Gastrointestinal Practice

The clinic nurse is performing an abdominal assessment on a client and preparing to auscultate bowel sounds. The nurse would place the stethoscope in which quadrant first? Click on the image to indicate your answer. -RUQ -LUQ -LLQ -RLQ

-RLQ **To auscultate bowel sounds, the nurse would begin in the right lower quadrant, at the ileocecal valve area, because normally bowel sounds are always present there. The diaphragm endpiece is used because bowel sounds are relatively high pitched. The stethoscope is held lightly against the skin because pressing too hard can stimulate more bowel sounds.

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? 1. Sweating and pallor 2. Bradycardia and indigestion 3. Double vision and chest pain 4. Abdominal cramping and pain

1. Sweating and pallor **Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

A client with appendicitis is scheduled for an appendectomy. The nurse providing preoperative teaching for the client describes the location of the appendix by stating that it is attached to which part of the gastrointestinal (GI) system? 1. Ileum 2. Cecum 3. Rectum 4. Jejunum

2. Cecum **The appendix, sometimes referred to as the vermiform appendix, is attached to the apex of the cecum. The other locations listed are incorrect.

The nurse is caring for a client with a small bowel obstruction who is prescribed a nasogastric (NG) tube for the purpose of stomach decompression. The nurse would anticipate a primary health care provider prescription for which type of suction? 1. Low and continuous 2. High and continuous 3. High and intermittent 4. Low and intermittent

4. Low and intermittent **Gastric mucosa can be traumatized and pulled into the tube if the suction pressure is placed on high or if the suction is continuous. The suction needs to be set on low pressure and intermittent suction control.

The nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which client factor documented by the nurse would increase the risk for PUD? 1. Recently retired from a job 2. Significant other has a gastric ulcer 3. Occasionally drinks 1 cup of coffee in the morning 4. Takes nonsteroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis

.4. Takes nonsteroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis **Risk factors for PUD include Helicobacter pylori infection, smoking (nicotine), chewing tobacco, corticosteroids, aspirin, NSAIDs, caffeine, alcohol, and stress. When an NSAID is taken as often as is typical for osteoarthritis, it will cause problems with the stomach. Certain medical conditions such as Crohn's disease, Zollinger-Ellison syndrome, and hepatic and biliary disease also can increase the risk for PUD by changing the amount of gastric and biliary acids produced. Recent retirement should decrease stress levels rather than increase them. Ulcer disease in a first-degree relative also is associated with increased risk for an ulcer. A significant other is not a first-degree relative; therefore, no genetic connection is noted in this relationship. Although caffeinated drinks are a known risk factor for PUD, the option states that the client drinks 1 cup of coffee occasionally.

The nurse has provided dietary instructions to a client with a diagnosis of peptic ulcer disease. Which client statement indicates that education was effective? 1. "Baked foods such as chicken or fish are all right to eat." 2. "Citrus fruits and raw vegetables need to be included in my daily diet." 3. "I can drink beer as long as I consume only a moderate amount each day." 4. "I can drink coffee or tea as long as I limit the amount to 2 cups daily."

1. "Baked foods such as chicken or fish are all right to eat." **Dietary modifications for the client with peptic ulcer disease include eliminating foods that can cause irritation to the gastrointestinal (GI) tract. Items that need to be eliminated or avoided include highly spiced foods, alcohol, caffeine, chocolate, and citrus fruits. Additionally, coffee should be eliminated because it contains peptides that stimulate gastrin release. Other foods may be taken according to the client's level of tolerance for those particular foods.

The nurse is providing dietary education to a client with gastroesophageal reflux disease (GERD). The nurse indicates that the client understands the teaching if the client states a plan to avoid which foods to prevent symptom exacerbation? Select all that apply. 1. Tea 2. Beer 3. Coffee 4. Oatmeal 5. Chocolate 6. Sweet potatoes

1. Tea 2. Beer 3. Coffee 5. Chocolate **Gastroesophageal reflux disease (GERD) results when gastric contents regurgitate through the lower esophageal sphincter (LES) and into the esophagus. This acid can contain both gastric and intestinal proteolytic enzymes, which are even more irritating to the esophageal mucosa. A big component of managing GERD is to modify the diet and avoid certain foods. These foods include tea, beer, coffee, and chocolate. Other foods to avoid include fatty foods and peppermint or spearmint. Eliminate options 4 and 6, as these are high-fiber foods that may help GERD symptoms. Therefore, if the client states an intention to avoid options 1, 2, 3, and 5, then the nurse can deduce that the client understands the dietary teaching.

A client had a colectomy 2 days earlier to remove a bowel tumor and had a new colostomy created. The client is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1. This is a normal, expected event. 2. The client is experiencing early signs of ischemic bowel. 3. The client would not have the nasogastric tube removed. 4. This indicates inadequate preoperative bowel preparation.

1. This is a normal, expected event. **As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client would begin passing stool via the colostomy.

The nurse is preparing to teach a client with a new colostomy about how to perform a colostomy irrigation. Which information would the nurse include in the teaching plan? 1. Use 500 to 1000 mL of warm tap water. 2. Suspend the irrigant 36 inches above the stoma. 3. Insert the irrigation cone ½ inch into the stoma. 4. If cramping occurs, open the irrigation clamp farther.

1. Use 500 to 1000 mL of warm tap water. **The usual procedure for colostomy irrigation includes using 500 to 1000 mL of warm tap water. The solution is suspended 18 inches above the stoma. The cone is inserted 2 to 4 inches into the stoma but would never be forced. If cramping occurs, the client would decrease the flow rate of the irrigant as needed by closing the irrigation clamp. This practice is not common because of odor-proof pouches.

The nurse is caring for a group of clients on the surgical nursing unit. The nurse anticipates that the client who underwent which procedure is most likely to have some long-term residual difficulty with absorption of nutrients? 1. Colectomy 2. Appendectomy 3. Ascending colostomy 4. Small bowel resection

4. Small bowel resection **The small intestine is responsible for the absorption of most nutrients. The client who has undergone removal of a segment of the small bowel is the one who has a decreased area with which to absorb nutrients. Decreased absorption is not a likely complication with the surgical procedures identified in the remaining options.

The nurse is teaching a client with hemorrhoids about measures to prevent constipation. Which statement by the client indicates a need for further teaching? 1. "I walk 1 to 2 miles every day." 2. "I need to decrease fiber in my diet." 3. "I have a bowel movement every other day." 4. "I drink 6 to 8 glasses of water every day."

2. "I need to decrease fiber in my diet." **An older client has an increased tendency to experience constipation because of decreased stomach-emptying time and a lowered basal metabolic rate. Adequate dietary fiber is an important factor in aiding bowel function. Dietary fiber increases fecal weight and water content and accelerates the transit of fecal mass through the gastrointestinal tract. The retention of water by the fiber has the ability to soften stools and promote regularity. Fluid intake and exercise also facilitate bowel elimination.

The nurse is teaching the postgastrectomy client about measures to prevent dumping syndrome. Which statement by the client indicates a need for further teaching? 1. "I need to lie down after eating." 2. "I need to drink liquids with meals." 3. "I need to avoid concentrated sweets." 4. "I need to eat small meals 6 times daily."

2. "I need to drink liquids with meals." **The client with dumping syndrome would avoid drinking liquids with meals. The client needs to be placed on a high-protein, moderate-fat, high-calorie diet and needs to lie down after eating. The client would avoid concentrated sweets, and frequent small meals are encouraged.

A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week; however, the client is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern about not being able to continue the tube feedings at home. Which nursing response is most appropriate at this time? 1. "Do you want to stay here in this facility for a few more days?" 2. "Tell me more about your concerns with your diet after going home." 3. "Have you discussed your feelings with your primary health care provider?" 4. "You need to talk to your primary health care provider about these concerns."

2. "Tell me more about your concerns with your diet after going home." **A client often has fears about leaving the secure, cared-for environment of the health care facility. This client has a fear about not being able to care for self at home and of not being able to handle the tube feedings at home. A therapeutic communication statement such as "Tell me more about . . ." often leads to valuable information about the client and the client's concerns. The statements in the remaining options are nontherapeutic.

The nurse is caring for a client diagnosed with a hiatal hernia. Which priority nursing action would the nurse include in the care plan for this client? 1. Offer the client small, frequent meals 2. Place the client in semi-Fowler's position 3. Teach the client to avoid lifting or straining 4. Encourage the client to drink fluids between meals

2. Place the client in semi-Fowler's position **Hiatal hernias occur when the upper portion of the stomach protrudes through the diaphragm. Common complications of hiatal hernia include gastroesophageal reflux disease (GERD), esophagitis, hemorrhage from gastric erosion, esophageal narrowing, stomach ulcerations, hernia strangulation, and regurgitation with subsequent tracheal aspiration. Although options 1, 3, and 4 are important measures to take while caring for a client with a hiatal hernia, option 2 is the priority action, as the client is at risk for tracheal aspiration and would remain in an upright position to prevent this complication and protect the airway.

The registered nurse is precepting a new nurse who is caring for a client with pernicious anemia as a result of a gastrectomy. Which statement made by the new nurse indicates understanding of this diagnosis? 1. "It's due to insufficient production of vitamin B12 in the colon." 2. "Increased production of intrinsic factor in the stomach leads to this type of anemia." 3. "Overproduction of vitamin B12 in the large intestine can result in pernicious anemia." 4. "Decreased production of intrinsic factor by the stomach affects absorption of vitamin B12 in the small intestine."

4. "Decreased production of intrinsic factor by the stomach affects absorption of vitamin B12 in the small intestine." **Intrinsic factor is produced in the stomach but is used to aid in the absorption of vitamin B12 in the small intestine. This vitamin is not produced or absorbed in the large intestine.

The nurse is caring for a client recently diagnosed with a hiatal hernia, and the client asks the nurse to describe a hiatal hernia. How would the nurse respond? 1. "It occurs when a portion of your intestines protrudes through a healing surgical scar." 2. "It occurs when a portion of your intestines bulges through a weak spot in the inguinal canal." 3. "It is when a portion of your intestines bulges through an abdominal wall opening near the navel." 4. "It is the herniation of the upper part of the stomach into the esophagus through an opening in your diaphragm."

4. "It is the herniation of the upper part of the stomach into the esophagus through an opening in your diaphragm." **Hiatal hernias occur when a portion of the stomach protrudes through an opening in the diaphragm. There are two types of hiatal hernias: sliding and paraesophageal, or rolling, hernias. Sliding hernias are more common and occur when the stomach junction and esophagus lie above the diaphragm. The hernia is noticed with the client lying supine and can be reduced when the client stands. Paraesophageal, or rolling, hiatal hernias are considered a medical emergency if acute in nature and occur when the fundus and greater curvature of the stomach roll up through the diaphragm, forming a pocket around the esophagus. Eliminate option 1 because this describes an incisional hernia. Eliminate option 2 because this describes an inguinal hernia. Eliminate option 3 because this describes an umbilical hernia. Therefore, option 4 is correct.

The nurse is caring for a client with pernicious anemia. Which prescription by the primary health care provider would the nurse anticipate? 1. Iron 2. Folic acid 3. Vitamin B6 4. Vitamin B12

4. Vitamin B12 **Pernicious anemia is caused by a deficiency of vitamin B12. Treatment consists of administration of high doses of oral vitamin B12. Monthly injections of vitamin B12 can also be administered but are less comfortable when compared to oral administration. Iron is prescribed for iron-deficiency anemia, folic acid is prescribed for folic acid deficiency, and vitamin B6 is ordered when there is pyridoxine deficiency.

A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that in this disorder, because the stomach lining produces a decreased amount of a substance known as the intrinsic factor, the client will need which medication? 1. An antacid 2. An antibiotic 3. Vitamin B6 injections 4. Vitamin B12 injections

4. Vitamin B12 injections **A lack of the intrinsic factor needed to absorb vitamin B12 is a feature of pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Vitamin B6 is not specifically lacking in pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers.

A client experiencing chronic dumping syndrome makes the following comments to the nurse. Which one indicates the need for further teaching? 1. "I eat at least 3 large meals each day." 2. "I eat while lying in a semirecumbent position." 3. "I have eliminated taking liquids with my meals." 4. "I eat a high-protein, low- to moderate-carbohydrate diet."

1. "I eat at least 3 large meals each day." **Dumping syndrome describes a group of symptoms that occur after eating. It is believed to result from rapid dumping of gastric contents into the small intestine, which causes fluid to shift into the intestine. Signs and symptoms of dumping syndrome include diarrhea, abdominal distention, sweating, pallor, palpitations, and syncope. To manage this syndrome, clients are encouraged to decrease the amount of food taken at each sitting, eat in a semirecumbent position, eliminate ingesting fluids with meals, and avoid consumption of high-carbohydrate meals.

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? 1. "I need to increase fiber in my diet every day." 2. "I will need to avoid caffeinated beverages." 3. "I'm going to learn some stress reduction techniques." 4. "I can have exacerbations and remissions with Crohn's disease."

1. "I need to increase fiber in my diet every day." **Crohn's disease is an inflammatory disease that can occur anywhere in the gastrointestinal tract but most often affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses. It is characterized by exacerbations and remissions. If stress increases the symptoms of the disease, the client is taught stress management techniques and may require additional counseling. The client is taught to avoid gastrointestinal stimulants containing caffeine and to follow a high-calorie and high-protein diet. A low-fiber diet may be prescribed, especially during periods of exacerbation.

The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? 1. "I need to limit my intake of dietary protein." 2. "I need to drink plenty, at least 8 to 10 cups daily." 3. "I need to eat regular meals and chew my food well." 4. "I will take the prescribed medications because they will regulate my bowel patterns."

1. "I need to limit my intake of dietary protein." **IBS is a functional gastrointestinal disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. A high-calorie, high-vitamin, high-protein and low-residue diet manages the problem. However, the diet is highly individualized, depending on physician preference. Eating regular meals, drinking 8 to 10 cups of liquid a day, and chewing food slowly help to promote normal bowel function. It is important to note that food and fluid tolerance is different with every client and that foods with residue may trigger diarrhea for some. Medication therapy depends on the main symptoms of IBS.

The nurse is completing an admission assessment for a client with suspected esophageal cancer. Which statement made by the client indicates the presence of a risk factor for esophageal cancer? 1. "I've been smoking for 20 years now." 2. "I eat plenty of fresh fruits and vegetables." 3. "I'm 5 feet, 8 inches tall and weigh 160 pounds." 4. "My alcohol consumption is about 2 beers per month."

1. "I've been smoking for 20 years now." **Primary risk factors associated with the development of esophageal cancer are smoking and obesity. The compounds in tobacco smoke may be responsible for the genetic mutations seen in many squamous cell carcinomas of the esophagus. Malnutrition, untreated gastroesophageal reflux disease (GERD), and excessive alcohol intake are also associated with esophageal cancer. Diets that are chronically deficient in fresh fruits and vegetables have also been implicated in the development of squamous cell carcinoma of the esophagus.

The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client on the signs and symptoms associated with dumping syndrome. Which client statement indicates that teaching was effective? 1. "It will cause diaphoresis and diarrhea." 2. "I have to monitor for hiccups and diarrhea." 3. "It will be associated with constipation and fever." 4. "I have to monitor for fatigue and abdominal pain."

1. "It will cause diaphoresis and diarrhea." **Dumping syndrome occurs after gastric surgery because food is not held for as long in the stomach and is dumped into the intestine as a hypertonic mass. This causes fluid to shift into the intestine, causing cardiovascular and gastrointestinal symptoms. Symptoms can typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea.

The nurse is caring for a client who had a laparoscopic cholecystectomy 1 day ago. The nurse plans pain-management techniques, knowing that the severity of the client's pain can be related to which factor? 1. Positioning of the client during surgery 2. How long the client had pain before surgery 3. The type of general anesthesia used during surgery 4. The use of nonsteroidal anti-inflammatory medications before surgery

1. Positioning of the client during surgery **The duration of the operation, the degree of tissue trauma, and the positioning of the client during surgery all may contribute to the presence and severity of postoperative pain. How long the client had pain before surgery, the type of general anesthesia, and nonsteroidal anti-inflammatory medications used before surgery are unrelated to the severity of pain in the postoperative period.

The nurse is reinforcing education to a client diagnosed with gastroesophageal reflux disease (GERD) regarding surgical therapy for the condition. How would the nurse describe laparoscopic fundoplication? 1. "The fundus of the stomach is wrapped around the lower esophagus and then sutured in place." 2. "A flexible scope is inserted down the esophagus and a balloon is inflated to dilate the esophagus." 3. "A small, flexible ring of titanium magnets is placed laparoscopically into the lower esophageal sphincter." 4. "Radiofrequency waves are delivered to the esophageal mucosa, which results in lesions that thicken the lower esophageal sphincter."

1. "The fundus of the stomach is wrapped around the lower esophagus and then sutured in place." **Surgical therapy is reserved for clients with severe gastroesophageal reflux disease (GERD) despite maximal medical management. There are several procedures used for intractable GERD, including laparoscopic fundoplication, the insertion of a LINX reflux management system, and radiofrequency ablation. Eliminate option 2, as this describes esophageal dilation, which is used to treat esophageal strictures. Eliminate option 3, as this describes the insertion of a LINX system. Eliminate option 4, as this describes radiofrequency ablation. Laparoscopic fundoplication refers to wrapping the fundus of the stomach around the lower esophagus and suturing it in place. Therefore, option 1 is correct.

Sulfasalazine is prescribed for a client with a diagnosis of ulcerative colitis, and the nurse instructs the client about the medication. Which statement made by the client indicates a need for further teaching? 1. "The medication will cause constipation." 2. "I need to take the medication with meals." 3. "I may be more sensitive to sunlight than usual." 4. "This medication needs to be taken as prescribed."

1. "The medication will cause constipation." **Sulfasalazine is an anti-inflammatory sulfonamide. Constipation is not associated with this medication. It can cause photosensitivity, and the client would be instructed to avoid sun and ultraviolet light. It needs to be administered with meals, if possible, to prolong intestinal passage. The client needs to take the medication as prescribed and continue the full course of treatment even if symptoms are relieved.

A client presents to the emergency department with upper gastrointestinal (GI) bleeding from a gastric ulcer and is in moderate distress. In planning care, which nursing action would be the priority for this client? 1. Assessment of vital signs 2. Complete abdominal examination 3. Thorough investigation of precipitating events 4. Insertion of a nasogastric tube and Hematest of emesis

1. Assessment of vital signs **The priority nursing action is to assess the vital signs. This would indicate the amount of blood loss that has occurred and also provides a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority.

The nurse is assessing a client with complaints of weight loss, abdominal bloating, lack of appetite, diarrhea, and foul-smelling, fatty stools. Based on these complaints, the nurse would suspect which condition? 1. Celiac disease 2. Bowel obstruction 3. Hirschsprung's disease 4. Gastroesophageal reflux disease (GERD)

1. Celiac disease **The key symptoms of celiac disease include weight loss, anorexia or lack of appetite, diarrhea or constipation, vomiting, abdominal pain or distention, and steatorrhea or fatty stools. Celiac disease is an autoimmune condition in which the ingestion of gluten results in small intestine mucosal damage, leading to chronic inflammation. The client's signs and symptoms are inconsistent with options 2, 3, or 4. Therefore, option 1 is correct.

A Penrose drain is in place on the first postoperative day in a client who has undergone a cholecystectomy procedure. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate? 1. Change the dressing. 2. Continue to monitor the drainage. 3. Notify the primary health care provider (PHCP). 4. Use a pen to circle the amount of drainage on the dressing.

1. Change the dressing. **Serosanguinous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is usually removed within 48 hours. A sterile dressing covers the site and would be changed if wet to prevent infection and skin excoriation. Although the nurse would continue to monitor the drainage, the most appropriate intervention is to change the dressing. The PHCP does not need to be notified.

The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the primary health care provider (PHCP)? 1. Dark red drainage 2. Dark brown drainage 3. Green-tinged drainage 4. Light yellowish-brown drainage

1. Dark red drainage **For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a green tinge. The PHCP needs to be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.

Diphenoxylate hydrochloride with atropine sulfate is prescribed for a client with ulcerative colitis. The nurse would monitor the client for which therapeutic effect of this medication? 1. Decreased diarrhea 2. Decreased cramping 3. Improved intestinal tone 4. Elimination of peristalsis

1. Decreased diarrhea **Diphenoxylate hydrochloride with atropine sulfate is an antidiarrheal product that decreases the frequency of defecation, usually by reducing the volume of liquid in the stools. The remaining options are not associated therapeutic effects of this medication.

The nurse is teaching dietary modifications to a client diagnosed with gastroesophageal reflux disease (GERD). Which would the nurse recommend to prevent exacerbation of GERD symptoms? Select all that apply. 1. Oatmeal 2. Watermelon 3. Whole milk 4. Whole-grain brown rice 5. Carbonated seltzer water

1. Oatmeal 2. Watermelon 4. Whole-grain brown rice **Dietary modification is an important part of GERD management. High-fiber foods and foods with a high water content are useful in lessening the severity of GERD symptoms. Foods to avoid include carbonated beverages and high-fat foods, such as whole milk. Therefore, eliminate options 3 and 5. Options 1, 2, and 4 are the correct answers.

The nurse is providing discharge instructions for a client following a Roux-en-Y gastric bypass surgery 3 days ago. What will the nurse include in the instructions? Select all that apply. 1. Do not drink fluids with meals. 2. Avoid foods high in carbohydrates. 3. Take an extended-release multivitamin daily. 4. Maintain a clear liquid diet for about 6 weeks. 5. Eat 6 small meals a day that are high in protein.

1. Do not drink fluids with meals. 2. Avoid foods high in carbohydrates. 5. Eat 6 small meals a day that are high in protein. **A Roux-en-Y gastric bypass is a combination of restrictive and malabsorptive surgery in which the size of the stomach is made much smaller and a large part of the small intestine (which absorbs food) is bypassed. Because the stomach is so small, clients are instructed to not drink fluids with meals because providers do not want them to fill up on less nutritional liquids before having food; to avoid foods high in carbohydrates because they are not as nutritional and tend to promote diarrhea and dumping syndrome; and to eat frequent, small meals that are high in protein. An extended-release vitamin will not be absorbed by the client since much of the small intestine is bypassed and food moves through quickly, and 6 weeks is too long a period to be on clear liquids. The typical bariatric surgery client is on clear liquids for only a few days and should then be on a high-protein diet.

The nurse is providing instructions to a client diagnosed with irritable bowel syndrome (IBS) who is experiencing abdominal distention, flatulence, and diarrhea. What interventions would the nurse plan to include in the instructions? Select all that apply. 1. Eat yogurt. 2. Take loperamide to treat diarrhea. 3. Use stress management techniques. 4. Avoid foods such as cabbage and broccoli. 5. Decrease fiber intake to less than 15 g/day.

1. Eat yogurt. 2. Take loperamide to treat diarrhea. 3. Use stress management techniques. 4. Avoid foods such as cabbage and broccoli. **IBS is a common, chronic functional disorder, meaning that no organic cause is currently known. Treatment is directed at psychological and dietary factors and medications to regulate stool output. Options 1, 2, 3, and 4 are correct, as clients diagnosed with IBS whose primary symptoms are abdominal distention and flatulence would be advised to avoid common gas-producing foods such as broccoli and cabbage and to consume yogurt, as it may be better tolerated than milk. In addition, the probiotics found in yogurt may be beneficial because alterations in intestinal bacteria are believed to exacerbate IBS. The client needs to be advised to take loperamide, a synthetic opioid that slows intestinal transit and treats diarrhea when it occurs. Also, psychological stressors are associated with development and exacerbation of IBS, so stress management techniques are important. Option 5, decrease fiber intake, is incorrect, as clients need to be encouraged to have a dietary fiber intake of at least 20 g/day.

The nurse cares for a client following a Roux-en-Y gastric bypass surgery. Which nursing intervention is appropriate? 1. Encourage the client to ambulate. 2. Position the client on the left side. 3. Frequently irrigate the nasogastric tube (NG) with 30 mL saline. 4. Discourage the use of the patient-controlled analgesia (PCA) machine.

1. Encourage the client to ambulate. **Bariatric clients are at risk for developing deep vein thrombosis and atelectasis. It is important to encourage ambulation to promote both venous return in the legs and lung expansion. Therefore, the correct option is 1. Option 2 is incorrect, as positioning on the left side is not indicated; positioning on the right side would be more appropriate to facilitate gastric emptying. Option 3 is incorrect, as the stomach after a Roux-en-Y procedure is very small and often holds only 30 mL, so frequent irrigation with 30 mL could lead to disruption of the anastomosis or staple line. Option 4 is incorrect because clients who have gastric bypass surgery are often in a considerable amount of pain, and it is important for their pain to be controlled so that they are able to do the activities required to prevent complications, such as coughing and deep breathing and ambulation.

The nurse is caring for an older client. The nurse would anticipate that medication dosages will be further adjusted if the client has dysfunction of which organ? 1. Liver 2. Stomach 3. Pancreas 4. Gallbladder

1. Liver **An important function of the liver is to break down medications and other toxic substances. The older client with liver disease is at increased risk for toxic medication effects and would be monitored carefully for adverse effects. Diseases of the stomach, pancreas, and gallbladder are a lesser concern for prolonged medication effects.

The nurse is giving dietary instructions to a client who has a new colostomy created to treat a bowel obstruction. The nurse would encourage the client to eat foods representing which diet for the first few weeks postoperatively? 1. Low fiber 2. Low calorie 3. High protein 4. High carbohydrate

1. Low fiber **For the first few weeks after colostomy formation, the client should consume a low-fiber diet. After this period, the client would eat a high-carbohydrate, high-protein diet. The client also is instructed to add new foods, including those with fiber, one at a time to determine tolerance to that food.

A client is admitted to the hospital with a diagnosis of acute diverticulitis. What would the nurse expect to be prescribed for this client? 1. NPO (nothing by mouth) status 2. Ambulation at least 4 times daily 3. Cholinergic medications to reduce pain 4. Coughing and deep breathing every 2 hours

1. NPO (nothing by mouth) status **During the acute phase of diverticulitis, the goal of treatment is to rest the bowel and allow the inflammation to subside. The client remains NPO and is placed on bed rest. Pain occurs from bowel spasms, and increased intra-abdominal pressure (coughing and deep breathing) may precipitate an attack. Ambulation and cholinergics will increase peristalsis.

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? 1. Notify the surgeon. 2. Administer the prescribed pain medication. 3. Call and ask the operating room team to perform surgery as soon as possible. 4. Reposition the client and apply a heating pad on the warm setting to the client's abdomen.

1. Notify the surgeon. **On the basis of the signs and symptoms presented in the question, the nurse would suspect peritonitis and notify the surgeon. Administering pain medication is not an appropriate intervention. Heat would never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the surgeon probably would perform the surgery earlier than the prescheduled time.

A client has been advanced to a solid diet after undergoing a subtotal gastrectomy. What is the appropriate nursing intervention in preventing dumping syndrome? 1. Remove fluids from the meal tray. 2. Give the client 2 large meals per day. 3. Ask the client to sit up for 1 hour after eating. 4. Provide a diet high in simple carbohydrate foods.

1. Remove fluids from the meal tray. **Factors to minimize dumping syndrome after gastric surgery include having the client lie down for at least 30 minutes after eating; giving small, frequent meals; having the client maintain a low-Fowler's position while eating, if possible; avoiding liquids with meals; and avoiding food sources high in simple carbohydrates (sugar, corn syrup, juice concentrate). Antispasmodic medications also are prescribed as needed to delay gastric emptying.

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse would anticipate a prescription from the primary health care provider for which type of diet for this client? 1. A low-fat diet 2. A low-fiber diet 3. A high-protein diet 4. A high-carbohydrate diet

2. A low-fiber diet **A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. Clients need to avoid high-fiber foods when experiencing acute diverticulitis. As the attack resolves, fiber can be added gradually to the diet.

A client with ulcerative colitis has a prescription to begin a salicylate compound medication to reduce inflammation. What instruction would the nurse give the client regarding when to take this medication? 1. On arising 2. After meals 3. On an empty stomach 4. 30 minutes before meals

2. After meals **Salicylate compounds, such as sulfasalazine, act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and increase fluid intake throughout the day. The medication needs to be taken after meals to reduce gastrointestinal irritation. The other options are incorrect and could cause gastric irritation.

The nurse caring for a client diagnosed with inflammatory bowel disease (IBD) recognizes that which classifications of medications may be prescribed to treat the disease and induce remission? Select all that apply. 1. Antidiarrheal 2. Antimicrobial 3. Corticosteroid 4. Aminosalicylate 5. Biological therapy 6. Immunosuppressant

2. Antimicrobial 3. Corticosteroid 4. Aminosalicylate 5. Biological therapy 6. Immunosuppressant **Pharmacological treatment for IBD aims to decrease the inflammation to induce and then maintain a remission. Five major classes of medications used to treat IBD are antimicrobials, corticosteroids, aminosalicylates, biological and targeted therapy, and immunosuppressants. Medications are chosen based on the location and severity of inflammation. Depending on the severity of the disease, clients are treated with either a "step-up" or "step-down" approach. The step-up approach uses less toxic therapies (e.g., aminosalicylates and antimicrobials) first, and more toxic medications (e.g., biological and targeted therapy) are started when initial therapies do not work. The step-down approach uses biological and targeted therapy first. Option 1, antidiarrheals, is incorrect. Although an antidiarrheal may be used to treat the symptoms of IBD, it does not treat the disease (the inflammation) or induce remission. In addition, antidiarrheals should be used cautiously in IBD because of the danger of toxic megacolon (colonic dilation greater than 5 cm).

A client is readmitted to the hospital with dehydration after surgery for creation of an ileostomy. The nurse assesses that the client has lost 3 lb of weight, has poor skin turgor, and has concentrated urine. The nurse interprets the client's clinical picture as correlating most closely with recent intake of which medication, which is contraindicated for the ileostomy client? 1. Folate 2. Biscodyl 3. Ferrous sulfate 4. Cyanocobalamin

2. Biscodyl **The client with an ileostomy is prone to dehydration because of the location of the ostomy in the gastrointestinal tract and would not take laxatives. Laxatives will compound the potential risk for the client. These clients are at risk for deficiencies of folate, iron, and cyanocobalamin and need to receive them as supplements if necessary.

The nurse is caring for a client prescribed enteral feeding via a newly inserted nasogastric (NG) tube. Before initiating the enteral feeding, the nurse would perform which action first? 1. Warm the feeding to 103° F (39.4° C). 2. Confirm NG placement by x-ray study. 3. Make sure the continuous enteral feeding tubing is primed. 4. Position the head of the client's bed to 30 degrees or greater.

2. Confirm NG placement by x-ray study. **Before initiating enteral feedings via a newly inserted NG tube, the placement of the tube is confirmed by x-ray. If the tube is not in the stomach, the client is at risk for aspiration. Formulas are administered at room temperature, not at 103° F. To prevent aspiration while administering a tube feeding, the nurse needs to place the client in an upright sitting position or elevate the head of the bed at least 30 degrees. Although this is an important action, it is not the priority. Priming the enteral feeding tube is important prior to initiating the feedings; however, it is not the priority action.

The nurse is providing dietary instructions to a client with a diagnosis of irritable bowel syndrome. The nurse determines that education was effective if the client states the need to avoid which food? 1. Rice 2. Corn 3. Broiled chicken 4. Cream of wheat

2. Corn **The client with irritable bowel needs to take in a diet that consists of 30 to 40 g of fiber daily because dietary fiber will help produce bulky, soft stools and establish regular bowel habits. The client needs to also drink 8 to 10 glasses of fluid daily and chew food slowly to promote normal bowel function. Foods that are irritating to the intestines need to be avoided. Corn is high in fiber but can be very irritating to the intestines and would be avoided. The food items in the other options are acceptable to eat.

The nurse is helping a client with celiac disease (CD) in ordering food. The nurse notes there is a need for further teaching if the client selects which food item? 1. Popcorn 2. Couscous 3. Fresh apple 4. Grilled chicken

2. Couscous **Celiac disease (CD) is an autoimmune condition in which the ingestion of gluten results in small intestine mucosal damage, leading to chronic inflammation. Therefore, it is imperative that the client avoid dietary sources of gluten. Options 1, 3, and 4 are considered safe to eat on a gluten-free diet. Clients with CD need to avoid BROW foods (barley, rye, oats, and wheat). Couscous is made from semolina, which is derived from durum wheat and contains gluten. Therefore, option 2 is the correct answer; it requires a need for further teaching from the nurse.

The nurse is caring for a client complaining of acid reflux and shortness of breath. A chest x-ray demonstrates protrusion of the upper portion of the stomach through the diaphragm. Which condition would the nurse suspect? 1. Esophagitis 2. Hiatal hernia 3. Umbilical hernia 4. Esophageal stricture

2. Hiatal hernia **Hiatal hernias occur when the upper portion of the stomach protrudes through the diaphragm. The pressure created by this process can result in acid reflux. Eliminate options 1 because although esophagitis is a complication of hiatal hernia, there are no data in the question to indicate that the esophagus is inflamed. Next, eliminate option 3 because an umbilical hernia refers to a protrusion of abdominal contents through a weakened spot in the abdominal wall near the navel area. Eliminate option 4 because if a stricture was present then it would be unlikely that protrusion would occur. Therefore, option 2 is the correct answer.

The nurse is caring for a teenage client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? 1. Leukopenia with a shift to the left 2. Leukocytosis with a shift to the left 3. Leukopenia with a shift to the right 4. Leukocytosis with a shift to the right

2. Leukocytosis with a shift to the left **Laboratory findings do not establish the diagnosis of appendicitis, but there is often an elevation of the white blood cell count (leukocytosis) with a shift to the left (an increased number of immature white blood cells).

After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication? 1. Stroke 2. Pernicious anemia 3. Bacterial meningitis 4. Peripheral arterial disease

2. Pernicious anemia **Billroth I surgery involves removing one half to two thirds of the stomach and reanastomosing the remaining segment of the stomach to the duodenum. With the loss of this much of the stomach, development of pernicious anemia is not uncommon. Pernicious anemia is a macrocytic anemia that most commonly is caused by the lack of intrinsic factor. During a Billroth I procedure, a large portion of the parietal cells, which are responsible for producing intrinsic factor (a necessary component for vitamin B12 absorption), are removed. In this anemia, the red blood cell is larger than usual and hence does not last as long in the circulation as normal red blood cells do, causing the client to have anemia with resultant fatigue. Vitamin B12 also is necessary for normal nerve function. Because of the lack of the necessary intrinsic factor, persons with pernicious anemia also experience paresthesias, impaired gait, and impaired balance. Although the symptoms could possibly indicate the other options listed, pernicious anemia is the most logical based on the surgery the client underwent.

The nurse is providing care for a client with a recent transverse colostomy created to resolve a bowel obstruction. Which observation requires immediate notification of the primary health care provider? 1. Stoma is beefy red and shiny 2. Purple discoloration of the stoma 3. Skin excoriation around the stoma 4. Semi-formed stool noted in the ostomy pouch

2. Purple discoloration of the stoma **Ischemia of the stoma would be associated with a dusky or bluish or purple color. A beefy red and shiny stoma is normal and expected. Skin excoriation needs to be addressed and treated but does not require as immediate attention as purple discoloration of the stoma. Semi-formed stool is a normal finding.

A client asks the nurse what causes gastroesophageal reflux disease (GERD). Knowing that GERD has many causative factors, the nurse would list which as contributors to GERD? Select all that apply. 1. Rapid gastric emptying 2. Reduced esophageal motility 3. Reflux of bile from the small intestine 4. Lower esophageal sphincter dysfunction 5. Reflux of gastric contents into the esophagus

2. Reduced esophageal motility 3. Reflux of bile from the small intestine 4. Lower esophageal sphincter dysfunction 5. Reflux of gastric contents into the esophagus **Gastroesophageal reflux disease (GERD) is a multifactorial disorder that occurs when intestinal and gastric contents move up into the esophagus, ultimately irritating and damaging the esophageal mucosa. Eliminate option 1 because delayed gastric emptying, not rapid gastric emptying, contributes to GERD. Options 2, 3, 4, and 5 are all factors that contribute to GERD. Therefore, options 2, 3, 4 and 5 are correct.

The nurse is caring for a client who had a subtotal gastrectomy. The nurse would assess the client for which signs and symptoms of dumping syndrome? 1. Diarrhea, chills, and hiccups 2. Weakness, diaphoresis, and diarrhea 3. Fever, constipation, and rectal bleeding 4. Abdominal pain, elevated temperature, and weakness

2. Weakness, diaphoresis, and diarrhea **Dumping syndrome occurs after gastric surgery because food is not held long enough in the stomach and is "dumped" into the small intestine as a hypertonic mass. This causes fluid to shift into the intestines, causing cardiovascular and gastrointestinal symptoms. Signs and symptoms typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea.

A client with a new ileostomy is concerned about the odor from stool in the ostomy drainage bag. The nurse would teach the client to include which food in the diet to reduce odor? 1. Eggs 2. Yogurt 3. Broccoli 4. Asparagus

2. Yogurt **The client needs to be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas-forming food as well. Broccoli, asparagus, and eggs are gas-forming foods. There are also optional charcoal filters that can deodorize the ileostomy.

The nurse is providing instructions to a client with a colostomy about measures to reduce the odor from the colostomy. Which client statement indicates that the educational session was effective? 1. "I need to be sure to eat at least 1 cucumber every day." 2. "I will need to increase my egg intake and try to eat ½ to 1 egg per day." 3. "Beet greens, parsley, or yogurt will help to control the colostomy odor." 4. "Green vegetables such as spinach and broccoli will prevent odor, and I should eat these foods every day."

3. "Beet greens, parsley, or yogurt will help to control the colostomy odor." **The client needs to be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also may reduce odor, but it is a gas-forming food and needs to be avoided. Cucumbers, eggs, and broccoli also are gas-forming foods and need to be avoided or limited by the client.

The nurse is caring for a client with gastroesophageal reflux disease (GERD) and provides client education on measures to decrease GERD. Which statement made by the client indicates a need for further teaching? 1. "I plan to eat four to six small meals a day." 2. "I need to sleep in the right side-lying position." 3. "I plan to have a snack 1 hour before going to bed." 4. "I will stop having a glass of wine each evening with dinner."

3. "I plan to have a snack 1 hour before going to bed." **The control of GERD involves lifestyle changes to promote health and control reflux. These lifestyle changes include eating four to six small meals a day; avoiding alcohol and smoking; sleeping in the right side-lying position to promote oxygenation; and frequent swallowing to clear the esophagus; and avoiding eating at least 3 hours before going to bed because reflux episodes are most damaging at night.

The nurse has given postprocedure instructions to a client who has undergone a colonoscopy. Which statement by the client indicates the need for further teaching? 1. "It is normal to feel gassy or bloated after the procedure." 2. "My abdominal muscles may be tender from the procedure." 3. "It is all right to drive once I've been home for an hour or so." 4. "Intake needs to be light at first and then progress to regular intake."

3. "It is all right to drive once I've been home for an hour or so." **The client would not drive for several hours after discharge because of the sedative medications used during the procedure. Important decisions also should be delayed for at least 12 to 24 hours for the same reason. The client may experience gas, bloating, or abdominal tenderness for a short while after the procedure, and this is normal. The client needs to resume intake slowly and progress as tolerated.

The nurse teaches a preoperative client about the use of a nasogastric (NG) tube for the planned surgery. Which statement indicates to the nurse that the client understands when the tube can be removed in the postoperative period? 1. "When I can tolerate food without vomiting." 2. "When my gastrointestinal system is healed enough." 3. "When my bowels begin to function again, and I begin to pass gas." 4. "When my primary health care provider says the tube can come out."

3. "When my bowels begin to function again, and I begin to pass gas." **NG tubes are discontinued when normal function returns to the gastrointestinal (GI) tract. Food would not be administered unless bowel function returns. The tube will be removed before GI healing. Although the primary health care provider (PHCP) determines when the NG tube will be removed, it does not determine effectiveness of teaching and the need for the NG tube.

The nurse is caring for a postoperative client who has just returned from surgery for creation of a colostomy. The nurse inspects the colostomy stoma and recognizes that which is a normal assessment finding for this client? 1. A pale color 2. A purple color 3. A brick-red color 4. A large amount of red drainage

3. A brick-red color **Normal characteristics of a stoma include a rose to brick-red color indicating viable mucosa, mild to moderate edema during the initial postoperative period, and a small amount of oozing blood from the stoma mucosa (because of its high vascularity) when it is touched. A pale color may indicate anemia. A stoma that is dark red to purple indicates inadequate blood supply to the stoma or bowel due to adhesions, low blood flow state, or excessive tension on the bowel at the time of construction. A small amount of bleeding is considered normal, but a moderate to large amount of bleeding from the stoma mucosa could indicate coagulation factor deficiency, stomal varices secondary to portal hypertension, or lower gastrointestinal bleeding.

A client with gastritis asks the nurse at a screening clinic about analgesics that will not cause epigastric distress. The nurse would tell the client that which medication is acceptable to take? 1. Ibuprofen 2. Indomethacin 3. Acetaminophen 4. Naproxen sodium

3. Acetaminophen **Analgesics such as acetaminophen are unlikely to cause epigastric distress. Ibuprofen, indomethacin, and naproxen sodium are nonsteroidal anti-inflammatory medications (NSAIDs) and are irritating to the gastrointestinal tract, so they need to be avoided in clients with gastritis.

A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain, and appendicitis is suspected. Laboratory tests are performed, and the nurse notes that the client's white blood cell (WBC) count is elevated. On the basis of these findings, the nurse would question which primary health care provider (PHCP) prescription documented in the client's medical record? 1. Apply a cold pack to the abdomen. 2. Maintain nothing by mouth (NPO) status. 3. Administer 30 mL of milk of magnesia (MOM). 4. Initiate an intravenous (IV) line for the administration of IV fluids.

3. Administer 30 mL of milk of magnesia (MOM). **Appendicitis would be suspected in a client with an elevated WBC count complaining of acute right lower abdominal quadrant pain. Laxatives are never prescribed because if appendicitis is present, the effect of the laxative may cause a rupture with resultant peritonitis. Cold packs may be prescribed for comfort. The client would be NPO and given IV fluids in preparation for possible surgery.

A client with a gastric ulcer is prescribed both magnesium hydroxide and cimetidine twice daily. How would the nurse schedule the medications for administration? 1. Drink 8 ounces of water between taking each medication. 2. Administer the cimetidine and magnesium hydroxide at the same time twice daily. 3. Administer each dose of cimetidine 1 hour prior to the administration of magnesium hydroxide. 4. Collaborate with the primary health care provider (PHCP), as the client should not be receiving both medications.

3. Administer each dose of cimetidine 1 hour prior to the administration of magnesium hydroxide. **Antacids, such as magnesium hydroxide, can decrease absorption of cimetidine. At least 1 hour needs to separate administration of an antacid and cimetidine. The remaining options are incorrect.

The nurse is caring for a client postoperatively after creation of a colostomy to treat a bowel tumor. What is an appropriate potential client problem? 1. Fear 2. Sexual dysfunction 3. Altered body image 4. Excessive nutritional intake

3. Altered body image **Altered body image for a client who is postoperative after creation of a colostomy relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). There are no data in the question to support sexual dysfunction or fear. Inadequate nutritional intake rather than excessive intake would more likely be a client problem.

A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain. Appendicitis is suspected, and appropriate laboratory tests are performed. The emergency department nurse reviews the test results and notes that the client's white blood cell (WBC) count is elevated. The nurse also reviews the prescriptions from the primary health care provider (PHCP). The nurse would contact the PHCP to question which order if noted in the client's record? 1. Maintain a semi-Fowler's position. 2. Maintain on NPO (nothing by mouth) status. 3. Apply a heating pad to the lower abdomen for comfort. 4. Initiate an intravenous (IV) line with the administration of IV fluids.

3. Apply a heating pad to the lower abdomen for comfort. **Appendicitis would be suspected in a client with an elevated WBC count who is complaining of acute right lower quadrant abdominal pain. A semi-Fowler's position is maintained for comfort. The client would be on NPO status and given IV fluids in preparation for possible surgery. Heat would never be applied to the abdomen because this may increase circulation to the appendix, potentially leading to increased inflammation and perforation.

A client who has undergone gastric surgery to remove a tumor has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action would the nurse take initially? 1. Call the surgeon to report the problem. 2. Reposition the NG tube to the proper location. 3. Check the suction device to make sure it is working. 4. Irrigate the NG tube with saline to remove the obstruction.

3. Check the suction device to make sure it is working. **After gastric surgery, the client will have an NG tube in place until bowel function returns. It is important for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse must ensure that the NG tube is attached to suction at the level prescribed and that the suction device is working correctly. The tip of the NG tube may be placed near the suture line. Because of this possibility, the nurse would never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned, the nurse needs to call the surgeon, who would do this repositioning under fluoroscopy.

The nurse checks the gastric residual of an unconscious client receiving nasogastric tube feedings continuously at 50 mL/hr. The nurse notes that the residual is 250 mL at 0800 and 300 mL at 0900. The nurse determines that the client is experiencing which complication? 1. Air in the stomach 2. Too slow an infusion rate 3. Delayed gastric emptying 4. Early signs of peptic ulcer

3. Delayed gastric emptying **If the gastric residual is greater than 200 mL for 2 consecutive hours, the client may be experiencing delayed gastric emptying. If this occurs, the feeding is stopped, and the primary health care provider needs to be notified. The nurse would assess whether abdominal girth is enlarged and would auscultate bowel sounds to rule out intestinal obstruction. Some clients benefit from administration of metoclopramide to stimulate gastric emptying. Air in the stomach would be accompanied by abdominal distention and increased abdominal girth. The infusion rate cannot be too slow if the client is not tolerating the rate. Early peptic ulcer could be detected by a Hematest-positive gastric aspirate. In addition, agency procedures need to be followed regarding gastric residuals.

A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client? 1. Carrots and ranch dip 2. Whole-grain cereal and milk 3. A cup of popcorn and a cola drink 4. Gelatin and a graham cracker

4. Gelatin and a graham cracker **The diet for the client with acute ulcerative colitis needs to be low fiber (low residue). The nurse would avoid providing foods such as whole-wheat grains, nuts, and fresh fruits or vegetables. Typically, lactose-containing foods also are poorly tolerated. The client also needs to avoid caffeine, pepper, and alcohol.

The nurse has implemented a bowel maintenance program for an unconscious client. The nurse would evaluate the plan as best meeting the needs of the client if which method was successful in stimulating a bowel movement? 1. Fleet enema 2. Fecal disimpaction 3. Glycerin suppository 4. Soap solution enema (SSE)

3. Glycerin suppository **The least amount of invasiveness needed to produce a bowel movement is best. Use of glycerin suppositories is the least invasive method and usually stimulates bowel evacuation within a half hour. Enemas may be needed on an every-other-day basis, but they are used cautiously (even if not contraindicated) because the Valsalva maneuver can increase intracranial pressure. Fecal disimpaction is done only when the client's rectum has become impacted from constipation as a result of inattention or failure of other measures. Stool softeners may be prescribed on a regular schedule for some clients to avoid hard, dry stools, but oral medication is not administered to an unconscious client.

The medication history of a client with peptic ulcer disease reveals intermittent use of several medications. The nurse would teach the client that which of these medications is not a part of the treatment plan because of its irritating effect on the lining of the gastrointestinal tract? 1. Nizatidine 2. Sucralfate 3. Ibuprofen 4. Omeprazole

3. Ibuprofen **Ibuprofen is a nonsteroidal anti-inflammatory drug that typically is irritating to the lining of the gastrointestinal tract and would be avoided by clients with a history of peptic ulcer disease. The other medications listed are frequently used to treat peptic ulcer disease. Nizatidine is an H2-receptor antagonist that reduces the secretion of gastric acid. Sucralfate coats the surface of an ulcer to promote healing. Omeprazole is a proton pump inhibitor that blocks transport of hydrogen ions into the lumen of the gastrointestinal tract.

During a home care visit, an adult client complains of chronic constipation. What would the nurse tell the client to do? 1. Increase potassium in the diet. 2. Include rice and bananas in the diet. 3. Increase fluid and dietary fiber intake. 4. Increase the intake of sugar-free products.

3. Increase fluid and dietary fiber intake. **Increase of fluid intake and dietary fiber will help change the consistency of the stool, making it easier to pass. Increasing the intake of rice and bananas will increase constipation. Increasing sugar-free products and potassium in the diet will not assist in alleviating constipation.

The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, would the nurse question? 1. Digoxin 2. Furosemide 3. Indomethacin 4. Propranolol hydrochloride

3. Indomethacin **Indomethacin is a nonsteroidal anti-inflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Digoxin is a cardiac medication. Furosemide is a loop diuretic. Propranolol hydrochloride is a beta-adrenergic blocking agent. Digoxin, furosemide, and propranolol are not contraindicated in clients with gastric disorders.

The nurse is assisting a client with Crohn's disease to ambulate to the bathroom. After the client has a bowel movement, the nurse would assess the stool for which characteristic that is expected with this disease? 1. Blood in the stool 2. Chalky gray stool 3. Loose, watery stool 4. Dark brown pellet-like stools

3. Loose, watery stool **Crohn's disease is characterized by nonbloody diarrhea of usually not more than 4 or 5 stools daily. Over time, the episodes of diarrhea increase in frequency, duration, and severity. Options 1, 2, and 4 are not characteristics of the stool in Crohn's disease.

The nurse is providing instructions to a client regarding measures to minimize the risk of dumping syndrome. The nurse would make which suggestion to the client? 1. Eat foods low in complex carbohydrates. 2. Increase fluid intake, particularly at mealtime. 3. Maintain a low-Fowler's position after eating. 4. Ambulate for at least 30 minutes following each meal.

3. Maintain a low-Fowler's position after eating. **The client at risk for dumping syndrome needs to be instructed to maintain a low-Fowler's position after eating for at least 30 minutes to reduce the symptoms of dumping syndrome by slowing the emptying of food from the stomach. The client also would be told that small, frequent meals are best and to avoid liquids with meals. The client needs to be taught to eat more protein such as meat, poultry, and fish and complex carbohydrates such as oatmeal and other whole-grain foods high in fiber. Avoiding carbohydrate food sources that are high-sugar foods, such as candy, syrup, sodas, and juices. also will assist in minimizing dumping syndrome.

The nurse is caring for a client experiencing an exacerbation of Crohn's disease. Which intervention would the nurse anticipate the primary health care provider prescribing? 1. Enteral feedings 2. Fluid restrictions 3. Oral corticosteroids 4. Activity restrictions

3. Oral corticosteroids **Crohn's disease is a form of inflammatory bowel disease that is a chronic inflammation of the gastrointestinal (GI) tract. It is characterized by periods of remission interspersed with periods of exacerbation. Oral corticosteroids are used to treat the inflammation of Crohn's disease, so option 3 is the correct one. In addition to treating the GI inflammation of Crohn's disease with medications, it is also treated by resting the bowel. Therefore, option 1 is incorrect. Option 2 is incorrect, as clients with Crohn's disease typically have diarrhea and would not be on fluid restrictions. Option 4, activity restrictions, is not indicated. The client can do activities as tolerated but needs to avoid stress and strain.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse would assess the client for which sign(s)/symptom(s) of duodenal ulcer? 1. Weight loss 2. Nausea and vomiting 3. Pain relieved by food intake 4. Pain radiating down the right arm

3. Pain relieved by food intake **A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the mid-epigastric area.

The nurse is assessing a client with a duodenal ulcer. The nurse interprets that which sign or symptom is most consistent with the typical presentation of duodenal ulcer? 1. Weight loss 2. Nausea and vomiting 3. Pain that is relieved by food intake 4. Pain that radiates down the right arm

3. Pain that is relieved by food intake **The most typical finding with duodenal ulcer is pain that is relieved by food intake. The pain is often described as a burning, heavy, sharp, or "hunger pang" pain that often localizes in the midepigastric area. It does not radiate down the right arm. The client with duodenal ulcer does not usually experience weight loss or nausea and vomiting; these symptoms are more typical in the client with a gastric ulcer.

The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the primary health care provider (PHCP)? 1. Hypotension 2. Bloody diarrhea 3. Rebound tenderness 4. A hemoglobin level of 12 mg/dL (120 mmol/L)

3. Rebound tenderness **Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the PHCP.

The nurse is evaluating the plan of care for a client with peptic ulcer disease (PUD) who is experiencing acute pain. The nurse determines that the expected outcomes have been met if the nursing assessment reveals which result? 1. The client reports some pain before meals. 2. The client frequently is awakened at 2 a.m. with heartburn. 3. The client has eliminated any irritating foods from the diet. 4. The client's pain is minimal with histamine H2-receptor antagonists.

3. The client has eliminated any irritating foods from the diet. **Expected outcomes for the client with PUD who is experiencing pain include elimination of irritating foods from the diet, effectiveness of prescribed medications to eliminate pain, self-reporting of absence of pain with medication, and an ability to sleep through the night without pain. The client who continues to be awakened by pain requires further modification of medication therapy, which may include adjustment of timing of histamine H2-receptor antagonist administration or an additional dose of antacid before the time when pain usually awakens the client.

The nurse is reinforcing education provided by the gastroenterologist regarding surgical techniques used to repair a hiatal hernia to a client diagnosed with a hiatal hernia. How would the nurse describe the gastropexy technique? 1. Removal of the herniated gastric sac 2. Closure of the hiatal defect in the diaphragm 3. The upper portion of the stomach is attached below the diaphragm. 4. The fundus of the stomach is wrapped around the distal portion of the esophagus and sutured together.

3. The upper portion of the stomach is attached below the diaphragm. **Hiatal hernias occur when the upper portion of the stomach protrudes through the diaphragm. There are several surgical techniques used to repair this defect. Eliminate option 1, as this describes herniotomy. Eliminate option 2, as this describes herniorrhaphy. Eliminate option 4, as this describes fundoplication. Option 3 is the correct answer, as the gastropexy technique involves attaching the stomach below the diaphragm to prevent reherniation.

A client with gastritis experiencing chronic gastric hypersecretion is scheduled for surgery. The nurse teaches the client that the procedure will lessen the stomach's production of acid by altering which structure? 1. Portal vein 2. Celiac artery 3. Vagus nerve 4. Pyloric valve

3. Vagus nerve **Vagotomy is a procedure that can reduce innervation to the stomach, thereby reducing the production of gastric acid. The portal vein drains venous blood from the stomach. The celiac artery brings arterial blood to the stomach. The pyloric valve separates the stomach from the duodenum. The pyloric valve may undergo surgical repair if it becomes stenosed; this procedure is known as pyloroplasty.

The nurse is caring for a client admitted to the hospital with suspected acute appendicitis. Which laboratory result would the nurse expect to note if the client does have appendicitis? 1. White blood cell (WBC) count of 4000 mm3 (4 × 109/L) 2. WBC count of 8000 mm (8 × 109/L) 3. WBC count of 18,000 mm3 (18 × 109/L) 4. WBC count of 26,000 mm3 (26 × 109/L)

3. WBC count of 18,000 mm3 (18 × 109/L) **Laboratory findings do not establish the diagnosis of appendicitis, but there is often a moderate elevation of the WBC count (leukocytosis) to 10,000 to 18,000 mm3 (10 to 18 × 109/L) with an increased number of immature WBCs. An inflammatory process causes a rise in the WBC count. A rise to 26,000 mm3 (26 × 109/L) may indicate a perforated appendix (greater than 20,000 mm3 [20 × 109/L]).

A client is diagnosed with a moderate case of acute ulcerative colitis. The nurse doing dietary teaching would give the client examples of foods to eat that represent which therapeutic diet? 1. High fat with milk 2. Low fiber with milk 3. High protein with milk 4. Low fiber without milk

4. Low fiber without milk **The client with a mild to moderate case of acute ulcerative colitis often is prescribed a diet that is low in fiber and does not include milk. This will help to reduce the frequency of diarrhea for this client. The remaining options are incorrect diets and may cause discomfort for the client.

The client with a small bowel obstruction asks the nurse to explain the purpose of the nasogastric tube attached to continuous gastric suction. The nurse determines that teaching has been effective if the client makes which statement? 1. "It will help to provide me with nourishment." 2. "It will help to relieve the congestion from excess mucus." 3. "It is used to remove gastric contents for laboratory testing." 4. "It will help to remove gas and fluids from my stomach and intestine."

4. "It will help to remove gas and fluids from my stomach and intestine." **Treatment of intestinal obstruction is directed toward decompression of the intestine by removal of gas and fluid. Nasogastric tubes may be used to decompress the stomach and bowel. Continuous gastric suction does not provide nourishment. The purpose of tracheal suctioning (not gastric suctioning) is to remove excess mucus that has led to congestion. Although gastric contents may be sent for laboratory analysis, it is not the main purpose for continuous gastric suction.

The nurse is performing an admission assessment on a client who has been admitted to the hospital with a diagnosis of suspected gastric ulcer. The nurse is asking the client questions about pain. Which client statement supports the diagnosis of gastric ulcer? 1. "The pain doesn't usually come right after I eat." 2. "The pain gets so bad that it wakes me up at night." 3. "The pain that I get is located on the right side of my chest." 4. "My pain comes shortly after I eat, maybe a half hour or so later."

4. "My pain comes shortly after I eat, maybe a half hour or so later." **Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be exacerbated by intake of food. The pain occurs 30 to 60 minutes after a meal and rarely occurs at night. Duodenal ulcer pain is usually located to the right of the epigastrium. The pain associated with a duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the client at night.

The nurse is teaching a client with gastroesophageal reflux disease (GERD) about lifestyle modifications to take to reduce GERD symptoms. The nurse determines there is a need for further teaching if the client makes which statement? 1. "I will choose low-fat foods from now on." 2. "I would cut down on the amount of coffee I drink." 3. "I'll avoid lying down for at least 3 hours after my last meal." 4. "Skipping breakfast and lunch and eating a large dinner will decrease my symptoms."

4. "Skipping breakfast and lunch and eating a large dinner will decrease my symptoms." **Lifestyle modifications for gastroesophageal reflux disease (GERD) include weight reduction if appropriate, decreasing caffeine and alcohol intake, avoiding lying down for at least 3 hours after eating, and eating small, frequent meals. Option 4 is the statement that requires further teaching because the client should eat small, frequent meals rather than one large meal, which would exacerbate symptoms. Therefore, option 4 is the client statement that presents a need for further teaching.

A client with Crohn's disease is experiencing acute pain, and the nurse provides information about measures to alleviate the pain. Which statement by the client indicates the need for further teaching? 1. "I know I can massage my abdomen." 2. "I will continue using antispasmodic medication." 3. "One of the best things I can do is use relaxation techniques." 4. "The best position for me is to lie supine with my legs straight."

4. "The best position for me is to lie supine with my legs straight." **Pain associated with Crohn's disease is alleviated by the use of analgesics and antispasmodics and also by practicing relaxation techniques, applying local cold or heat to the abdomen, massaging the abdomen, and lying with the legs flexed. Lying with the legs extended is not useful because it increases the muscle tension in the abdomen, which could aggravate inflamed intestinal tissues as the abdominal muscles are stretched.

A client has a large, deep duodenal ulcer diagnosed by endoscopy. Which sign or symptom indicative of a complication would the nurse look for during the client's post procedure assessment? 1. Bradycardia 2. Nausea and vomiting 3. Numbness in the legs 4. A rigid, boardlike abdomen

4. A rigid, boardlike abdomen **The client with a large, deep duodenal ulcer is at risk for perforation of the ulcer. If this occurs, the client will experience sudden, sharp, intolerable, and severe pain beginning in the midepigastric area and spreading over the abdomen, which then becomes rigid and boardlike. Tachycardia, not bradycardia, may occur as hypovolemic shock develops. Nausea and vomiting may not occur if the pyloric sphincter is intact. Numbness in the legs is not an associated finding.

The nurse is caring for a client after abdominal surgery to treat a malignant bowel tumor with creation of a colostomy. The nurse is assessing the client for a prolapsed stoma and would expect to note which observation if this is present? 1. A sunken and hidden stoma 2. A narrow and flattened stoma 3. A stoma that is dusky or bluish 4. A stoma that is elongated with a swollen appearance

4. A stoma that is elongated with a swollen appearance **A prolapsed stoma is one in which the bowel protrudes, causing an elongated and swollen appearance of the stoma. **A retracted stoma is characterized by a sinking of the stoma. A stoma with a narrow opening is described as being stenosed. Ischemia of the stoma would be associated with a dusky or bluish color.

The nurse is caring for a client with acute respiratory distress syndrome on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, the nurse would take which action? 1. Document the findings. 2. Reassess the pH in 4 hours. 3. Instill 30 mL of sterile water. 4. Administer a dose of a prescribed antacid.

4. Administer a dose of a prescribed antacid. **The client on a mechanical ventilator who has a nasogastric tube in place needs to have the gastric pH monitored at the beginning of each shift or at least every 12 hours. Because of the risk of stress ulcer formation, a pH lower than 5 (acidic) would be treated with prescribed antacids. If there is no prescription for the antacid, the primary health care provider would be notified. Documentation of the findings needs to be done after the administration of an antacid. Sterile water instillation is not an appropriate treatment.

A client is scheduled for an upper gastrointestinal (GI) endoscopy. Which assessment is essential to include in the plan of care following the procedure? 1. Assessing pulses 2. Monitoring urine output 3. Monitoring for rectal bleeding 4. Assessing for the presence of the gag reflex

4. Assessing for the presence of the gag reflex **Following the procedure, the client remains NPO (nothing by mouth) until the gag reflex returns, which is usually in 1 to 2 hours. The remaining options are not specific assessments related to this procedure.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube? 1. Checking for normal serum electrolyte levels 2. Checking for normal pH of the gastric aspirate 3. Checking for proper nasogastric tube placement 4. Checking for the presence of bowel sounds in all four quadrants

4. Checking for the presence of bowel sounds in all four quadrants **Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, pH of the gastric aspirate, and tube placement are important assessments for the client with a nasogastric tube in place but would not assist in determining the readiness for removing the nasogastric tube.

The nurse would instruct a client with an ileostomy to include which action as part of essential care of the stoma? 1. Massage the area below the stoma. 2. Take in high-fiber foods such as nuts. 3. Limit fluid intake to prevent diarrhea. 4. Cleanse the peristomal skin meticulously.

4. Cleanse the peristomal skin meticulously. **The peristomal skin must receive meticulous cleansing because ileostomy drainage has more enzymes and is more caustic to the skin than colostomy drainage. The area below the ileostomy may be massaged as needed if the ileostomy becomes blocked by high-fiber foods. Foods such as nuts and those with seeds will pass through the ileostomy. The client needs to be taught that these foods will remain undigested. Fluid intake would be at least 6 to 8 glasses of water per day to prevent dehydration.

The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis? 1. Hypercalcemia 2. Hypernatremia 3. Frothy, fatty stools 4. Decreased hemoglobin

4. Decreased hemoglobin **Ulcerative colitis is an inflammatory disease of the large colon. Findings associated with ulcerative colitis include diarrhea with up to 10 to 20 liquid bloody stools per day, weight loss, anorexia, fatigue, increased white blood cell count, increased erythrocyte sedimentation rate, dehydration, hyponatremia, and hypokalemia (not hypercalcemia). Because of the loss of blood, clients with ulcerative colitis commonly have decreased hemoglobin and hematocrit levels. Clients with ulcerative colitis have bloody diarrhea, not steatorrhea (fatty, frothy, foul-smelling stools).

The nurse is caring for a client who has just returned from the operating room after colectomy to remove a bowel tumor and the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is appropriate based on this assessment? 1. Apply ice to the stoma site. 2. Apply pressure to the stoma site. 3. Notify the primary health care provider (PHCP). 4. Document the amount and characteristics of the drainage.

4. Document the amount and characteristics of the drainage. **During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Applying ice or pressure to the stoma site are inappropriate actions. Notifying the PHCP is unnecessary because this is an expected finding.

A client has just had surgery to create an ileostomy for treatment of a bowel obstruction. The nurse assesses the client in the postoperative period for which most frequent complication of this type of surgery? 1. Folate deficiency 2. Malabsorption of fat 3. Intestinal obstruction 4. Fluid and electrolyte imbalance

4. Fluid and electrolyte imbalance **A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.

A client with peptic ulcer disease states that stress frequently causes exacerbation of the disease. The nurse determines that which item mentioned by the client is most likely to be responsible for the exacerbation? 1. Sleeping 8 to 10 hours a night 2. Ability to work at home periodically 3. Eating 5 or 6 small meals per day 4. Frequent need to work overtime on short notice

4. Frequent need to work overtime on short notice **Psychological or emotional stressors that exacerbate peptic ulcer disease may be found either at home or in the workplace. Of the items listed, the frequent need to work overtime on short notice is potentially the most stressful because it is the item over which the client has the least control. An ability to work at home periodically is not necessarily stressful because it allows increased client control over timing and location of work. Adequate rest and a proper dietary pattern (options 1 and 3) would alleviate symptoms, not worsen them.

A client with a diagnosis of stomach ulcer from gastric hyperacidity asks the nurse why the acid has not caused an ulcer in the small intestine as well. The nurse responds that the pH of intestinal contents is raised by bicarbonate, which is present in which area of the body? 1. Bile 2. Parietal cells 3. Liver enzymes 4. Pancreatic juice

4. Pancreatic juice **Pancreatic juice is rich in bicarbonate, which helps to neutralize the gastric acid in food entering the small intestine from the stomach. The duodenal papilla, which is an opening about 10 cm below the level of the pylorus, is responsible for carrying bile and pancreatic juices into the duodenum. Bile, parietal cells, and liver enzymes are not substances rich in bicarbonate and are incorrect.

A client who has undergone creation of a colostomy has a concern about body image. What action by the client indicates the most significant progress toward identified goals? 1. Looking at the ostomy site 2. Reading the ostomy product literature 3. Watching the nurse empty the ostomy bag 4. Practicing proper cutting of the ostomy appliance

4. Practicing proper cutting of the ostomy appliance **The client is expected to have body image disturbance after colostomy. The client progresses through normal grieving stages to adjust to this change. The client demonstrates the greatest degree of acceptance when participating in the actual colostomy care. Each incorrect option represents an interest in colostomy care but is a passive activity. The correct option shows the client participating in self-care.

The nurse is performing an assessment on a client with atrophic gastritis who has a diagnosis of pernicious anemia. Which finding would the nurse expect to note in this client? 1. Dyspnea 2. Dusky mucous membranes 3. Shortness of breath on exertion 4. Red tongue that is smooth and sore

4. Red tongue that is smooth and sore **Classic signs of pernicious anemia include weakness, mild diarrhea, and a smooth red tongue that is sore. The client also may have nervous system signs and symptoms such as paresthesias, difficulty with balance, and occasional confusion. The client does not exhibit dyspnea, the mucous membranes do not become dusky, and the client does not exhibit shortness of breath.

The nurse would anticipate that the primary health care provider (PHCP) will prescribe which treatment for a client with pernicious anemia? 1. Oral iron tablets 2. Blood transfusions 3. Gastric tube feedings 4. Vitamin B12 injections

4. Vitamin B12 injections **A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Iron is used for anemia that results from a lack of iron. Blood transfusions are not needed for pernicious anemia because a lack of red blood cells is not the problem. Gastric tube feedings will not replace vitamin B12. Vitamin B12 needs to be given by injection to ensure absorption.