Gastrointestinal Disorders

A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. What should the nurse tell the client? "Ulcerative colitis can be cured by the use of steroids." "Steroids are used in severe flare-ups because they can decrease the incidence of bleeding." "Long-term use of steroids will prolong periods of remission." "The side effects of steroids outweigh their benefits to clients with ulcerative colitis."

"Steroids are used in severe flare-ups because they can decrease the incidence of bleeding."

The nurse is teaching a client with cirrhosis about the diet to follow on discharge. Which diet should the nurse encourage the client to follow? high-calorie, restricted protein, low-sodium diet bland, low-protein, low-sodium diet well-balanced normal nutrients, low-sodium diet high-protein, high-calorie, high-potassium diet

well-balanced normal nutrients, low-sodium diet

The health care provider (HCP) has prescribed bethanechol for a client with gastroesophageal reflux disease (GERD). The nurse should assess the client for which adverse effect? constipation urinary urgency hypertension dry oral mucosa

urinary urgency

The nurse is obtaining a health history for an adult with a possible hiatal hernia. Which of the following is a risk factor for this client that would most likely contribute to the development of a hiatal hernia? having a sedentary desk job being 5 feet, 3 inches (160 cm) tall and weighing 190 lb (86.2 kg) using laxatives frequently being 40 years old

being 5 feet, 3 inches (160 cm) tall and weighing 190 lb (86.2 kg)

What is an appropriate nursing goal for a client who has ulcerative colitis? maintains a daily record of intake and output verbalizes the importance of small, frequent feedings uses a heating pad to decrease abdominal cramping accepts that a colostomy is inevitable at some time in his life

verbalizes the importance of small, frequent feedings

A nurse is supervising a new nurse who is preparing to perform wound care for a client whose abdominal wound is infected with vancomycin-resistant enterococci. The supervising nurse should make sure that the new nurse: confirms proper fit of protective eyewear before entering the client's room. wears a gown and gloves while caring for the client. assembles all wound care supplies after donning protective equipment but before entering the client's room. remembers to remove the gown before the gloves after completing client care.

wears a gown and gloves while caring for the client.

The nurse is reviewing the nurses' notes and lab reports for a client who is receiving total parenteral nutrition (TPN). Which finding is the best indication that the goals for TPN are being achieved for the client? urine negative for glucose serum potassium level of 4 mEq/L (4 mmol/L) serum glucose level of 96 mg/dL (5.3 mmol/L) weight gain of 0.5 lb/day (0.2 kg/day)

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

An adolescent girl with severe malnutrition is admitted to an acute care facility. After a thorough examination, the physician diagnoses anorexia nervosa. When developing the care plan for this client, the nurse is most likely to include which nursing diagnosis? Hopelessness Powerlessness Chronic low self-esteem Deficient knowledge (nutrition)

Chronic low self-esteem

A client who is having an abdominal perineal resection with permanent colostomy asks, "Where will my colostomy be placed?" Which should the nurse tell the client? "The surgeon will decide that during surgery." "Do you have a preference on the placement of it?" "In the midline of the abdomen, near your umbilicus." "A permanent colostomy is usually located on the left side of the abdomen."

"A permanent colostomy is usually located on the left side of the abdomen."

An enterostomy nurse is providing an in-service session on caring for colostomies. Which statement by a nurse indicates the need for further teaching? "I can make a small pin hole in the bag to let the gas out, so I don't have to change the appliance frequently." "I can remove the bag momentarily to allow gas to escape." "I can place an odor-relieving tablet in the bag when changing the appliance to reduce odors." "I can unclamp the bag momentarily to allow gas to escape."

"I can make a small pin hole in the bag to let the gas out, so I don't have to change the appliance frequently."

A nurse is caring for a client who is postoperative day 3 after an appendectomy. The client is not eating well and reports feeling bloated and slightly queasy. What should be the nurse's priority action? Encourage client to ambulate and increase fluids. Complete a thorough gastrointestinal focused assessment. Reassure the client that this is common after abdominal sugary. Request prescriptions for antiemetic and laxatives.

Complete a thorough gastrointestinal focused assessment.

A client plans to travel to a country where hepatitis B is common. What should the nurse advise the client about the most effective way to prevent the disease? Drink purified water. Avoid crowded, enclosed spaces. Complete the vaccination series. Observe safe sex practices.

Complete the vaccination series.

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? Acute pain related to biliary spasms Deficient knowledge related to prevention of disease recurrence Anxiety related to unknown outcome of hospitalization Imbalanced nutrition: Less than body requirements related to biliary inflammation

Acute pain related to biliary spasms

A client who had abdominal surgery 4 days ago reports that "something gave way" during a sneeze. The nurse observes a wound evisceration. What should the nurse do next? Apply a sterile, moist dressing. Assess heart rate and blood pressure. Notify the health care provider. Measure the length of the protrusion.

Apply a sterile, moist dressing.

A client is having an acute attack of diverticulitis. What should the nurse do first? Prepare the client for a colonoscopy. Encourage the client to eat a high-fiber diet. Assess the client for signs of peritonitis. Encourage the client to drink a glass of water every 2 hours.

Assess the client for signs of peritonitis.

The client with an intestinal obstruction continues to have acute pain even though the nasoenteric tube is patent and draining. What should the nurse do first? Reassure the client that the nasoenteric tube is functioning. Assess the client for signs of peritonitis. Administer an opioid as prescribed. Reposition the client on the left side.

Assess the client for signs of peritonitis.

A nurse is caring for a client that received a colostomy 2 days ago. Which is the priority intervention? Assess the drainage from the stoma. Provide teaching on colostomy irrigation. Assist the client in dietary planning. Encourage the client to look at the stoma.

Assess the drainage from the stoma.

Thirty minutes after a Sengstaken-Blakemore tube is inserted, the client appears to be having difficulty breathing. What should the nurse do first? Remove the tube. Deflate the esophageal portion of the tube. Determine whether the tube is obstructing the airway. Increase the oxygen flow rate.

Determine whether the tube is obstructing the airway.

The nurse is teaching a client with stomatitis about managing oral discomfort. Which instruction is most appropriate? Drink hot tea at frequent intervals. Gargle with an antiseptic mouthwash. Use an electric toothbrush. Eat a soft, bland diet.

Eat a soft, bland diet.

In the early postoperative period following abdominal surgery, the nurse notes a bright red, 3″ × 5″ (7.6 × 12.7 cm) area of drainage on the client's dressing. What should be the nurse's first action in response to this observation? Ignore it because drainage is normal. Increase the intravenous (IV) flow rate. Take the client's vital signs. Change the dressing.

Take the client's vital signs.

A client is diagnosed with peptic ulcer disease caused Helicobacter pylori infection. The client is following a 2-week drug regimen that includes clarithromycin along with omeprazole and amoxicillin. How should the nurse instruct the client to take these medications? Alternate the use of the drugs. Take the drugs at different times during the day. Discontinue all drugs if nausea occurs. Take the drugs for the entire 2-week period.

Take the drugs for the entire 2-week period.

The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms? The client: may be developing hypocalcemia. is experiencing a reaction to meperidine. has a nutritional imbalance. needs a muscle relaxant to promote rest.

may be developing hypocalcemia.

The nurse is assigned a client with a nasogastric (NG) tube attached to low intermittent suction. What intervention will the nurse include in the plan of care? Irrigate the NG tube every shift with normal saline. Assess lung sounds every 24 hours. Turn off the NG tube suction while auscultating bowel sounds. Instruct the client to position NG tube as needed for comfort.

Turn off the NG tube suction while auscultating bowel sounds.

When caring for a client with hepatitis B, which situation would expose the nurse to the virus? contact with fecal material a blood splash into the nurse's eyes touching the client's arm with ungloved hands while taking a blood pressure disposing of syringes and needles without recapping

a blood splash into the nurse's eyes

The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance? hypercalcemia metabolic acidosis metabolic alkalosis respiratory acidosis

metabolic alkalosis

The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube on low continuous suction. Which acid-base imbalance is most likely to occur? respiratory alkalosis metabolic alkalosis respiratory acidosis metabolic acidosis

metabolic alkalosis

A nurse is caring for a client with watery diarrhea and dehydration. Given the client's recent history of heavy antibiotic use, what interventions should the nurse consider? wearing gown and gloves when working in the room encouraging oral fluids between meals administering PRN anti-diarrhea medication regularly encouraging bulk-forming foods for meals

wearing gown and gloves when working in the room

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note yellow sclerae. light amber urine. circumoral pallor. black, tarry stools.

yellow sclerae.

Following an emergency cholecystectomy, the client has a Jackson-Pratt drain with closed suction. After 4 hours, the drainage unit is full. What should the nurse do? Notify the surgeon. Remove the drain and suction unit. Check the dressing for bleeding. Empty the drainage unit.

Empty the drainage unit.

When planning care for a client with a small-bowel obstruction, which should the nurse consider to be the primary goal? reporting pain relief maintaining body weight maintaining fluid balance ambulating 4 times per day

maintaining fluid balance

A client with chronic pancreatitis should be assessed for which finding? nausea and vomiting confusion and agitation fever and tachycardia muscle twitching and tremors

nausea and vomiting

Following a subtotal gastrectomy, a client has a nasogastric (NG) tube connected to low suction. What should the nurse do? Irrigate the tube with 30 mL of sterile water every hour, if needed. Reposition the tube if it is not draining well. Monitor the client for nausea, vomiting, and abdominal distention. Change to high suction if the drainage is sluggish on low suction.

Monitor the client for nausea, vomiting, and abdominal distention.

A client with a well-managed ileostomy has the sudden onset of abdominal cramps, vomiting, and watery discharge from the ileostomy. What should the nurse tell the client to do? Take an antiemetic. Increase fluid intake to 3 L per day. Use 30 mL of milk of magnesia daily. Notify the health care provider (HCP).

Notify the health care provider (HCP).

A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. The client's partner reports that the client has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's partner. The question by the nurse that demonstrates the nurse's understanding of Mallory-Weiss tearing is "Has your partner had recent forceful vomiting?" "Is your partner being treated for tuberculosis?" "Has your partner recently fallen or injured their chest?" "What spices and condiments does your partner use on food?"

"Has your partner had recent forceful vomiting?"

Which statement indicates that the client with a peptic ulcer understands the dietary modifications to follow at home? "I should eat a bland, soft diet." "It's important to eat six small meals a day." "I should drink several glasses of milk a day." "I should avoid alcohol and caffeine."

"I should avoid alcohol and caffeine."

The nurse is evaluating the lifestyle modifications a client has made to prevent gastroesophageal reflux. Which statement indicates that the client understands how to prevent reflux? "I lie down and rest for 45 minutes after each meal." "I sleep on my left side at night to help my stomach empty more quickly." "I try to eat smaller amounts of food more often throughout the day." "I've increased my fluid intake at meals to help improve my digestion."

"I try to eat smaller amounts of food more often throughout the day."

A nurse has been asked to obtain a client's signature on an operative consent form. When the nurse approaches the client, who is scheduled for a cholecystectomy later in the day, the client asks the nurse why the procedure is needed. Which response by the nurse is appropriate? "You have stones in your gallbladder and the treatment is to remove the gallbladder." "This is a common procedure performed using a scope and will relieve your symptoms." "The surgeon feels this is the best option for you at this time based on your symptoms." "I will ask the surgeon to come speak to you about the procedure."

"I will ask the surgeon to come speak to you about the procedure."

The nurse is teaching dietary considerations to a client who had a gastric resection. The nurse understands that the instruction has been effective if the client says which statement? "I will drink three glasses of milk each day." "I will only have 30 mL of fluid with each meal." "I will limit protein intake." "I will rest for 30 minutes after eating."

"I will rest for 30 minutes after eating."

The client with a nasogastric (NG) tube has abdominal distention. What should the nurse do first? Call the health care provider (HCP). Irrigate the NG tube. Check the function of the suction equipment. Reposition the NG tube.

Check the function of the suction equipment.

During clindamycin therapy, a nurse monitors a client for pseudomembranous colitis. This serious adverse reaction to clindamycin results from superinfection with which organism? Staphylococcus aureus Bacteroides fragilis Escherichia coli Clostridioides difficile

Clostridioides difficile

A client is scheduled to undergo an exploratory laparoscopy. The registered nurse (RN) asks the licensed practical nurse (LPN) to prepare the client for surgery. The RN must confirm that the LPN has specialized training before delegating which task? weighing the client teaching the client coughing and deep breathing exercises teaching the client how to collect a urine specimen initiating I.V. therapy, as ordered

initiating I.V. therapy, as ordered

A client is in a metabolic acidosis from severe diarrhea. What assessment finding would be most concerning? irregular heart rate abdominal cramping respiratory rate of 28 excoriated skin around the rectum

irregular heart rate

A client's abdominal incision eviscerates. What should the nurse do first? Take the client's vital signs, and call the health care provider. Lower the client's head and elevate the feet. Cover the incision with a dressing moistened with sterile normal saline solution. Start an emergency infusion of IV fluids.

Cover the incision with a dressing moistened with sterile normal saline solution.

The nurse determines that a client's abdominal wound has eviscerated. What should the nurse do first? Notify the health care provider. Reinsert the protruding viscera into the abdominal cavity. Place the client in reverse Trendelenburg position. Cover the wound with sterile saline-moistened dressings.

Cover the wound with sterile saline-moistened dressings.

A client with cirrhosis has been referred to hospice care. Assessment data reveal a need to discuss nutrition with the client. What is the nurse's priority intervention? Discuss meals that include low-fat high-carbohydrate content. Discuss the importance of drinking at least 64 oz (1,920 mL) of water daily. Discuss meals that have a high-fiber, high-protein content. Discuss the importance of eliminating caffeine in the diet.

Discuss meals that include low-fat high-carbohydrate content.

A nurse is planning care for an adult who is hospitalized for diarrhea and dehydration. The client is receiving intravenous fluids but continues to have watery stools. The nurse reviews the intake and output record for the last 24 hours (view the chart). Which action should the nurse take? Restrict fluids. Increase fluids. Have the client suck on ice chips. Administer an antiemetic.

Increase fluids.

A client with peptic ulcer disease is taking cimetidine. What is the expected outcome of this drug? Heal the ulcer. Protect the ulcer surface from acids. Reduce acid concentration. Limit gastric acid secretion.

Limit gastric acid secretion.

The nurse assesses the client's stoma during the initial postoperative period. What observation should the nurse report to the health care provider (HCP) immediately? The Stoma: is slightly edematous. is dark red to purple. oozes a small amount of blood. does not expel stool.

is dark red to purple.

A client has been taking aluminum hydroxide 30 mL six times per day at home to treat a peptic ulcer. The client has been unable to have a bowel movement for 3 days. What should the nurse determine is the most likely cause of the client's constipation? The client has not been including enough fiber in his diet. The client needs to increase daily exercise. The client is experiencing an adverse effect of aluminum hydroxide. The client has developed a gastrointestinal obstruction.

The client is experiencing an adverse effect of aluminum hydroxide.

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 will have an increase in urine output. Abdominal swelling would decrease. The client would develop diarrhea. The client's level of consciousness (LOC) would improve.

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

The nurse is developing a plan of care for a client with Crohn disease who is receiving total parenteral nutrition (TPN). Which intervention(s) should the nurse include? Select all that apply. Monitor vital signs once a shift. Weigh the client daily. Change the central venous line dressing daily. Monitor the IV infusion rate hourly. Tape all IV tubing connections securely.

Weigh the client daily. Monitor the IV infusion rate hourly. Tape all IV tubing connections securely.

When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as a canker sore of the oral soft tissues. an acute stomach infection. acid indigestion. an early sign of peptic ulcer disease.

a canker sore of the oral soft tissues.

A client develops chronic pancreatitis. The nurse should suggest which diet? a low-protein, high-fiber diet distributed over four to five moderate-sized meals daily a low-fat, bland diet distributed over five to six small meals daily a high-calcium, soft diet distributed over three meals and an evening snack daily a diabetic exchange diet distributed over three meals and two snacks daily

a low-fat, bland diet distributed over five to six small meals daily

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 deficient knowledge acute pain ineffective tissue perfusion

deficient fluid volume

The client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client decreases the intake of which foods? fats high-sodium foods carbohydrates high-calcium foods

fats

A client with cancer of the stomach had a total gastrectomy 2 days earlier. Which finding indicates the client is ready to try a liquid diet? The client: is hungry. took pain medication 2 hours ago. has frequent bowel sounds. has had a bowel movement.

has frequent bowel sounds.

At the beginning of the shift, the nurse is assigned a client with an ascending colostomy. Which picture identifies the correct placement where the nurse will assess the stoma? image A image B image C image D

image D (the ascending colon)

After an exploratory laparotomy, a client develops a subhepatic abscess. After the abscess is incised and the drainage cultured, the infecting organism is identified as Bacteroides fragilis. The physician orders clindamycin, 300 mg I.V. every 6 hours. Before administering the antibiotic, the nurse reviews the client's medication history because clindamycin may enhance the action of neuromuscular blocking agents. antiarrhythmic agents. anticonvulsant agents. beta-adrenergic blocking agents.

neuromuscular blocking agents.

A client is being admitted to the hospital with abdominal pain, anemia, and bloody stools. The client complains of feeling weak and dizzy. The client has rectal pressure and needs to urinate and move their bowels. The nurse should help the client to the bathroom. to the bedside commode. onto the bedpan. to a standing position so they can urinate.

onto the bedpan.

A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention? heart rate of 94 beats/minute oxygen saturation (SaO2) of 89% decreased cough and gag reflexes blood-tinged stools

oxygen saturation (SaO2) of 89%

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? dyspnea and fatigue ascites and orthopnea purpura and petechiae gynecomastia and testicular atrophy

purpura and petechiae

The nurse diagnoses a client with acute pancreatitis. The client is being transferred to another facility. The nurse completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm the nurse's diagnosis? recent weight loss and temperature elevation presence of blood in the client's stool and recent hypertension presence of easy bruising and bradycardia adventitious breath sounds and hypertension

recent weight loss and temperature elevation

A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test? "I'll avoid eating or drinking anything 6 to 8 hours before the test." "I'll drink full liquids the day before the test." "There is no need for special preparation before the test." "I'll take a laxative to clear my bowels before the test."

"I'll avoid eating or drinking anything 6 to 8 hours before the test."

A client who has been treated for diverticulitis is being discharged on oral propantheline bromide. The nurse should instruct the client to take the drug with meals and at bedtime. immediately before meals and at bedtime. 30 minutes before meals and at bedtime. 1 hour after meals and at bedtime.

30 minutes before meals and at bedtime.

A nurse is working with a client in a long-term care facility who has been experiencing urge incontinence. What action by the nurse would best assist the client in addressing this issue? Place absorbant pads beneath the client's buttocks. Remind the client to drink fluids regularly. Assist the client to the bathroom 30 minutes after a meal. Administer antidiarrheal medication.

Assist the client to the bathroom 30 minutes after a meal.

The nurse is providing postoperative instructions to a client who will be discharged with a biliary catheter and must learn to irrigate the catheter. Which explanation would the nurse provide to the client regarding the procedure? It is acceptable to aspirate back to check for catheter drainage during irrigation. If irrigation of the catheter is done correctly, there is no risk of infection. Tap water may be used for irrigation because the catheter is in the gastrointestinal tract. Notify the healthcare provider if there are any signs of purulent drainage.

Notify the healthcare provider if there are any signs of purulent drainage.

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." bleeding into the peritoneal cavity." pressure on the bladder." pressure on the gallbladder."

infection in the peritoneal cavity."

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. The appendix may develop gangrene and rupture, especially in a middle-aged client. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage.

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.

Which nursing intervention(s) should the nurse implement when caring for a client during the first 24 hours after an appendectomy? Select all that apply. Place the client in a semi-Fowler position. Maintain a clear liquid diet for 48 hours. Monitor temperature every 2 hours. Teach the client how to care for the incision. Apply an abdominal binder.

Place the client in a semi-Fowler position. Teach the client how to care for the incision.

The nurse is caring for a client postoperatively who received an inhalation anesthetic during GI surgery. The client complains of being very cold and is shivering. The nurse provides extra blankets. What additional intervention is needed? Notify the physician immediately. Increase the I.V. fluid infusion rate. Provide oxygen as ordered. Monitor fluid intake and output.

Provide oxygen as ordered.

The nurse is caring for multiple clients on a medical-surgical floor. Which task may the nurse delegate to unlicensed assistive personnel (UAP)? irrigating a nasogastric (NG) tube assisting a client 3 days post-op to ambulate in the hallway taking orthostatic blood pressure readings on a client on a new medication administering an antacid to a client with symptoms of heartburn

assisting a client 3 days post-op to ambulate in the hallway

The nurse assigns an unlicensed assistive personnel (UAP) to provide care for a client with peptic ulcer disease. Concerned about possible ulcer perforation, the nurse should instruct the UAP to report to the nurse immediately if the client has: an elevated pulse. confusion. severe abdominal pain. constipation.

severe abdominal pain.

A nurse is teaching a client with malabsorption syndrome about the disorder and its treatment. The client asks which part of the GI tract absorbs food. The nurse tells the client that products of digestion are absorbed mainly in the stomach. small intestine. large intestine. rectum.

small intestine.

A client has a suspected slow gastrointestinal bleed. Because of this, the nurse specifically instructs the unlicensed assistive personnel (UAP) to look for and report which symptom? hypotension bright red blood in the stools tarry stools jaundice

tarry stools

A 36-year-old female client has been diagnosed with hemorrhoids. Which factor in the client's history would most likely be a primary cause of the hemorrhoids? the client's age three vaginal births the client's job as a schoolteacher varicosities in the client's legs

three vaginal births

A client with severe inflammatory bowel disease is receiving total parenteral nutrition (TPN). When administering TPN, the nurse must take care to maintain the ordered flow rate because giving TPN too rapidly may cause hyperglycemia. air embolism. constipation. dumping syndrome.

hyperglycemia.

A nurse is caring for a client after a hemorrhoidectomy. Which order would the nurse question on the medical record? warm sitz baths as needed fluid encouragement stool softener daily low-fiber diet

low-fiber diet

The nurse is reviewing the chart information for a client with increased ascites. The data include temperature 98.9°F (37.2°C); heart rate 118 bpm; shallow respirations 26 breaths/min; blood pressure 128/76 mm Hg; and percutaneous oxygen saturation (SpO2) 89% on room air. What should the nurse do first? Assess heart sounds. Obtain a prescription for blood cultures. Prepare for a paracentesis. Raise the head of the bed.

Raise the head of the bed.

A client who is legally blind must undergo a colonoscopy. The nurse is helping the healthcare provider obtain informed consent. When obtaining informed consent from a client who is visually impaired, the nurse should take which step? Read the consent form to the client and ask if there are any questions. Contact the client's nearest relative to obtain consent. Make sure the client's family is present when the consent form is signed. Document on the consent form that the client is unable to sign the consent because of being legally blind.

Read the consent form to the client and ask if there are any questions.

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of increasing fluid intake to prevent dehydration. wearing an appliance pouch only at bedtime. consuming a low-protein, high-fiber diet. taking only enteric-coated medications.

increasing fluid intake to prevent dehydration.

A client is admitted with increased ascites related to cirrhosis. The client has a large round and firm abdomen. The client is not able to lie flat in bed and requests to be placed in a high Fowler's position to sleep. Which nursing diagnosis should receive top priority? fatigue excess fluid volume ineffective breathing pattern imbalanced nutrition: less than body requirements

ineffective breathing pattern

A client with end-stage pancreatic cancer has decided to terminate medical intervention. What should a nurse anticipate when consulting with palliative care? decreased need for antidepressant medication referral for bereavement counseling decreased need for nutritional supplementation decreased need for pain medications

referral for bereavement counseling

The nurse is taking care of a client immediately following an endoscopy of the upper gastrointestinal tract. What should the nurse assess to determine whether the client is recovering from anesthesia? return of the gag reflex bowel sounds peripheral pulses intake and output

return of the gag reflex

The nurse is developing a care management plan with a client who has been diagnosed with gastroesophageal reflux disease (GERD). What should the nurse instruct the client to do? Select all that apply. Avoid a diet high in fatty foods. Avoid beverages that contain caffeine. Eat three meals a day, with the largest meal being at dinner in the evening. Avoid all alcoholic beverages. Lie down for 30 minutes after consuming each meal. Use over-the-counter (OTC) antisecretory agents rather than prescriptions.

Avoid a diet high in fatty foods. Avoid beverages that contain caffeine. Avoid all alcoholic beverages.

A 53-year-old client undergoes colonoscopy for colorectal cancer screening. A polyp was removed during the procedure. Which nursing interventions are necessary when caring for the client immediately after colonoscopy? Select all that apply. Instruct the client to follow a clear liquid diet after recovery from sedation. Observe the client closely for signs and symptoms of bowel perforation. Monitor vital signs frequently until they are stable. Inform the client that there may be blood in the stool and to report excessive blood immediately. Tell the client to report excessive flatus.

Observe the client closely for signs and symptoms of bowel perforation. Monitor vital signs frequently until they are stable. Inform the client that there may be blood in the stool and to report excessive blood immediately.

A client has anemia resulting from bleeding from ulcerative colitis and is to receive two units of packed red blood cells (PRBCs). The client is receiving an infusion of total parenteral nutrition (TPN). In preparing to administer the PRBCs, the nurse should take which action to ensure client comfort and safety? Discontinue the TPN infusion. Start an intravenous (IV) infusion of normal saline. Administer PRBCs in the same IV line as the TPN. Wait until the TPN infusion is completed, and use the same IV line to infuse the PRBCs.

Start an intravenous (IV) infusion of normal saline.

A physician calls the nurse for an update on a client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, the nurse goes to assess the client. Which assessment finding explains the absence of drainage? The client has been lying on their side for 2 hours with the drain positioned upward. The client has a nasogastric (NG) tube in place that drained 400 ml. The Hemovac drain isn't compressed; instead it's fully expanded. There is a moderate amount of dry drainage on the outside of the dressing.

The Hemovac drain isn't compressed; instead it's fully expanded.

A client is diagnosed with pancreatitis. Which assessment would be of most concern to the nurse? increased serum amylase moderate upper right quadrant pain low-grade fever bluish discoloration in periumbilical area

bluish discoloration in periumbilical area

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has cirrhosis. peptic ulcer disease. appendicitis. cholelithiasis.

cirrhosis.

A nurse is caring for a client 1 hour post-laparotomy who reports abdominal pain rating 5/10. What will the nurse prioritize when administering the ordered morphine? administer the medication before the pain becomes severe administer the medication when the pain is reported as 9/10 administer the medication every 3 hours around the clock minimize medication administration to avoid dependency

administer the medication before the pain becomes severe

The nurse manager of a surgical unit observes a nurse providing colostomy care to a client without using any personal protective equipment (PPE). What is the most appropriate response by the nurse manager in relation to PPE use? "PPE should be used when you risk exposure to blood or bodily fluids." "If you're not using PPE, you need to be careful not to touch any of the drainage." "You should be aware that PPE is used when caring for any client in the hospital." "In the future, have the physician write an order for PPE for clients with colostomies."

"PPE should be used when you risk exposure to blood or bodily fluids."

One month following a subtotal gastrectomy for cancer, the nurse is evaluating the nursing care goal related to improved nutrition. What indicates that the client has attained the goal? The client: has regained weight loss. has resumed their normal dietary intake of three meals a day. has controlled nausea and vomiting through regular use of antiemetics. has achieved adequate nutritional status through oral or parenteral feedings.

has achieved adequate nutritional status through oral or parenteral feedings.

A client with cirrhosis of the liver is in the hospital. The nurse involves the client in developing a plan of care. What would be important aspects to include in this plan? identifying nursing goals and explaining the importance of following these goals discussing collaborative goals and involving the client in identifying and prioritizing important interventions informing the client of the extent of damage to the liver and drawing up a contract to start the rehabilitative process identifying the potential and actual problems, informing the client about options, and arranging for the client to attend Alcoholics Anonymous

discussing collaborative goals and involving the client in identifying and prioritizing important interventions