GI/Hepatic
A client has a PRN prescription for ondansetron (Zofran). For which conditions should the nurse administer this medication to the postoperative client? 1. Paralytic ileus 2. Incisional pain 3. Urinary retention 4. Nausea and vomiting
Answer: 4- Nausea and vomiting Rationale: Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. The other options are incorrect. Focus on the subject, the action of ondansetron. Recalling that this medication is an antiemetic will direct you to the correct option.
A client has a PRN prescription for loperamide hydrochloride (Imodium). For which condition should the nurse administer this medication? 1. Constipation 2. Abdominal pain 3. An episode of diarrhea 4. Hematest-positive nagogastric tube drainage
Answer: 3- An episode of diarrhea Rationale: Loperamide is an antidiarrheal agent. It is used to manage acute and chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used to the conditions in options 1, 2, and 4. Focus on the subject, the action of loperamide. Recalling that this medication is an antidiarrheal agent will direct you to the correct option.
A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? 1. Lying recumbent following meals 2. Consuming small, frequent, bland meals 3. Raising the head of the bed on 6- inch blocks 4. Taking H2-receptor antagonist medications
Answer 1- Lying recumbent following meals Rationale: Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm where the esophagus usually is positioned. The client usually experiences pain from reflux caused by ingestion of irritating foods, lying flat following meals or at night, and eating large or fatty meals. Relief is obtained with the intake of small, frequent, and bland meals, use of H2-receptor antagonists and antacids, and elevation of the thorax following meals and during sleep. Focus on the subject, the action contraindicated in hiatal hernia. Thinking about the pathophysiology that occurs in hiatal hernia will direct you to the correct option.
The nurse is planning to teach a client with gastroesophageal reflux disease about substances to avoid. Which items should the nurse include on this list? Select all that apply. 1. Coffee 2. Chocolate 3. Peppermint 4. Nonfat milk 5. Fried chicken 6. Scrambled eggs
Answer: 1, 2, 3, and 5 Rationale: Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus will increase reflux and exacerbate the symptoms of gastroesophageal reflux disease (GERD) and therefore should be avoided. Aggravating substances include chocolate, coffee, fried or fatty foods, peppermint, carbonated beverages, and alcohol. Options 4 and 6 do not promote this effect. Focus on the subject, substances that increase lower esophageal pressure. Use knowledge of the effect of various foods on LES pressure and GERD. However, if you are unsure, select the options that identify the most healthful food item(s).
A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. 1. Administer stool softeners as prescribed 2. Instruct the client to limit fluid intake to avoid urinary retention 3. Instruct the client to avoid activities that will initiate vasovagal responses. 4. Encourage a high-fiber diet to promote bowel movements without straining 5. Apply cold packs to the anal-rectal area over the dressing until packing is removed 6. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding
Answer: 1, 4, 5 Rationale: Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance of bleeding and incision rupture. Stool softeners and a high-fiber diet will help the client avoid straining, therapy reducing the chances of rupturing the incision. An ice pack will increase comfort and decrease bleeding. Options 2, 3, an 6 are incorrect interventions Focus on the subject, postoperative hemorrhoidectomy care. Recall that decreasing fluid intake will cause difficulty with defecation because of hard stool. Recognize that Fowler's position will increase pressure in the rectal area, causing increased bleeding and increased pain. From the remaining options, think about vasovagal response and that prevention of the vasovagal response is not a concern with hemorrhoidectomy.
The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to note documented in the client's record? 1. Diarrhea 2. Chronic constipation 3. Constipation alternating with diarrhea 4. Stool constantly oozing from the rectum
Answer: 1- Diarrhea Rationale: Crohn's disease is characterized by nonbloody diarrhea of unusually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration and severity. Options 2, 3, and 4 are not characteristics of Crohn's disease. Focus on the subject, the characteristics of Crohn's disease. Eliminate option 4 first as the most unlikely occurrence. From the remaining options, think about the pathophysiology associated with Crohn's disease to direct you to the correct option.
The health care provider has determined that a client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D
Answer: 1- Hepatitis A Rationale: Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids. Note the strategic words MOST LIKELY. Recalling the modes of transmission of the various types of hepatitis is required to answer this question. Remember that hepatitis A is transmitted by the fecal-oral route.
The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for this client? 1. Low-protein diet 2. High-protein diet 3. Moderate-fat diet 4. High-carbohydrate diet
Answer: 1- Low-protein diet Rationale: Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration of hepatocytes. Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. If the client has hepatic encephalopathy, a low-protein diet would be prescribed. Focus on the subject, an elevated ammonia level. Recall the physiology of the liver to assist in answering. Also, note that the correct option and option 2 are opposite, which should provide you with the clue that one of these options is correct.
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? 1. Malaise 2. Dark stools 3. Weight gain 4. Left upper quadrant discomfort
Answer: 1- Malaise Rationale: Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts. Focus on the subject, expected assessment findings. Recalling the function of the liver will direct you to the correct option. Remember that fatigue and malaise are common.
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing interventions? 1. Notify the health care provider (HCP) 2. Administer the prescribed pain medication 3. Call and ask the operating room team to perform the surgery as soon as possible 4. Reposition the client and apply a heating pad on the warm setting to the client's abdomen
Answer: 1- Notify the health care provider Rationale: On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the HCP. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the HCP probably would perform the surgery earlier than the prescheduled time. Note the strategic words MOST APPROPRIATE. Focus on the signs and symptoms in the question and consider the complications that can occur with appendicitis. Noting that the signs presented in the question indicate a complication will assist in directing you to the correct option.
The nurse is assessing for stoma prolapse in a client with a colostomy. What should the nurse observe if stoma prolapse occurs? 1. Protruding stoma 2. Sunken and hidden stoma 3. Narrowed and flattened stoma 4. Dark- and bluish colored stoma
Answer: 1- Protruding stoma Rationale: A prolapsed stoma is one in which the bowel protrudes through the stoma. A stoma retraction is characterized by sinking of the stoma. A stoma with a narrowed opening at the level of the skin or fascia is said to be stenosed. Ischemia of the stoma would be associated with a dusky or bluish color. Focus on the subject, the characteristics of prolaptsed stoma. Focusing on the word PROLAPSE will direct you to the correct option.
The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? 1. Sweating and pallor 2. Bradycardia and indigestion 3. Double vision and chest pain 4. Abdominal cramping and pain
Answer: 1- Sweating and pallor Rationale: Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. Note the strategic word, EARLY. Think about the pathophysiology associated with dumping syndrome and its etiology to answer correctly
A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1. This is a normal, expected event 2. The client is experiencing early signs of ischemic bowel 3. The client should not have the nasogastric tube removed 4. This indicates inadequate preoperative bowel preparation
Answer: 1- This is a normal, expected event Rationale: As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect. Focus on the subject, that the client is passing flatus from the stoma. Recalling the normal progression of bowel activity following ostomy formation will direct you to the correct option.
A client with Crohn's disease is scheduled to receive an infusion of inflizimab (Remicade). What intervention by the nurse will determine the effectiveness of treatment? 1. Monitoring the leukocyte count for 2 days after the infusion 2. Checking the frequency and consistency of bowel movements 3. Checking serum liver enzyme levels before and after the infusion 4. Carrying out a Hematest on gastric fluids after the infusion is complete
Answer: 2- Checking the frequency and consistency of bowel movements Rationale: The principal manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab (Remicade) is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea. Options 1, 3, and 4 are unrelated to this medication. Focus on the subject, Crohn's disease, and evaluating the effectiveness of medication. Eliminate option 4 because gastric bleeding is not characteristic of Crohn's disease. Monitoring the leukocyte count and liver enzyme levels is appropriate when infliximab (Remicade) is given but not to evaluate the effectiveness of treatment, eliminating options 1 and 3.
A client has been taking omeprazole (Prilosec) for 4 weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absences of which symptom? 1. Diarrhea 2. Heartburn 3. Flatulence 4. Constipation
Answer: 2- Heartburn Rationale: Omeprazole is a proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called heartburn by clients. Omeprazole is not used to treat the conditions identified in options 1, 3, and 4. Focus on the subject, the optimal intended effect of omeprazole. Recalling that this medication is a proton pump inhibitor will direct you to the correct option.
A client is admitted to the hospital with viral hepatitis, complaining of "no appetite" and "losing my taste for food". What instruction should the nurse give the client to provide adequate nutrition? 1. Select foods high in fat 2. Increase intake of fluids, including juices 3. Eat a good supper when anorexia is not as severe 4. Eat less often, preferably only three large meals daily
Answer: 2- Increase intake of fluids, including juices Rationale: Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. And adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important. Focus on the subject, a diet for viral hepatitis. Thank about the pathophysiology associated with hepatitis and focus on the client's complaints to direct you to the correct option.
A client who chronically uses nonsteroidal anti-inflammatory drugs (NSAIDs) has been taking misoprostol (Cytotec). The nurse determines that the medication is having the intended therapeutic effect if which finding is noted. 1. Resolved diarrhea 2. Relief of epigastric pain 3. Decreased platelet count 4. Decreased white blood cell count
Answer: 2- Relief of epigastric pain Rationale: The client who chronically uses nonsteroidal anti-inflammatory drugs (NSAIDs) is prone to gastric mucosal injury. Misoprostol is a gastric protectant and is given specifically to prevent this occurrence. Diarrhea can be a side effect to the medication but is not an intended effect. Options 3 and 4 are incorrect. Focus on the subject, the intended therapeutic effect of misoprostol for a client who chronically uses NSAIDs. This indicates that the medication is being given to prevent the occurrence of specific symptoms. Recalling that NSAIDs can cause gastric mucosal injury will direct you to the correct option.
A client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing the client's pain. What type of pain is consistent with this diagnosis? 1. Burning and aching, located in the left lower quadrant and radiating to the hip 2. Severe and unrelenting, located in the epigastric area and radiating to the back 3. Burning and aching, located in the epigastric area and radiating to the umbilicus 4. Severe and unrelenting, located in the lower left quadrant and radiating to the groin
Answer: 2- Severe and unrelenting, located in the epigastric area and radiating to the back Rationale: The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back. The other options are incorrect. Noting the word ACUTE will assist in eliminating options 1 and 3 because they are comparable or alike. From the remaining options, recalling the anatomical location of the pancreas will direct you to the correct option.
The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse monitors the client, knowing that this client is at risk for which vitamin deficiency? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin E
Answer: 2- Vitamin B12 Rationale: Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of function of the parietal cells. The source of intrinsic factor is lost, which results in an inability to absorb vitamin B12. This leads to the development of pernicious anemia. The client is not at risk for vitamin A, C, or E deficiency. Focus on the subject, vitamin deficiency in a client with gastritis. Recalling the pathophysiology related to pernicious anemia and vitamin B12 deficiency will direct you to the correct option.
The nurse is doing preoperative teaching with a client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which statement? 1. "I will be able to pass stool by the rectum eventually" 2. "The drainage from this type of ostomy will be formed" 3. "I will need to drain the pouch regularly with a catheter" 4. "I will need to wear a drainage bag for the rest of my life"
Answer: 3- "I will need to drain the pouch regularly with a catheter" Rationale: A Kock pouch is a continent ileostomy. As the ileostomy beings to function, the client drains it every 3 to 4 hours and then decreases the draining to about three times a day, or as needed when full. The client does not need to wear a drainage bag but should wear and absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool from the rectum only if an ileal anal pouch or anastomosis were created. This type of operation is a two-stage procedure. Note the strategic word, BEST. Think about the anatomy related to the creation of a Kock pouch to assist in answering correctly.
The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography procedure. The nurse determines that the client needs further information if the client makes which statement? 1. "I know I must sign the consent form" 2. "I hope the throat spray keeps me from gagging" 3. "I'm glad I don't have to lie still for this procedure" 4. "I'm glad some IV medication will be given to relax me"
Answer: 3- "I'm glad I don't have to lie still for this procedure" Rationale: The client does have to lie still for endoscopic retrograde cholangiopancreatography (ERCP), which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed. Note the strategic words NEEDS FURTHER INFORMATION. These words indicate a negative event query and ask you to select an option that is incorrect. Invasive procedures require consent, so option 1 can be eliminated. Noting the name of the procedure and considering the anatomical location will assist you in eliminating option 2 and 4.
A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin (Biaxin), esomeprazole (Nexium), and amoxicillin (Amoxil). Which statement by the client indicates the best understanding of the medication regimen? 1. "My ulcer will heal because these medications will kill the bacteria" 2. "These medications are only taken when I have pain from my ulcer" 3. "The medications will kill the bacteria and stop the acid production" 4. "These medications will coat the ulcer and decrease the acid production in my stomach"
Answer: 3- "The medications will kill the bacteria and stop the acid production" Rationale: Triple therapy for Helicobacter pylori infection usually includes two antibacterial mediations and a proton pump inhibitor. Clarithromycin and amoxicillin are antibacterials. Esomeprazole is a proton pump inhibitor. These medications will kill the bacteria and decrease acid production. Focus on the subject, the medications and their actions. Eliminate option 1 because the medications do more than kill the bacteria. These medications are taken not only when there is pain but continually until gone, usually for 1 to 2 weeks. This will eliminate option 2. These medications do not coat the ulcer, eliminating option 4.
The nurse has given instructions to a client who has just been prescribed cholestyramine (Questran). Which statement by the client indicates a need for further instructions? 1. "I will continue taking vitamin supplements" 2. "This medication will help lower my cholesterol" 3. "This medication should only be taken with water" 4"A high-fiber diet is important while taking this medication"
Answer: 3- "This medication should only be taken with water" Rationale: Cholestyramine (Questran) is a bile acid sequenstrant used to lower the cholesterol level, and client compliance is a problem because of its taste and palatability. The use of flavored products or fruit juices an improve the taste. Some side effects of bile acid sequestrants include constipation and decreased vitamin absorption. Note the strategic words NEED FOR FURTHER INSTRUCTIONS. These words indicate a negative event query and the close-ended work ONLY in the correct options.
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1. Dorsiflex the client's foot 2. Measure the abdominal girth 3. Ask the client to extend the arms 4. Instruct the client to lean forward
Answer: 3- Ask the client to extend the arms Rationale: Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bend up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect. Focus on the subject, the procedure for assessment of asterixis. Remember that asterixis is irregular flapping movements of the fingers and wrists. This will direct you to the correct option.
An older client recently has been taking cimetidine (Tagamet). The nurse monitors the client for which most frequent central nervous system side effect of this medication? 1. Tremors 2. Dizziness 3. Confusion 4. Hallucinations
Answer: 3- Confusion Rationale: Cimetidine is a histamine (H2)- receptor antagonist. Older clients are especially susceptible to central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, and hallucinations. Note the strategic word, MOST. Use knowledge of the older client and medication effects to direct you to the correct option.
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? 1. Clamp the T-tube 2. Irrigate the T-tube 3. Document the findings 4. Notify the heath care provider
Answer: 3- Document the findings Rationale: Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output. Note the strategic words, MOST APPROPRIATE. Options 1 and 2 can be eliminated because a T-tube is noted irrigated and would not be clamped with this amount of drainage. From the remaining options, you must know normal expected findings following this surgical procedure.
The nurse is caring for a client following a Billroth II procedure. Which postoperative prescription should the nurse question and verify? 1. Leg exercises 2. Early ambulation 3. Irrigating the nasogastric tube 4. Coughing and deep-breathing exercises
Answer: 3- Irrigating the nasogastric tube Rationale: In a Billroth II procedure, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically prescribed by the health care provider. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions. Note the words QUESTION AND VERIFY. Eliminate options 1, 2, and 4 because they are comparable or alike and are general postoperative measures. Also, consider the anatomical location of the surgical procedure to assist in directing you to the correct option.
The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? 1. Ambulate following a meal 2. Eat high-carbohydrate foods 3. Limit the fluids taken with meals 4. Sit in a high Fowler's position during meals
Answer: 3- Limit the fluids taken with meals Rationale: Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a Billroth II procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed. Eliminate options 1 and 4 first because these measure are comparable or alike and will promote gastric emptying. From the remaining options, select the measure that will delay gastric emptying.
The nurse is doing an admission assessment on a client with a history of duodenal ulcer. to determine whether the problem is currently active, the nurse should assess the client for which symptoms(s) of duodenal ulcer? 1. Weight loss 2. Nausea and vomiting 3. Pain relieved by food intake 4. Pain radiating down the right arm
Answer: 3- Pain relieved by food intake Rationale: A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the mid-epigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer. Eliminate options 1 and 2 because they are comparable or alike: if the client is vomiting, weight loss will occur. Next, think about the symptoms of duodenal and gastric ulcer. Choose the correct option over option 4, knowing that the pain does not radiate down the right arm and that a pattern of pain-food-relief occurs with duodenal ulcer.
The client has begun medication therapy with pancrelipase (Pancrease MT). The nurse evaluates that the medication is having the optimal intended benefit if which effect is observes? 1. Weight loss 2. Relief of heartburn 3. Reduction of steatorrhea 4. Absence of abdominal pain
Answer: 3- Reduction of steatorrhea Rationale: Pancrelipase (Pancrease, Creon) is a pancreatic enzyme used in clients with pancreatitis as digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. Its use could result in weight gain but should not result in weight loss if it is aiding in digestion. Focus on the subject, intended benefit of the medication and on the name of the medication. Use knowledge of physiology of the pancreas to assist in directing you to the correct option.
The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? 1. Bradycardia 2. Numbness in the legs 3. Nausea and vomiting 4. A rigid, boardlike abdomen
Answer: 4- A rigid, boardlike abdomen Rationale: Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the mid-epigastric area and spreading over the abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding. Focus on the subject, perforation. Option 2 can be eliminated easily because it is not related to perforation. Eliminated option 1 next because tachycardia rather than bradycardia would develop if perforation occurs. From the remaining options, note the strategic words MOST LIKELY to help direct you to the correct option
A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? 1. Monitoring the temperature 2. Monitoring the complaints of heartburn 3. Giving warm gargles for a sore throat 4. Assessing for the return of the gag reflex
Answer: 4- Assessing for the return of the gag reflex Rationale: The nurse places highest priority on assessing for the return of the gag reflex. This assessment addresses the client's airway. The nurse also monitors the clients vital signs and for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client's airway take priority. Note the strategic words HIGHEST PRIORITY. Use the ABC's- airway, breathing, and circulation. The correction option addresses the airway.
A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of the type of surgery? 1. Folate deficiency 2. Malabsorption of fat 3. Intestinal obstruction 4. Fluid and electrolyte imbalance
Answer: 4- Fluid and electrolyte imbalance Rationale: A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period. Noted the strategic words MOST FREQUENT. Also note the subject, the ileostomy. Remember that ileostomy drainage is liquid, placing the client at risk for fluid and electrolyte imbalance.
A client with a gastric ulcer has a prescription for sucralfate (Carafate), 1 g by mouth four times daily. The nurse should schedule the medication for which times? 1. With meals and at bedtime 2. Every 6 hours around the clock 3. One hour after meals and at bedtime 4. One hour before meals and at bedtime.
Answer: 4- One hour before meals and at bedtime Rationale: Sucralfate is a gastric protectant. The medication should be scheduled for administration 1 hour before meals and at bedtime. The medication is timed to allow it to form a protective coating over the ulcer before food intake stimulates gastric acid production and mechanical irritation. The other options are incorrect. Focus on the subject, times to administer sucralfate. Note the client's diagnosis and think about the pathophysiology associated with a gastric ulcer to assist in directing you to the correct option.
The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain? 1. Right lower quadrant, radiating to the back 2. Right lower quadrant, radiating to the umbilicus 3. Right upper quadrant, radiating to the left scapula and shoulder 4. Right upper quadrant, radiating to the right scapula and shoulder
Answer: 4- Right upper quadrant, radiating to the right scapula and shoulder Rationale: During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula and shoulder. This is determined by the pattern of dermatomes in the body. The other options are incorrect. Focus on the subject, the location of pain associated with cholecystitis. Recalling the anatomical location of the gallbladder will direct you to the correction option.
A client has a new prescription for metoclopramide (Reglan). On review of the chart, the nurse identifies that this medication can be safely administered with which condition? 1. Intestinal obstruction 2. Peptic ulcer with melena 3. Diverticulitis with perforation 4. Vomiting following cancer chemotherapy
Answer: 4- Vomiting following cancer chemotherapy Rationale: Metoclopramide is a gastrointestinal stimulant and antiemetic. Because it is a gastrointestinal stimulant, it is contraindicated with gastrointestinal obstruction, hemorrhage, or perforation. It is used in the treatment of emesis after surgery, chemotherapy, and radiation. Focus on the subject, safe use of metoclopramide. Recalling the classification and action of this medication and that it is an antiemetic will direct you to the correct option.
A histamine (H2)-receptor antagonist will be prescribed for a client. The nurse understand that which medications are H2-receptor antagonists? Select all that apply. 1. Nizatidine (Axid) 2. Ranitidine (Zantac) 3. Famotidine (Pepcid) 4. Cimetidine (Tagemet) 5. Esomeprazole (Nexium) 6. Lansoprazole (Prevacid)
Answers: 1, 2, 3, and 4 Rationale: H2-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist in preventing complications of peptic ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions. The other medications listed are proton pump inhibitors. Focus on the subject, medications that are classified as H2-receptor antagonists. Recalling that these medication names end with -dine will assist in answering this question. Also, recall that proton pump inhibitor medication names end with -zole.
The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Administer antacids as prescribed 2. Encourage coughing and deep-breathing 3. Administer anticholinergics as prescribed 4. Give small, frequent high-calorie feedings 5. Maintain the client in a supine and flat position 6. Give meperidine (Demerol) as prescribed for pain
Answers: 1, 2, 3, and 6 Rationale: The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions. Because abdominal pain is a prominent symptoms of pancreatitis, pain medications such as meperidine is prescribed. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress gastrointestinal secretions. Focus on the subject, care for the client with acute pancreatitis. Think about the pathophysiology associated with pancreatitis and note the word ACUTE. This will assist in selecting the correct options.
