Nursing -- GI Surgeries

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

A,B,D

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

A,B,D

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

A,B,E

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

A,C,E

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

A

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

A

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

A

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

B

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

B

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

C

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

C

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

C

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

C,D,E

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

D

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

D

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

D

a Send a blood sample for a type and crossmatch. b. Insert a large intravenous line for fluid resuscitation. C. Obtain the heart rate and blood pressure. d. Assess and maintain a patent airway. ABC'S

D

After teaching a client who has a femoral hernia, the nurse assesses the client's understanding. Which statement indicates the client needs additional teaching related to the proper use of a truss? a. I will put the truss before I go to bed each night b. I'll put some powder under the truss to avoid skin irritation. c. the truss will help my hernia because I cant have surgery d. if I have abdominal pain, I'll let my health care provider know right away

a

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

b

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

A

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

A,C,E

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

A,D,E

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

A,D,F

a nurse cares for a client who is recovering from a hemmorrhoidectomy. The client states, "I need to have a bowel movement." Which action should the nurse take? a. obtain the client while providing privacy. b. stay with the client while providing privacy c. make sure the call light is in reach to signal completion d. gather supplies to collect to stool sample for the laboratory.

b