GI Exam

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

ANS: A A client recovering from chronic pancreatitis should be limited to one floor until strength and activity increase. The client will need a bathroom on the same floor for frequent defecation. Assessing pulse rate and preparation of meals is not specific to chronic pancreatitis. Although the client should be encouraged to stop drinking alcoholic beverages, asking about alcohol availability is not adequate to assess this client's safety.

When performing an assessment, the nurse detects a fruity odor on the client's breath. What does the nurse do next? a. Assess the client's blood sugar level. b. Assess the client's stool for occult blood. c. Instruct the client in oral hygiene techniques. d. Assess the client for petechiae, itching, and jaundice.

ANS: A A fruity odor to the breath may indicate uncontrolled or undiagnosed diabetes mellitus. The client's blood sugar level should be checked immediately for hyperglycemia. The nurse may perform the other assessment tests for the client, but they will not be helpful in determining the cause of the fruity breath.

A client is admitted with jaundice and suspected hepatitis B. Which intervention does the nurse add to the client's care plan? a. Encourage rest during this period. b. Assist the client with ambulation. c. Place the client on a clear liquid diet. d. Administer PRN prochlorperazine maleate (Compazine).

ANS: A During the icteric phase, the client is encouraged to rest. Rest reduces the metabolic demands of the liver and promotes hepatic cell regeneration. The client may or may not need assistance with ambulation. The diet should be high in carbohydrates and calories for energy; clear liquids may be needed if the client is nauseated. The client may or may not need antiemetics.

The nurse is assessing health fair participants for risks for hepatitis. The nurse recognizes which client as being at greatest risk for developing hepatitis B? a. College student who has had several sexual partners b. Woman who takes acetaminophen daily for headaches c. Businessman who travels frequently d. Older woman who has eaten raw shellfish

ANS: A Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route. A person with multiple sexual partners has more opportunities to contract the infection.

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

ANS: A PTC uses iodinated dye, so the client should be asked about seafood allergies, specifically to shellfish. Documentation should occur, but this is not the priority. The client will need a ride home afterward if the procedure is done on an outpatient basis. There is no bowel preparation for PTC.

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

ANS: A The client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show a good understanding of the preparation for the procedure.

The nurse monitors for which clinical manifestation in a client with a decreased fecal urobilinogen concentration? a. Clay-colored stools b. Petechiae c. Asterixis d. Melena

ANS: A When fecal urobilinogen levels are decreased as a result of biliary cirrhosis, the stools become lighter or clay-colored.

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

ANS: A, B, C, E Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP.

A client has jaundice and ascites. Which laboratory values indicate hepatic disease? (Select all that apply.) a. Albumin, 2.0 g/dL b. Potassium, 3.0 mEq/L c. Alanine aminotransferase (ALT), 45 IU/L d. Aspartate aminotransferase (AST), 45 U/L e. Unconjugated (indirect) bilirubin, 1 mg/dL f. Ammonia, 120 mg/dL

ANS: A, C, D, E, F Decreased albumin and increased ALT, AST, unconjugated bilirubin, and ammonia all indicate hepatic disease. When the liver is damaged, albumin is not produced by the hepatic cells. ALT and AST liver enzymes increase with liver disease. Bilirubin, the primary component of bile, can be measured as direct or indirect and, if elevated, can indicate impaired secretion. Elevated levels of ammonia indicate severe hepatocellular damage. Decreased potassium does not indicate possible liver involvement but can be reduced by vomiting and diarrhea.

A client has cirrhosis. Which nursing intervention would be most effective in controlling ascites? a. Monitoring intake and output b. Providing a low-sodium diet c. Increasing oral fluid intake d. Weighing the client daily

ANS: B A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.

A client is admitted with cirrhosis and hepatopulmonary syndrome. Which clinical manifestation does the nurse monitor for progression or resolution of this problem? a. Right upper quadrant pain b. Crackles on auscultation c. Skin and scleral jaundice d. Nausea and vomiting

ANS: B An increase in intra-abdominal pressure from ascites can lead to hepatopulmonary syndrome. This is manifested by dyspnea and crackles on auscultation. The other symptoms are consistent with liver disease but are not specific to respiratory involvement.

The nursing assistant is helping a client who has advanced cirrhosis with a bath and other hygiene. Which action by the assistant requires intervention by the registered nurse? a. Helping the client apply lotion to dry skin areas b. Giving the client a basin of warm water and soap to use c. Providing a soft toothbrush for oral care d. Helping the client keep nails trimmed short

ANS: B Clients with advanced cirrhosis often have pruritus. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap. The other actions are appropriate.

A client is in the emergency department after a motor vehicle crash, and the nurse notices a "steering wheel mark" across the client's chest. Which action by the nurse is most appropriate? a. Ask the client where in the car he or she was during the crash. b. Assess the client by gently palpating the abdomen for tenderness. c. Notify the laboratory to come draw blood for blood type and crossmatch. d. Place the client on the stretcher in reverse Trendelenburg position.

ANS: B The liver is often injured by a steering wheel in a motor vehicle crash. Because the client's chest was marked by the steering wheel, the nurse should perform an abdominal assessment. Assessing the client's position in the crash is not needed because of the steering wheel imprint. The client may or may not need a blood transfusion. The client does not need to be in reverse Trendelenburg position.

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

ANS: B This observation could indicate an abdominal aortic aneurysm, which could be life threatening and should never be palpated. The nurse notifies the provider at once. An x-ray may be indicated. Auscultation is part of assessment, but the nurses priority action is to notify the provider.

A client with an esophagogastric tube suddenly experiences acute respiratory distress. Which is the nurse's first action? a. Call the health care provider. b. Cut the balloon ports and remove the tube. c. Place the client upright and apply oxygen. d. Reduce the balloon pressure slightly.

ANS: B When respiratory compromise is noted in a client with an esophagogastric tube, the nurse should immediately cut both ports with a pair of scissors that is kept at the bedside and remove the tube. The nurse would not call the health care provider until the client was out of immediate danger. Once the tube has been removed, the nurse can reposition the client and apply oxygen

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

ANS: B, D Alanine aminotransferase and ammonia are related to the liver. Amylase and lipase are related to the pancreas. Urobilinogen evaluates both hepatic and biliary function.

A client has cirrhosis and has developed ascites and edema. Which laboratory value does the nurse correlate with this condition? a. Blood glucose, 120 mg/dL b. Serum sodium, 135 mEq/L c. Serum albumin, 2.1 g/dL d. Blood urea nitrogen, 18 mg/dL

ANS: C Ascites occurs as a result of the inability of the liver to synthesize albumin. Loss of albumin leads to edema. This client's albumin level is low, which correlates with the condition. Sodium and blood urea nitrogen (BUN) levels are normal. The glucose level is slightly high, but this is not directly related to edema.

The nurse is assessing a client for asterixis. Which instruction to the client is most appropriate? a. "Close your eyes and take turns touching your nose with your fingers." b. "Sit on the edge of the bed and hold your legs straight out for 30 seconds." c. "Extend your arm, flex your wrist upward, and extend your fingers." d. "Say 'EEEEE' while I listen to your lungs in the back on both sides."

ANS: C Asterixis, or liver flap, is a tremor in the client's wrists and fingers. The correct technique for assessing the presence of asterixis is to extend the arm, dorsiflex the wrist, and extend the fingers. The other directions are not related to asterixis.

The client is scheduled for a colonoscopy. Which statement indicates that the client needs additional teaching about the procedure? a. "I may have gas and abdominal cramps after the test." b. "I will take strong laxatives the afternoon before the test." c. "I will take my Coumadin with a sip of water tomorrow morning." d. "I will take nothing by mouth after midnight on the day of the test."

ANS: C Blood thinners should not be taken before colonoscopy because bleeding may occur if polyps are removed. The client should stop taking warfarin (Coumadin) approximately 2 weeks before the colonoscopy. The other answers describe accurate complications of the colonoscopy and preparation for the procedure.

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

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

The client with end-stage cirrhosis presents with GI bleeding, combativeness, and confusion. The nurse anticipates an order to administer which medication? a. Omeprazole (Prilosec) b. Somatostatin (Octreotide) c. Propranolol (Inderal) d. Lactulose (Heptalac)

ANS: D Lactulose helps rid the body of ammonia. Excess ammonia leads to encephalopathy, which this client is manifesting. Omeprazole is a proton pump inhibitor used for reflux and ulcer disease. Somatostatin is given to treat bleeding from esophageal varices. Inderal is given to prevent bleeding from esophageal varices.

A client with severe esophageal varices is scheduled for trans-jugular intrahepatic portal-systemic shunt (TIPS) insertion. The nurse determines that teaching has been effective when the client makes which statement? a. "I will be discharged home after I wake up completely." b. "The procedure may be painful because I get only light sedation." c. "My liver will function normally within 8 hours of placement of the shunt." d. "I will be monitored closely for a while after the procedure is over."

ANS: D This procedure is performed in the radiology department under heavy sedation or general anesthesia. The client will be monitored as would any other postoperative client. The other statements are inaccurate.

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

ANS: C Mutations in both the BRCA2 and p16 genes increase the risk for developing pancreatic cancer in a small number of cases. The other factors do not appear to be linked to increased risk.

The nurse finds a positive Blumberg's sign in a client with abdominal pain. Which action does the nurse plan? a. Have the client be NPO in preparation for surgery. b. Document this normal finding in the client's record. c. Immediately auscultate the client's abdomen for bowel sounds. d. Repeat the maneuver with the client in a supine position, with the knees flexed.

ANS: A A positive Blumberg's sign (rebound tenderness), an abnormal sign, is indicative of peritoneal inflammation, which commonly accompanies appendicitis. The client should be made NPO in preparation for surgery to remove the appendix. The maneuver should not be repeated with the client in the supine position. The nurse should perform auscultation before percussion for the abdominal assessment.

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

ANS: A After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position.

A client is diagnosed with hepatitis B. Which information does the nurse include in the teaching plan as a priority? a. "Avoid drinking any alcohol until the doctor says you can." b. "You will need aggressive control of your serum lipids." c. "Once your lab work returns to normal, you can donate blood again." d. "Wash your hands well after handling meat and shellfish."

ANS: A Alcohol has a hepatotoxic effect, and clients with any liver disease should not drink it. Serum lipids need control in clients with fatty liver. Once a client has hepatitis B, he or she should not donate blood or organs. Handling contaminated shellfish is a cause of hepatitis A infection.

A client is in the emergency department after a motor vehicle crash. In assessing the client, which clinical sign alerts the nurse to the presence of possible liver trauma? a. Abdominal pain referred to the right shoulder b. Left upper quadrant abdominal pain and swelling c. Abdominal pain referred to the spine and legs d. Abdominal pain with accompanying rebound tenderness

ANS: A One of the key features of liver trauma is abdominal pain that is increased on deep breathing and is referred to the right shoulder. The liver is on the right, not the left, side of the body. Liver injury does not produce pain that radiates to the spine and down the legs. Rebound tenderness can indicate peritonitis.

A client had a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? a. Urine output of 20 mL/hr b. Systolic blood pressure increase of 10 mm Hg c. Respiratory rate drop from 18 to 14 d. A 3-pound drop in weight

ANS: A Rapid removal of ascitic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. The nurse would expect the client's weight to drop as fluid is removed. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. A slight increase in systolic blood pressure is insignificant.

A client is refusing to take lactulose (Heptalac) because of diarrhea. Which is the nurse's best response to this client? a. "Diarrhea is expected; that's how your body gets rid of ammonia." b. "You may take Kaopectate liquid daily for loose stools." c. "Do not take any more of the medication until your stools firm up." d. "We will need to send a stool specimen to the laboratory."

ANS: A The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The client must understand that this is an expected and therapeutic effect for him or her to remain compliant. The other statements are inaccurate.

A client with hepatitis C is being treated with ribavirin (Copegus). What nursing action takes priority? a. Educating the client on ways to remain complaint with the drug regimen b. Teaching the client that transient muscle aching is a common side effect c. Ensuring that the client returns to the clinic each week for follow-up care d. Showing the client how to take and record a radial pulse for 1 minute

ANS: A Treatment with ribavirin takes up to 48 weeks, making compliance a serious issue. The nurse should work with the client on a strategy to remain compliant for this length of time. The other actions are not warranted.

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

ANS: A, C, E Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or parenteral nutrition. The nurse should collaborate with the registered dietitian, clinical pharmacist, and health care provider to plan and implement the more appropriate nutritional interventions. The nursing assistant and certified herbalist would not assist with this clinical decision.

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

ANS: A, D, F Obesity, pregnancy, and diabetes are all risk factors for the development of cholelithiasis. A diet low in saturated fats and moderate alcohol intake may decrease the risk. Although metabolic syndrome is a precursor to diabetes, it is not a risk factor for cholelithiasis. The client should be informed of the connection.

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

ANS: B Before being digested, food must be broken down into a liquid form. This liquid is called chyme. Secretin is the hormone that inhibits acid production and decreases gastric motility. Absorption is carried out as the nutrients produced by digestion move from the lumen of the GI tract into the bodys circulatory system for uptake by individual cells. The secretions that help digest food include hydrochloric acid, bile, and digestive enzymes.

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

ANS: B Clients taking antibiotics are at risk for Clostridium difficile infection. The most common test for this disorder is a stool sample for ELISA toxin A+B. Colonoscopy, ova and parasites, and stool culture are not warranted at this time.

The nurse is screening clients at a health fair. Which client is at highest risk for the development of colon cancer? a. Older white client with irritable bowel syndrome b. Middle-aged African-American client who smokes cigars c. Middle-aged Asian client who travels and eats out frequently d. Older American Indian client taking hormone replacement therapy

ANS: B Colon cancer is more prevalent among African Americans and smokers. Irritable bowel syndrome, travel, and hormone replacement therapy do not increase the risk for colon cancer.

The nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD) completed. The client tells the nurse that her mouth is very dry after the procedure. Which is the nurse's best action? a. Keep the client NPO (nothing by mouth). b. Check the client's gag reflex. c. Offer the client sips of clear liquids. d. Provide the client with a few ice chips.

ANS: B The back of the throat is numbed for the EGD, impairing the gag reflex. Therefore the client is initially NPO postoperatively. The nurse should check the gag reflex before offering any type of liquid to the client. The client may be given ice chips or sips of fluids once the gag reflex has returned.

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

ANS: B The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.

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

ANS: B, C, D During the healing phase of pancreatitis, the client should be provided small, frequent, moderate- to high-carbohydrate, high-protein, low-fat meals. Protein shakes can be provided to supplement the diet. Foods and beverages should not contain caffeine and should be bland.

A nurse cares for a client with pancreatic cancer who is prescribed implanted radioactive iodine seeds. Which actions should the nurse take when caring for this client? (Select all that apply.) a. Dispose of dirty linen in a red "biohazard" bag. b. Place the client in a private room. c. Wear a lead apron when providing client care. d. Bundle care to minimize exposure to the client. e. Initiate Transmission-Based Precautions.

ANS: B, C, D The client should be placed in a private room and dirty linens kept in the client's room until the radiation source is removed. The nurse should wear a lead apron while providing care, ensuring that the apron always faces the client. The nurse should also bundle care to minimize exposure to the client. Transmission-Based Precautions will not protect the nurse from the implanted radioactive iodine seeds.

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

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

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

ANS: B, D, F The client should be advised to stay sober, and AA is a great resource. The client requires a low-fat diet, and cooking spray is low in fat compared with butter or margarine. If the client smokes, he or she must stop because nicotine can precipitate an exacerbation. A nicotine patch may help the client quit smoking. The client must rest until his or her strength returns. The client requires high carbohydrates and calories for healing; complex carbohydrates are not preferred over simple ones. Dairy products do not cause a problem.

The nurse is caring for a client who has just returned from abdominal surgery. When auscultating the client's abdomen, the nurse does not hear any bowel sounds. Which is the nurse's best action? a. Notify the health care provider. b. Percuss the abdomen. c. Document the finding. d. Insert a nasogastric tube.

ANS: C Absent bowel sounds are expected immediately following abdominal surgery. The finding should be noted in the client's record for later reference. The provider does not need to be notified at this time. The nurse should insert a nasogastric tube if ordered by the physician if the ileus persists. Percussion may be performed but may be uncomfortable for the client and will not reveal the cause of the ileus.

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

ANS: C After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse should remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness.

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

ANS: C Before conducting an assessment about the client's feelings, the nurse should determine whether he or she is willing and able to talk about them. If the client is open to the conversation and his or her room is not appropriate, an alternative meeting space may be located. The nurse should be present for the client during this time, and pulling up a chair and sitting with the client indicates that presence. Because the nurse is assessing the client's response to a terminal diagnosis, it is not necessary to have detailed information about the projected prognosis; the nurse knows that the client is facing an end-of-life illness.

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

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

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

ANS: C Paralytic ileus is a common complication of acute pancreatitis. The client should not eat until this has resolved. Bowel sounds and decreased pain are not reliable indicators of peristalsis. Instead, the nurse should assess for passage of flatus or bowel movement.

The nurse monitors for which serologic marker in the client who is a carrier of chronic hepatitis B? a. Anti-hepatitis C virus (HCV) antibodies b. Anti-hepatitis B (HBs) antibodies c. Hepatitis B surface antigen (HBsAg) antibodies d. Hepatitis A virus (HAV) antibodies

ANS: C Persistent presence of the serologic marker HBsAg after 6 months indicates a carrier state or chronic hepatitis. The other markers are not indicative of a carrier state.

A client has a family history of colon cancer. Which laboratory tests are ordered to rule out colon cancer? a. Cholesterol b. Serum lipase c. Carcinoembryonic antigen d. Xylose absorption

ANS: C The carcinoembryonic antigen can indicate colorectal, stomach, or pancreatic cancer if elevated. Elevated cholesterol and serum lipase may indicate pancreatitis. Decreased xylose absorption may indicate malabsorption in the small intestine.

A client is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which nursing intervention is the priority? a. Keep the client sedated to prevent tube dislodgement. b. Maintain balloon pressure at between 15 and 20 mm Hg. c. Irrigate the gastric lumen with normal saline. d. Maintain the client's airway.

ANS: D Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration and occlusion of the airway. The client usually is intubated and mechanically ventilated during this procedure. The other interventions are not a priority over airway.

A client is receiving an infusion of vasopressin (Pitressin) to treat bleeding esophageal varices. Which client complaint indicates to the nurse that a serious adverse effect of the drug may be occurring? a. Acute nausea and vomiting b. A pounding frontal headache c. Vertigo and syncope d. Midsternal chest pain

ANS: D Midsternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. The other side effects do not necessarily indicate that a serious side effect has occurred.

The nurse is performing an abdominal assessment on an older client. Which assessment finding does the nurse expect as a normal consequence of aging? a. Increased salivation and drooling b. Hyperactive bowel sounds and loose stools c. Increased gastric acid production and heartburn d. Impaired sensation to defecate and constipation

ANS: D Older adults may lose the sensation to defecate, resulting in constipation. Salivation decreases with aging, along with peristalsis and gastric acid production.

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

ANS: D Risk factors for pancreatic cancer include obesity, older age, high intake of red meat, and cigarette smoking. Sushi and wine intake are not risk factors for pancreatic cancer.

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

Postoperative care for a client recovering from an open Whipple procedure should include placing the client in a semi-Fowler's position to reduce tension on the suture line and anastomosis sites, setting the nasogastric tube to low suction to remove free air buildup and pressure, assessing vital signs frequently to assess fluid and electrolyte complications, and providing intravenous fluids.

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

ANS: A Complications of a Whipple procedure include secretions that drain from a fistula and peritonitis. Absent bowel sounds, pain at the incision site, and NG tube drainage are normal postoperative findings.

Which question best assists the nurse in assessing a client with acute diarrhea? a. "Have you traveled outside the country recently?" b. "Have you had a colonoscopy lately?" c. "Do you have any trouble swallowing?" d. "Do you have any allergies?"

ANS: A A history of recent travel may help pinpoint an infectious source for the client's diarrhea. A colonoscopy will not cause acute diarrhea. Trouble swallowing is not related to diarrhea. Allergic reactions do not typically cause acute diarrhea.

An older client has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? a. "Changes in your liver cause drugs to be metabolized differently." b. "Perhaps you don't need as high a dose of the drug as before." c. "Stomach muscles atrophy with age and you digest more slowly." d. "Your body probably can't tolerate as much medication anymore."

ANS: A Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugspossibly to toxic levels. The other options do not accurately explain this age-related change.

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

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

A client is receiving lactulose (Heptalac). Which laboratory value leads the nurse to intervene? a. Serum potassium, 2.6 mEq/L b. Serum sodium, 132 mEq/L c. Serum glucose, 108 mg/dL d. Blood urea nitrogen, 16 mg/dL

ANS: A Lactulose can cause the client to have several loose stools daily. The nurse should monitor for hypokalemia and dehydration. This client's potassium level is low, indicating hypokalemia. The serum sodium level is slightly low, but hyponatremia is not a complication of lactulose therapy. The blood glucose is slightly high, but this is unrelated. Blood urea nitrogen (BUN) is normal

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

ANS: A The client is not asking the nurse to actually explain why the cancer has occurred. The client may be expressing his or her feelings of confusion, frustration, distress, and grief related to this diagnosis. Reminding the client to keep a positive attitude for his or her family does not address the client's emotions or current concerns. The nurse should validate that there is no easy or straightforward answer as to why the client has cancer. Telling a client that cancer is a trial is untrue and may diminish the client-nurse relationship.

A client just had a paracentesis. Which nursing intervention is a priority for this client? a. Monitor urine output. b. Maintain bedrest as per protocol. c. Position the client flat in bed. d. Secure the trocar to the abdomen with tape.

ANS: B After a paracentesis, the client should remain on bedrest with the head of the bed elevated. A client with liver dysfunction is at risk for bleeding, and bedrest decreases this risk. Clients with liver dysfunction must have intake and output monitored, but this is not the priority after this procedure. A drain may be placed for short-term therapy in some clients.

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

ANS: A, B, C, E Several age-related changes occur in the gastrointestinal system. These include decreased hydrochloric acid production, diminished nerve function that leads to decreased sensation of the need to pass stool, decreased fat digestion, decreased peristalsis in the large intestine, and calcification of pancreatic vessels.

The nurse performs percussion of a client's abdomen. Which findings may the nurse determine with this assessment technique? (Select all that apply.) a. Hepatomegaly b. Kidney stones c. Ascites d. Large mass below the liver e. Biliary colic f. Ileus

ANS: A, C, D, F Percussion allows the nurse to identify the presence of masses, fluid, enlarged organs, and air in the abdomen. The nurse would not be able to identify biliary colic or kidney stones with percussion.

A client reports that he has been passing black stools for the last few days. Which findings from the client's health history does the nurse consider as possible causes? (Select all that apply.) a. Cirrhosis b. Cholecystitis c. Hemorrhoids d. Diverticulitis e. Long-term use of NSAIDs f. Use of iron supplements

ANS: A, E, F Cirrhosis may cause black stools when bleeding occurs from esophageal varices. Long-term NSAID use may lead to gastric ulcer development and bleeding. Iron supplements may turn the color of the stool black. Hemorrhoids or diverticulitis would result in stools that are streaked with red. Cholecystitis may result in pale-colored stools if bile flow is obstructed.

A thin, cachectic-appearing client has hepatic portal-systemic encephalopathy (PSE). The family expresses distress that the client is receiving so little protein in the diet. Which explanation by the nurse is most appropriate? a. "A low-protein diet will help the liver rest and will restore liver function." b. "Less protein in the diet will help with the confusion." c. "Despite looking so thin, protein will not help with weight gain." d. "Less protein is needed to prevent fluid from leaking into the abdomen."

ANS: B A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. The other statements are not correct.

The nurse is reviewing a client's history. Which statement by the client indicates a need for health teaching? a. "I drink 1 to 2 glasses of red wine a week." b. "Because of my arthritis, I take a lot of Tylenol." c. "One of my cousins died of liver cancer 10 years ago." d. "I got a hepatitis vaccine before traveling last year."

ANS: B Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about this limitation and should explore other drug options with the client to manage his or her arthritis pain. The other statements do not necessarily require health teaching by the nurse.

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

ANS: B After cholecystectomy, clients need a nutritious diet without a lot of excess fat; otherwise a special diet is not recommended for most clients. Good fluid intake is healthy for all people but is not related to the surgery. Drinking fluids between meals helps with dumping syndrome, which is not seen with this procedure. Restriction of sweets is not required.

An abdominal ultrasound is scheduled for the client. Which statement by the client indicates that the nurse's teaching about the procedure was effective? a. "The IV contrast may burn when it is injected." b. "I will drive myself home after the test is completed." c. "I will empty my bladder completely before the test." d. "I may have to take a laxative to pass the barium afterward."

ANS: B Because sedation is not used for this test, clients may drive themselves home after the abdominal ultrasound is completed. Barium and IV contrast are not needed. The client's bladder should be full for accurate visualization.

The nurse assesses dullness at the left anterior axillary line. The nurse is concerned about which condition that the client may have? a. Cirrhosis b. Splenomegaly c. Bowel obstruction d. Abdominal aortic aneurysm

ANS: B Dullness in front of the tenth intercostal space, at the left anterior axillary line, is indicative of splenomegaly, which is commonly seen with mononucleosis. Cirrhosis would be noted with percussion in the client's left upper quadrant, indicating hepatomegaly. The nurse may note tympanic sounds with bowel obstruction. Percussion would not be used to assess abdominal aortic aneurysm.

The nurse is preparing to perform an abdominal assessment on a client with suspected cholecystitis. In what sequence does the nurse palpate the client's abdomen? a. Palpate the lower quadrants only. b. Palpate the upper quadrants last. c. Palpate the upper quadrants only. d. Defer palpation and use percussion only.

ANS: B The client with cholecystitis will report pain in the right upper quadrant of the abdomen. Tender or painful areas should be palpated last to prevent the client from tensing his or her abdominal muscles because of pain, thereby making the examination more difficult. All quadrants should be palpated. Palpation is an important assessment tool that should not be deferred for this client.

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

ANS: B The local anesthetic used during this procedure will depress the clients gag reflex. After the procedure, the nurse should ensure that the gag reflex is intact before offering food or fluids. The client does not need to be restricted to cool beverages only and is not required to wait 4 hours before oral intake is allowed. Telling the client to remain NPO does not inform the client of when he or she can have fluids, nor does it reflect the clients readiness for them.

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

ANS: B The nurse should encourage the client to use the PCA pump prior to napping and upon awakening. Administering additional intravenous morphine while the client sleeps places the client at risk for respiratory depression. The nurse should also evaluate dosages received compared with dosages requested and contact the provider if the dose or frequency is not adequate. Only the client should push the pain button on a PCA pump.

A client is admitted with end-stage cirrhosis and severe vomiting. Which problem should the nurse monitor the client most carefully for? a. Intrahepatic bile stasis b. Bleeding esophageal varices c. Decreased excretion of bilirubin d. Accumulation of ascites in the abdomen

ANS: B The portal hypertension that accompanies end-stage cirrhosis predisposes the client to esophageal varices. These varices can rupture from increased pressure in the esophagus caused by coughing or vomiting. Bleeding varices can be life threatening. None of the other assessments take priority over monitoring for bleeding from esophageal varices.

The nurse is caring for a client who is receiving radiation treatment for oral cancer. Which problem does the nurse anticipate for this client? a. Failure to absorb nutrients from the stomach b. Inability to digest protein c. Impaired ability to soften and break down food d. Difficulty swallowing food

ANS: C Saliva is responsible for the softening of food in the mouth and contains an enzyme, salivary amylase (ptyalin), which assists in the breakdown of carbohydrates. Radiation to the oral cavity can result in reduction of saliva production. Radiation to the mouth will not impair swallowing, ability to digest protein, or ability to absorb nutrients from the stomach.

Which statement made by a client traveling to a nonindustrialized country indicates the need for further teaching regarding the prevention of viral hepatitis? a. "I will drink bottled water while I'm gone." b. "I will not share my drinking glass." c. "I should eat plenty of fresh fruits and vegetables." d. "I will use careful handwashing."

ANS: C The client should be advised to avoid fresh, raw fruits and vegetables because they can be contaminated by tap water. Drinking bottled water, not sharing glasses (or eating utensils), and careful handwashing are all good ways to prevent illness.

While a health history is obtained from a client with a new diagnosis of advanced pancreatic cancer, the client begins to cry. Which is the nurse's best response? a. "I am so sorry for making you cry!" b. "I will step out for a few minutes until you feel better." c. "I can see that you are upset about this. It is all right to cry." d. "I can see that I am upsetting you. Let's move on to something else."

ANS: C The nurse should recognize the client's feelings and should allow the client to cry. Moving on to another topic shows disregard for the client's feelings. The nurse should not leave the room but should stay to offer support. Apologizing to the client does not place the focus on the client or acknowledge the client's feelings and emotions in this situation.

The nurse correlates which data in the client's history as a predisposing factor for Laënnec's cirrhosis? a. Gallstones b. Alcohol abuse c. Viral hepatitis d. Heart disease

ANS: B Laënnec's cirrhosis, also known as alcoholic cirrhosis, is caused by the toxic effect of alcohol on the liver. The nurse should ask the client about a history of alcohol use. The other factors are not related to this type of cirrhosis.

A client is bleeding from esophageal varices. The health care provider is arranging sclerotherapy for the client. Before the client goes to interventional radiology, the nurse prepares to administer which medication? a. Terlipressin (Glypressin) b. Enoxaparin (Lovenox) c. Lactulose (Heptalac) d. Spironolactone (Aldactone)

ANS: A Terlipressin is a vasoactive drug that works by reducing portal pressure, which decreases bleeding. These drugs are often given in conjunction with sclerotherapies. Enoxaparin is a low-molecular-weight heparin, which would be contraindicated in a client with bleeding problems. Lactulose helps rid the body of ammonia. Aldactone is a diuretic.

The nurse is caring for a client who just completed an upper GI radiographic series with oral barium contrast. Which instructions does the nurse provide to the client? a. "Drink plenty of fluids over the next few days." b. "Do not eat or drink anything for 6 hours after the test." c. "You may not drive or operate heavy machinery today." d. "Do not take any blood thinners for 24 hours after the test."

ANS: A The client is encouraged to drink plenty of fluids after a barium swallow to help eliminate the barium from the colon. Limiting the diet as the barium is being cleared is not necessary. The test will not make the client drowsy, so driving should not be limited. Similarly, blood thinners will not affect the client.

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

ANS: A The client who has undergone a laparoscopic cholecystectomy may report free air pain due to retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide. Cold compresses and drinking a warm beverage would not be helpful. Coughing and deep breathing are important postoperative activities, but they are not related to discomfort from carbon dioxide.

The nurse reviews laboratory results for a client with cirrhosis and finds the following: hematocrit, 72%; blood urea nitrogen (BUN), 42 mg/dL; and sodium, 166 mEq/L. Which action by the nurse is most appropriate? a. Check the client's blood pressure and pulse. b. Increase the client's oral fluid intake. c. Call the health care provider. d. Document the results in the chart.

ANS: A These values are all elevated, which can occur in hypovolemia. The nurse should assess the client for signs of hypovolemia, including tachycardia and hypotension. The nurse should consult with the provider about the client's fluid status before increasing oral fluids but after obtaining vital signs. Documentation should occur after all assessments have been completed and must include actions taken.

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

ANS: A Using the ABCs, airway and oxygenation status should always be assessed first, so checking the endotracheal tube is the first action. Next, the nurse should start the IV line (circulation). After that, the Foley catheter can be inserted and the nasogastric tube can be set.

A client has been taking naproxen (Naprosyn) for several months. Which assessment question is important for the nurse to ask? a. "Have you experienced any constipation?" b. "Have you had any stomach pain or indigestion?" c. "Have you had any difficulty swallowing?" d. "Have you noticed any weight loss lately?"

ANS: B Long-term use of NSAIDs for chronic pain can precipitate peptic ulcer formation through inhibition of prostaglandins, which normally protects the gastric mucosa. The client should be assessed for stomach pain or indigestion. This medication does not typically cause constipation or difficulty swallowing. Weight loss would not be related to this medication

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

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

A client has been diagnosed with hepatitis A. The nurse evaluates that teaching regarding the disease is understood when the client makes which statement? a. "Some medications have been known to induce hepatitis A." b. "I may have been exposed when we ate shrimp last weekend." c. "I may have been infected through a recent blood transfusion." d. "My infection with Epstein-Barr virus can co-infect me with hepatitis A."

ANS: B The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. The other statements are not accurate.

Which laboratory data does the nurse correlate with advanced disease in a client with cirrhosis? a. Elevated serum protein level b. Elevated serum ammonia level c. Decreased serum ammonia level d. Decreased lactate dehydrogenase level

ANS: B The serum ammonia level is elevated in the presence of advanced disease because conversion of ammonia to urea for excretion is decreased. The other laboratory values do not correlate with advanced disease.

2. A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client? a. "Have you been experiencing any constipation?" b. "Are you eating a diet high in fiber and fluids?" c. "Do you have a history of high blood pressure?" d. "What vitamins and supplements are you taking?"

ANS: A Ischemic colitis is a life-threatening complication of alosetron. The nurse should assess the client for constipation. The other questions do not identify complications related to alosetron.

A nurse cares for a client with ulcerative colitis. The client states, "I feel like I am tied to the toilet. This disease is controlling my life." How should the nurse respond? a. "Let's discuss potential factors that increase your symptoms." b. "If you take the prescribed medications, you will no longer have diarrhea." c. "To decrease distress, do not eat anything before you go out." d. "You must retake control of your life. I will consult a therapist to help."

ANS: A Clients with ulcerative colitis often express that the disorder is disruptive to their lives. Stress factors can increase symptoms. These factors should be identified so that the client will have more control over his or her condition. Prescription medications and anorexia will not eliminate exacerbations. Although a therapist may assist the client, this is not an appropriate response. DIF: Applying/Application REF: 1180 KEY: Ulcerative colitis| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

A nurse reviews the chart of a client who has Crohn's disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions? a. Serum potassium of 2.6 mEq/L b. Client ate 20% of breakfast meal c. White blood cell count of 8200/mm3 d. Client's weight decreased by 3 pounds

ANS: A Fistulas place the client with Crohn's disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium level takes priority. DIF: Applying/Application REF: 1184 KEY: Crohn's disease| electrolyte imbalance MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A nurse cares for a client who has a Giardia infection. Which medication should the nurse anticipate being prescribed for this client? a. Metronidazole (Flagyl) b. Ciprofloxacin (Cipro) c. Sulfasalazine (Azulfidine) d. Ceftriaxone (Rocephin)

ANS: A Metronidazole is the drug of choice for a Giardia infection. Ciprofloxacin and ceftriaxone are antibiotics used for bacterial infections. Sulfasalazine is used for ulcerative colitis and Crohn's disease. DIF: Remembering/Knowledge REF: 1190 KEY: Parasitic infection| medication MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find? a. Severe, steady right lower quadrant pain b. Abdominal pain associated with nausea and vomiting c. Marked peristalsis and hyperactive bowel sounds d. Abdominal pain that increases with knee flexion

ANS: A Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion. DIF: Remembering/Knowledge REF: 1169 KEY: Inflammatory bowel disorder| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this client's teaching? a. "Drink plenty of fluids to prevent dehydration." b. "You should only drink 1 liter of fluids daily." c. "Increase your protein intake by drinking more milk." d. "Sips of cola or tea may help to relieve your nausea."

ANS: A The client should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided. DIF: Applying/Application REF: 1173 KEY: Inflammatory bowel disorder| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Pale and bluish stoma b. Liquid stool c. Ostomy pouch intact d. Blood-smeared output

ANS: A The nurse should assess the stoma for color and contact the health care provider if the stoma is pale, bluish, or dark. The nurse should expect the client to have an intact ostomy pouch with dark green liquid stool that may contain some blood. DIF: Applying/Application REF: 1177 KEY: Ostomy care| postoperative nursing MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse assesses a client with Crohn's disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Distended abdomen b. Temperature of 100.0° F (37.8° C) c. Loose and bloody stool d. Lower abdominal cramps

ANS: A The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the client's provider should be notified right away. Low-grade fever, bloody diarrhea, and abdominal cramps are common symptoms of Crohn's disease. DIF: Applying/Application REF: 1179 KEY: Crohn's disease| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

The nurse is preparing the client for a computed tomography (CT) scan of the abdomen with IV contrast. Which question does the nurse ask the client before the examination? a. "Are you allergic to shrimp, scallops, or shellfish?" b. "Have you had anything to eat or drink in the past 12 hours?" c. "Did you finish taking all the prescribed laxatives?" d. "Can you tolerate being tilted from side to side?"

ANS: A Allergies to iodine or seafood can cause a cross-allergic reaction to the contrast dye used for CT scans. Clients reporting such allergies should be scheduled for CT without contrast to avoid anaphylactic reactions. The client does not need to be NPO for this test and does need not to take laxatives. The client is not tilted during the CT scan.

15. A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider? a. White blood cell (WBC) count of 1500/mm3 b. Fatigue c. Nausea and diarrhea d. Mucositis and oral ulcers

ANS: A Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the client's WBC count is very low (normal range is 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately.

The nurse is caring for a client who is to receive 5-fluorouracil (5-FU) chemotherapy IV for the treatment of colon cancer. Which assessment finding leads the nurse to contact the health care provider? a. White blood cell (WBC) count of 1500/mm3 b. Presence of fatigue with a headache c. Presence of slight nausea and no appetite d. Two diarrhea stools yesterday

ANS: A Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the clients WBC count is very low (normal range, 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately.

A client with Crohns disease has a draining fistula. Which finding leads the nurse to intervene most rapidly? a. Serum potassium of 2.6 mEq/L b. The client not wanting to eat anything c. White blood cell count of 8200/mm3 d. The client losing 3 pounds in a week

ANS: A Fistulas place the client with Crohns disease at risk for hypokalemia, which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium takes priority.

The nurse is caring for a client with Giardia lamblia infection. Which medication does the nurse anticipate teaching the client about? a. Metronidazole (Flagyl) b. Ciprofloxacin (Cipro) c. Sulfasalazine (Azulfidine) d. Ceftriaxone (Rocephin)

ANS: A Flagyl is the drug of choice for Giardia lamblia infection. Cipro and Rocephin are antibiotics used for bacterial infections. Azulfidine is used for ulcerative colitis and Crohns disease

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

ANS: A Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route. A person with multiple sexual partners has more opportunities to contract the infection. Hepatitis B is not transmitted through medications, casual contact with other travelers, or raw shellfish. Although an overdose of acetaminophen can cause liver cirrhosis, this is not associated with hepatitis B. Hepatitis E is found most frequently in international travelers. Hepatitis A is spread through ingestion of contaminated shellfish

The nurse notes a bulge in a clients groin that is present when the client stands and disappears when the client lies down. Which conclusion does the nurse draw from these assessment findings? a. Reducible inguinal hernia b. Indirect umbilical hernia c. Strangulated ventral hernia d. Incarcerated femoral hernia

ANS: A In a reducible hernia, the contents of the hernial sac can be replaced into the abdominal cavity by gentle pressure or by lying flat. The contents of irreducible, strangulated, or incarcerated hernias may not be replaced into the abdomen when the client lies down.

The nurse reviews a health teaching for a client with Crohns disease. Which instruction does the nurse provide for the client? a. You should have a colonoscopy every few years. b. You should eat a diet that is high in protein and fiber. c. You should avoid heavy lifting and tight-fitting clothes. d. You should take the Asacol whenever you have loose stools.

ANS: A Long-term inflammatory bowel disease increases the risk of colon cancer, so regular colonoscopies are recommended. A high-fiber diet is not recommended for clients with Crohns disease because fiber can further irritate the inner lining of the bowel. Asacol (mesalamine [5-aminosalicylic acid]) should be taken daily, not as needed. Avoiding heavy lifting and tight-fitting clothes is not necessary.

The nurse is caring for a client who has undergone removal of a benign colonic polyp. The client asks the nurse why a follow-up colonoscopy is necessary. Which is the nurses best response? a. You are at risk for developing more polyps in the future. b. You may have other cancerous lesions that could not be seen right now. c. The doctor can remove only a few of the polyps during each colonoscopy. d. This test will ensure that you have healed where the polyp was removed.

ANS: A Once a person has developed a polyp, risk for occurrence of multiple polyps is present. The physician usually can remove all visible polyps during the colonoscopy procedure. Follow-up colonoscopy is not done to ensure that healing occurred where a polyp was removed, or to check for cancerous lesions that were not visible during the first procedure.

The nurse is caring for a client with a parasitic gastrointestinal infection. What statement by the client indicates a need for further teaching? a. I will have my housekeeper keep my toilet very clean. b. I need to shower or bathe every day. c. I need to have my well water tested. d. My sexual partner needs to have a stool test.

ANS: A Parasitic infections can be transmitted to other people. The client himself or herself should keep the toilet area clean instead of possibly exposing another person to the disease. The other statements are accurate

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

ANS: A Rapid removal of ascetic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the clients weight to drop as fluid is removed. Six kilograms is less than 3 pounds and is expected.

The nurse conducts a physical assessment for a client with abdominal pain. Which finding leads the nurse to suspect appendicitis? a. Severe, steady right lower quadrant (RLQ) pain b. Abdominal pain that started a day after vomiting began c. Abdominal pain that increases with knee flexion d. Marked peristalsis and hyperactive bowel sounds

ANS: A Right lower quadrant pain, specifically at McBurneys point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has a gastroenteritis. Abdominal pain due to appendicitis decreases with knee flexion. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis.

The nurse is caring for a client who has been diagnosed with a bowel obstruction. Which assessment finding leads the nurse to conclude that the obstruction is in the small bowel? a. Potassium of 2.8 mEq/L, with a sodium value of 121 mEq/L b. Losing 15 pounds over the last month without dieting c. Reports of crampy abdominal pain across the lower quadrants d. High-pitched, hyperactive bowel sounds in all quadrants

ANS: A Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range, 3.5 to 5.0 mEq/L) and hyponatremic (normal range, 136 to 145 mEq/L). Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched, hyperactive bowel sounds may be noted with large and small bowel obstructions. Crampy abdominal pain across the lower quadrants is associated with large bowel obstruction.

The nurse is teaching a client how to use a truss for a femoral hernia. Which statement by the client indicates the need for further teaching? a. I will put on the truss before I go to bed each night. b. I will put some powder under the truss to avoid skin irritation. c. The truss will help my hernia because I cant have surgery. d. If I have abdominal pain, I will let my health care provider know right away.

ANS: A The client is instructed to apply the truss before arising, not before going to bed at night. The other statements show accurate knowledge in using a truss.

The nurse is meeting a client post-liver transplantation for the first time and notices a tremor as they shake hands. The client states this has not happened before. Which action by the nurse is most appropriate? a. Conduct a thorough assessment, then notify the surgeon of the findings. b. Review today's laboratory work, including liver function studies. c. Assess the client's vital signs, and offer acetaminophen if the client is febrile. d. Perform an assessment of the client's gross and fine motor skills.

ANS: A The client may be exhibiting asterixis. Any sign of deteriorating neurologic function could indicate that the new liver is not working properly. The surgeon must be notified, but first the nurse should conduct a thorough assessment of the client. Reviewing today's laboratory work is important, but this is not the best option because the client's liver could have deteriorated after the laboratory work was drawn. Clients with any type of liver problem should not take acetaminophen. Assessing the client's fine and gross motor skills is part of an assessment.

3. After teaching a client who has a femoral hernia, the nurse assesses the client's understanding. Which statement indicates the client needs additional teaching related to the proper use of a truss? a. "I will put on the truss before I go to bed each night." b. "I'll put some powder under the truss to avoid skin irritation." c. "The truss will help my hernia because I can't have surgery." d. "If I have abdominal pain, I'll let my health care provider know right away."

ANS: A The client should be instructed to apply the truss before arising, not before going to bed at night. The other statements show an accurate understanding of using a truss.

The nurse is caring for a client who has acute viral gastroenteritis. Which dietary instruction does the nurse provide to the client? a. Drink plenty of fluids to prevent dehydration. b. You can have only clear liquids to drink. c. Milk products will give you extra protein. d. You can have sips of cola or tea to relieve nausea.

ANS: A The client should drink plenty of fluids to prevent dehydration. Clients are not necessarily restricted to clear liquids. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.

The nurse is caring for a client with an umbilical hernia who reports increased abdominal pain, nausea, and vomiting. The nurse notes high-pitched bowel sounds. Which conclusion does the nurse draw from these assessment findings? a. Bowel obstruction; client should be placed on NPO status. b. Perforation of the bowel; client needs emergency surgery. c. Adhesions in the hernia; client needs elective surgery. d. Hernia is dangerously enlarged; client needs a nasogastric (NG) tube.

ANS: A The client with a hernia presenting with abdominal pain, fever, tachycardia, nausea and vomiting, and hypoactive bowel sounds should be suspected of having developed strangulation. Strangulation poses a risk of intestinal obstruction. The client should be placed on NPO status, and the health care provider should be notified. The symptoms are not suggestive of enlargement of the hernia, adhesion formation, or bowel perforation.

A client admitted with hepatopulmonary syndrome is experiencing dyspnea but does not want oxygen increased because the client's nose keeps bleeding from it. The client becomes agitated when discussing this with the nurse. The client's oxygen saturation is 92%. What intervention by the nurse is best? a. Instruct the client to sit in as upright a position as possible. b. Tell the client that humidity can be added, but that the oxygen must be worn. c. Document the client's refusal in the chart, and call the health care provider. d. Call the health care provider to request an extra dose of the client's diuretic.

ANS: A The client with hepatopulmonary syndrome is often dyspneic. Because the oxygen saturation is not significantly low, the nurse should first allow the client to sit upright to see if that helps. If the client remains dyspneic, or if the oxygen saturation drops further, the nurse should investigate adding humidity to the oxygen and seeing whether the client will tolerate that. The other two options may be beneficial, but they are not the best choices. If the client is comfortable, his or her agitation will decrease; this will improve respiratory status.

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

ANS: A The client with hepatopulmonary syndrome is often dyspneic. Because the oxygen saturation is not significantly low, the nurse should first allow the client to sit upright to see if that helps. If the client remains dyspneic, or if the oxygen saturation drops further, the nurse should investigate adding humidity to the oxygen and seeing whether the client will tolerate that. The other two options may be beneficial, but they are not the best choices. If the client is comfortable, his or her agitation will decrease; this will improve respiratory status.

11. A nurse cares for a client who states, "My husband is repulsed by my colostomy and refuses to be intimate with me." How should the nurse respond? a. "Let's talk to the ostomy nurse to help you and your husband work through this." b. "You could try to wear longer lingerie that will better hide the ostomy appliance." c. "You should empty the pouch first so it will be less noticeable for your husband." d. "If you are not careful, you can hurt the stoma if you engage in sexual activity."

ANS: A The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the client's concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by engaging in sexual activity.

A client tells the nurse that her husband is repulsed by her colostomy and refuses to be intimate with her after surgery. Which is the nurses best response? a. Lets talk to the ostomy nurse to help you and your husband work through this. b. You could try to wear longer lingerie that will better hide the ostomy appliance. c. You should empty the pouch first so it will be less noticeable for your husband. d. If you are not careful, you can hurt the stoma if you engage in sexual activity.

ANS: A The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the clients concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by becoming intimate with her husband.

20. A nurse cares for a client who has a new colostomy. Which action should the nurse take? a. Empty the pouch frequently to remove excess gas collection. b. Change the ostomy pouch and wafer every morning. c. Allow the pouch to completely fill with stool prior to emptying it. d. Use surgical tape to secure the pouch and prevent leakage.

ANS: A The nurse should empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy wafers with paste should be used to secure and seal the ostomy appliance; surgical tape should not be used.

The nurse is caring for a client with Crohns disease and colonic strictures. Which assessment finding requires the nurse to consult the health care provider immediately? a. Distended abdomen b. Temperature of 100.0 F (37.8 C) c. Traces of blood in the stool d. Crampy lower abdominal pain

ANS: A The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the clients provider should be notified right away. Low-grade fever, bloody diarrhea, and crampy abdominal pain are common symptoms of Crohns disease

A client has an anorectal abscess. Which teaching topic does the nurse address as the priority? a. Perineal hygiene b. Comfort measures c. Nutrition therapy d. Antibiotic use

ANS: A The priority intervention for a client with an anorectal abscess focuses on maintaining meticulous perineal hygiene to prevent infection. Comfort measures are also important, but are not as high a priority. Nutrition management and antibiotic teaching may or may not be needed

A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, I do not want to take this medication because it causes diarrhea. How should the nurse respond? a. Diarrhea is expected; thats how your body gets rid of ammonia. b. You may take Kaopectate liquid daily for loose stools. c. Do not take any more of the medication until your stools firm up. d. We will need to send a stool specimen to the laboratory.

ANS: A The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The client must understand that this is an expected and therapeutic effect for him or her to remain compliant. The nurse should not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication

A client who has had a colostomy placed in the ascending colon expresses concern that the effluent collected in the colostomy pouch has remained liquid for 2 weeks after surgery. Which is the nurses best response? a. This is normal for your type of colostomy. b. I will let the health care provider know, so that it can be assessed. c. You should add extra fiber to your diet to stop the diarrhea. d. Your stool will become firmer over the next few weeks.

ANS: A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. The provider may be notified, but this is not the best response from the nurse. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the clients diet or with the passage of time.

16. A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, "The stool in my pouch is still liquid." How should the nurse respond? a. "The stool will always be liquid with this type of colostomy." b. "Eating additional fiber will bulk up your stool and decrease diarrhea." c. "Your stool will become firmer over the next couple of weeks." d. "This is abnormal. I will contact your health care provider."

ANS: A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet or with the passage of time.

The nurse is performing a physical examination on a client. Which assessment finding leads the nurse to check the clients abdomen for the presence of an acquired umbilical hernia? a. Body mass index (BMI) of 41.9 b. Cholecystectomy last year c. History of irritable bowel syndrome d. Daily dose of lansoprazole (Prevacid) 30 mg orally

ANS: A This type of hernia is associated with obesity. The other assessment findings do not place the client at increased risk for an acquired umbilical hernia.

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

ANS: A Treatment of hepatitis C with ribavirin takes up to 48 weeks, making compliance a serious issue. The nurse should work with the client on a strategy to remain compliant for this length of time. Muscle aching is not a common side effect. The client will be on this medication for many weeks and does not need a blood toxicity examination. There is no need for the client to assess his or her radial pulse prior to taking the medication

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

ANS: B, D Symptoms of hemorrhage and hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, diaphoresis, cool and clammy skin, and confusion

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

ANS: A, B Clients who are experiencing biliary colic may present with tachycardia, pallor, diaphoresis, prostration, or other signs of shock. The nurse should stay with the client, lower the client's head, and contact the provider or Rapid Response Team for immediate assistance. Treatment for shock usually includes intravenous fluids; therefore, decreasing fluids would be an incorrect intervention. The client's tachycardia is a result of shock, not pain. Performing the vagal maneuver or administering opioids could knock out the client's compensation mechanism.

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

ANS: A, B, C, D In adults, the most common cause of anemia is GI bleeding. This is commonly associated with colon cancer, diverticulitis, inflammatory bowel disease, and peptic ulcer disease. Pernicious anemia is not associated with GI bleeding.

A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding - Erosion of the bowel wall b. Abscess formation - Localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon - Transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction - Paralysis of colon resulting from colorectal cancer e. Fistula - Dilation and colonic ileus caused by paralysis of the colon

ANS: A, B, D Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon. DIF: Understanding/Comprehension REF: 1181 KEY: Ulcerative colitis MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A nurse plans care for a client who is recovering from an inguinal hernia repair. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Encouraging ambulation three times a day b. Encouraging normal urination c. Encouraging deep breathing and coughing d. Providing ice bags and scrotal support e. Forcibly reducing the hernia

ANS: A, B, D Postoperative care for clients with an inguinal hernia includes all general postoperative care except coughing. The nurse should promote lung expansion by encouraging deep breathing and ambulation. The nurse should encourage normal urination, including allowing the client to stand, and should provide scrotal support and ice bags to prevent swelling. A hernia should never be forcibly reduced, and this procedure is not part of postoperative care.

7. A nurse plans care for a client who has chronic diarrhea. Which actions should the nurse include in this client's plan of care? (Select all that apply.) a. Using premoistened disposable wipes for perineal care b. Turning the client from right to left every 2 hours c. Using an antibacterial soap to clean after each stool d. Applying a barrier cream to the skin after cleaning e. Keeping broken skin areas open to air to promote healing

ANS: A, B, D The nurse should use premoistened disposable wipes instead of toilet paper for perineal care, or mild soap and warm water after each stool. Antibacterial soap would be too abrasive and damage good bacteria on the skin. The nurse should apply a thin layer of a medicated protective barrier after cleaning the skin. The client should be re-positioned frequently so that he or she is kept off the affected area, and open skin areas should be covered with DuoDerm or Tegaderm occlusive dressing to promote rapid healing.

The nurse is caring for an older client with Salmonella food poisoning. Which is the priority action of the nurse? a. Monitor vital signs. b. Maintain IV fluids. c. Provide perineal care. d. Initiate Isolation Precautions.

ANS: B Dehydration can occur quickly in older clients with Salmonella food poisoning caused by diarrhea, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions, but are of lower priority than fluid replacement. Contact Isolation is not regularly instituted for Salmonella infection. Standard Precautions are usually sufficient.

A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Distended abdomen b. Inability to pass flatus c. Bradycardia d. Hyperactive bowel sounds e. Decreased urine output

ANS: A, B, E A client with peritonitis may present with a distended abdomen, diminished bowel sounds, inability to pass flatus or feces, tachycardia, and decreased urine output secondary to dehydration. Bradycardia and hyperactive bowel sounds are not associated with peritonitis. DIF: Remembering/Knowledge REF: 1170 KEY: Inflammatory bowel disorder| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this client's assessment? (Select all that apply.) a. "Which food types cause an exacerbation of symptoms?" b. "Where is your pain and what does it feel like?" c. "Have you lost a significant amount of weight lately?" d. "Are your stools soft, watery, and black in color?" e. "Do you experience nausea associated with defecation?"

ANS: A, B, E The nurse should ask the client about factors that may cause exacerbations of symptoms, including food, stress, and anxiety. The nurse should also assess the location, intensity, and quality of the client's pain, and nausea associated with defecation or meals. Clients who have IBS do not usually lose weight and stools are not black in color.

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

ANS: A, B, E When assessing a client with suspected cirrhosis, the nurse should ask about alcohol consumption, including amount and frequency; sexual history and orientation (specifically men having sex with men); illicit drug use; history of tattoos; and history of military service, incarceration, or work as a firefighter, police officer, or health care provider. A family history of cancer and work as a plumber do not put the client at risk for cirrhosis

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

ANS: A, C The options for colon cancer screening for people over the age of 50 include colonoscopy every 10 years and CT colonography, double-contrast barium enema, or flexible sigmoidoscopy every 5 years.

After teaching a client with an anal fissure, a nurse assesses the client's understanding. Which client actions indicate that the client correctly understands the teaching? (Select all that apply.) a. Taking a warm sitz bath several times each day b. Utilizing a daily enema to prevent constipation c. Using bulk-producing agents to aid elimination d. Self-administering anti-inflammatory suppositories e. Taking a laxative each morning

ANS: A, C, D Taking warm sitz baths each day, using bulk-producing agents, and administering anti-inflammatory suppositories are all appropriate actions for the client with an anal fissure. The client should not use enemas or laxatives to promote elimination, but rather should rely on bulk-producing agents such as psyllium hydrophilic mucilloid (Metamucil). DIF: Applying/Application REF: 1189 KEY: Skin lesions/wounds| bowel care MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

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

ANS: A, C, D Care for a client who has hepatopulmonary syndrome should include oxygen therapy, the head of bed elevated at least 30 degrees or as high as the client wants to improve breathing, elevated feet to decrease dependent edema, and daily weights. There is no need to place the client in a prone position, on the clients stomach. Although physical therapy may be helpful to a client who has been hospitalized for several days, physical therapy is not an intervention specifically for hepatopulmonary syndrome

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

ANS: A, C, D Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush should be used to prevent gum bleeding, and the clients nails should be trimmed short to prevent the client from scratching himself or herself. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap.

A nurse teaches a client how to avoid becoming ill with Salmonella infection again. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Wash leafy vegetables carefully before eating or cooking them." b. "Do not ingest water from the garden hose or the pool." c. "Wash your hands before and after using the bathroom." d. "Be sure meat is cooked to the proper temperature." e. "Avoid eating eggs that are sunny side up or undercooked."

ANS: A, C, D, E Salmonella is usually contracted via contaminated eggs, beef, poultry, and green leafy vegetables. It is not transmitted through water in garden hoses or pools. Clients should wash leafy vegetables well, wash hands before and after using the restroom, make sure meat and eggs are cooked properly, and, because it can be transmitted by flies, keep flies off of food. DIF: Applying/Application REF: 1191 KEY: Inflammatory bowel disorder| infection control MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

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

ANS: A, C, D, E Nurses should always use Standard Precautions for client care, and policies should reflect this. Needleless systems and reduction of sharps can help prevent hepatitis. Postexposure prophylaxis should be provided immediately. All health care workers should receive the hepatitis vaccinations that are available.

The infection control nurse wants to decrease the number of health care professionals who contract viral hepatitis at work. Which actions does the nurse initiate? (Select all that apply.) a. Strengthen policies related to consistent use of Standard Precautions. b. Mandate hepatitis vaccination for workers in high-risk areas. c. Implement a needleless system for IV therapy. d. Reduce the number of "sharps" needed for client care where possible. e. Provide postexposure prophylaxis in a timely manner.

ANS: A, C, D, E Nurses should always use Standard Precautions for client care, and policies should reflect this. Needleless systems and reduction of sharps can help prevent hepatitis. Postexposure prophylaxis should be provided immediately. All health care workers should receive the hepatitis vaccinations that are available.

A nurse is teaching a community group about food poisoning and gastroenteritis. Which statements by the nurse are accurate? (Select all that apply.) a. Rotavirus is more common among infants and younger children. b. Escherichia coli diarrhea is transmitted by contact with infected animals. c. Dont drink water when swimming to prevent E. coli infection. d. All clients with botulism require hospitalization. e. Parasitic diseases may not show up for 1 to 2 weeks after infection.

ANS: A, C, D, E Rotavirus is more common among the youngest of clients, not drinking water while swimming can help prevent E. coli infection, people with botulism need to be hospitalized to monitor for respiratory failure and paralysis, and parasitic diseases may take up to 2 weeks to become symptomatic. The other statements are not accurate.

The client asks the nurse how to avoid becoming ill with Salmonella infection again. Which are appropriate responses from the nurse? (Select all that apply.) a. Wash leafy vegetables carefully before eating or cooking them. b. Do not ingest water from the garden hose or the pool. c. Wash your hands before and after using the bathroom. d. Be sure meat is cooked to the proper temperature. e. Avoid eating eggs that are sunny side up or undercooked. f. When eating outdoors, be sure to keep flies off your food.

ANS: A, C, D, E, F Salmonella is usually contracted via contaminated eggs, beef, poultry, and green leafy vegetables. It is not transmitted through water in garden hoses or pools. Clients should wash leafy vegetables well, wash hands before and after using the restroom, make sure eggs and meat are cooked properly, and, because it can be transmitted by flies, keep flies off of food.

A nurse teaches a community group about food poisoning and gastroenteritis. Which statements should the nurse include in this group's teaching? (Select all that apply.) a. "Rotavirus is more common among infants and younger children." b. "Escherichia coli diarrhea is transmitted by contact with infected animals." c. "To prevent E. coli infection, don't drink water when swimming." d. "Clients who have botulism should be quarantined within their home." e. "Parasitic diseases may not show up for 1 to 2 weeks after infection."

ANS: A, C, E Rotavirus is more common among the youngest of clients. Not drinking water while swimming can help prevent E. coli infection. Parasitic diseases may take up to 2 weeks to become symptomatic. People with botulism need to be hospitalized to monitor for respiratory failure and paralysis. Escherichia coli is not transmitted by contact with infected animals. DIF: Applying/Application REF: 1172 KEY: Inflammatory bowel disorder| infection control MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

5. A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with this diagnosis? (Select all that apply.) a. Serum potassium of 2.8 mEq/L b. Loss of 15 pounds without dieting c. Abdominal pain in upper quadrants d. Low-pitched bowel sounds e. Serum sodium of 121 mEq/L

ANS: A, C, E Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range is 3.5 to 5.0 mEq/L) and hyponatremic (normal range is 136 to 145 mEq/L). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions.

1. A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.) a. Performs hand hygiene and positions the client in high-Fowler's position, with pillows behind the head and shoulders b. Instructs the client to extend the neck against the pillow once the NG tube has reached the oropharynx c. Checks for correct placement by checking the pH of the fluid aspirated from the tube d. Secures the NG tube by taping it to the client's nose and pinning the end to the pillowcase e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent

ANS: A, C, E The client's head should be flexed forward once the NG tube has reached the oropharynx. The NG tube should be secured to the client's gown, not to the pillowcase, because it could become dislodged easily. All the other actions are appropriate.

A nurse teaches a community group ways to prevent Escherichia coli infection. Which statements should the nurse include in this group's teaching? (Select all that apply.) a. "Wash your hands after any contact with animals." b. "It is not necessary to buy a meat thermometer." c. "Stay away from people who are ill with diarrhea." d. "Use separate cutting boards for meat and vegetables." e. "Avoid swimming in backyard pools and using hot tubs."

ANS: A, D Washing hands after contact with animals and using separate cutting boards for meat and other foods will help prevent E. coli infection. The other statements are not related to preventing E. coli infection. DIF: Applying/Application REF: 1172 KEY: Inflammatory bowel disorder| infection control MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse is teaching a community group ways to prevent Escherichia coli infection. Which statements made by the nurse are accurate? (Select all that apply.) a. Wash your hands after any contact with animals. b. It is not necessary to buy a meat thermometer. c. Stay away from people who are ill with diarrhea. d. Use separate cutting boards for meat and vegetables. e. Avoid swimming in backyard pools and using hot tubs.

ANS: A, D Washing hands after contact with animals and using separate cutting boards for meat and other foods will help prevent E. coli infection. The other statements are not related to preventing E. coliinfection

8. A nurse cares for a client who has a nasogastric (NG) tube. Which actions should the nurse take? (Select all that apply.) a. Assess for proper placement of the tube every 4 hours. b. Flush the tube with water every hour to ensure patency. c. Secure the NG tube to the client's upper lip. d. Disconnect suction when auscultating bowel peristalsis. e. Monitor the client's skin around the tube site for irritation.

ANS: A, D, E The nurse should assess for proper placement, tube patency, and output every 4 hours. The nurse should also monitor the skin around the tube for irritation and secure the tube to the client's nose. When auscultating bowel sounds for peristalsis, the nurse should disconnect suction.

The nurse is helping a student prepare to insert a nasogastric tube for an adult client with a bowel obstruction. Which actions by the student indicate to the nurse that a review of the procedure is needed? (Select all that apply.) a. Gathering supplies, including an 8 Fr Levin tube, sterile gloves, tape, and water-soluble lubricant b. Performing hand hygiene and positioning the client in high Fowlers position, with pillows behind the head and shoulders c. Attaching a 60-mL irrigation syringe to the end of the nasogastric tube before inserting it into the nose d. Instructing the client to extend the neck against the pillow once the nasogastric tube has reached the oropharynx e. Checking for correct placement by checking the pH of the fluid aspirated from the tube f. Securing the nasogastric tube by taping it to the clients nose and pinning the end to the pillowcase g. Connecting the nasogastric tube to intermittent medium suction with an anti-reflux valve on the air vent

ANS: A, D, F An 8 Fr nasogastric tube is too small for drainage of thick stomach contents. Sterile gloves are not needed for the procedure. The tube should be secured to the clients gown, not to the pillowcase, because it could become dislodged easily. The clients head should be flexed forward once the tube has reached the oropharynx. All the other actions are appropriate. A 60-mL irrigation syringe should be attached to the end of the tube before insertion so that gastric fluid does not erupt from the tube when it enters the stomach.

A nurse assesses a client who is hospitalized for botulism. The client's vital signs are temperature: 99.8° F (37.6° C), heart rate: 100 beats/min, respiratory rate: 10 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take? a. Decrease stimulation and allow the client to rest. b. Stay with the client while another nurse calls the provider. c. Increase the client's intravenous fluid replacement rate. d. Check the client's blood glucose and administer orange juice.

ANS: B A client with botulism is at risk for respiratory failure. This client's respiratory rate is slow, which could indicate impending respiratory distress or failure. The nurse should remain with the client while another nurse notifies the provider. The nurse should monitor and document the IV infusion per protocol, but this client does not require additional intravenous fluids. Allowing the client to rest or checking the client's blood glucose and administering orange juice are not appropriate actions. DIF: Applying/Application REF: 1191 KEY: Inflammatory bowel disorder| respiratory distress/failure MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I will avoid large crowds and people who are sick." b. "I will take this medication with my breakfast each morning." c. "Nausea and vomiting are common side effects of this drug." d. "I must wash my hands after I play with my dog."

ANS: B Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing. DIF: Applying/Application REF: 1183 KEY: Ulcerative colitis| medication safety MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

After teaching a client who was hospitalized for Salmonella food poisoning, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I will let my husband do all of the cooking for my family." b. "I'll take the ciprofloxacin until the diarrhea has resolved." c. "I should wash my hands with antibacterial soap before each meal." d. "I must place my dishes into the dishwasher after each meal."

ANS: B Ciprofloxacin should be taken for 10 to 14 days to treat Salmonella infection, and should not be stopped once the diarrhea has cleared. Clients should be advised to take the entire course of medication. People with Salmonella should not prepare foods for others because the infection may be spread in this way. Hands should be washed with antibacterial soap before and after eating to prevent spread of the bacteria. Dishes and eating utensils should not be shared and should be cleaned thoroughly. Clients can be carriers for up to 1 year. DIF: Applying/Application REF: 1173 KEY: Inflammatory bowel disorder| medications| antibiotics| medication safety MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

A nurse cares for an older adult client who has Salmonella food poisoning. The client's vital signs are heart rate: 102 beats/min, blood pressure: 98/55 mm Hg, respiratory rate: 22 breaths/min, and oxygen saturation: 92%. Which action should the nurse complete first? a. Apply oxygen via nasal cannula. b. Administer intravenous fluids. c. Provide perineal care with a premedicated wipe. d. Teach proper food preparation to prevent contamination.

ANS: B Dehydration caused by diarrhea can occur quickly in older clients with Salmonella food poisoning, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions but are of lower priority than fluid replacement. The nurse should teach the client about proper hand hygiene to prevent the spread of infection, and preparation of food and beverages to prevent contamination. DIF: Applying/Application REF: 1173 KEY: Inflammatory bowel disorder| hydration MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this client's plan of care? a. Low-fiber diet b. Skin protection c. Antibiotic administration d. Intravenous glucocorticoids

ANS: B Protecting the client's skin is the priority action for a client who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohn's disease includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids. DIF: Applying/Application REF: 1181 KEY: Crohn's disease| bowel care MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A nurse cares for a client with a new ileostomy. The client states, "I don't think my friends will accept me with this ostomy." How should the nurse respond? a. "Your friends will be happy that you are alive." b. "Tell me more about your concerns." c. "A therapist can help you resolve your concerns." d. "With time you will accept your new body."

ANS: B Social anxiety and apprehension are common in clients with a new ileostomy. The nurse should encourage the client to discuss concerns. The nurse should not minimize the client's concerns or provide false reassurance. DIF: Applying/Application REF: 1180 KEY: Ostomy care| coping| support MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

After teaching a client who has a new colostomy, the nurse provides feedback based on the client's ability to complete self-care activities. Which statement should the nurse include in this feedback? a. "I realize that you had a tough time today, but it will get easier with practice." b. "You cleaned the stoma well. Now you need to practice putting on the appliance." c. "You seem to understand what I taught you today. What else can I help you with?" d. "You seem uncomfortable. Do you want your daughter to care for your ostomy?"

ANS: B The nurse should provide both approval and room for improvement in feedback after a teaching session. Feedback should be objective and constructive, and not evaluative. Reassuring the client that things will improve does not offer anything concrete for the client to work on, nor does it let him or her know what was done well. The nurse should not make the client convey learning needs because the client may not know what else he or she needs to understand. The client needs to become the expert in self-management of the ostomy, and the nurse should not offer to teach the daughter instead of the client. DIF: Applying/Application REF: 1179 KEY: Ostomy care| psychosocial response| coping MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I'll rinse my rectal area with warm water after each stool and apply zinc oxide ointment." b. "I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel." c. "I must take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry." d. "I shall clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment."

ANS: B Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not an effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry. DIF: Applying/Application REF: 1179 KEY: Bowel care| inflammatory bowel disorder MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse is caring for a client hospitalized with botulism. The nurse obtains the following vital signs: temperature99.8 F (37.6 C), pulse100, respiratory rate10 and shallow, and blood pressure100/62 mm Hg. What action by the nurse is most appropriate? a. Allow the client rest periods without interruption. b. Stay with the client while another nurse calls the physician. c. Check the clients IV rate and document all findings. d. Help the client order appropriate food items from the menu.

ANS: B A client with botulism is at risk for respiratory failure. This clients respiratory rate is slow and shallow, which could indicate impending respiratory distress or failure. The nurse should remain with the client while another nurse notifies the provider. Nothing is allowed by mouth until all respiratory function and swallowing are normal. The nurse should monitor and document the IV infusion per protocol, but this does not take priority. Allowing the client to rest and ordering food items are not appropriate actions.

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

ANS: B A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the clients dietary protein will cause complications of liver failure and should not be suggested. Increased intravascular protein will help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein

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

ANS: B A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful

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

ANS: B Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about this limitation and should explore other drug options with the client to manage his or her arthritis pain. Two glasses of wine each week, a cousin with liver cancer, and the hepatitis vaccine do not place the client at risk for a liver disorder, and therefore do not require any health teaching.

The nurse is caring for a client with severe ulcerative colitis who has been prescribed adalimumab (Humira). Which client statement indicates that additional teaching about the medication is needed? a. I will avoid large crowds and people who are sick. b. I will take this medication with food or milk. c. Nausea and vomiting are common side effects. d. I will wash my hands after I play with my dog.

ANS: B Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing.

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

ANS: B Although family members may be afraid that they will contract hepatitis C, the nurse should educate the clients family about how the virus is spread. Viral hepatitis, or hepatitis C, is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing, blood and organ transplantation, accidental needle sticks, unsanitary tattoo equipment, and sharing of intranasal cocaine paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. The nurse would be violating privacy laws by sharing the clients status with the brother.

4. A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which action should the nurse take? a. Assess the client's heart rate and blood pressure. b. Determine when the client last voided. c. Ask if the client is experiencing flatus. d. Auscultate all quadrants of the client's abdomen.

ANS: B Assessment findings indicate that the client may have an over-full bladder. In the immediate postoperative period, the client may experience difficulty voiding due to urinary retention. The nurse should assess when the client last voided. The client's vital signs may be checked after the nurse determines the client's last void. Asking about flatus and auscultating bowel sounds are not related to a hemorrhoidectomy.

The nurse is performing a physical assessment for a client who underwent a hemorrhoidectomy the previous day. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which is the nurses priority action? a. Assess the clients vital signs. b. Determine the last time the client voided. c. Insert a rectal tube to facilitate passage of flatus. d. Document the findings in the clients chart.

ANS: B Assessment findings indicate that the client may have an overfull bladder. In the immediate postoperative period, the client may experience difficulty voiding owing to urinary retention. A rectal tube should not be inserted for a client who had a hemorrhoidectomy the previous day. The clients vital signs may be checked after the nurse determines the clients last void. The nurse should document all findings and actions in the clients medical record.

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

ANS: B Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client.

Which statement by a client with alcohol-induced cirrhosis indicates the need for further teaching? a. "I cannot drink any alcohol at all anymore." b. "I need to avoid protein in my diet." c. "I should not take over-the-counter medications." d. "I should eat small, frequent, balanced meals."

ANS: B Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client.

The nurse is caring for a client who is having approximately 20 foul-smelling stools each day. Laboratory Gram stain testing indicates the presence of white blood cells (WBCs) and red blood cells (RBCs) in the stool. Which organism does the nurse expect to see in the culture report? a. Helicobacter pylori b. Campylobacter jejuni c. Clostridium botulinum d. Norwalk virus

ANS: B Campylobacter gastroenteritis causes foul-smelling diarrhea with up to 20 to 30 stools per day for 7 days. Both RBCs and WBCs are present in a Gram stain of the stools. Infection with Clostridium causes not diarrhea, but constipation, paralysis, and respiratory failure. H. pylori is a common cause of gastric ulcers, not gastroenteritis. Norwalk virus produces milder illness with diarrhea and vomiting.

The nurse provides discharge teaching for a client who was hospitalized for Salmonella food poisoning. Which client statement indicates that additional teaching is needed? a. I will let my husband do the cooking for my family. b. I will take the ciprofloxacin (Cipro) until the diarrhea has resolved. c. I will wash my hands with antibacterial soap before and after each meal. d. I will make sure that my dishes go straight into the dishwasher after each meal.

ANS: B Cipro should be taken for 10 to 14 days to treat Salmonella infection, and should not be stopped once the diarrhea has cleared. Clients should be advised to take the entire course of medication. People with Salmonellashould not prepare foods for others because the infection may be spread in this way. Dishes and eating utensils should not be shared and should be cleaned thoroughly. Hands should be washed with antibacterial soap before and after eating to prevent spread of the bacteria. Clients can be carriers for up to 1 year.

1. After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk

ANS: B Clients with IBS are advised to eat a high-fiber diet (30 to 40 g/day), with 8 to 10 cups of liquid daily. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants.

The nurse is caring for a client who had ileostomy surgery 10 days ago. The client verbalizes concerns that the effluent has not become formed and is still liquid green. Which is the nurses best response? a. I will call your health care provider right away because the stool should be semi-solid by now. b. Your stools will firm up in a few weeks as your body gets used to the ileostomy. c. You should eat a high-fiber diet to help make the stool bulkier and more solid. d. You can add buttermilk or yogurt to your diet and avoid carbonated soft drinks.

ANS: B Effluent from an ileostomy will become less liquid (but not solid) over time as the body adapts to loss of the large bowel. This process takes time and the client should be reassured of this. Clients with a new ileostomy should avoid high-fiber diets for the first few weeks because blockage of the bowel may occur. Buttermilk, yogurt, and carbonated drinks will not affect this process.

Which laboratory findings does the nurse recognize as potentially causing complications of liver disease? a. Elevated aspartate transaminase (AST) and lactate dehydrogenase (LDH) levels b. Elevated prothrombin time and international normalized ratio (INR) c. Decreased serum albumin and serum globulin levels d. Decreased serum alkaline phosphatase and alanine aminotransferase (ALT) levels

ANS: B Elevated prothrombin time and INR are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. The other values do not necessarily place the client at increased risk for complications.

The nurse recognizes that fetor hepaticus is consistent with which assessment finding? a. Purpuric lesions on the extremities b. A fruity or musty breath odor c. Warm and bright red palms d. Jaundice of the sclera

ANS: B Fetor hepaticus is a distinctive breath odor that presents with chronic liver disease. The client's breath has a fruity or musty odor. The other statements do not apply to fetor hepaticus.

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

ANS: B Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention. Anti-rejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse should not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.

A client who underwent liver transplantation 2 weeks ago reports a temperature of 101° F (38.3° C) and right flank pain. Which is the nurse's best response? a. "The anti-rejection drugs you are taking made you susceptible to infection." b. "You should go to the hospital immediately to have your new liver checked out." c. "You should take an additional dose of cyclosporine today." d. "Take acetaminophen (Tylenol) every 4 hours until you feel better."

ANS: B Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention. The other statements are not appropriate.

A client is scheduled for a paracentesis. Which activity does the nurse delegate to the unlicensed assistive personnel? a. Have the client sign the informed consent form. b. Assist the client to void before the procedure. c. Help the client lie flat in bed, on the right side. d. Get the client into a chair after the procedure.

ANS: B For safety, the client should void just before a paracentesis. The nurse or the provider should have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the side of the bed and leaning over the bedside table. The client will be on bedrest after the procedure

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

ANS: B For safety, the client should void just before a paracentesis. The nurse or the provider should have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the side of the bed and leaning over the bedside table. The client will be on bedrest after the procedure.

A client has liver cancer. Which statement by the client about treatment options demonstrates an accurate understanding? a. "I guess it's a good thing that surgery is usually so successful." b. "I choose hepatic arterial infusion of chemo to limit side effects." c. "Because I have only local metastases, I am thinking about transplant." d. "This disease is so rare, no wonder no good treatments are available."

ANS: B Hepatic arterial chemotherapy infusion allows chemotherapeutic agents to be delivered directly into the liver tumor, limiting systemic side effects. Surgery is not usually successful because the cancer is frequently widespread when detected. Transplant is considered only for primary liver tumors that have not metastasized. The lack of successful treatments is due not to rarity, but rather to the fact that generally the cancer has already spread when found.

A client underwent the first stage of a restorative proctocolectomy with ileo-anal anastomosis (RPC-IPAA). What topic is a high priority for the nurse to teach? a. Perineal care b. Ostomy care c. Nutrition therapy d. Relaxation techniques

ANS: B In the first stage of the RPC-IPAA procedure, the temporary ileostomy is created. Because the effluent is caustic, severe skin irritation can occur. The client needs good instruction on ostomy care and comfort measures. Perineal care is not needed because stool drains through the ostomy. Nutrition therapy and relaxation techniques are not as high a priority as preventing skin damage.

17. A nurse cares for a middle-aged male client who has irritable bowel syndrome (IBS). The client states, "I have changed my diet and take bulk-forming laxatives, but my symptoms have not gotten better. I heard about a drug called Amitiza. Do you think it might help?" How should the nurse respond? a. "This drug is still in the research phase and is not available for public use yet." b. "Unfortunately, lubiprostone is approved only for use in women." c. "Lubiprostone works well. I will recommend this prescription to your provider." d. "This drug should not be used with bulk-forming laxatives."

ANS: B Lubiprostone (Amitiza) is a new drug for IBS with constipation that works by simulating receptors in the intestines to increase fluid and promote bowel transit time. Lubiprostone is currently approved only for use in women. Trials with increased numbers of male participants are needed prior to Food and Drug Administration approval for men.

A middle-aged male client has irritable bowel syndrome that has not responded well to diet changes and bulk-forming laxatives. He asks the nurse about the new drug lubiprostone (Amitiza). What information does the nurse provide him? a. This drug is investigational right now for irritable bowel syndrome. b. Unfortunately, this drug is approved only for use in women. c. Lubiprostone works well only in a small fraction of irritable bowel cases. d. Lets talk to your health care provider about getting you a trial prescription.

ANS: B Lubiprostone (Amitiza) is approved only for use in women. The other statements are not accurate.

The nurse is caring for a client with colon cancer and a new colostomy. The client wishes to talk with someone who had a similar experience. Which is the nurses best response? a. Most people who have had a colostomy are reluctant to talk about it. b. I will make a referral to the United Ostomy Associations of America. c. You can get all the information you need from the enterostomal therapist. d. I do not think that we have any other clients with colostomies on the unit right now.

ANS: B Nurses need to become familiar with community-based resources to assist clients better. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. Many people are willing to share their ostomy experience in the hope of helping others. The nurse should not brush aside the clients request by saying that no colostomy clients are present on the unit at the time.

10. An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first? a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Obtain the client's complete health history.

ANS: B On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present, because this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or obtaining a complete health history is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity.

The nurse is caring for a client who is brought to the emergency department following a motor vehicle crash. The nurse notes that the client has ecchymotic areas across the lower abdomen. Which is the priority action of the nurse? a. Measure the clients abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the clients hemoglobin and hematocrit. d. Ask whether the client was riding in the front or back seat of the car.

ANS: B On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present; this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or asking about seating in the car is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity.

The nurse has taught self-care measures to a client with an anal fissure. Which action by the client requires the nurse to do additional teaching? a. Taking warm sitz baths several times daily b. Administering daily enemas to prevent constipation c. Using bulk-producing agents to aid elimination d. Self-administering anti-inflammatory suppositories

ANS: B The client should not use enemas to promote elimination, but rather should rely on bulk-producing agents such as psyllium hydrophilic mucilloid (Metamucil). The other actions are appropriate.

The nurse is providing preoperative teaching for a client who will undergo herniorrhaphy surgery. Which instruction does the nurse give to the client? a. Eat a low-residue diet for the first week after surgery. b. Change the dressing every day until the staples are removed. c. Take acetaminophen (Tylenol) 1000 mg every 4 hours for pain. d. Cough and deep breathe every 2 hours for the first week after surgery.

ANS: B The dressing should be changed every day until the staples are removed, so the client can check the incision for signs of infection. Constipation is common following hernia surgery, so clients should include adequate amounts of fiber in the diet. The maximum daily dosage of Tylenol is 4000 mg. Taking 1000 mg of Tylenol every 4 hours means that intake is 6000 mg/day, which could cause toxicity and liver damage. The client should change positions and take deep breaths to facilitate lung expansion but should avoid coughing, which can place stress on the incision line

A client post-hemorrhoidectomy feels the need to have a bowel movement. Which action by the nurse is best? a. Have the client use the bedside commode. b. Stay with the client, providing privacy. c. Make sure toilet paper and the call light are in reach. d. Plan to send a stool sample to the laboratory.

ANS: B The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure needed items are within reach is an important nursing action too, but it does not take priority over client safety. The other two actions are not needed in this situation.

12. A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, "I need to have a bowel movement." Which action should the nurse take? a. Obtain a bedside commode for the client to use. b. Stay with the client while providing privacy. c. Make sure the call light is in reach to signal completion. d. Gather supplies to collect a stool sample for the laboratory.

ANS: B The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure the call light is within reach is an important nursing action too, but it does not take priority over client safety. Obtaining a bedside commode and taking a stool sample are not needed in this situation.

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

ANS: B The liver is often injured by a steering wheel in a motor vehicle crash. Because the clients chest was marked by the steering wheel, the nurse should perform an abdominal assessment. Assessing the clients position in the crash is not needed because of the steering wheel imprint. The client may or may not need a blood transfusion. The client does not need to be in reverse Trendelenburg position.

8. A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family members. Which action should the nurse take? a. Contact the provider and recommend a psychiatric consult for the client. b. Encourage the client to verbalize feelings about the diagnosis. c. Provide education about new treatment options with successful outcomes. d. Ask family and friends to visit the client and provide emotional support.

ANS: B The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the client's feelings with discussions related to cancer prognosis and treatment. The nurse should not assume that the client desires family or friends to visit or provide emotional support.

The nurse has completed the teaching session for a client with a new colostomy. Which feedback statement by the nurse is the most appropriate? a. I realize that you had a tough time today, but it will get easier with practice. b. You cleaned the stoma well. Now you need to practice putting on the appliance. c. You seem to understand what I taught you today. What else can I help you with? d. You seem uncomfortable. Do you want your daughter to care for your ostomy?

ANS: B The nurse should provide both approval and room for improvement in feedback after a teaching session. Feedback should be objective and constructive, and not evaluative. Reassuring the client that things will improve does not offer anything concrete for the client to work on, nor does it let him or her know what was done well. The nurse should not make the client convey learning needs because the client may not know what else he or she needs to understand. The client needs to become the expert in self-management of the ostomy, and the nurse should not offer to teach the daughter instead of the client.

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

ANS: B The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications, blood transfusions, or Epstein-Barr virus. Toxic and drug-induced hepatitis is caused from exposure to hepatotoxins, but this is not a form of hepatitis A. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection that is not associated with hepatitis A

A client who had a liver transplant a month ago is admitted with fever and tachycardia. Which medication does the nurse prepare to administer to this client? a. Ceftriaxone (Rocephin) b. Cyclosporine (Sandimmune) c. Azithromycin (Zithromax) d. Ribavirin (Copegus)

ANS: B This client is showing signs of transplant rejection, which is treated with immune suppressive drugs, such as cyclosporine. Ceftriaxone and azithromycin are antibiotics. Ribavirin is used to treat hepatitis C.

The nurse conducts a physical assessment for a client with severe right lower quadrant (RLQ) abdominal pain. The nurse notes that the abdomen is rigid and the clients temperature is 101.1 F (38.4 C). Which laboratory value does the nurse bring to the attention of the health care provider as a priority? a. A left shift in the white blood cell count b. White blood cell count, 22,000/mm3 c. Serum sodium, 149 mEq/L d. Serum creatinine, 0.7 mg/dL

ANS: B This client may have appendicitis based on RLQ pain. A white blood cell count of 22,000/mm3 is severely elevated and could indicate a perforated appendix, as could the fever. The nurse should bring these findings to the providers attention as soon as possible. A left shift would be expected in uncomplicated appendicitis. The sodium reading is only slightly high; this could be due to hemoconcentration from vomiting or from decreased intake. The creatinine level is normal.

The nurse is caring for a client with perineal excoriation caused by diarrhea from acute gastroenteritis. Which client statement indicates that additional teaching about perineal care is needed? a. I will rinse my rectal area with warm water after each stool and then apply zinc oxide ointment. b. I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel. c. I will take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry. d. I will clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment.

ANS: B Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not an effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry.

After teaching a client with a parasitic gastrointestinal infection, a nurse assesses the client's understanding. Which statements made by the client indicate that the client correctly understands the teaching? (Select all that apply.) a. "I'll have my housekeeper keep my toilet clean." b. "I must take a shower or bathe every day." c. "I should have my well water tested." d. "I will ask my sexual partner to have a stool test." e. "I must only eat raw vegetables from my own garden."

ANS: B, C, D Parasitic infections can be transmitted to other people. The client himself or herself should keep the toilet area clean instead of possibly exposing another person to the disease. Parasites are transmitted via unclean water sources and sexual practices with rectal contact. The client should test his or her well water and ask sexual partners to have their stool examined for parasites. Raw vegetables are not associated with parasitic gastrointestinal infections. The client can eat vegetables from the store or a home garden as long as the water source is clean. DIF: Applying/Application REF: 1190 KEY: Parasitic infection| infection control MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

2. After teaching a client who is recovering from a colon resection, the nurse assesses the client's understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. "I must change the ostomy appliance daily and as needed." b. "I will use warm water and a soft washcloth to clean around the stoma." c. "I might start bicycling and swimming again once my incision has healed." d. "Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown." e. "I will check the stoma regularly to make sure that it stays a deep red color." f. "I must avoid dairy products to reduce gas and odor in the pouch."

ANS: B, C, D The ostomy appliance should be changed as needed when the adhesive begins to decrease, placing the appliance at risk of leaking. Changing the appliance daily can cause skin breakdown as the adhesive will still be secured to the client's skin. The client should avoid using soap to clean around the stoma because it might prevent effective adhesion of the ostomy appliance. The client should use warm water and a soft washcloth instead. The tissue of the stoma is very fragile, and scant bleeding may occur when the stoma is cleaned. The flange should be cut to fit snugly around the stoma to reduce contact between excretions and the client's skin. Exercise (other than some contact sports) is important for clients with an ostomy. The stoma should remain a soft pink color. A deep red or purple hue indicates ischemia and should be reported to the surgeon right away. Yogurt and buttermilk can help reduce gas in the pouch, so the client need not avoid dairy products.

The nurse is providing discharge teaching for a client who has undergone colon resection surgery with a colostomy. Which statements by the client indicate that the instruction was understood? (Select all that apply.) a. I will change the ostomy appliance daily and as needed. b. I will use warm water and a soft washcloth to clean around the stoma. c. I will start bicycling and swimming again once my incision has healed. d. I will notify the doctor right away if any bleeding from the stoma occurs. e. I will check the stoma regularly to make sure that it stays a deep red color. f. I will avoid dairy products to reduce gas and odor in the pouch. g. I will cut the flange so it fits snugly around the stoma to avoid skin breakdown.

ANS: B, C, G The client should avoid using soap to clean around the stoma because it might prevent effective adhesive of the ostomy appliance. The client should use warm water and a soft washcloth instead. The stoma should remain a soft pink color. A deep red or purple hue indicates ischemia and should be reported to the surgeon right away. The tissue of the stoma is very fragile, and scant bleeding may occur when the stoma is cleaned. Yogurt and buttermilk can help reduce gas in the pouch, so the client need not avoid dairy products. Exercise (other than some contact sports) is important for clients with an ostomy.

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

ANS: B, E, F Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the clients confusion. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first? a. Inspection of oral mucosa b. Recent dietary intake c. Heart rate and rhythm d. Percussion of abdomen

ANS: C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this client than heart rate and rhythm. DIF: Applying/Application REF: 1172 KEY: Ulcerative colitis| hydration MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, "I am having trouble swallowing this pill." Which action should the nurse take? a. Contact the clinical pharmacist and request the medication in suspension form. b. Empty the contents of the capsule into applesauce or pudding for administration. c. Ask the health care provider to prescribe the medication as an enema instead. d. Crush the pill carefully and administer it in applesauce or pudding.

ANS: C Asacol is the oral formula for mesalamine and is produced as an enteric-coated pill that should not be crushed, chewed, or broken. Asacol is not available as a suspension or elixir. If the client is unable to swallow the Asacol pill, a mesalamine enema (Rowasa) may be administered instead, with a provider's order. DIF: Applying/Application REF: 1176 KEY: Ulcerative colitis| medication safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

After teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I'll ride my bike or take a long walk at least three times a week." b. "I must try to include at least 25 grams of fiber in my diet every day." c. "I will take a laxative nightly at bedtime to avoid becoming constipated." d. "I should use my legs rather than my back muscles when I lift heavy objects."

ANS: C Laxatives are not recommended for clients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining. DIF: Applying/Application REF: 1187 KEY: Diverticulitis| medication MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Health Promotion and Maintenance

A nurse assesses a client who is hospitalized with an exacerbation of Crohn's disease. Which clinical manifestation should the nurse expect to find? a. Positive Murphy's sign with rebound tenderness to palpitation b. Dull, hypoactive bowel sounds in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Reports of abdominal cramping that is worse at night

ANS: C The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn's disease. A positive Murphy's sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohn's disease. Nightly worsening of abdominal cramping is not consistent with Crohn's disease. DIF: Applying/Application REF: 1182 KEY: Crohn's disease| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse cares for a teenage girl with a new ileostomy. The client states, "I cannot go to prom with an ostomy." How should the nurse respond? a. "Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance." b. "The pouch won't be as noticeable if you avoid broccoli and carbonated drinks prior to the prom." c. "Let's talk to the enterostomal therapist about options for ostomy supplies and dress styles." d. "You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable."

ANS: C The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible. DIF: Applying/Application REF: 1180 KEY: Ostomy care| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client who has had fecal occult blood testing tells the nurse that the test was negative for colon cancer and wishes to cancel a colonoscopy scheduled for the next day. Which is the nurses best response? a. I will call and cancel the test for tomorrow. b. You need two negative fecal occult blood tests. c. This does not rule out the possibility of colon cancer. d. You should wait at least a week to have the colonoscopy.

ANS: C A negative result does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed, so the entire colon can be visualized and a tissue sample taken for biopsy. The client need not wait a week before the colonoscopy. Two negative fecal occult blood tests do not rule out the presence of colorectal cancer (CRC).

18. A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this client's plan of care? a. "You may experience nausea and vomiting for the first few weeks." b. "Carbonated beverages can help decrease acid reflux from anastomosis sites." c. "Take a stool softener to promote softer stools for ease of defecation." d. "You may return to your normal workout schedule, including weight lifting."

ANS: C Clients recovering from a colon resection should take a stool softener as prescribed to keep stools a soft consistency for ease of passage. Nausea and vomiting are symptoms of intestinal obstruction and perforation and should be reported to the provider immediately. The client should be advised to avoid gas-producing foods and carbonated beverages, and avoid lifting heavy objects or straining on defecation.

7. A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, "My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it." How should the nurse respond? a. "Your doctor should not have given you that information prior to the colonoscopy." b. "The colonoscopy is required due to the high percentage of false negatives with the blood test." c. "A negative fecal occult blood test does not rule out the possibility of colon cancer." d. "I will contact your doctor so that you can discuss your concerns about the procedure."

ANS: C A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the client's concerns prior to contacting the provider.

The nursing care plan specifies obtaining abdominal girth measurements each shift. The nurse takes the measurement, but when compared with the previous measurement, the new finding is several millimeters off. Which action by the nurse is best? a. Document the finding in the client's chart. b. Look to see when the client last had a dose of diuretic. c. Ensure that the client's abdomen and flanks are marked with pen. d. Obtain the measurement while the client sits upright.

ANS: C Abdominal girth is measured at the end of exhalation, at the level of the umbilicus, while the client lies flat. To ensure that measurements are taken in the same place each time, the nurse should mark the client's abdomen and flanks with pen. Findings do need to be documented, but this is not the best action when such inconsistency is noted between measurements. Use of a diuretic might decrease ascites, but the best action remains ensuring that measurements are taken in a consistent manner.

The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the highest priority? a. Skin integrity b. Blood pressure c. Heart rate and rhythm d. Abdominal percussion

ANS: C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Abdominal percussion is an important part of physical assessment but has lower priority for this client than heart rate and rhythm.

The nurse is caring for a client who just had colon resection surgery with a new colostomy. Which teaching objective does the nurse include in the clients plan of care? a. Understanding colostomy care and lifestyle implications b. Learning how to change the appliance independently c. Demonstrating the correct way to change the appliance by discharge d. Not being afraid to handle the ostomy appliance tomorrow

ANS: C Client learning goals must be measurable and objective with a time frame, so the nurse can determine whether they have been met. When the goal is to have the client demonstrate a particular skill, the nurse can easily determine whether the goal was met. The specific time frame of by discharge is easily measurable also. The other goals are all subjective and cannot be measured objectively. The first two options do not have time frames. Tomorrow is a vague time frame.

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

ANS: C Clients who have chronic cirrhosis may have alienated relatives over the years because of substance abuse. The nurse should assist the client to identify a friend, neighbor, or person in his or her recovery group for support. The nurse should not minimize the clients concerns by brushing off the clients comment. Attending AA may be appropriate, but this response doesnt address the clients concern. Making peace with the clients family may not be possible. This statement is not client-centered.

The nurse is preparing a client with diverticulitis for discharge from the hospital. Which statement by the client indicates that additional teaching is needed? a. I will ride my bike or take a long walk at least three times a week. b. I will try to include at least 25 g of fiber in my diet every day. c. I will take a senna laxative at bedtime to avoid becoming constipated. d. I will use my legs rather than my back muscles when I lift heavy objects.

ANS: C Laxatives are not recommended for clients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining.

The nurse is caring for an older client with gastroenteritis. Which order does the nurse consult with the health care provider about? a. IV 0.45% NS at 50 mL/hr b. Clear liquids as tolerated c. Diphenoxylate hydrochloride/atropine sulfate (Lomotil) orally, after each loose stool d. Acetaminophen (Tylenol), 325-650 mg orally every 4 hr PRN pain

ANS: C Lomotil can cause drowsiness and can increase the older clients risk for falls. The nurse should consult with the provider to see if this medication is really necessary and, if an antidiarrheal medication is warranted, what other options might be available. The other orders are appropriate, although the nurse would have to monitor the clients total 24-hour Tylenol dosage to ensure that the client did not receive more than 4000 mg/24 hr.

The nurse is assessing a client with mild liver disease. Which assessment does the nurse perform to detect the presence of ascites in this client? a. Measure lower extremities to assess for edema. b. Inspect and palpate the abdomen for distention. c. Palpate the abdomen in assessing for a fluid wave. d. Percuss the liver while listening for dullness.

ANS: C Mild ascites may be difficult to detect and can be assessed by percussion. Shifting dullness and a fluid wave alert the nurse to the presence of ascites. The other findings are inconsistent with ascites.

9. A nurse cares for a client with colon cancer who has a new colostomy. The client states, "I think it would be helpful to talk with someone who has had a similar experience." How should the nurse respond? a. "I have a good friend with a colostomy who would be willing to talk with you." b. "The enterostomal therapist will be able to answer all of your questions." c. "I will make a referral to the United Ostomy Associations of America." d. "You'll find that most people with colostomies don't want to talk about them."

ANS: C Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). The nurse should not suggest that the client speak with a personal contact of the nurse. Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse should not brush aside the client's request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others.

A client is brought to the emergency department with an abrupt onset of vomiting, abdominal cramping, and diarrhea 2 hours after eating food at a picnic. Which infectious microorganism does the nurse suspect as the probable cause? a. Salmonella b. Giardia lamblia c. Staphylococcus aureus d. Clostridium botulinum

ANS: C Staphylococcus can be found in meat and dairy products and can be transmitted to people. Food poisoning occurs, especially if foods are left unrefrigerated over a period of time. Symptoms of Staphylococcus food poisoning include sudden onset of vomiting, abdominal cramping, and diarrhea within 2 to 4 hours. The clients symptoms are not consistent with infection by the other microorganisms.

The nurse is caring for a client who is scheduled to have fecal occult blood testing. Which instructions does the nurse give to the client? a. You must fast for 12 hours before the test. b. You will be given a cleansing enema the morning of the test. c. You must avoid eating meat for 48 hours before the test. d. You will be sedated and will require someone to accompany you home.

ANS: C The client is instructed to avoid meat, aspirin, vitamin C, and anti-inflammatory drugs for 48 hours before the test. The other directions are not accurate for this test.

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

ANS: C The client should be advised to avoid fresh, raw fruits and vegetables because they can be contaminated by tap water. Drinking bottled water, and not sharing plates, glasses, or eating utensils are good ways to prevent illness, as is careful handwashing

19. A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client? a. "Eat low-fiber and low-residual foods." b. "White rice and bread are easier to digest." c. "Add vegetables such as broccoli and cauliflower to your new diet." d. "Foods high in animal fat help to protect the intestinal mucosa."

ANS: C The client should be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer.

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

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

The nurse is caring for a client who is hospitalized with exacerbation of Crohns disease. What does the nurse expect to find during the physical assessment? a. Positive Murphys sign with rebound tenderness b. Dullness in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Abdominal cramping that the client says is worse at night

ANS: C The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohns disease. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohns disease. Nightly worsening of abdominal cramping is not consistent with Crohns disease. A positive Murphys sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis.

The nurse is caring for a client who has been newly diagnosed with colon cancer. The client has become withdrawn from family members. Which strategy does the nurse use to assist the client at this time? a. Ask the health care provider for a psychiatric consult for the client. b. Explain the improved prognosis for colon cancer with new treatment. c. Encourage the client to verbalize feelings about the diagnosis. d. Allow the client to remain withdrawn as long as he or she wishes.

ANS: C The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the clients feelings with a generalization about cancer prognosis and treatment. The nurse should not ignore the clients withdrawal behavior.

The nurse is preparing to begin teaching the client about how to care for a new ileostomy. Which consideration is the highest priority for the nurse when planning teaching for this client? a. Informing the client about what to expect with basic ostomy care b. Starting the teaching after the client has received pain medication c. Starting the teaching when the client is ready to look at the stoma d. Making sure that all needed supplies are ready at the clients bedside

ANS: C The nurse should wait until the client is ready to look at the ostomy and stoma before initiating teaching about ostomy care. The nurse should monitor clues from the client and encourage him or her to start taking an active role in management. Effective learning will occur only when the learner is ready. The other considerations are of lower priority for the client and nurse.

The nurse is caring for a teenage girl with a new ileostomy. She tells the nurse tearfully that she cannot go to the prom with an ostomy. Which is the nurses best response? a. You should get your prom dress one size larger to hide the ostomy appliance. b. You should avoid broccoli and carbonated drinks so that the pouch wont fill with air under your dress. c. Lets talk to the enterostomal therapist (ET) about options for ostomy supplies and dress styles so that you can look beautiful for the prom. d. You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable.

ANS: C The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible.

The nurse is performing a physical assessment of a client with a new diagnosis of colorectal cancer. The nurse notes the presence of visible peristaltic waves and, on auscultation, hears high-pitched bowel sounds. Which conclusion does the nurse draw from these findings? a. The tumor has metastasized to the liver and biliary tract. b. The tumor has caused an intussusception of the intestine. c. The growing tumor has caused a partial bowel obstruction. d. The client has developed toxic megacolon from the growing tumor.

ANS: C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. Assessment findings do not indicate metastasis to the liver, intussusception of the intestine, or toxic megacolon

6. A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action should the nurse take? a. Ask if the client is experiencing pain in the right shoulder. b. Perform a rectal examination and assess for polyps. c. Contact the provider and recommend computed tomography. d. Administer a laxative to increase bowel movement activity.

ANS: C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. The nurse should contact the provider with these results and recommend a computed tomography scan for further diagnostic testing. This assessment finding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The registered nurse is not qualified to complete a rectal examination for polyps, and laxatives would not help this client.

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

ANS: C The risk of contracting a primary carcinoma of the liver is higher in clients with cirrhosis from any cause. Blunt liver trauma, diabetes mellitus, and chronic malnutrition do not increase a persons risk for developing liver cancer.

The nurse recognizes which client as being at greatest risk for the development of carcinoma of the liver? a. Middle-aged client with a history of diabetes mellitus b. Young adult client with a history of blunt liver trauma c. Older adult client with a history of cirrhosis d. Older adult client with malnutrition

ANS: C The risk of contracting a primary carcinoma of the liver is higher in clients with cirrhosis from any cause. The other factors do not increase a person's risk for developing liver cancer.

A client just returned to the nursing unit after having a trans-jugular intrahepatic portal-systemic shunt (TIPS) procedure. Which clinical finding does the nurse expect to observe in this client? a. Decreased level of consciousness b. Decreased urinary volume c. Increased blood pressure d. Increased abdominal girth

ANS: C With TIPS placement, ascitic fluid is routed into the venous system, resulting in vascular volume expansion. An increase in blood pressure is reflective of increased circulating volume. The client should not have the other findings.

6. A nurse assesses a male client with an abdominal hernia. Which abdominal hernias are correctly paired with their physiologic processes? (Select all that apply.) a. Indirect inguinal hernia - An enlarged plug of fat eventually pulls the peritoneum and often the bladder into a sac b. Femoral hernia - A peritoneum sac pushes downward and may descend into the scrotum c. Direct inguinal hernia - A peritoneum sac passes through a weak point in the abdominal wall d. Ventral hernia - Results from inadequate healing of an incision e. Incarcerated hernia - Contents of the hernia sac cannot be reduced back into the abdominal cavity

ANS: C, D, E A direct inguinal hernia occurs when a peritoneum sac passes through a weak point in the abdominal wall. A ventral hernia results from inadequate healing of an incision. An incarcerated hernia cannot be reduced or placed back into the abdominal cavity. An indirect inguinal hernia is a sac formed from the peritoneum that contains a portion of the intestine and pushes downward at an angle into the inguinal canal. An indirect inguinal hernia often descends into the scrotum. A femoral hernia protrudes through the femoral ring and, as the clot enlarges, pulls the peritoneum and often the urinary bladder into the sac.

After teaching a client with diverticular disease, a nurse assesses the client's understanding. Which menu selection made by the client indicates the client correctly understood the teaching? a. Roasted chicken with rice pilaf and a cup of coffee with cream b. Spaghetti with meat sauce, a fresh fruit cup, and hot tea c. Garden salad with a cup of bean soup and a glass of low-fat milk d. Baked fish with steamed carrots and a glass of apple juice

ANS: D Clients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup of bean soup) should be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet. DIF: Applying/Application REF: 1187 KEY: Diverticular disease| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

A nurse cares for a client who has food poisoning resulting from a Clostridium botulinum infection. Which assessment should the nurse complete first? a. Heart rate and rhythm b. Bowel sounds c. Urinary output d. Respiratory rate

ANS: D Severe infection with C. botulinum can lead to respiratory failure, so assessments of oxygen saturation and respiratory rate are of high priority for clients with suspected C. botulinum infection. The other assessments may be completed after the respiratory system has been assessed. DIF: Applying/Application REF: 1191 KEY: Hydration| inflammatory bowel disorder MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client with a mechanical bowel obstruction reports that abdominal pain, which was previously intermittent and colicky, is now more constant. Which is the priority action of the nurse? a. Measure the abdominal girth. b. Place the client in a knee-chest position. c. Medicate the client with an opioid analgesic. d. Assess for bowel sounds and rebound tenderness.

ANS: D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse need not measure abdominal girth. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse should not medicate the client until the physician has been notified of the change in his or her condition.

14. A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? a. Administer intravenous opioid medications. b. Position the client with knees to chest. c. Insert a nasogastric tube for decompression. d. Assess the client's bowel sounds.

ANS: D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse should not medicate the client until the provider has been notified of the change in his or her condition. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse need not insert a nasogastric tube for decompression.

The nurse is teaching a client how to care for a new ileostomy. Which client statement indicates that additional teaching is needed? a. I will consult the pharmacist before filling any new prescriptions. b. I will empty the ostomy pouch when it is half-filled with stool or gas. c. I will wash my hands with antibacterial soap before and after ostomy care. d. I will call my health care provider if I have not had ostomy drainage for 3 hours.

ANS: D A client with an ileostomy should call the provider if no drainage has come from the ostomy in 6 to 12 hours. The other statements indicate good understanding of self-management

13. An emergency room nurse cares for a client who has been shot in the abdomen and is hemorrhaging heavily. Which action should the nurse take first? a. Send a blood sample for a type and crossmatch. b. Insert a large intravenous line for fluid resuscitation. c. Obtain the heart rate and blood pressure. d. Assess and maintain a patent airway.

ANS: D All of the options are important nursing actions in the care of a trauma client. However, airway always comes first. The client must have a patent airway, or other interventions will not be helpful.

A client is brought to the emergency department after being shot in the abdomen and is hemorrhaging heavily. Which action by the nurse is the priority? a. Draw blood for type and crossmatch. b. Start two large IVs for fluid resuscitation. c. Obtain vital signs and assess skin perfusion. d. Assess and maintain a patent airway.

ANS: D All options are important nursing actions in the care of a trauma client. However, airway always comes first. The client must have a patent airway, or other interventions will not be helpful.

The nurse is caring for a client who is taking mesalamine (5-aminosalicylic acid) (Asacol, Rowasa) for ulcerative colitis. The client has trouble swallowing the pill. Which action by the nurse is most appropriate? a. Crush the pill carefully and administer it to the client in applesauce or pudding. b. Empty the contents of the capsule into applesauce or pudding for administration. c. Contact the clients health care provider to request an order for Asacol suspension. d. Contact the clients health care provider to request an order for Rowasa enemas instead.

ANS: D Asacol is enteric coated and should not be crushed, chewed, or broken. If the client is unable to swallow the Asacol pill, Rowasa enemas may be administered instead, with a providers order. Asacol is not available as a suspension or elixir.

Which laboratory finding does the nurse expect to find on assessment of a client with advanced cirrhosis? a. Amylase, 129 IU/L; alkaline phosphate, 45 U/L b. Reticulocyte count, 1%; magnesium, 1.5 mEq/L c. Hemoglobin, 14 g/dL; direct bilirubin, 0.2 mg/dL d. Prothrombin time (PT), 17.5 seconds; albumin, 1.6 g/dL

ANS: D Cirrhosis frequently results in impaired production of clotting factors, with increased PT and partial thromboplastin time (PTT). Serum albumin is decreased with cirrhosis because protein formation within the liver is impaired. The other laboratory values are within normal limits and would not be expected with advanced cirrhosis.

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

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

5. A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer? a. A 37-year-old who drinks eight cups of coffee daily b. A 44-year-old with irritable bowel syndrome (IBS) c. A 60-year-old lawyer who works 65 hours per week d. A 72-year-old who eats fast food frequently

ANS: D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer.

The nurse is screening clients at a community health fair. Which client is at highest risk for development of colorectal cancer? a. Young adult who drinks eight cups of coffee every day b. Middle-aged client with a history of irritable bowel syndrome c. Older client with a BMI of 19.2 who works 65 hours per week d. Older client who travels extensively and eats fast food frequently

ANS: D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Irritable bowel syndrome, a heavy workload, and coffee intake do not increase the risk for colon cancer. A BMI of 19.2 is within normal limits.

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

ANS: D If pain is present in a certain area of the abdomen, that area should be palpated last to keep the client from tensing up, which could possibly affect the rest of the examination. Auscultation of the abdomen occurs prior to palpation.

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

ANS: D Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration and occlusion of the airway. The client usually is intubated and mechanically ventilated during this treatment. The client should be sedated, balloon pressure should be maintained between 15 and 20 mm Hg, and the lumen can be irrigated with saline or tap water. However, these are not a higher priority than airway patency.

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

ANS: D Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. Nausea and vomiting, headache, and vertigo and syncope are not side effects of vasopressin

The nurse is caring for a client who has food poisoning that may be the result of Clostridium botulinum infection. Which is the priority nursing assessment for this client? a. Heart rate and rhythm b. Bowel sounds and heart tones c. Fluid balance and urine output d. Oxygen saturation and respiratory rate

ANS: D Severe infection with Clostridium botulinum can lead to respiratory failure, so assessments of oxygen saturation and respiratory rate are of high priority for clients with suspected Clostridium botulinum infection. The other assessments may be completed after the respiratory system has been assessed.

The nurse is teaching self-care measures for a client who has hemorrhoids. Which nursing intervention does the nurse include in the plan of care for the client? a. Instruct the client to use dibucaine (Nupercainal) ointment whenever needed. b. Teach the client to choose low-fiber foods to make bowels move more easily. c. Tell the client to take his or her time on the toilet when needing to defecate. d. Encourage the client to dab with moist wipes instead of wiping with toilet paper.

ANS: D The client should be instructed to use wet wipes and dab the anal area after defecating to avoid further irritation. Dibucaine can be used only for short periods of time because long-term use can mask worsening symptoms. Clients with hemorrhoids require high-fiber foods. The client should not be encouraged to strain at stool or to spend long periods of time on the toilet, because this increases pressure in the rectal area, which can make hemorrhoids worse.

The nurse is caring for a client with Crohns disease who has developed a fistula. Which nursing intervention is the highest priority? a. Monitor the clients hematocrit and hemoglobin. b. Position the client to allow gravity drainage of the fistula. c. Check and record blood glucose levels every 6 hours. d. Encourage the client to consume a diet high in protein and calories.

ANS: D The client with Crohns disease is already at risk for malabsorption and malnutrition. Malnutrition impairs healing of the fistula and immune responses. Therefore, maintaining adequate nutrition is a priority for this client. The client will require 3000 calories per day to promote healing of the fistula. Monitoring the clients blood sugar and hemoglobin levels is important, but less so than encouraging nutritional intake. The client need not be positioned to facilitate gravity drainage of the fistula, because fistulas often are found in the abdominal cavity.

A female client is admitted with an exacerbation of ulcerative colitis. Which laboratory value does the nurse correlate with this condition? a. Potassium, 5.5 mEq/L b. Hemoglobin, 14.2 g/dL c. Sodium, 144 mEq/L d. Erythrocyte sedimentation rate (ESR), 55 mm/hr

ANS: D The erythrocyte sedimentation rate (ESR) is an indicator of inflammation, which is elevated during an exacerbation of ulcerative colitis. The normal range for the ESR is 0 to 33 mm/hr. Diarrhea caused by ulcerative colitis will result in loss of potassium and hypokalemia with levels lower than 3.5 mEq/L. Bloody diarrhea will lead to anemia, with hemoglobin levels lower than 12 g/dL in females. The sodium level is normal.

The nurse is caring for a client who has suffered abdominal trauma in a motor vehicle crash. Which laboratory finding indicates that the clients liver was injured? a. Serum lipase, 49 U/L b. Serum amylase, 68 IU/L c. Serum creatinine, 0.8 mg/dL d. Serum transaminase, 129 IU/L

ANS: D The level of serum transaminase, a liver enzyme, is elevated with liver trauma. The other laboratory values are within normal limits and are not specific for the liver.

21. A nurse cares for a client who has a family history of colon cancer. The client states, "My father and my brother had colon cancer. What is the chance that I will get cancer?" How should the nurse respond? a. "If you eat a low-fat and low-fiber diet, your chances decrease significantly." b. "You are safe. This is an autosomal dominant disorder that skips generations." c. "Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer." d. "You should have a colonoscopy more frequently to identify abnormal polyps early."

ANS: D The nurse should encourage the client to have frequent colonoscopies to identify abnormal polyps and cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer. Changing the client's diet, preemptive chemotherapy, and removal of polyps will decrease the client's risk but will not prevent cancer. However, a client at risk for colon cancer should eat a low-fat and high-fiber diet.

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

ANS: D To avoid possible exposure to infectious agents, the nurse dons gloves prior to handling any bodily secretions. Recent exposure to illness is not related to collecting a stool sample. The nurse can visually inspect the stool for food particles, but it still needs analysis in the laboratory. The container should be dated and timed, but safety for the staff and other clients comes first.

The nurse helps a client with diverticular disease choose appropriate dinner options. Which menu selections are most appropriate? a. Roasted chicken, rice pilaf, cup of coffee with cream b. Spaghetti with meat sauce, fresh fruit cup, hot tea with lemon c. Chicken Caesar salad, cup of bean soup, glass of low-fat milk d. Baked fish with steamed asparagus, dinner roll with butter, glass of apple juice

ANS: D Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup of bean soup) should be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet