HW Gastrointestinal system

A nurse is reinforcing discharge teaching with a client who is postoperative for a traditional cholecystectomy and has a T-tube in place. Which of the following instructions should the nurse include in the teaching?

"Empty the drainage bag at the same time each day." The nurse should instruct the client to empty the drainage bag at the same time each day to monitor the amount of drainage in a 24 hr period.

A nurse is reinforcing teaching to a client about how to perform fecal occult blood testing for screening of colorectal cancer. Which of the following statements by the client indicates a need for further teaching?

"I will continue my low-dose aspirin therapy regimen." NSAIDs and aspirin interfere with this testing. This statement indicates a need for further teaching.

nurse is reinforcing teaching with a parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?

"I will keep my baby in an upright position after feedings." The infant should be maintained in an upright position for 1 hr after feedings.

A nurse is collecting data from a client who has gastroesophageal reflux disease (GERD) and reports having heartburn every night. Which of the following actions should the nurse identify as a contributing factor to the client's heartburn?

Drinking orange juice regularly Spicy and acidic foods, such as orange juice, irritate inflamed esophageal tissue and decrease the pressure of the lower esophageal sphincter, causing heartburn.

A nurse is reinforcing preoperative teaching with a client who is to undergo a bowel resection at 1300 next week. Which of the following statements client indicates to the nurse a need for further teaching?

"I will take my warfarin with a glass of water the night before my surgery." Certain medications place the client at greater risk during surgery. Warfarin, NSAIDs, and aspirin are anticoagulants that can alter blood clotting and lead to bleeding. The client should discontinue these medications 7 to 14 days before surgery.

A nurse is caring for a client who routinely drinks alcohol. Which of the following information should the nurse provide the client about alcohol consumption?

"Medication is metabolized faster when alcohol is consumed regularly." Medication is metabolized faster when alcohol is consumed regularly due to alcohol-induced hepatic drug-metabolizing enzymes.

A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make?

"The pain will dissipate if you ambulate frequently." The client who has right shoulder pain following the procedure should ambulate as soon and as much as possible to dissipate the carbon dioxide gas that was injected into the abdominal cavity to visualize and access the abdominal structure. The carbon dioxide causes referred pain in the clavicle and shoulder area.

A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following information should the nurse include in the teaching?

"You may experience a small amount of bleeding around the stoma." A small amount of bleeding around the stoma and its stem can occur; however, an increase in bleeding should be reported to the surgeon.

A nurse is reinforcing teaching with a client who is lactose intolerant. Which of the following statements should the nurse include in the teaching?

"You should decrease the dairy products in your diet." A decrease in dairy products will reduce the symptoms associated with lactose intolerance.

A nurse is caring for a client and is preparing to insert a large bore NG tube. Identify the order of the steps the nurse should perform. (Move the steps of NG tube placement into the box on the right, placing them in the selected order of performance. Use all the steps.)

1. place the tube in a basin of warm water 2. measure how far to insert the tube. 3. determine how far to insert the tube 4. lubricate the tube with a water-soluble gel or water 5. insert the tube. 6. obtain an x-ray.

A nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for GERD. Available is famotidine 40 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

2.5

A nurse is caring for a client who requires an NG tube. After inserting the tube, the nurse tests the pH of the client's aspirate. Which of the following pH levels should the nurse identify as an indication of correct placement of the tube?

4.0 This is an acidic pH, which indicates gastric drainage. The tube is likely to be in the stomach.

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse identify as a risk factor for this condition?

History of ibuprofen use The nurse should identify long-term NSAID use as a risk factor for peptic ulcer disease. Aspirin and glucocorticoids can also induce peptic ulcers.

A nurse assisting with a staff in-service is discussing aspiration. Which of the following descriptions should the nurse include in the teaching as a manifestation dysphagia?

Inconsistent vocal ability after swallowing The nurse should include that some clients who have difficulty swallowing might have silent aspiration where there is no coughing when food is aspirated.

A nurse collecting data from a client who has manifestations of appendicitis. Where should the nurse palpate to monitor for pain at McBurney's point? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

McBurney's point is found between the navel and the anterior iliac crest. RLQ

A nurse is preparing to administer orlistat to a client for treatment of obesity. For which of the following adverse effects should the nurse monitor?

Oily fecal spotting Because the medication reduces the gastrointestinal tract's absorption of fat, oily fecal spotting is an adverse effect of orlistat.

A nurse is caring for a child who has acute diarrhea and reports that he is thirsty. Which of the following fluids should the nurse give the child?

Pedialyte Pedialyte is an oral rehydration therapy used for children who have dehydration due to diarrhea. Pedialyte provides the child with fluids, sugar, and electrolyte content that is lost due to diarrhea.

A nurse is reviewing the laboratory values of a client who is receiving total parenteral nutrition (TPN): glucose 72 mg/dL, chloride 100 mEq/L, sodium 138 mEq/L, and potassium 3.0 mEq/L. Which of the following actions should the nurse plan to take?

Request a potassium replacement. This potassium level is below the expected reference range. Therefore, the nurse should initiate cardiac monitoring and request a potassium replacement.

A nurse is caring for a client who is postoperative and has a prescription for a full liquid diet. The nurse enters the client's room to find he has just received a dietary tray. Which of the following items on the tray should the nurse remove?

Scrambled eggs A full liquid diet includes foods that are liquid at room or body temperature. Scrambled eggs do not liquefy at room temperature. They are a component of a soft diet.

A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestation should the nurse expect to find?

Spider angioma The nurse should expect to find spider angioma, which indicates portal hypertension, on the client who has advanced cirrhosis.

A nurse is reinforcing dietary teaching with a client who tells the nurse she would like to reduce her solid fat intake and increase oil intake in her diet. Which of the following instructions should the nurse include in the teaching?

Use safflower oil instead of butter when baking. The client should replace butter with safflower oil when baking to decrease solid fats and increase oil intake.

A nurse is caring for a client who is postoperative and has a prescription for a clear liquid diet. The nurse enters the client's room to find he has just received a dietary tray. Which of the following items on the tray should the nurse remove?

Vanilla pudding A clear liquid diet includes only foods that are clear at room or body temperature. Pudding contains milk and should not be on a clear liquid diet tray.

A client tells the nurse that he suspects that he grinds his teeth at night. Along with giving the client a dental referral, the nurse should explain that the client should see a dentist for this problem, which she should document as which of the following disorders?

​Bruxism Bruxism, a clenching or grinding of the teeth during sleep, can damage to the teeth. A dentist can provide a custom-fitted, comfortable dental appliance to protect the teeth during sleep.

A nurse in a clinic is caring for a client who has alcohol use disorder. The client reports frequent bruising and nosebleeds. Which of the following conditions should the nurse suspect?

​Cirrhosis Excessive alcohol use can cause liver cirrhosis leading to impaired bleeding time. The nurse should check the client for other findings such as clay-colored stools, anorexia, and weight loss.

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

​Cranberry juice Cranberry juice is an acceptable component of a clear liquid diet, along with apple juice and grape juice.

A nurse is caring for a client who is postoperative and has an NG tube that has drained 2,500 mL in the past 6 hr. The nurse should monitor the client for which of the following electrolyte imbalances?

​Decreased potassium level Loss of gastric fluid is a common cause of potassium depletion.

The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?

​Paralytic ileus A paralytic ileus in the postoperative client is indicated by the absence of bowel sounds, abdominal distention, and the client passing no stool or flatus. It is often caused by bowel handling during surgery and opioid analgesic use.

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

Assist the client to the left Sims' position. This position makes it easier for the enema solution to flow by gravity into the sigmoid and rectum and promotes retention of the solution. The nurse should also have the client's right leg flexed to facilitate tube insertion.

A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching?

Avoid medications in capsule or enteric form. The client should not take medications in capsule or enteric form because the medication may enter the pouch undigested.

A nurse is caring for a client who has a prescription for a stool guaiac test. The client asks the nurse about the purpose of the test. The nurse should respond by stating that the stool guaiac is testing for which of the following findings in the client's feces?

Blood A guaiac (fecal occult blood) test detects microscopic amounts of blood in the stool and is a screening tool for colorectal cancer.

A nurse is caring for a newly admitted adolescent who has anorexia nervosa. Which of the following findings should the nurse expect?

Lanugo is a finding associated with anorexia nervosa.

A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?

Lower the height of the solution bag. Lowering the bag slows the solution's flow rate temporarily and should relieve cramping.

A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care?

Maintain the client in Fowler's position. The nurse should place the client in Fowler's position to reduce pressure on the diaphragm and to promote function of the nasogastric tube.

A nurse is inserting an NG tube. Identify the sequence the nurse should follow. (Move the steps of NG tube insertion on the left into the box on the right, placing them in the selected order of performance. All steps must be used.)

Place the client in high Fowler's position because it promotes the client's ability to swallow during the procedure. The nurse should also raise the bed to promote good body mechanics and prevent injury to herself.The nurse should measure the tube in order to know how far to advance the tube. When determining placement length, the nurse should measure the distance from the tip of the nose to earlobe to xiphoid process. The nurse should mark the tube as an indication of how far to advance to the stomach.The nurse should lubricate 7.5 to 10 cm (4 to 6 in) of the end of the tube with water-soluble lubricating jelly. This minimizes friction against the nasal mucosa and aids insertion of the tube. The nurse should insert the tube along the base of the nares to minimize the discomfort of the tube rubbing against the upper nasal turbinates.The nurse should advance the tube downward and backward. Downward pressure helps the tube curl around the corner of the nasopharynx. Backward motion aligns the tube with the nasopharynx structures. This also helps prevent coiling of the tube in the oropharynx. With the tube just above the oropharynx, the nurse should instruct the client to flex head forward, take a small sip of water, and swallow. The nurse should advance the tube 2.5 to 5 cm (1 to 2 in) with each swallow. The flexed position closes off the upper airway to the trachea and opens the esophagus. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Swallowing water reduces gagging or choking. If the client begins to cough, gag, or choke, the nurse should withdraw the tube slightly and stop tube advancement. The nurse should instruct the client to breathe easily and take sips of water. The nurse should check the position of the tube according to agency policy and then secure it.

A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority?

Potassium 2.5 mEq/L When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is a potassium level of 2.5 mEq/dL. In the presence of fluid volume deficit, potassium depletion can occur. Complications from hypokalemia include cardiac and respiratory manifestations.