture and sensitivity if indicated. Ensure patent I.V. access for fluid bolus.

Which would be the most appropriate measure for preventing the development of a paralytic ileus in a client who had renal surgery yesterday?

Encourage the client to ambulate every 2 to 4 hours.

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN?

Handle TPN using strict aseptic technique.

An adult client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, board-like abdomen. After obtaining the client's vital signs, what should the nurse do next?

Notify the health care provider.

A client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond?

Notify the physician.

The client has chronic pancreatitis. What should the nurse teach the client to do to monitor the effectiveness of pancreatic enzyme replacement?

Observe stools for steatorrhea.

A client had surgery for a bowel obstruction 4 days ago. The nurse assesses that the client has not passed any flatus, and there are no bowel sounds. Even though the abdomen has become more distended, the client feels little discomfort. In considering the plan of care, what is the most appropriate first step for the nurse to take?

Obtain an order for nasogastric tube insertion.

The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable for the last 24 hours, but the client now has a temperature of 38.4° C (101.1° F), a heart rate of 116 bpm, and a respiratory rate of 26 breaths/minute. The client has an IV infusion running at a keep-open rate. The nurse contacts health care provider (HCP) and receives several prescriptions (see chart).Which prescription should the nurse implement first?

Obtain blood cultures.

The nurse is caring for a client receiving narcotics for pain control. The client reports no bowel movement since admission. What interventions should the nurse consider? Select all that apply.

Offer hot drinks with meals. Encourage doubling hall walking. Suggest drinking more fluids like water. Order high-fiber foods to be added to the diet.

A client with diverticulitis has developed peritonitis following diverticular rupture. When assessing the client, what should the nurse do? Select all that apply.

Percuss the abdomen to note tympany. Percuss the liver to note lack of dullness. Monitor the vital signs for fever. Auscultate bowel sounds to note frequency.

The nurse is caring for a client that has undergone a colon resection. While turning the client, wound dehiscence with evisceration occurs. What is the nurse's first response?

Place saline-soaked sterile dressings on the wound.

When the nurse is providing care for a client hospitalized with acute pancreatitis who has severe abdominal pain, which nursing interventions would be most appropriate for this client? Select all that apply.

Place the client in a side-lying position. Administer morphine sulfate for pain as needed. Monitor the client's respiratory status. Obtain daily weights.

A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl (11.32 mmol/L); blood urea nitrogen (BUN): 12 mg/dl (0.67 mmol/L); Creatinine: 0.9 mg/dl (0.05 mmol/L); Sodium: 136 mEq/L (136 mmol/L); Potassium: 2.2 mEq/L (2.2 mmol/L); Chloride: 99 mEq/L (99 mmol/L); CO2: 33 mEq/L (33 mmol/L). Which result should the nurse identify as critical and report immediately?

Potassium

A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that the blood pressure is 96/60 mm Hg, with a heart rate of 120 bpm. The client just vomited coffee-ground-like material. Based on these data what should the nurse do first?

Prepare to insert a nasogastric (NG) tube.

A nurse is developing a care plan for a client with hepatic encephalopathy. Which are goals for the care for this client? Select all that apply.

Prevent constipation. Administer lactulose to reduce blood ammonia levels. Monitor coordination while walking. Check the pupil reaction. Provide food and fluids high in carbohydrate.

Which measure should be implemented promptly after a client's nasogastric (NG) tube has been removed?

Provide the client with oral hygiene.

The nurse is reviewing the chart information for a client with increased ascites. The data include the following: temperature 98.9°F (37.2°C), heart rate 118 bpm, shallow respirations 26 breaths/min, blood pressure 128/76 mm Hg, and SpO2 89% on room air. What should the nurse do first?

Raise the head of the bed.

What should the nurse teach a client about how to avoid the dumping syndrome? Select all that apply.

Reduce fluids with meals, but take fluids between meals. Obtain adequate amounts of protein and fat with each meal. Eat in a relaxing environment.

The nurse administers lactulose to a client with cirrhosis. What is the expected outcome from the administration of the lactulose?

Reduced serum ammonia levels.

A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?

Stop the feedings and check for residual volume.

One month following a subtotal gastrectomy for cancer, the nurse is evaluating the nursing care goal related to nutrition. What indicates that the client has attained the goal? The client has:

The client has achieved adequate nutritional status through oral or parenteral feedings.

A nurse is caring for a client diagnosed with hepatic encephalopathy. Which sign or symptom would indicate that the disease is improving? Select all that apply.

The client is able to circle choices on the menu. The client is able to eat previously restricted food items.

When the nurse is assessing the client's abdomen, which finding best indicates that a client's peristaltic activity is returning to normal after surgery?

The client passes flatus.

The nurse working in an internal medicine clinic receives four phone calls from clients with chronic pancreatitis. Which client should the nurse contact first?

The client reporting increased thirst and hunger.

A physician orders lactulose, 30 ml three times daily, for a client with cirrhosis to treat elevated serum ammonia level. The nurse will know that this medication is effective by which finding?

The client's level of consciousness (LOC) would improve.

A nurse is caring for a client who had gastric bypass surgery two days ago. Which assessment finding requires immediate intervention?

The client's right lower leg is red, swollen, and warm to touch.

A client is admitted with advanced hepatic failure, including symptoms of fatigue and confusion. These symptoms are likely due to which cause?

The liver is not breaking down the ammonia, and it acts as a neurotoxin on the brain.

The nurse has received a change-of-shift report. The nurse should assess which client first?

a 72-year-old admitted 2 days ago with a blood alcohol level of 0.08

After completing assessment rounds, which client should the nurse discuss with the health care provider (HCP) first?

a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular

A client with inflammatory bowel disease is receiving total parenteral nutrition (TPN). The basic component of the client's TPN solution is most likely to be:

a hypertonic dextrose solution.

A nurse is assessing a client who has a history of a bleeding peptic ulcer. What assessment findings should the nurse report immediately?

abdominal distension; cool, clammy skin; weak, thready pulse

In evaluating a client's response to nutrition therapy, which laboratory test would be of highest priority to examine?

albumin level

A nurse is checking the laboratory results of an adult client with colon cancer admitted for further chemotherapy. The client has lost 30 lb (13.6 kg) since initiation of the treatment. Which laboratory result should be reported to the health care provider (HCP)?

albumin level of 2.8 g/dL (28 g/L)

A client has severe diarrhea that has lasted for 2 days. The nurse should now assess the client for which symptom?

arrhythmia

A client presents with cirrhosis of the liver secondary to alcohol abuse. Which assessment findings would warrant immediate action by the nurse?

ascites and hematemesis

A nurse is caring for a client with advanced cirrhosis. Upon assessment, the nurse notes pallor with a distended and firm abdomen. What is the most likely cause?

ascites increasing significantly due to hypoalbuminemia

The nurse observes that the client's total parenteral nutrition (TPN) solution is infusing too slowly. The nurse calculates that the client has received 300 mL less than was prescribed for the day. The nurse should:

assess the infusion system, note the client's condition, and notify the health care provider.

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. Which assessment finding will the nurse expect?

black and tarry stool

A client is diagnosed with pancreatitis. Which assessment would be of most concern to the nurse?

bluish discoloration in periumbilical area

A client is experiencing gastrointestinal bleeding from a duodenal ulcer. Which clinical assessments made by the nurse would determine that the client is in the compensatory stage of shock? Select all that apply.

cold, clammy skin blood pressure within normal range decreased urinary output

A client with hepatitis C develops complications of liver failure including a prolonged prothrombin time (PT) and partial-prothrombin time (PTT). The client is told to anticipate blood products to be administered today and asks the nurse what the blood products will be. What should the nurse tell the client?

cryoprecipitate and fresh frozen plasma

A client is recovering from abdominal surgery and has a nasogastric (NG) tube inserted. Which is the expected outcome of inserting the NG tube in the client's gastrointestinal tract?

decompression

The nurse should assess the client who is being admitted to the hospital with upper GI bleeding for which finding? Select all that apply.

decreased urine output tachycardia rapid respirations thirst

A client reports abdominal pain and vomiting for 24 hours. The client's blood pressure is 98/48 mm Hg. The client is diagnosed with large-bowel obstruction. What is the priority nursing diagnosis for the client?

deficient fluid volume

The nurse is to administer an enteral feeding to an adult client. Prior to initiating the feeding, the nurse evaluates the gastric residual. What should the nurse determine from evaluating the gastric residual?

extent of overdistention of the stomach

The nurse is instructing the client about taking metoclopramide. The nurse should instruct the client to report which adverse effect?

extrapyramidal reactions

A client is admitted with peritonitis. The priority of nursing care for this client is:

fluid and electrolyte balance.

Eight hours following bowel surgery, the nurse observes that the client's urine output has decreased from 50 to 20 mL/h. The nurse should assess the client further for which condition?

hemorrhage

A client with cholecystitis continues to have severe right upper quadrant pain. The nurse obtains the following vital signs: temperature 101.1° F (38.4° C); pulse 114 bpm; respirations 22/min; blood pressure 142/90 mm Hg. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends to the health care provider for the client to receive:

hydromorphone IV.

A client is admitted from the emergency department reporting severe right lower quadrant abdominal pain and an elevated white blood cell count and a low grade fever. The nurse continues to monitor the patient while waiting for the physician. The nurse will identify the following as a major concern:

hypotension.

A client with a diagnosis of cirrhosis and hepatic encephalopathy is receiving lactulose. Which assessment finding indicates a therapeutic effect of lactulose?

improved cognition

Before abdominal surgery for an intestinal obstruction, the nurse monitors the client's urine output and finds that the total output for the past 2 hours was 35 mL. The nurse then assesses the client's total intake and output over the last 24 hours and notes 2,000 mL of IV fluid for intake, 500 mL of drainage from the nasogastric tube, and 700 mL of urine for a total output of 1,200 mL. How should the nurse interpret these findings?

inadequate fluid replacement

A client is admitted with acute pancreatitis. The nurse should monitor which laboratory values?

increased serum amylase and lipase levels

A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?

increased urine output