NCLEX-CARE OF THE PATIENT WITH A GASTROINTESTINAL DISORDER

A sexually active 20-year-old client has developed viral hepatitis. Which statement made by the client would indicate a need for teaching?

1. "I can never drink alcohol again."

The nurse is teaching a client with a newly diagnosed hiatal hernia about measures to prevent recurrence of symptoms. Which statement should be included in the teaching?

2. "Avoid lying down for an hour after eating."

A client with possible hiatal hernia complains of frequent heartburn and regurgitation. The nurse should gather further information about the presence of which sign or symptom?

2. Difficulty swallowing

The nurse is collecting admission data on the client with hepatitis. Which finding would be a direct result of this client's condition?

2. Drowsiness

The nurse is instructing a client who had a herniorrhaphy about how to reduce postoperative swelling following the procedure. Which should the nurse suggest to the client to prevent swelling?

2. Elevate the scrotum.

A client has had a partial gastrectomy and the nurse is reinforcing discharge instructions. The nurse should tell the client about the need for which? Select all that apply.

2. Iron supplements 4. Calcium supplements 5. Vitamin B12 injections

The nurse is admitting a client to the hospital for the treatment of dehydration. The client reports nausea, vomiting, diarrhea, and cramping for the past week. The nurse asks the client about medications he is taking. The client denies taking prescription medications but states he has been taking some herbs given to him by his cousin. The nurse alerts the health care provider when the client states he has been taking which herb?

2. Senna

A client with Crohn's disease has a prescription to begin taking antispasmodic medication. The nurse should time the medication so that each dose is taken at which time?

3. 30 minutes before meals

The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to see documented in the record?

1. Diarrhea

A client has undergone esophagogastroduodenoscopy (EGD). The nurse places highest priority on which action as part of the client's care plan?

2. Checking for return of a gag reflex

The nurse is interpreting the laboratory results of a client who has a history of chronic ulcerative colitis. Which result indicates a complication of ulcerative colitis?

1. Hemoglobin 10.2 g/dL

A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting, and a gastric ulcer is suspected. The nurse should gather which additional supportive data from the client for this diagnosis?

1. History of alcohol use, smoking, and weight loss

A client is seen in the ambulatory care office for a routine examination. Which statement by the client would be important for the nurse to follow up?

1. "I just lost a family member to gastrointestinal cancer."

The nurse is reviewing the health care record of a client with a diagnosis of chronic pancreatitis. Which data noted in the record indicate poor absorption of dietary fats?

1. Steatorrhea

The nurse should include which information when reinforcing home care instructions for a client who has peptic ulcer disease?

3. Learn to use stress reduction techniques.

A licensed practical nurse (LPN) is assisting in the insertion of a nasogastric (NG) tube for an adult client. The LPN helps determine the correct length to insert the tube by performing which measurement?

4. From the tip of the client's nose to the earlobe and then down to the top of the sternum

The nurse is collecting data on a client with a diagnosis of peptic ulcer disease. Which history is least likely associated with this disease?

4. History of the use of acetaminophen (Tylenol) for pain and discomfort

The nurse is caring for a client with a nasogastric (NG) tube and tests the pH of the aspirate to determine correct placement. The nurse notes that the pH is 5. Which information does this indicate?

2. Placement of the NG tube is accurate.

A client arrives at the emergency department complaining of severe abdominal pain and is placed on NPO status. During a quick assessment the nurse observes that the client has both Cullen's sign and Grey Turner's sign and pancreatitis is suspected. The nurse should perform the following actions/prescriptions in which priority order? Arrange the actions in the order they should be performed. All options must be used.

1. Obtain vital signs and draw blood for laboratory analysis. 2. Ensure the client receives intravenous pain medication. 3. Hydrate the client with intravenous fluids. 4. Place a nasogastric tube. Client is NPO (nothing by mouth). 5. Inquire about when pain occurs and previous history including medications and alcohol.

The nurse provides information to a client following a gastrectomy who is now diagnosed with pernicious anemia. Which instructions about pernicious anemia should the nurse reinforce? Select all that apply

1. Provide meticulous and frequent oral hygiene. 2. Use additional lightweight blankets as needed. 4. Check blood serum vitamin B12 levels every 1 to 2 years.

The nurse is collecting data on a client admitted to the hospital with hepatitis. Which data indicate that the client may have liver damage?

1. Pruritus

The nurse who is assisting in the care of a client within the first 24 hours following a total gastrectomy for gastric cancer should avoid which intervention?

2. Irrigating the nasogastric (NG) tube

The nurse is reinforcing instructions to a client and his family about alcohol abuse and chronic cirrhosis. The nurse knows to include which essential elements in the discharge teaching guide? Select all that apply.

2. Avoid potentially hepatotoxic over-the-counter drugs. 3. Teach symptoms of complications and when to seek prompt medical attention. 4. Explain that cirrhosis of the liver is a chronic illness and the importance of continuous health care. 6. Avoid spicy and rough foods and activities that increase portal pressure such as straining at stool, coughing, sneezing and vomiting.

The nurse is collecting data about how well a client with a gastrointestinal (GI) disorder is able to digest food. Which processes are involved in the complete digestive process? Select all that apply.

2. Chemical 4. Absorption 5. Mechanical 6. Active transport

The nurse is assigned to care for a client who had a Sengstaken-Blakemore tube inserted when more conservative treatment failed to alleviate the condition. The nurse should suspect that the client has which diagnosis?

2. Esophageal varices

The nurse analyzes the results of laboratory studies performed on a client with peptic ulcer disease (PUD). Which laboratory value would indicate a complication associated with the disease?

2. Hemoglobin 10.2 g/dL

The nurse is working with a client diagnosed with anorexia nervosa. The nurse plans care, focusing on which as the primary problem?

3. Impaired nutritional status

The nurse is reviewing the health care provider's prescriptions written for a client admitted with acute pancreatitis. Which health care provider prescription should the nurse verify if noted in the client's chart?

3. Position the client supine and flat.

The nurse gathers data from a client admitted to the hospital with gastroesophageal reflux disease (GERD) who is scheduled for a Nissen fundoplication. Based on an understanding of this disease, the nurse determines that the client may be at risk for which complication?

3. Aspiration

A health care provider places a Miller-Abbott tube in a client who has a bowel obstruction. Six hours later, the nurse measures the length of the tube outside of the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action should the nurse take next?

3. Document the finding in the client's record.

Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. Which is the best rationale for checking gastric residual volume before administering the tube feeding?

3. Evaluate absorption of the last feeding.

The nurse is preparing to administer an enteral feeding through a nasogastric tube. The nurse should place the client in which position during and after the feedings?

3. Fowler's

A client with a possible hiatal hernia complains of difficulty swallowing. Which other sign/symptom is associated with a hiatal hernia?

3. Heartburn and regurgitation

A health care provider asks the nurse to obtain a Salem Sump tube for gastric intubation. The nurse selects which tube from the unit storage area?

4. Tube with a lumen and an air vent

The nurse is caring for a client with pneumonia with a history of bleeding esophageal varices. Based on this information, the nurse plans care, knowing that which could result in a potential complication?

4. Vigorous coughing

The nurse is evaluating the effect of dietary counseling on the client with cholecystitis. The nurse determines that the client understands the instructions given if the client states that which food item is acceptable to include in the diet?

4. Turkey and lettuce sandwich

The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency?

4. Vitamin B12

A calcium supplement is prescribed for a client with hypoparathyroidism in the management of hypocalcemia. The client arrives at the clinic for a follow-up visit and complains of chronic constipation, and the nurse reinforces instructions to the client about measures to alleviate the constipation. Which comment by the client would indicate a need for further teaching?

4. "I need to add 0.5 ounce of mineral oil to my daily diet."

A client receiving a high cleansing enema complains of pain and cramping. The nurse should take which corrective action?

4. Clamp the tubing for 30 seconds and restart the flow at a slower rate.

The nurse is getting a client who underwent umbilical hernia repair ready for discharge. The nurse tells the client that it is important to continue to do which action after discharge?

1. Avoid coughing.

A client is admitted to the hospital with acute viral hepatitis. Which sign/symptom should the nurse expect to note based on this diagnosis?

1. Fatigue

Which statement by the spouse of a client with end-stage liver failure indicates the need for further teaching by the multidisciplinary team regarding the management of pain?

3."This opioid will cause very deep sleep, which is what my husband needs."

The nurse observes that a client's nasogastric tube has suddenly stopped draining. The tube is connected to suction, the machine is on and functioning and all connections are snug. The tube is secured properly and does not appear to have been dislodged. After checking placement, the nurse gently flushes the tube with 30 mL of normal saline, but the tube still is not draining. The nurse analyzes this problem as which?

4. Channels of gastric secretions may be bypassing the holes in the tube; turning the client will promote stomach emptying.

A client is admitted to the hospital with a diagnosis of acute pancreatitis. The nurse plans care, knowing that which problem occurs with this disorder?

2. Alteration in comfort related to abdominal pain

The nurse is reinforcing discharge instructions to a client with a hiatal hernia. Which should the nurse include in the teaching session? Select all that apply.

2. It is advisable to stop smoking cigarettes. 3. Wait at least 1 hour after meals to perform chores. 4. Be sure to elevate the head of the bed during sleep.

The nurse should include which instruction in a teaching plan for a client who has peptic ulcer disease?

2. Learn to use stress reduction techniques.

The nurse is reinforcing instructions to a client about insertion of a Sengstaken-Blakemore tube. Which statement by the client indicates an understanding of the teaching?

2. The tube will be inserted through my nose to my stomach.

A postgastrectomy client is at high risk for hyperglycemia related to uncontrolled gastric emptying of fluid and food into the small intestine (dumping syndrome). Because of this risk, the nurse plans to monitor which data?

3. Postprandial blood glucose readings

The nurse is caring for a client with a Sengstaken-Blakemore tube. To prevent ulceration and necrosis of oral and nasal mucosa, the nurse should plan to perform which action?

3. Provide frequent oral and nasal care on a regular basis.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The health care provider has now prescribed the nasogastric tube to be discontinued. To determine the client's readiness for discontinuation of the nasogastric tube, which measure should the nurse check?

4. Presence of bowel sounds in all four quadrants

The nurse assigned to care for a client with cirrhosis reviews the medical record and notes that the client has difficulty maintaining an effective breathing pattern due to pressure on the diaphragm. The nurse plans care knowing that which client position will best assist in facilitating breathing?

4. Semi-Fowler's

A postoperative client has regained bowel sounds and is ready to start a clear liquid diet. The nurse is told that the health care provider has written a prescription to remove the nasogastric (NG) tube. The nurse assists in the procedure and asks the client to do which during tube removal?

4. Take a breath and hold it until the tube is out.

The nurse is checking a client for the correct placement of a nasogastric (NG) tube. The nurse aspirates the client's stomach contents and checks its pH level. Which pH value indicates the correct placement of the tube?

1. 3.5

The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to note? Select all that apply.

1. Administer antacids, as prescribed. 3. Encourage coughing and deep breathing. 4. Administer anticholinergics, as prescribed.

A client who has undergone a colostomy several days ago is reluctant to leave the hospital and has not yet looked at the ostomy site. Which measures are most likely to promote coping? Select all that apply.

1. Ask a member of the local ostomy club to visit with the client before discharge. 2. Ask the enterostomal nurse specialist to consult with the client before discharge. 5. Ask the client to begin doing one part of the ostomy care and increase tasks daily.

A client with viral hepatitis states to the nurse, "I am so yellow." The nurse should take which action?

1. Assist the client in expressing feelings.

A client who has undergone a subtotal gastrectomy is being prepared for discharge. Which items concerning ongoing self-management should the nurse reinforce to the client? Select all that apply.

1. Eat smaller and more frequent meals. 3. Drink fluids between meals not with them.

The nurse documents that a client with a hiatal hernia is implementing effective health maintenance measures after the client reports doing which action?

1. Eating low-fat or nonfat foods

The nurse has assisted with the insertion of a Levin tube for gastrointestinal (GI) decompression. Which settings will the health care provider prescribe? Select all that apply.

1. Low 5. Intermittent

A client in the emergency department reports right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescriptions? Select all that apply.

1. Milk of magnesia 2. Heat pad to the abdomen

The nurse is assisting in caring for a client with a Sengstaken-Blakemore tube. Which article should the nurse place at the bedside?

1. Scissors

A client has been diagnosed with chronic gastritis and has been told that there is too little intrinsic factor being produced. The nurse tells the client that which therapy will be prescribed to treat the problem?

1. Vitamin B12 injections

A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse tells the client to avoid which position that could aggravate the pain?

2. Lying flat

A generally healthy 63-year-old man is seen in the health care provider's office for a routine examination. Which statement made by the client is important for the nurse to follow up on?

3. "Everyone in my immediate family has died from gastrointestinal cancer."

A client is admitted to an acute care facility with complications of celiac disease. Which question should be helpful initially in obtaining information for the nursing care plan?

3. "What is your understanding of celiac disease?"

A client arrives at the emergency department and complains of severe abdominal pain. The initial diagnosis is acute abdomen, and an x-ray and an abdominal ultrasonogram are prescribed to be obtained immediately. The nurse prepares the client for these diagnostic tests and reviews the health care provider's prescriptions. Which prescription should the nurse question if written on the health care provider's prescription form?

3. Administration of an opioid analgesic

The nurse is reinforcing dietary instructions for a client with peptic ulcer disease. Which action does the nurse encourage the client to do?

3. Eat anything as long as it does not aggravate or cause pain.

The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. On review of the postoperative prescriptions, which should the nurse clarify?

3. Irrigating the nasogastric (NG) tube

The nurse has assisted in the insertion of a Levin tube for gastrointestinal (GI) decompression. The nurse plans to set the suction to which pressure?

3. Low and intermittent

The nurse is performing an abdominal assessment on a client. The nurse interprets that which finding is abnormal and should be reported to the registered nurse (RN) or health care provider?

3. Pulsation between the umbilicus and pubis

A postgastrectomy client who is being discharged from the hospital tells the nurse, "I hope my stomach problems are over. I need to get back to work right away. I've missed a lot of work, and I'm really behind. If I don't get my act together, I may lose my job." Based on the client's statement, the nurse determines that at this time, it is appropriate to discuss which topic?

3. Reducing stressors in life

The nurse is reinforcing home care instructions to a client following a gastric resection. The nurse should include which instruction?

3. Take actions to prevent dumping syndrome.

The nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement made by the client supports the diagnosis of gastric ulcer?

4. "My pain comes shortly after I eat, maybe a half hour or so later."

The nurse is caring for a client with esophageal varices who is going to have a Sengstaken-Blakemore tube inserted. The nurse brings which priority item to the bedside so that it is available at all times?

4. A pair of scissors

A client is receiving bolus feedings via a nasogastric tube. The nurse plans to place the client's head of the bed (HOB) in which optimal position once the feeding is completed?

4. Elevated 30 to 45 degrees with the client in the right lateral position for 60 minutes

A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting. A gastric ulcer is suspected. Which data would further support this diagnosis?

4. History of chronic obstructive pulmonary disease with weight loss

The nurse is assisting in planning stress management strategies for the client with irritable bowel syndrome. Which suggestion should the nurse give to the client?

4. Learn measures such as biofeedback or progressive relaxation.

The nurse is participating in a health screening clinic and is preparing materials about colorectal cancer. The nurse plans to include which risk factor for colorectal cancer in the material?

4. Personal history of ulcerative colitis or gastrointestinal (GI) polyps

The nurse is reinforcing discharge instructions to a client who has had a total gastrectomy. The nurse tells the client about the importance of returning to the health care clinic as scheduled for which priority assessment?

4. Vitamin B12 and folic acid studies