Gastrointestinal Disorders NCLEX 3000
A client recently diagnosed with colon cancer states, "I am having trouble sleeping because of thoughts of how life will change after surgery." What is the best response by the nurse? 1 "I will request a chaplain to come and talk with you." 2 "I will refer you to a cancer support group." 3 "I will talk to the charge nurse about this." 4"I will sit and talk with you about how you are feeling."
"I will sit and talk with you about how you are feeling."
diverticulitis A client was hospitalized and treated for acute diverticulitis. The nurse has reinforced discharge education. Which statement by the client indicates that the client understands the discharge instructions? "I'll reduce my fluid intake." "I'll decrease the fiber in my diet." "I'll take all of my antibiotics." "I'll exercise to increase my intra-abdominal pressure."
"I'll take all of my antibiotics." Explanation: Antibiotics are used to reduce inflammation. The client with acute diverticulitis typically isn't allowed anything orally until the acute episode subsides. Parenteral fluids are given until the client feels better; then it's recommended that the client drink eight 8-oz (237-ml) glasses of water per day and gradually increase fiber in the diet to improve intestinal motility. During the acute phase, activities that increase intra-abdominal pressure should be avoided to decrease pain and the chance of intestinal obstruction. Remediation: Diverticular disease
One hour before a client is to undergo abdominal surgery, the physician orders atropine, 0.3 mg I.M. The client asks the nurse why this drug must be administered. How should the nurse respond?
1. "Atropine decreases salivation and gastric secretions."
A client admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. Discharge teaching should include which instruction?
1. "Continue to take antacids, even if your symptoms subside."
A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing is:
1. "Tell me about your husband's alcohol usage."
A nurse is assigned to care for four clients. Which client should a nurse assess first? A postoperative client who just returned from surgery and is vomiting A client with gastroenteritis and fever A client with recurrent diarrhea A client with a history of gastric bleeding
1. A postoperative client who just returned from surgery and is vomiting # prevent aspiration
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?
1. Acute pain related to biliary spasms
When preparing a client for a hemorrhoidectomy, the nurse should take which action?
1. Administer an enema as ordered.
PUD antacids While obtaining a client's medication history, the nurse learns that the client takes ranitidine (Zantac), as prescribed, to treat a peptic ulcer. The nurse continues gathering medication history data to assess for potential drug interactions. The nurse should instruct the client to avoid taking a drug from which class with ranitidine?
1. Antacids
To verify the placement of a gastric feeding tube, the nurse should perform at least two tests. One test requires instilling air into the tube with a syringe and listening with a stethoscope for air passing into the stomach. What is another test method? 1 Aspiration of gastric contents and testing for a pH less than 6 2 Instillation of 30 ml of water while listening with a stethoscope 3 Cessation of reflex gagging 4 Ensuring proper measurement of the tube before insertion
1. Aspiration of gastric contents and testing for a pH less than 6 Explanation: Aspiration of gastric secretions with a pH less than 6 indicates placement in the stomach. A pH greater than 6 would indicate placement in the intestine
A client with constipation is prescribed an irrigating enema. Which steps should the nurse take when administering an enema?
1. Assist the client into the left-lateral Sims' position., 2. Lubricate the distal end of the rectal catheter., 6. Be sure to keep the solution container below 18" above bed level.
A client, age 82, is admitted to an acute care facility for treatment of an acute flare-up of a chronic GI condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the GI tract. Which age-related change increases the risk of anemia?
1. Atrophy of the gastric mucosa
The physician orders morphine for a client who complains of postoperative abdominal pain. For maximum pain relief, when should the nurse anticipate administering morphine? 1 Before the pain becomes severe 2 When the pain becomes severe 3 Every 3 hours, whether or not the client has pain 4As seldom as possible to avoid morphine dependency
1. Before the pain becomes severe # more effective explanation 2 when pain becomes severe # meds are less effective, longer to provide relief 3 Q3H or no pain # large dose 4 Giving morphine as seldom as possible to avoid dependency would cause needless client suffering.
A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's dusky-appearing stoma is related to which factor? Blood supply to the stoma has been interrupted. This is a normal finding 1 day after surgery. The ostomy bag should be adjusted. An intestinal obstruction has occurred.
1. Blood supply to the stoma has been interrupted. explanation the normal color stoma are cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion, which may result from interruption of the stoma's blood supply and may lead to tissue damage or necrosis.
Which nursing intervention should the nurse perform for a client receiving enteral feedings through a gastrostomy tube?
1. Change the tube feeding solutions and tubing at least every 24 hours.
contact precautionsWhich infections require contact precautions?
1. Clostridium difficile, 3. Methicillin-resistant staphylococcus aureus
diagnosis What is the primary nursing diagnosis for a client with a bowel obstruction?
1. Deficient fluid volume
IBD A client with mild diarrhea, fever, and abdominal discomfort is being evaluated for inflammatory bowel disease (IBD). Which statement about IBD is true?
1. Diarrhea is the most common sign of IBD.
Which diagnostic test would be used first to evaluate a client with acute upper GI bleeding?
1. Endoscopy
A client is preparing to undergo abdominal paracentesis. Which nursing interventions should be performed before the procedure? 1 Explain the procedure to the client. 2 Make sure informed consent was obtained. 3 Instruct the client to void. 4 Have the client lie flat in bed. # sit up 5 Open the paracentesis tray using clean technique. # sterile
1. Explain the procedure to the client., 2. Make sure informed consent was obtained., 3. Instruct the client to void.
irrigation The nurse is teaching a client how to irrigate his stoma. Which action indicates that the client needs more teaching?
1. Hanging the irrigation bag 24" to 36" (60 to 90 cm) above the stoma
While a client is being prepared for discharge, the nasogastric (NG) feeding tube becomes clogged. To remedy this problem and teach the client's family how to handle it at home, what should the nurse do?
1. Irrigate the tube with cola
A client is receiving a cleansing enema. During the procedure, the client reports abdominal cramping. What should the nurse do?
1. Lower the fluid bag so that the instillation slows.
A nurse is assigned the care of six clients and has the aid of a nursing assistant. Which task is appropriate for the nurse to delegate to the nursing assistant?
1. Measuring and recording nasogastric tube output
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?
1. Notify the physician.
A nurse is caring for a client with an ileostomy. What is the most common complication of this procedure?
1. Peristomal skin irritation
constipation When caring for a client who has had constipation for 4 days, what should be the nurse's primary client care concern? Promoting defecation Relieving pain Providing nutrition Monitoring output
1. Promoting defecation Explanation: Constipation for 4 days is a problem that needs attention. The nurse's primary concern should be assisting the client's bowel motility and fecal elimination. Though pain is an important concern associated with constipation, the pain will not subside until the constipation is resolved. Nutrition is a secondary concern when a client is severely constipated. Until bowel motility is reestablished, there will be no fecal output to monitor.
A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?
1. Relieving abdominal pain
PUD antacids Why are antacids administered regularly, rather than as needed, to treat peptic ulcer disease? To keep gastric pH at 3.0 to 3.5 To promote client compliance To maintain a regular bowel pattern To increase pepsin activity
1. To keep gastric pH at 3.0 to 3.5 Explanation: To maintain a gastric pH of 3.0 to 3.5 throughout each 24-hour period, regular (not as needed) doses of an antacid are needed to treat peptic ulcer disease. Frequent administration of an antacid tends to decrease client compliance. Antacids don't regulate bowel patterns, and they decrease pepsin activity.
A client comes to the emergency department with suspected cholecystitis. Which data collection findings are characteristic of this diagnosis?
1. Transient epigastric pain radiating to the back and right shoulder, 2. Burning in the chest after eating fried foods, 3. Flatulence, 4. Nausea
When collecting data on 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: "Aphthous stomatitis is a canker sore of the oral soft tissues." "Aphthous stomatitis is an acute stomach infection." "Aphthous stomatitis is acid indigestion." "Aphthous stomatitis is an early sign of peptic ulcer disease."
1. a canker sore of the oral soft tissues. Explanation: Aphthous STOMAtitis # ORAL refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks.
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
1. auscultate bowel sounds.
The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:
1. destroys the odor-proof seal.
A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must stay alert for: diaphoresis, vomiting, and diarrhea. manifestations of electrolyte disturbances. # enteral feeding manifestations of hypoglycemia. constipation, dehydration, and hypercapnia. # enteral feeding
1. diaphoresis, vomiting, and diarrhea. feeding intolerance include Diaphoresis, vomiting, and diarrhea, abdominal cramps, nausea, aspiration, and glycosuria
A client with severe inflammatory bowel disease is receiving total parenteral nutrition (TPN). When monitoring TPN, the nurse must take care to maintain the prescribed flow rate because giving TPN too rapidly may cause:
1. hyperglycemia.
surgery While preparing a client for cholecystectomy, the nurse explains that incentive spirometry will be used after surgery primarily to:
1. increase respiratory effectiveness.
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:
1. increasing fluid intake to prevent dehydration.
A client with amebiasis, an intestinal infection, is prescribed metronidazole (Flagyl). When teaching the client about adverse reactions to this drug, the nurse should mention:
1. metallic taste.
A 32-year-old male client with appendicitis is experiencing severe abdominal pain. An abdominal X-ray film reveals intraperitoneal air. The nurse should prepare the client for: surgery. colonoscopy. nasogastric tube insertion. barium enema.
1. surgery.
A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:
1. yellow sclerae.
GERD To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? "Lie down and rest after each meal." "Avoid alcohol and caffeine." "Drink 16 ounces of water with each meal." "Eat three well-balanced meals every day."
2. "Avoid coffee and alcoholic beverages." Explanation: A client with gastroesophageal reflux disease should avoid alcohol, caffeine, and foods that increase acidity, all of which can cause epigastric pain. To further prevent reflux, the client should remain upright for 2 to 3 hours after eating; avoid eating for 2 to 3 hours before bedtime; avoid bending and wearing tight clothing; avoid drinking large fluid volumes with meals; and eat small, frequent meals to help reduce gastric acid secretion.
The nurse is teaching an elderly client about good bowel habits. Which statement by the client would indicate to the nurse that additional teaching is required?
2. "I need to use laxatives regularly to prevent constipation."
A client who is about to undergo gastric bypass surgery calls the nurse into the room. The client says she's concerned that friends will learn about her upcoming surgery. She pleads with the nurse to keep her surgery a secret. Which response by the nurse is best?
2. "I'm not at liberty to discuss your case with anyone except those directly involved in your care unless you authorize me to do so."
A client is recovering from a small-bowel resection. To relieve pain, the physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours. How soon after administration should meperidine's onset of action occur?
2. 15 to 30 minutes
After admission for acute appendicitis, a client undergoes an appendectomy. He complains of moderate postsurgical pain for which the physician prescribes pentazocine (Talwin), 50 mg by mouth every 4 hours. How soon after administration of this drug can the nurse expect the client to feel relief?
2. 15 to 30 minutes
When a client resumes oral feedings after having gastric resection, the nurse watches for early manifestations of dumping syndrome. The vasomotor disturbances associated with this syndrome usually occur how soon after eating?
2. 5 to 30 minutes
Anticholinergic The nurse is monitoring a client receiving paregoric to treat diarrhea for drug interactions. Which drugs can produce additive constipation when given with an opium preparation? Antiarrhythmic drugs Anticholinergic drugs Anticoagulant drugs Antihypertensive drugs
2. Anticholinergic drugs
GERD A client undergoes a barium swallow fluoroscopy that confirms gastroesophageal reflux disease (GERD). Based on this diagnosis, the client should be instructed to take which action?
2. Avoid caffeine and carbonated beverages., 4. Stop smoking., 5.Take antacids 1 hour and 3 hours after meals.
A 72-year-old client seeks help for chronic constipation. This is a common problem for elderly clients due to several factors related to aging. Which of the following is one such factor?
2. Decreased abdominal strength
The nurse is developing a plan of care for a client with hepatitis A. What is the main route of transmission of this hepatitis virus?
2. Feces
One day after undergoing a traditional cholecystectomy, a client is scheduled to stand at the bedside and walk. What should a nurse teach the client to do before standing and walking for the first time after surgery?
2. Flex her legs when moving to a sitting position.
An 86-year-old client with a history of atrial fibrillation takes 5 mg of warfarin (Coumadin) daily. Warfarin therapy makes the client at risk for which complications?
2. Hemorrhage, 3. Hepatitis, 5. Hematuria
PUD A 58-year-old client with osteoarthritis is admitted to the hospital with peptic ulcer disease. Which findings are commonly associated with peptic ulcer disease?
2. History of nonsteroidal anti-inflammatory drug (NSAID) use, 3. Epigastric pain that's relieved by antacids, 5. Nausea and weight loss
The nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?
2. Increased urine output
skill The nurse is assessing a client who complains of abdominal pain, nausea, and diarrhea. When examining the client's abdomen, which sequence should the nurse use?
2. Inspection, auscultation, percussion, and palpation
A client takes 30 ml of magnesium hydroxide and aluminum hydroxide with simethicone (Maalox TC) by mouth 1 hour and 3 hours after each meal and at bedtime for treatment of a duodenal ulcer. Why does the client take this antacid so frequently? It has a slow onset of action. It has a short duration of action. It has a prolonged half-life. It's highly metabolized.
2. It has a short duration of action. Explanation: Because of the short duration of action, frequent doses of antacids are needed. Antacids usually provide a rapid to immediate onset of action, don't have prolonged half-lives, and aren't highly metabolized.
skill A client seeks medical attention after developing acute abdominal pain. Which action by the nurse would help ensure accurate auscultation of the client's bowel sounds?
2. Making sure the client's bladder is empty before auscultating
A client with severe abdominal pain is being evaluated for appendicitis. What is the most common cause of appendicitis?
2. Obstruction of the appendix
When preparing a client, age 50, for surgery to treat appendicitis, the nurse assists in formulating a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?
2. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix
diagnosis Which condition is most likely to have a nursing diagnosis of Deficient fluid volume?
2. Pancreatitis
When caring for a client with acute pancreatitis, the nurse should use which comfort measure?
2. Positioning the client on the side with the knees flexed
A client is scheduled for an endoscopy. On admission, the nurse asks the client if he has an advance directive, and the client states, "No." What should the nurse do next?
2. Provide the client with information about an advance directive.
As part of a routine screening for colorectal cancer, a client must undergo fecal occult blood testing. Which foods should the nurse instruct the client to avoid 48 to 72 hours before the test and throughout the collection period?
2. Red meat,. 3. Turnips, 4. Horseradish
A client is scheduled for bowel resection with anastomosis involving the large intestine. Because of the surgical site, the nurse assists in formulating the nursing diagnosis of Risk for infection. To complete the nursing diagnosis statement, which "related-to" phrase should be added?
2. Related to the presence of bacteria at the surgical site
After undergoing a liver biopsy, the client should be placed in which position?
2. Right lateral decubitus position
As a result of a viral infection, a client develops gastroenteritis. The physician prescribes kaolin and pectin mixture (Kaopectate), 60 ml by mouth after each loose bowel movement, up to eight doses daily. The client asks the nurse how soon the medication will take effect. How should the nurse respond?
2. Within 30 minutes
hepatitis A client has just been diagnosed with hepatitis A. During assessment, which signs and/or symptoms would the nurse anticipate to find? Severe abdominal pain radiating to the shoulder. Anorexia, nausea, and vomiting. Eructation and constipation. # gallbladder disease Abdominal ascites # advanced hepatic disease,
2. anorexia, nausea, and vomiting , fatigue
The nurse is caring for a client with an endotracheal tube who receives enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as residual volume. The purpose of the nurse's actions is to avoid:
2. aspiration.
Following a liver transplant a client develops ascites. The nurse should teach the client to: 1 increase water intake. # increase ascites = fluid retention in abdomen 2 brace the abdomen with a pillow during coughing. 3 perform 10 leg raises every waking hour. #put unwanted tension on the abdominal wound 4 reduce requests for pain medicine.
2. brace the abdomen with a pillow during coughing. # to educe the risk of wound dehiscence following liver transplantation
For a client who must undergo colon surgery, the physician orders preoperative cleansing enemas. The nurse anticipates administration of neomycin to this client to: control postoperative nausea and vomiting. decrease the intestinal bacteria count. increase the intestinal bacteria count. prevent the development of megacolon.
2. decrease the intestinal bacteria count. Explanation: The antibiotic neomycin sulfate is prescribed to decrease the bacterial count and reduce the risk of fecal contamination during surgery. After surgery, the physician may prescribe an antiemetic — not an antibiotic — to control postoperative nausea and vomiting. Antibiotics have no relation to megacolon development. To prevent this complication, the client should avoid opioid analgesics, such as morphine, which can decrease intestinal motility and contribute to megacolon. Remediation: neomycin sulfate
When evaluating a client for complications of acute pancreatitis, the nurse would observe for:
2. decreased urine output.
For a client with cirrhosis, deterioration of hepatic function is best indicated by:
2. difficulty in arousal.
A client with gastroenteritis is admitted to an acute care facility with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that:
2. enteric precautions must be continued.
The nurse is performing an assessment on a client who has developed a paralytic ileus. The client's bowel sounds will be: hyperactive. hypoactive. high-pitched. blowing.
2. hypoactive. Explanation: If a paralytic ileus occurs, bowel sounds will be hypoactive or absent. Hyperactive bowel sounds may signify hunger, intestinal obstruction, or diarrhea. High-pitched sounds may signify a dilated bowel. A blowing sound may be a bruit from a partially obstructed abdominal aorta. Remediation: Bowel sounds, hypoactive
A client is admitted with suspected cirrhosis. During assessment, the nurse is most likely to detect:
2. muscle wasting.
vit K phytonadione (Mephyton).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:
2. phytonadione (Mephyton). # vit K
The nurse is teaching a client about malabsorption syndrome 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:
2. small intestine.
PUD A client with peptic ulcer disease is prescribed aluminum-magnesium complex Riopan. When teaching about this antacid preparation, the nurse should instruct the client to take it with:
2. water.
The nurse must administer an enema to an adult client. The appropriate distance for inserting an enema into an average-sized adult is:
3" to 4".
PUD A client with a peptic ulcer is about to begin a therapeutic regimen that includes a bland diet, antacids, and ranitidine (Zantac). Before the client is discharged, the nurse should provide which instruction? Eat three balanced meals every day." "Stop taking the drugs when your symptoms subside." "Avoid aspirin and products that contain aspirin." "Increase your intake of fluids containing caffeine."
3. "Avoid aspirin and products that contain aspirin." Explanation: Aspirin is a gastric irritant and should be avoided by clients with peptic ulcer to prevent further erosion of the stomach lining. The client should eat small, frequent meals rather than three large ones. Antacids and ranitidine prevent acid accumulation in the stomach; they should be taken even after symptoms subside. Caffeine should be avoided because it increases acid production in the stomach.
pancreatitis The nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct?
3. "Maintain a high-carbohydrate, low-fat diet."
A client with acute diarrhea is prescribed paregoric, 5 ml by mouth up to four times daily, until the diarrhea subsides. The client asks the nurse how soon the medication will start to work after the first dose is taken. How should the nurse respond?
3. "Within 1 hour"
diverticulitis A client who has been treated for diverticulitis is being discharged on oral propantheline bromide (Pro-Banthine). The nurse should instruct the client to take the drug at which times?
3. 30 minutes before meals and at bedtime
meperidine After checking the client's chart for possible contraindications, the nurse is administering meperidine (Demerol), 50 mg I.M., to a client with pain after an appendectomy. The nurse would question which medication if noted on the physician's orders for this client? An antibiotic An antiemetic A monoamine oxidase (MAO) inhibitor A loop diuretic
3. A monoamine oxidase (MAO) inhibitor Explanation: MAO inhibitors increase the effects of meperidine and can cause rigidity, hypotension, and excitation -> avoid taking meperidine within 14 days after using MAO
A client is admitted with increased ascites related to cirrhosis. Which nursing diagnosis should receive top priority?
3. Ineffective breathing pattern
A nurse approaches a client with an 0800 dose of his scheduled pancreatin. The client states, "I'm not going to take that medicine. It makes me nauseated." What should the nurse do first? Tell the patient that he is required to take all prescribed medications. Ask the client to talk to his physician about changing the medication. Instruct the client about the benefit of taking the medication. Delay giving the medication until later in the day.
3. Instruct the client about the benefit of taking the medication. Explanation: Clients are not required to take any medications, according to the Patient's Bill of Rights. In referring the client to his physician, the nurse is avoiding her responsibility of dealing with the client's concern. The nurse does not have the authority to change the medication administration time.
TPN A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention would the nurse use to determine if TPN is providing adequate nutrition? Accelerating the infusion if it falls behind schedule Ensuring that the TPN tubing has an in-line filter Monitoring the client's weight every day Recording fluid intake and output
3. Monitoring the client's weight every day Explanation: By weighing the client every day, the nurse helps the team evaluate the client's response to TPN. Maintenance of the current weight is one indicator of adequate nutrition; weight loss may indicate inadequate nutrition, whereas weight gain may indicate adequate nutrition or fluid retention. The nurse shouldn't accelerate a TPN infusion that has fallen behind because this can cause wide fluctuations in the blood glucose level. Use of an in-line filter on TPN tubing traps bacteria and particles but has no effect on nutrition. The nurse records intake and output to evaluate fluid replacement — not the nutritional adequacy of TPN.
A client with Crohn's disease is admitted to a semiprivate room late in the afternoon. The next day, the client reports that he was not able to sleep during the night because the hallway lights bothered him. He asks that he be moved to a bed next to a window. What should the nurse do?
3. Move him to the next available window-side bed.
A client with abdominal pain secondary to a malignant mass in the colon is receiving fentanyl by transdermal patch. His current patch expires in 48 hours and he reports a pain level of 8 on a 1-to-10 scale. What should a nurse do? Replace the patch with a new patch. Massage the patch. Notify the client's physician. Apply a warm compress to the patch.
3. Notify the client's physician. Explanation: Because the client is not receiving adequate pain relief from the fentanyl patch, the client's physician should be notified. It is inappropriate to replace the patch early. Massaging the patch or applying warmth to it may increase the drug's absorption, but these are not acceptable practices because the patch is designed to release the drug at a controlled rate over a 3-day period.
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?
3. Observe the client closely for signs and symptoms of bowel perforation., 4. Monitor vital signs frequently until they're stable., 5. Inform the client that there may be blood in his stool and that he should report excessive blood immediately.
The nurse should expect to administer which vaccine to the client after a splenectomy?
3. Pneumovax 23
The nurse is caring for a client with cirrhosis. Which data collection findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?
3. Purpura and petechiae
Which of the following is a warning sign of colon cancer?
3. Rectal bleeding
A client is admitted to the emergency department with complaints of double vision, difficulty swallowing, dry mouth, and muscle weakness. A nurse also observes that the client has drooping eyelids and slurred speech. He states that he recently ate home-canned green beans. The nurse suspects exposure to botulism. What type of infection control precaution is necessary? Airborne precautions Contact precautions Standard precautions Droplet precautions
3. Standard precautions
A client comes to the emergency department complaining of acute GI distress. When obtaining the client's history, the nurse inquires about his family history. Which disorder has a familial basis?
3. Ulcerative colitis
An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse should be concerned most with the potential for:
3. aspiration.
A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this client's stools to be:
3. black and tarry.
The physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should:
3. collect the specimen in a sterile container.
A client with cholecystitis is receiving propantheline bromide (Pro-Banthine). The client is given this medication because it:
3. inhibits contraction of the bile duct and gallbladder.
The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours ago. The client has a nasogastric (NG) tube. The nurse should:
3. irrigate the NG tube gently with normal saline solution.
When planning care for a client with a small-bowel obstruction, the nurse should consider the primary goal to be:
3. maintaining fluid balance.
skill A 68-year-old male is being admitted to the hospital with abdominal pain, anemia, and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. The nurse should help him:
3. onto the bedpan.
A client who received an inhalation anesthetic during GI surgery experiences severe shivering postoperatively. In addition to providing extra blankets, the nurse should:
3. provide oxygen as prescribed.
A client with viral hepatitis A is being treated in an acute care facility. To prevent the spread of the disease, the nurse uses which precaution? Place the client in a private room. Wear a mask when handling the client's bedpan. Wear gloves when caring for the client and wash her hands after touching the client. Wear a gown when providing personal care for the client.
3. wear gloves when caring for the client and wash her hands after touching the client. # To maintain enteric precautions and prevent spread of the diseas
A client with recent onset of epigastric discomfort is scheduled for an upper GI series (barium swallow). When teaching the client how to prepare for the test, which instruction should the nurse provide? 1 "Eat a low-residue diet for 2 days before the test." 2 "Eat a clear liquid diet for 2 days before the test." 3 "Take a potent laxative the day before the test." 4 "Avoid eating or drinking anything for 6 to 12 hours before the test."
4. "Avoid eating or drinking anything for 6 to 8 hours before the test."
During a client-teaching session, which instruction should the nurse give to a client receiving kaolin and pectin (Kaopectate) for treatment of diarrhea?
4. "Drink 8 to 13 8-oz glasses (2 to 3 L) of fluid daily."
A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment? "I'll eat three large meals every day without any food restrictions." "I'll lie down immediately after a meal." "I'll gradually increase the amount of heavy lifting I do." "I'll eat frequent, small, bland meals that are high in fiber."
4. "I'll eat frequent, small, bland meals that are high in fiber." Explanation Hiatal hernia is the increased intra abdominal pressure by stomach protrudes into the chest -> GOALS decreasing intra abdominal pressure
hepatitis A client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurse's best response?
4. "You may have eaten contaminated restaurant food."
A nursing assistant is assisting a nurse with feeding clients. Which client should the nurse assign to the nursing assistant?
4. A client with bilateral blindness
The nurse caring for a client with small-bowel obstruction would plan to implement which nursing intervention first?
4. Administering I.V. fluids
A nurse is working with a nursing assistant, who is given the task of calculating three clients' intake and output at the end of the shift. When the nurse reviews the nursing assistant's work, she discovers inaccuracies in the nursing assistant's results. What should the nurse do? Report the problem to the shift supervisor or nurse-manager. Avoid assigning this task to the nursing assistant in the future. Schedule the nursing assistant for a class on calculating intake and output. Ask the nursing assistant to show her how she determined the results.
4. Ask the nursing assistant to show her how she determined the results. Explanation: When a problem in the practice of a coworker is identified, the first action to take is to determine what caused the problem. In some cases, this can lead to a simple solution, such as showing a coworker how a task is performed. Reporting the problem directly to a supervisor is not necessary if the problem can be resolved directly between the nurse and nursing assistant. If a particular task falls within the job responsibilities of a nursing assistant, avoiding the assignment of that task to the nursing assistant is an unacceptable solution. Sending the nursing assistant to the class is a secondary solution if the problem cannot be resolved.
Which food should be included in a client's diet during the first 6 to 8 weeks after ileostomy surgery?
4. Banana
One year ago, a client was diagnosed with cirrhosis of the liver caused by alcohol abuse. Since then, he has been noncompliant with the prescribed protein-restricted diet. After a friend finds him semiconscious at home, the client is admitted to the hospital. When initial laboratory test results show an elevated ammonia level, he's diagnosed with hepatic encephalopathy. The physician prescribes lactulose (Cephulac), 200 g diluted in 700 ml of tap water, given as a retention enema every 4 hours. For which other condition is lactulose prescribed?
4. Constipation
Which medication should the nurse expect to administer to a client with constipation?
4. Docusate sodium (Colace)
The surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member?
4. Enterostomal nurse
irrigation A nurse is irrigating an open wound of the abdomen. In which direction should she arrange for the irrigation solution to flow through the wound? From outside the wound to inside it From the center of the wound to its outer edges From the lower border of the wound upward across the wound From the top inside of the wound, through the wound, and then out
4. From the top inside of the wound, through the wound, and then out explanation to decrease the risk of contaminating the wound with microbes from outside the wound
hepatitis When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function?
4. Irritability and drowsiness
While palpating a client's right upper quadrant, the nurse would expect to find which of the following structures?
4. Liver
A client with left hemiparesis is having difficulty handling eating utensils. A nurse asks the physician to request a consult with which discipline? Physical therapy Vocational rehabilitation Speech therapy Occupational therapy
4. Occupational therapy Explanation: Occupational therapy is responsible for teaching the client how to eat using special utensils. Physical therapy assists with mobility, vocational rehabilitation supports job training, and speech therapy assists with swallowing.
A client is admitted to the health care facility with nausea, vomiting, and abdominal cramps and distention. Which test result is most significant? Blood urea nitrogen (BUN) level of 29 mg/dl # dehydration Serum sodium level of 132 mEq/L Urine specific gravity of 1.025 # dehydration Serum potassium level of 3 mEq/L
4. Serum potassium level of 3 mEq/L explanation # hypokalemia cause cardiac arrhythmias and asystole # life threatening
consent A physician asks a nurse to witness an informed consent of a client scheduled for gastric bypass surgery. What should the nurse do?
4. Sign the consent only if she sees the client sign it.
antacids After taking an antacid, the client asks the nurse where antacids act in the body. How should the nurse respond?
4. Stomach
Which outcome indicates effective client teaching to prevent constipation?
4. The client reports engaging in a regular exercise regimen.
A client has a newly created colostomy. After participating in counseling with the nurse and receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which behavior suggests that the client is beginning to accept the change in body image?
4. The client touches the altered body part.
A client is undergoing an extensive diagnostic workup for a suspected GI problem. The nurse discovers that the client has a family history of ulcer disease. Which blood type also is a risk factor for duodenal ulcers?
4. Type O
PUD The nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:
4. alcohol abuse and smoking.
A client is in the late stage of cirrhosis. When planning the client's diet, the nurse should focus on providing increased amounts of:
4. carbohydrate.
A client with hepatitis C develops liver failure and GI hemorrhage. The blood products that would most likely bring about hemostasis in the client are:
4. cryoprecipitate and fresh frozen plasma.
The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
4. drink liquids only between meals.
The physician prescribes lactulose (Cephulac), 30 ml by mouth three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor:
4. level of consciousness (LOC).
Alterations in hepatic blood flow resulting from a drug interaction also can affect:
4. metabolism and excretion.
precautions A client is diagnosed with shigellosis. The nurse teaches the client and family how the disease is transmitted and treated and discusses the need for enteric precautions. The nurse should explain that enteric precautions must be maintained:
4. until three fecal cultures are negative for Shigella.
A client with cirrhosis is ordered to have a daily measurement of his abdominal girth. Identify the anatomical landmark where the tape measure should be placed when obtaining this measurement.
Abdominal girth should be measured at the umbilicus to obtain the most accurate measurement.
A client had a gastroscopy while under local anesthesia. Before resuming the client's oral fluid intake, which action should the nurse take first? Listen for bowel sounds. Determine whether the client can talk. Check for a gag reflex. Determine the client's mental status.
Check for a gag reflex. Explanation: After a gastroscopy, the nurse should check for the presence of a gag reflex before giving oral fluids. This step is essential to prevent aspiration. The presence of bowel sounds, the ability to speak, and mental status within normal limits wouldn't ensure the presence of a gag reflex.
The nurse is caring for a client in the postoperative period who had an open colon resection. The nurse attempts to change the dressing but observes the protrusion of intestine through the wound. What is the priority nursing action at this time? Call the health care provider to provide a description of the wound. Put the dressing back over the wound until the health care provider arrives. Push the abdominal contents back into the wound and secure with a binder. Cover the wound with a sterile dressing moistened with normal saline.
Cover the wound with a sterile dressing moistened with normal saline. Explanation: Evisceration is the protrusion of body organs from a wound. It may occur following surgery because of delayed wound healing or from forceful straining. When this event occurs, the first action by the nurse is to cover the wound with a sterile dressing moistened with normal saline to prevent drying out of abdominal contents. The next step would be to call the health care provider. The nurse should not push the contents back in the wound or replace with a wound dressing that is not sterile. Remediation: Wound care (dehiscence and evisceration)
A client with colorectal cancer being prepared for colostomy placement tells the nurse, "I am very nervous and unsure about this surgery." What should the nurse's initial action be when caring for this client? Determine what the client already knows about colostomies. Show the client pictures of colostomies to prepare for the surgery. Arrange for someone who has a colostomy to visit the client. Provide the client with written materials about colostomy care
Determine what the client already knows about colostomies. Explanation: Initially, the nurse should determine not only what the client already knows but also what the client wants to know. The nurse should evaluate the client's perceptions of how a colostomy will affect the client's lifestyle and sexuality. Providing written materials and pictures and arranging for a visit by someone who has an ostomy are all appropriate interventions when the client is ready to receive more detailed information.
A client with a new colostomy asks the nurse how to avoid detachment from the ostomy bag. What is the best response by the nurse? Limit fluid intake. Eat more fruits and vegetables. Empty the bag when it's about half full. Tape the end of the bag to the surrounding skin.
Empty the bag when it's about half full. Explanation: Emptying the bag when partially full prevents the bag from becoming heavy and detaching from the skin or skin barrier. Limiting fluids may cause constipation, but won't prevent leakage. Increasing fruits and vegetables in the diet will help prevent constipation, not leakage. Taping the bag to the skin will secure the bag to the skin, but won't prevent detachment and could irritate the surrounding skin. Remediation: Colostomy
The nurse is preparing to administer a 75% strength tube-feeding formula. The full-strength formula is available. To prepare 500 mL of feeding, the nurse should plan to dilute how many milliliters of the full-strength formula with water? Record your answer as a whole number.
Explanation: To determine the amount of formula to use, multiply the 500 mL of full-strength formula by 75% (0.75): 500 mL X 0.75 = 375 mL
surgery A client is scheduled to have a cholecystectomy. Which education should the nurse reinforce regarding the use of incentive spirometry? Select all that apply. It increases alveolar inflation. It will eliminate the need for nasogastric intubation. It will promote lung expansion. It will improve nutritional status during recovery. It will promote deep breathing. decrease the amount of postoperative analgesia needed
It increases alveolar inflation. It will promote lung expansion. It will promote deep breathing.
poisoning A nurse is caring for a child who has been treated in the emergency department after ingesting drain cleaner. Which nursing interventions would be appropriate in this child care? (Select all that apply.) Observe vital signs for subtle changes. Determine the child's ability to speak. Administer oral antibiotics. Observe for swelling of the tongue. Position the child flat in bed.
Observe vital signs for subtle changes. Determine the child's ability to speak. Observe for swelling of the tongue. Explanation: Subtle changes in vital signs can indicate changes in oxygenation in children. Assessing the ability to speak and for tongue swelling helps to determine airway compromise and patency. Oral antibiotics are not indicated and the child may have burning in the esophagus that prohibits oral intake. The child should be positioned semi-Fowler's or high Fowler's to maintain airway patency and to prevent aspiration if the child is vomiting.
poisoning Which nursing intervention is the best way to help reduce the occurrence of poisoning in children? Place the number for poison control in the home. Provide education to those who care for children. Identify children who are at risk of poisoning. Teach parents to read toy labels.
Provide education to those who care for children. Explanation: Educating those who care for children about poisoning is the best way to reduce the occurrence of poisoning. Identifying high-risk groups will help but won't reduce poisoning. Reading toy labels will help to identify toys that may contain lead and may help reduce lead exposure. Having the number to poison control is essential if poisoning has occurred but will not prevent poisoning. Remediation: Lead Poisoning
cleft The nurse is caring for an infant after a cleft lip and cleft palate repair. Which nursing intervention is a priority to prevent tissue infection after the repair? Keep the suture line moist at all times. Allow the infant to suck on a pacifier. Rinse the infant's mouth after each feeding. Feed the infant with a catheter-tipped syringe.
Rinse the infant's mouth after each feeding. Explanation: To prevent formula buildup around the suture line, the infant's mouth is usually rinsed. The sutures should be kept clean and dry. Placing objects in the mouth is generally avoided after surgery. Infants are fed by mouth using a catheter-tipped, plunger-type syringe.
Locate the abdominal quadrant where the nurse would expect to palpate the liver.
The liver is located in the right upper abdominal quadrant.
gastroscopy A client presents to the outpatient center for a gastroscopy that reveals redness and inflammation of the stomach indicating acute gastritis. Which action should be included in the immediate management? Advise the client to reduce work-related stress # recovery phase Prepare the client for gastric resection. # serious erosion Treat the underlying cause of disease. Administer enteral tube feedings. #recovery phase
Treat the underlying cause of disease. Explanation: Discovering and treating the cause of gastritis is the most beneficial approach in the immediate management phase. Reducing the amount of stress and reducing or eliminating oral intake until the symptoms are gone are important in the recovery phase. A gastric resection is considered only when serious erosion has occurred.
The nurse is caring for a client with alcohol-related acute pancreatitis. Which intervention is most appropriate to reduce the exacerbation of pain? lying supine taking aspirin eating low-fat foods abstaining from alcohol
abstaining from alcohol Explanation: Abstaining from alcohol is imperative to reduce injury to the pancreas; in fact, it may be enough to completely control pain. Lying supine usually aggravates the pain because it stretches the abdominal muscles. Taking aspirin can cause bleeding in hemorrhagic pancreatitis. During an attack of acute pancreatitis, the client usually isn't allowed to ingest anything orally.
A client reports right lower quadrant pain, nausea, vomiting, and a low-grade fever for the past 12 hours. The health care provider documents rebound tenderness, an elevated white blood cell count (WBC), and positive psoas sign. Based on these findings, what would the nurse suspect? appendicitis pancreaterm-50titis cholecystitis constipation
appendicitis Explanation: Right lower quadrant pain, rebound tenderness, nausea, vomiting, elevated WBC, a positive psoas sign, and a low-grade fever are findings consistent with acute appendicitis. The other disorders may mimic appendicitis; however, the pain of pancreatitis is usually localized in the left upper quadrant, cholecystitis is associated with right upper quadrant pain, and constipation would not cause a fever. Remediation: Appendicitis, pediatric
A client reports excessive flatulence. Which food, reported by the client as consumed regularly, may be responsible for this? cauliflower ice cream meat potatoes
cauliflower
poisoning The ingestion of substances containing lead is mostly influenced by which risk factor? child's age child's gender child's nationality a parent with the same habit
child's age Explanation: The highest risk of lead poisoning occurs in young children who tend to put things in their mouths.
A nurse is collecting data on a client with a history of constipation. Which data, obtained by the nurse, would indicate a risk factor for constipation? a 66-year-old white male daily fluid intake of 72 ounces (2.1 L) diet high in cheese, lean meats, and pasta engages in walking 20 minutes every other day
diet high in cheese, lean meats, and pasta Explanation: A diet low in fiber and high in cheese, lean meats, and pasta promotes constipation. Normal bowel elimination is promoted by moderate physical activity and adequate fluid intake. Age alone is not a risk factor for constipation; it is certain medications and inactivity that put the older client at risk for constipation.
surgery The nurse is caring for a client who is postoperative after abdominal surgery and reporting "gas pains." What action by the nurse can assist the client with alleviating the discomfort associated with gas? Encourage the client to ambulate. Administer opioid analgesics. Encourage the client to drink iced liquids. Have the client turn to the right side.
encourage the client to ambulate. Explanation: The nurse should encourage the client to ambulate to increase peristaltic movement of the bowel to alleviate gas and promote bowel function. Opioid analgesics often make the problem of gas worse by slowing motility. Hot liquids and not cold promote the elimination of gas. The client should lay on the left side to promote evacuation of gas.
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?
explanation: A colostomy can be performed along any site of the colon. The location of an ascending colostomy is on the right side of the abdomen. An ostomy located in the ascending colon would likely produce continuous liquid output because feces in this section contain the most water and, therefore, have a liquid consistency. A sigmoid colostomy is located on the sigmoid colon and located close to the location of a descending colostomy in the left side of the abdomen. The transverse colostomy is horizontal across middle abdomen or toward the right side of the body
gastroscopy A client is suspected of having gastric cancer. The nurse expects to prepare the client for which diagnostic test that will aid in confirming the diagnosis of gastric cancer? barium enema colonoscopy gastroscopy serum chemistry levels
gastroscopy Explanation: A gastroscopy will allow direct visualization of the tumor. A barium enema or colonoscopy would help to diagnose colon cancer. Serum chemistry levels don't contribute data useful to the assessment of gastric cancer.
hepatitis Several children at a day care center have been infected with hepatitis A virus. Which instruction reinforced by the nurse would reduce the risk of spreading hepatitis A to other children and staff members? hand washing after diaper changes isolation of the sick children using masks during contact with children sterilization of all eating utensils
hand washing after diaper changes Explanation: Children in day care centers are at risk of hepatitis A infection, which is transmitted via the fecal-oral route due to poor hand hygiene practices and poor sanitation. Isolation of sick children, use of masks during contact, and sterilization of all eating utensils would not be useful in breaking the chain of infection
PUD A nurse is assigned to care for a client with peptic ulcer disease. Which finding will the nurse report immediately to the health care provider? blood pressure 140/84 mm Hg abdominal pain loss of appetite heart rate 126 bpm
heart rate 126 bpm Explanation: Pulse rate is a cardiovascular system assessment, and tachycardia is an indicator of hidden bleeding, as well as a compensatory mechanism when a client is in the early stage of shock. Loss of appetite can occur from a number of factors and is not something to be alarmed about. Abdominal pain is expected with peptic ulcer disease. BP of 140/84 mm Hg is not an indicator of GI bleeding.
The nurse is caring for a client that has taken an overdose of acetaminophen. For which initial complication should the nurse closely monitor the client? brain damage heart failure hepatic damage kidney stones
hepatic damage Explanation: The damage to the hepatic system is not from acetaminophen, but from one of its metabolites. This metabolite binds to liver cells in large quantities. Brain damage and heart failure may develop later, but not initially. Kidney stones are not complications of acetaminophen overdose. Remediation: Pharmacology: Drug Binding
surgery When assisting with development of a postoperative care plan for a client after gastric resection, which would be the priority? body image nutritional needs skin care spiritual needs
nutritional needs Explanation: After gastric resection, a client may require total parenteral nutrition or jejunostomy tube feedings to maintain adequate nutritional status. Body image isn't much of a problem for this client because clothing can cover the incision site. Wound care of the incision site is necessary to prevent infection; otherwise, the skin shouldn't be affected. Spiritual needs may be a concern, depending on the client, and should be addressed as the client demonstrates readiness to share concerns.
A client has been admitted to the emergency department with severe right upper quadrant pain. Based on the signs and symptoms and laboratory data documented in the chart shown, the nurse would expect the client to have which diagnosis? labs glucose 462 mg/dL; WBC 14,000; lipase 214 units/L; & calcium 6.5 mg/dL peptic ulcer Crohn's disease pancreatitis irritable bowel syndrome
pancreatitis Explanation: The assessment findings combined with the laboratory results suggest pancreatitis. Signs and symptoms of pancreatitis include severe right upper quadrant pain, fever, nausea, and vomiting. Inflammation of the pancreas results in leukocytosis. Injured beta cells are unable to produce insulin, leading to hyperglycemia, which may be as high as 500 to 900 mg/dL. Lipase and amylase levels become elevated as the pancreatic enzymes leak from injured pancreatic cells. Calcium becomes trapped as fat necrosis occurs, leading to hypocalcemia. Peptic ulcer, Crohn's disease, and irritable bowel syndrome do not cause amylase or lipase levels to increase.
pancreatitis The nurse receives a client at the clinic for follow-up after being treated in the hospital for pancreatitis. When gathering data from the client, which finding should immediately be reported to the health care provider? dry, itchy, and scaly skin abdomen bloated but non-tender greenish-yellow bruise over the IV site shortness of breath with minimal exertion
shortness of breath with minimal exertion Explanation: In pancreatitis, the nurse should watch for signs and symptoms of worsening of the condition: shortness of breath with minimal exertion, respiratory failure and tachycardia (signs of hypocalcemia and hypomagnesemia), and acute changes in abdominal symptoms/size. The other findings are expected and are not a reason to be alarmed.
The nurse is reviewing laboratory results for a client with peritonitis. Which results would the nurse expect to observe? partial thromboplastin time (PTT) longer than 100 seconds hemoglobin (Hb) level below 10 mg/dl potassium level above 5.5 mEq/L white blood cell (WBC) count above 15,000/μL
white blood cell (WBC) count above 15,000/μL Explanation: Because of infection, the client's WBC count will be elevated. A PTT longer than 100 seconds may suggest disseminated intravascular coagulation (DIC), a serious complication of septic shock. A hemoglobin level below 10 mg/dl may occur from hemorrhage. A potassium level above 5.5 mEq/L may suggest renal failure.