Med Surg 2 Test 2

Complications of TPN

1. Metabolic problems Refeeding syndrome- fluid retention and electrolyte imbalances HYPOPHOSPHATEMIA Hypo or Hyperglycemia Liver dysfunction Hyperlipidemia 2. Catheter related problems Air embolus Pneumothorax Hemorrhage INFECTION

Pancreatitis complications

1. Pancreatic Pseudocyst- accumulation of fluid, pancreatic enzymes, tissue debris, and inflammatory exudates 2. Pancreatic abscess- when pseudocyst gets infected causing extensive necrosis in the pancreas

A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? a. Assessment of vital signs b. Completion of abdominal examination c. Insertion of the prescribed nasogastric tube d. Thorough investigation of precipitating events

A

Signs of compensation for metabolic acidosis include a. Deep rapid respirations b. Flushing of the skin c. Hypoventilation d. Increased confusion.

A

Signs of compensation for metabolic acidosis include a. Deep rapid respirations b. Flushing of the skin c. Hypoventilation d. Increased confusion.

A

With acute pancreatitis, what lab value rises within 12 hours and stays elevated for 4 days? a. Serum amylase b. Serum lipase. c. Serum potassium d. Serum triglyceride

A

The nurse anticipates a patient will need an esophagastroduodenoscopy (EGD). Select all the actions that are appropriate in this patient's care. A. Signed informed consent B. Teaching related to conscious sedation C. Full set of vital signs prior to procedure D. Clear liquids until procedure E. Keep the patient NPO until gag reflex returns post- procedure

A, B, C, E

Signs and symptoms of a bowel perforation might include: Select all that apply: a. Free air under the diaphragm on Xray b. A sudden change in pain and new pain in the shoulder c. Changes in vital signs including elevated temperature d. A flat, soft abdomen

A,B,C

The nurses places a priority on which of these interventions to care for a client with an NG Tube. Select all that apply: a. Positioning the patient in Semi- Fowler's position b. Frequent oral care for dry oral mucosa c. Use of low intermittent suctioning d. Frequent assessment of bowel sounds e. Keep the patient on bedrest

A,B,C,D

Peritonitis clinical manifestations

Abdominal pain Round tenderness Muscular rigidity Spasms Distention Fever Tachycardia Tachypnea N/V Altered bowel habits

Diverticulitis clinical manifestations

Acute LLQ pain (location of sigmoid colon) Palpable abdominal mass N/V Systemic symptoms of infection

Acute abdominal pain Dx

CBC Urinalysis x-Ray/CT EKG Pregnancy Test (if female childbearing age)

Intestinal Dx studies

CT/X-ray Sigmoidoscopy Colonoscopy CBC Blood chemistry

The nurse is changing the subclavian dressing of a client. When assessing the catheter insertion site, the nurse notes the presence of yellow drainage from around the sutures that are anchoring the catheter. What should the nurse obtain before cleaning the site?

Culture specimen

1. The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates an accurate understanding of this disorder? Cushing's disease results from ... a. An oversecretion of insulin b. An undersecretion of corticotropic hormones c. An undersecretion of mineralocorticoid hormones d. An increased pituitary secretion of adrenocorticotropic hormone (ACTH)

D

A client arrives at the clinic complaining of fatigue, lack of energy, constipation, and depression. Hypothyroidism is diagnosed, and levothyroxine (Synthroid) is prescribed. What is an expected outcome of the medication? a. Alleviate depression b. Increase energy levels c. Increase blood glucose levels d. Achieve normal thyroid hormone levels

D

GI drug therapy

Fluid replacement H2 receptor blocker (ranindine) PPI (omezprazole)

GI nursing priorities

Focus on identifying s/s of shock :Tachycardia, weak pulse, hypotension, cool extremities, prolonged capillary refill, and apprehension, hemorrhage (1500mL hypotension & tachycardia) Urine output (best measure of vital organ profusion) Bowel sounds Palpation of abdomen

H. Pylori

H. Pylori infection often occurs by fecal-oral route. In the stomach, the bacteria can survive a long time by colonizing the gastric epithelial cells within the mucosal layer. The bacteria produce urease, which metabolizes urea-producing ammonium chloride and other damaging chemicals. Urease activates the immune response with both antibody production and the release of inflammatory cytokines. This leads to increased gastric secretion and produces tissue damage

peritonitis Dx

HX & physical CBC with differential Serum electrolytes Abdominal x-ray Paracentesis and culture CT/Ultrasound Peritoneoscopy

Diverticulitis Patient Teaching

High fiber diet High levels of physical activity increase fluid intake to 2L/day Wt. reduction Avoid increase in intraabdominal pressure (straining at stool, bending)

Acute Abdominal Pain Assessment

Hx and Physical (abdomen, rectum, pelvis) Description of pain Description of symptoms Description of sequence of symptoms Patient position: Fetal posture- peritoneal irritation Supine posture with outstretched legs- visceral pain Restlessness with seated posture- bowel obstruction, gallstones

Cholecystitis clinical manifestations

Indigestion Pain in RUQ to right shoulder and scapula Fever N/V Restlessness Diaphoresis Chills Jaundice

Pancreatitis clinical manifestations

LUQ abdominal pain that radiates to the back Flushing cyanosis Dyspnea N/V Low grade fever Hypotension Tachycardia Jaundice

Gastritis etiology

Occurs as a result of breakdown in the normal gastric mucosal barrier. This barrier normally protects the stomach tissue from the corrosive action of HCl acid and pepsin. When barrier is broken, HCl acid and pepsin can diffuse back into mucosa. The back diffusion results in edema, disruption of capillary walls with loss of plasma into the gastric lumen, and possible hemorrhage

Difference between PPN & CPN

PPN: nutritional support is needed for only a short time Protein and caloric requirements are not high Risk of central catheter Supplementation or Oral intake CPN: indicated for long term support

Peritonitis nursing assessment

Pain: including location Presence and quality of bowel sounds Abdominal distention Abdominal guarding Nausea Fever Manifestations of shock

H. Pylori Tx

Triple drug therapy: PPI 2 antibiotics

Cholecystitis DX

Ultrasound ERCP with culture Percutaneous transhepatic cholangiography Labs: WBC: increased Bilirubin levels: increased Serum enzymes: increased Serum amylase: increased

pernicious anemia Tx

Vit B12

Intestinal obstruction clinical manifestations

abdominal pain vomiting distention constipation

abdominal distension

excessive gas accumulation, enlarged abdomen, generalized tympany usually caused by obstruction or paralytic ileus

Gastrointestinal bleeding clinical manifestation

hematemesis melena occult blood

absent bowel sounds

no bowel sounds upon auscultation usually caused by peritonitis, paralytic ileus, or obstruction

rebound tenderness

sudden pain when fingers withdrawn quickly usually caused by peritoneal inflammation or appendicitis

hematemesis

vomiting of blood usually caused by esophageal varices, bleeding peptic ulcer

Patient education following laparoscopic cholecystectomy

1. Remove the bandages on the puncture sites the day after surgery and you can shower. 2. Notify your surgeon if any of the following signs and symptoms occurs: • Redness, swelling, bile- colored drainage or pus from any incision • Severe abdominal pain, nausea, vomiting, fever, chills 3. You can gradually resume normal activities. 4. Return to work within 1 wk of surgery. 5. You can resume your usual diet, but a low-fat diet is usually better tolerated for several weeks after surgery.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment data should alert the nurse to this occurrence? a. Inability to pass flatus b. Loss of anal sphincter control c. Severe, constant pain with rapid onset d. Firm, nontender mass palpable at the lower right costal margin

A

In caring for a client with cholelithiasis and a possible biliary obstruction what clinical findings would you expect? Select all that apply a. Clay colored or light colored bowel movements b. Abdominal pain c. Dilute yellow urine d. Jaundice e. Normal appetite

A,B,D

In preparing a client for a colonoscopy, the nurse should explain that: Select all that apply. a. a signed permit is necessary b. sedation may be used during the procedure c. a light meal should be eaten the day before the procedure d. bowel cleansing is necessary for preparation

A,B,D

A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder? Select all that apply. a. Fever b. Nausea c. Lethargy d. Tremors e. Confusion f. Bradycardia

A,B,D,E

The nurse performs a detailed assessment of the abdomen of a patient with a possible bowel obstruction, knowing that a manifestation of an obstruction in the small intestine is (select all that apply) a. Projectile vomiting b. Diarrhea that is loose or liquid c. Persistent, colicky abdominal pain d. Increased, tinkling bowel sounds above the blockage

A,C,D

intestinal obstruction nursing diagnosis

Acute pain r/t abdominal distention and increased peristalsis Deficient fluid volume r/t decrease in intestinal fluid absorption, third space fluid shifts into the bowel lumen and peritoneal cavity, NG suction, and vomiting

Nursing management of IV lines for PN

Add nothing to PN solutions PN solution label includes: nutrient contents, time mixed, date and expiration, patient name Follow proper aseptic technique IV tubing changed q24h

A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially? a. Warm the client b. Maintain a patent airway c. Administer thyroid hormone d. Administer fluid replacement

B

A client with a head injury develops SIADH. Symptoms the nurse would expect to find include a. Hypernatremia and edema b. Low urine output and thirst c. Muscle spasticity and hypertension d. Weight gain and decreased glomerular rate

B

A patient with chronic gastritis associated with the presence of H. pylori is treated with triple-drug therapy. The nurse explains to the patient that the drugs commonly included in this regimen include a. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix). b. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec). c. Sucralfate (Carafate), nystatin (Mycostatin), and bismuth subsalicylate (Pepto-Bismol). d. Metoclopramide (Reglan), bethanechol (Urecholine), and promethazine (Phenergan).

B

The nurse is taking the patient's blood pressure, while inflating the cuff the nurse notices jerking motions of the patient's arm and hand. The nurse suspects the patient has a. Hypokalemia b. Hypocalcemia c. Hypernatremia d. Hypercalcemia

B

The nurse knows that an important role of the pancreas that may be diminished during pancreatitis is a. release of secretin b. release of bicarbonate to decrease acidity of gastric chyme. c. decrease in cholesterol metabolism. d. release of gastrin by duodenal mucosa

B

Which of the following would be the most important for a nurse to teach a client who is hospitalized with acute pancreatitis prior to discharge? a. The importance of monitoring amylase and lipase levels b. Avoidance of alcohol use for up to a year c. Use of aspirin instead of acetaminophen as an OTC medication d. How to care for a T-tube

B

Select all the statement that apply to the proper administration of total parenteral nutrition. a. can only be administered in a central line b. can hang for only 24 hours c. required glucose monitoring every six hours and PRN d. appropriate to use line to piggyback antibiotics e. label should contain all nutrients as well as date, time and expiration date.

B,C,E

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrate an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply. a. Polyuria b. Shakiness c. Palpitations d. Blurred vision e. Lightheadedness f. Fruity breath odor

B,C,E

Important nursing interventions when caring for a client with Cushing syndrome include? Select all that apply. a. Restricting protein intake b. Monitoring blood glucose levels c. Observing for signs of hypotension d. Administering medication in equal doses e. Protecting patient from exposure to infection

B,E

A client if admitted to a hospital with a diagnosis of DKA. The initial blood glucose level was 950 mg/dl. A continuous intravenous infusion of short-acting insulin is initiated along with intravenous rehydration with normal saline. The serum glucose level is now 240 mg/dl. The nurse would next prepare to administer which item? a. Ampule of 50% dextrose b. NPH insulin subcutaneously c. Intravenous fluids containing dextrose d. Phenytoin (Dilantin) for the prevention of seizures

C

A client is brought to the emergency department in an unresponsive state, and a diagnosis or hyperglycemic hyperosmolar nonketotic (HHNC) syndrome is made. The nurse would immediately prepare to initiate which anticipated health care providers' prescription? a. Endotracheal intubation b. 100 units of NPH insulin c. Intravenous infusion of normal saline d. Intravenous infusion of sodium bicarbonate

C

A patient admitted with a GI bleed has an initial hemoglobin of 12.5g/dL and hematocrit of 40%. Four hours later the patient has a hemoglobin of 9.8d/dL and hematocrit of 24%. The patient has stable vital signs, is receiving lactated ringers at 150ml/hr and has had drainage but no sign of blood from the nasogastric tube. You interpret these findings as a. The nasogastric tube needs to be replaced. b. The patient needs to go to surgery ASAP. c. This decrease is hemoglobin and hematocrit was caused by hemodilution from fluid replacement therapy. d. The lab needs to be called to re-draw the hemoglobin and hematocrit.

C

A patient with SIADH has a serum sodium level of 129. The nurse is concerned about potential complications from this laboratory finding and implements safety measure. Which of the following would be a priority? a. Place the patient in isolation. b. Wear a mask when entering the patient's room c. Pad the side rails. d. Place the patient in soft wrist restraints.

C

After several diagnostic tests, a client is diagnosed with diabetes insipidus (DI). The nurse performs an assessment on the client, knowing that which symptom is most indicative of this disorder? a. Fatigue b. Diarrhea c. Polydipsia d. Weight gain

C

Levothyroxine (Synthroid) is prescribed for a client diagnosed with hypothyroidism. Upon review of the client's record, the nurse notes that the client is taking warfarin (Coumadin). Which modification to the plan of care should the nurse review with the client's health care provider? a. A decreased dosage of levothyroxine b. An increased dosage of levothyroxine c. A decreased dosage of warfarin sodium d. An increased dosage of warfarin sodium

C

The nurse should teach the client who is receiving warfarin sodium that: a. Partial thromboplastin time values determine the dosage of warfarin to take. b. Protamine sulfate is used to reverse the effects of warfarin sodium. c. International Normalized Ratio (INR) is used to assess effectiveness. d. Warfarin sodium will facilitate clotting of the blood.

C

The nurse teaches the client that the best time to take corticosteroids for replacement purposes is? (What is the patients diagnosis?) a. Once a day at bedtime b. Every other day on awakening c. On arising and in the late afternoon d. At consistent intervals every 6-8 hours

C

The pernicious anemia that may accompany gastritis is due to which of the following? a. Chronic autoimmune destruction of cobalamin stores in the body b. Progressive gastric atrophy from chronic breakage in the mucosal barrier and blood loss c. A lack of intrinsic factor normally produced by acid- secreting cells of the gastric mucosa d. Hyperchlorhydria resulting from an increase in acid- secreting parietal cells and degradation of RBS's

C

You are a nurse caring for a client that has just returned from a cholecystectomy. All of the following interventions are appropriate for this patient except a. Encourage early ambulation b. Deep breathe and cough every hour c. Regular diet d. Splint abdomen when moving and coughing

C

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understand discharge instructions if the client states that which symptoms are associated with the diagnosis? Select all that apply. a. Tremors b. Weight lose c. Feeling cold d. Loss of body hair e. Persistent lethargy f. Puffiness of the face

C,D,E,F

The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. a. Provide a cool environment for the client b. Instruct the client to consume a high-fat diet c. Instruct the client about thyroid replacement therapy d. Encourage the client to consume fluids and high-fiber foods in the diet e. Inform the client that iodine preparations will be prescribed to treat the disorder f. Instruct the client to contact the health care provider if episodes of chest pain occur.

C,D,F

A client is diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings would the nurse expect to note as confirming this diagnosis? Select all that apply. a. Increase in pH b. Comatose state c. Deep, rapid breathing d. Decreased urine output e. Elevated blood glucose level f. Low plasma bicarbonate level

C,E,F

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain? a. Right lower quadrant, radiating to the back b. Right lower quadrant, radiating to the umbilicus c. Right lower quadrant, radiating to the left scapula and shoulder d. Right upper quadrant, radiating to the right scapula and shoulder

D

The nurse is caring for a client admitted to the emergency department with DKA. In the acute phase, the nurse plans for which priority intervention? a. Correct the acidosis b. Administer 5% dextrose intravenously c. Apply a monitor for an electrocardiogram d. Administer short-duration insulin intravenously

D

Acute abdominal pain Etiology

Damage to organs in the abdomen and pelvis, which leads to inflammation, infection, obstruction, bleeding, and perforation.

Gastritis risk factors

Drugs: NSAIDS, Aspirin, Corticosteroids Diet: Alcohol, spicy foods Microorganisms: H. Pylori

GI bleeding DX

Endoscopy (primary tool) Angiography Labs: CBC BUN Serum electrolytes PTT Liver enzymes ABGs Type and cross match

Diverticulitis Complication

Erosion of the bowel Perforation in peritoneum Abscess Peritonitis Bleeding

Peritonitis complications

Hypovolemic shock Sepsis Abscess formation Paralytic ileus Respiratory distress syndrome

Diverticulitis nursing interventions

NPO IV fluids NG suction Antibiotic therapy Surgery: -Possible resection of the colon - Possible temporary colostomy

Pancreatitis TX

NPO with NG tube to suction Albumin (If shock present) IV calcium gluconate (If tetany) Lactated ringers solution Pain medication (morphine) PPI (omeprazole [Prilosec]) Antibiotics if necrotizing pancreatitis)

NG nursing care

Positioning the patient in Semi-Fowler's position Frequent oral care for dry oral mucosa Use of low intermittent suctioning Frequent assessment of bowel sounds

GI Acute nursing interventions

Remain calm, use caution when administering sedatives for restlessness as signs of shock may be masked by drugs Maintain IV I/O

Pancreatitis Labs

Serum amylase: increased Serum lipase: increased Urinary amylase: increased Blood glucose: increased Serum calcium: decreased Serum triglycerides: increased

melena

abnormal, black, tarry stool containing digested blood usually caused by cancer, bleeding in upper GI from ulcers, varices

Pernicious anemia

complication of gastritis that is caused when there is a lack of intrinsic factor normally produced by acid secreting cells of the gastric mucosa

post-op care for cholecystectomy

o monitoring for complications such as bleeding, making the patient comfortable, and preparing the patient for discharge. o A common postoperative complaint is referred pain to the shoulder because of the CO2 that is used to inflate the abdominal cavity during surgery. Placing the patient in the Sims' position (on left side with right knee flexed) helps move the gas pocket away from the diaphragm. o Encourage deep breathing along with movement and ambulation. o The pain can usually be relieved by NSAIDs or codeine. o The patient is allowed clear liquids and can walk to the bathroom to void. o If the patient has a T tube, you must maintain bile drainage and monitor T-tube function and drainage.

abdominal ultrasound

• Procedure: A conductive gel is applied to skin and a transducer is placed on the area. • Purpose: Detects abdominal masses (tumors, cysts), gallstones, biliary and liver disease. • Nursing Responsibilities: Instruct patient to be NPO for 8-12 hr. Air or gas can reduce quality of images. Food intake can cause gallbladder contraction, resulting in suboptimal study.

Colonoscopy

• Procedure: Directly visualizes entire colon up to ileocecal valve with flexible fiberoptic scope. Patient's position is changed frequently during procedure to assist with advancement of scope to cecum. • Purpose: Used to diagnose or detect inflammatory bowel disease, polyps, tumors, and diverticulosis and dilate strictures. Procedure allows for biopsy and removal of polyps without laparotomy. • Nursing Responsibilities: ♣ Before: Bowel preparation prior varies depending on HCP. For example, patient follows either a low-residue or full liquid diet the day before until bowel cleansing begins. Bowel cleansing follows a split-dose regimen. The evening before the procedure the patient drinks 2 L of oral polyethylene glycol (PEG) lavage solution. The second 2 L dose begins 4-6 hr before procedure. Explain to patient that a flexible scope will be inserted while patient in side-lying position and sedation will be given. • After: Patient may experience abdominal cramps caused by stimulation of peristalsis because the bowel is constantly inflated with air during procedure. Observe for rectal bleeding and manifestations of perforation (e.g., malaise, abdominal distention, tenesmus). Check vital signs.

EGD

• Procedure: Directly visualizes mucosal lining of esophagus, stomach, and duodenum with flexible endoscope. Test may use video imaging to visualize stomach motility. • Purpose: Detects inflammation, ulcerations, tumors, varices, or Mallory-Weiss tears. Biopsies may be taken. Varices can be treated with band ligation or sclerotherapy. • Nursing responsibilities: ♣ Before: Keep patient NPO for 8 hr. Make sure signed consent is on chart. Give preoperative medication if ordered. Explain to patient that local anesthesia may be sprayed on throat before insertion of scope and that patient will be sedated during procedure. ♣ After: Keep patient NPO until gag reflex returns. Gently tickle back of throat to determine reflex. Use warm saline gargles for relief of sore throat. Check temperature q15-30min for 1-2 hr (sudden temperature spike is sign of perforation).

Sigmoidosotmy

• Procedure: Directly visualizes rectum and sigmoid colon with lighted flexible endoscope. Sometimes a special table is used to tilt patient into knee-chest position. • Purpose: Used to detect tumors, polyps, inflammatory and infectious diseases, fissures, hemorrhoids. • Nursing Responsibilities: ♣ Before: Bowel preparation similar to colonoscopy (see Colonoscopy). Explain to patient knee-chest position (unless patient is older or very ill), need to take deep breaths during insertion of scope, and possible urge to defecate as scope is passed. Encourage patient to relax and let abdomen go limp. ♣ After: Observe for rectal bleeding after polypectomy or biopsy.

Lower GI or Barium enema

• Procedure: Fluoroscopic x-ray examination of colon using contrast medium, which is administered rectally (enema). Double-contrast or air-contrast barium enema is test of choice. Air is infused after the barium flows through transverse colon. • Purpose: Used to detect the presence of tumors, diverticula, and polyps. • Nursing responsibilities: ♣ Before: Administer laxatives and enemas until colon is clear of stool evening before procedure. Administer clear liquid diet evening before procedure. Keep patient NPO for 8 hr before test. Instruct patient about barium being given by enema. Explain that cramping and urge to defecate may occur during procedure and patient may be placed in various positions on tilt table. ♣ After: Give fluids, laxatives, or suppositories to assist in expelling barium. Observe stool for passage of contrast medium. Tell patient that stool may be white for up to 72 hr.

Upper GI barium swallow

• Procedure: Fluoroscopic x-ray study using contrast medium. • Purpose: Used to diagnose structural abnormalities of esophagus, stomach, and duodenum. • Nursing Responsibilities: o Before: Explain procedure including the need to drink contrast medium and assume various positions on x-ray table. Keep patient NPO for at least 8 hr. Tell patient to avoid smoking after midnight. o After: Take measures to prevent contrast medium impaction (fluids, laxatives). Tell patient that stool may be white for up to 72 hr.

Scintigraphy

• Procedure: Sulfur colloid or patient's RBCs are injected, and images of abdomen are obtained at intermittent intervals. • Purpose: determines the site of active GI blood loss. • Nursing Responsibilities: ♣ Before: Tell patient that the substance used contains only traces of radioactivity and poses little to no danger. Schedule no more than one radionuclide test a day. Explain to patient need to lie flat during scanning.