CH 2 Exam 3

The nurse is caring for a postoperative client who had an extensive oral and neck surgery. The client is now describing throbbing pain in the head. The nurse anticipates that the health care provider will request which medication for this client? a. Diphenhydramine (Benadryl) b. Midazolam (Versed) intravenously c. Morphine sulfate intravenously d. Oxycodone plus acetaminophen (Percocet, Tylox)

C

The nurse is teaching a client, newly diagnosed with migraines, about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? "I can still eat Chinese food." "I must not miss meals." "It is okay to drink a few wine coolers." "I need to use fake sugar in my coffee."

"I must not miss meals." **The client understands the teaching plan about trigger control for migraines when the client states that he/she must not miss meals. Until triggers are identified, a headache diary would be considered. Missing meals is a trigger for many people suffering from migraines. The client must not skip any meals until the triggers are identified.Chinese food frequently contains monosodium glutamate. Monosodium glutamate-containing foods, alcohol, and artificial sweeteners are triggers for many people suffering from migraines and need to be eliminated until the triggers are identified.

A male patient's sister was recently diagnosed with colorectal cancer (CRC), and his brother died of CRC 5 years ago. The patient asks the nurse whether he will inherit the disease too. How does the nurse respond? "Have you asked your primary health care provider what he or she thinks your chances are?" "It is hard to know what can predispose a person to develop a certain disease." "No. Just because they both had CRC doesn't mean that you will have it, too." "The only way to know whether you are predisposed to CRC is by genetic testing."

"The only way to know whether you are predisposed to CRC is by genetic testing." **The nurse's response to the patient who asks if he will inherit CRC is "the only way to know whether you are predisposed to CRC is by genetic testing." Genetic testing is the only definitive way to determine whether the patient has a predisposition to develop CRC.Asking the patient what the primary health care provider thinks is an evasive response by the nurse and does not address the patient's concerns. A higher incidence of the disease has been noted in families who have a history of CRC. It is not, however, the responsibility of the nurse to engage in genetic counseling. This patient might not be predisposed to developing CRC.

Psychological Integrity

*Allow pts with gastric cancer to express feelings of grief, fear, and anxiety

Safe and Effective Care Environment

*Consult with dietitian, pt, and family regarding nutrition modifications for pts with GERD *Teach pt and family to recognize symptoms of dysphagia *Remain with pt with dysphagia during meals to prevent choking episodes or intervene quickly

Health Promotion and Maintenance

*Refer ostomy pts to the United Ostomy Associations of America and American Cancer Society *Teach pts with IBS to avoid GI stimulants, such as caffeine, alcohol, and milk/milk products and to manage stress *Instruct pts on dietary modifications to decrease the occurrence of CRC, such as eating a diet high in fiber and avoiding red meat *Teach adults 50 years and older to have routine screening for CRC; people with genetic predisposition should have earlier and more frequent screening *Teach people to prevent or manage constipation to help avoid hemorrhoids; teach pts the importance of maintaining a healthy weight to decrease the risk for hemorrhoids *Teach pts and caregivers how to provide colostomy care, including dietary measures, skin care, and ostomy products

As a result of being treated with radiation for oral cancer, a client is experiencing xerostomia. What collaborative resource does the nurse suggest for this client's care? a. Dentist b. Occupational therapist c. Psychiatrist d. Speech therapist

A

The nurse admits an immunocompromised client who has contracted herpes simplex stomatitis. The nurse anticipates that the health care provider will request which medication? a. Acyclovir (Zovirax) b. Diphenhydramine (Benadryl) c. Nystatin (Mycostatin) d. Tetracycline syrup (Sumycin syrup)

A

The nurse is working with the dietitian to plan a menu for a patient who has persistent difficulty swallowing. What is a suitable breakfast selection for this patient? Scrambled eggs and toast Oatmeal and orange juice Puréed fruit and English muffin Cream of wheat and applesauce

Cream of wheat and applesauce **A breakfast selection of both cream of wheat and applesauce are foods of semisolid consistency and are appropriate for this patient. The patient who is having difficulty swallowing would be given semisolid foods and thickened liquids.Toast would not be appropriate, and orange juice would have to be thickened before it is given to this patient. An English muffin would be inappropriate for this patient because it is not a semisolid food.

Psychological Integrity

GI health problems markedly affect lifestyle and may invoke emotions such as anger, denial, and depression

The nurse is reinforcing the instructions on swallowing provided by the speech-language pathologist to a client diagnosed with esophageal cancer. Which instruction to the client is the highest priority? A. Place food at the back of the mouth as you eat. Correct B. Do not be overly concerned with tongue or lip movements. C. Before swallowing, tilt the head back to straighten the esophagus. D. Do not attempt to reach food particles that are on the lips or around the mouth.

Placing food at the back of the mouth when eating will help the client avoid aspirating. Both tongue movements and sealing of the lips should be monitored in this client. The client's head should be tilted forward in the chin-tuck position. The client should be able to reach food particles on her or his lips and around the mouth with the tongue.

Which patient assessment information is correlated with a diagnosis of chronic gastritis? Anorexia, nausea, and vomiting Frequent use of corticosteroids Hematemesis and anorexia Radiation therapy, smoking, and excessive alcohol use

Radiation therapy, smoking, and excessive alcohol use **Treatment with radiation therapy, smoking, and alcohol use are known to be associated with the development of chronic gastritis.Anorexia, nausea, and vomiting are all signs and symptoms of acute gastritis. Corticosteroid use and hematemesis are also more likely to be signs and symptoms of acute gastritis.

A patient diagnosed with ulcerative colitis (UC) is to be discharged on loperamide (Imodium) for symptomatic management of diarrhea. What does the nurse include in the teaching about this medication? "Be aware of the signs/symptoms of toxic megacolon that we discussed." "If diarrhea increases, you must let your primary health care provider know." "You must avoid pregnancy." "You will need to decrease your dose of sulfasalazine (Azulfidine)."

"Be aware of the signs/symptoms of toxic megacolon that we discussed." **In teaching a UC patient discharged on loperamide, the nurse tells the patient to be aware of signs/symptoms of toxic megacolon that were discussed. Antidiarrheal drugs may precipitate colonic dilation and toxic megacolon. Toxic megacolon is characterized by an enlarged colon with fever, leukocytosis, and tachycardia.Loperamide will decrease diarrhea rather than increase it. Constipation is sometimes a problem. No contraindication for pregnancy is noted. Sulfasalazine therapy typically continues on a long-term basis.

Psychological Integrity

*Allow pt the opportunity to express fear or anxiety regarding the diagnosis of esophageal cancer *Refer pt and family to psychological couseling, hospice, spiritual care, and case manager as needed

Psychological Integrity

*Assist pt with CRC with the grieving process *Be aware that having a colostomy is a life-altering event that can severely impact one's body image, issues related to sexuality and fear of acceptance should be discussed

Health Promotion and Maintenance

*Identify pts at risk for gastritis and PUD, especially those with H. pylori and older adults who take large amounts of NSAIDs *Teach pts to prevent PUD by avoiding excess consumption of caffeine, alcohol, coffee, aspirin, NSAIDs, and contaminated food and water by avoiding smoking *Teach pts to adhere to H. pylori treatment to prevent development of gastric cancer

The wife of a client with Alzheimer's disease mentions to the home health nurse that, although she loves him, she is exhausted caring for her husband. What does the nurse do to alleviate caregiver stress? Arranges for respite care Provides positive reinforcement and support to the wife Restrains the client for a short time each day, to allow the wife to rest Teaches the client improved self-care

Arranges for respite care **The home health nurse can help relieve caregiver stress for the wife caring for her husband with Alzheimer's disease by arranging for respite care for the wife. Respite care can give the wife some time to reenergize and will provide a social outlet for the client.Providing positive reinforcement and support is important but does not help provide a solution to the wife's situation. Restraints are almost never appropriate and are used only as a last resort. The client with Alzheimer's disease typically is unable to learn improved self-care.

A client returns to the neurosurgical floor after undergoing an anterior cervical diskectomy and fusion (ACDF). What is the nurse's first action? Administer pain medication. Assess airway and breathing. Assist with ambulation. Check the client's ability to void.

Assess airway and breathing. **The nurse's first action when a client returns to the neurosurgical floor after having an anterior cervical discectomy is to assess the airway and breathing. Assessment in the immediate postoperative period after an ACDF is maintaining an airway and ensuring that the client has no problem with breathing.Administration of pain medication, ambulation, and assessing the client's ability to void are important but are not the highest priority.

The nurse is providing instructions to a client who has a history of stomatitis. Which instructions does the nurse include in the client's teaching plan? a. Encourage the client to eat acidic foods to decrease bacteria. b. Mouth care should be performed twice daily. c. Rinse the mouth with warm saline or sodium bicarbonate. d. Use a medium-bristled toothbrush for oral care.

C

The nurse and the dietitian are planning sample diet menus for a patient who is experiencing dumping syndrome. Which sample meal is best for this patient? Chicken salad on whole wheat bread Liver and onions Chicken and rice Cobb salad with buttermilk ranch dressing

Chicken and rice **Chicken and rice is the best sample meal for this patient. It is the only selection suitable for the patient who is experiencing dumping syndrome because it contains high protein without the addition of milk or wheat products.The patient with dumping syndrome would not be allowed to have mayonnaise, onions, or buttermilk ranch dressing. Buttermilk dressing is made from milk products. The patient can have whole wheat bread only in very limited amounts.

Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis? Cloudy, turbid CSF Decreased white blood cells Decreased protein Increased glucose

Cloudy, turbid CSF **Cloudy, turbid CSF indicates to the nurse that the client may have bacterial meningitis.Clear fluid is a sign of viral meningitis. Increased white blood cells, increased protein, and decreased glucose are signs of bacterial meningitis.

What is a common gastrointestinal problem that older adults experience more frequently as they age? Decreased hydrochloric acid levels Excess lipase production Increased liver size Increased peristalsis

Decreased hydrochloric acid levels **In older adults, decreased hydrochloric acid levels (hypochlorhydria) results from atrophy of the gastric mucosa.A decrease in lipase production results from calcification of pancreatic vessels. A decrease in the number and size of hepatic cells leads to decreased liver weight and mass. Peristalsis decreases, and nerve impulses are dulled.

A client with severe muscle spasticity has been prescribed tizanidine (Zanaflex, Sirdalud). The nurse instructs the client about which adverse effect of tizanidine? Drowsiness Hirsutism Hypertension Tachycardia

Drowsiness **Adverse effects of tizanidine include drowsiness and sedation. Tizanidine (Zanaflex, Sirdalud) is a centrally acting skeletal muscle relaxant.It does not cause hirsutism, hypertension, or tachycardia.

In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? Indication of allergies Level of consciousness Loss of sensation Patent airway

Patent airway **The nursing priority when assessing a client with a spinal cord injury is a patent airway. Clients with injuries at or above T6 are at risk for respiratory complications. Assessing for a patent airway is essential.Asking the client about current medications and allergies is part of every trauma assessment. Assessing the level of consciousness utilizing the Glasgow Coma Score (GCS) is an important part of the trauma assessment. Determining the level of loss of sensation will be included in the neurological evaluation.

Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? Encouraging nutrition Frequent ambulation Regular turning and repositioning Special pressure-relief devices

Regular turning and repositioning **Regular turning and repositioning are the best way to prevent complications of immobility in clients with spinal cord problems.A registered dietitian may be consulted to encourage nutrition to optimize diet for general health and to reduce osteoporosis. Frequent ambulation may not be possible for these clients. Use of special pressure-relief devices is important but is not the best way to prevent immobility complications.

To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the primary health care team is a nursing priority? Nutritional therapy Occupational therapy Physical therapy Respiratory therapy

Respiratory therapy **To help prevent death for a client with spinal cord injury, collaboration with the Respiratory therapy team is a priority. A client with a cervical spinal cord injury is at risk for breathing problems including pneumonia and aspiration, resulting from the interruption of spinal innervation to the respiratory muscles. Collaboration with Respiratory therapy is crucial.Collaboration with nutritional therapy, occupational therapy, and physical therapy does not help prevent the leading cause of death in clients with spinal cord injury.

The Certified Wound, Ostomy, and Continence Nurse is teaching a patient with colorectal cancer how to care for a newly created colostomy. Which patient statement reflects a correct understanding of the necessary self-management skills? "I will have my spouse change the bag for me." "If I have any leakage, I'll put a towel over it." "I can put aspirin tablets in the pouch in order to reduce odor" "I will apply a non-alcoholic skin sealant around the stoma and allow it to dry prior to applying the bag."

"I will apply a non-alcoholic skin sealant around the stoma and allow it to dry prior to applying the bag." **The patient statement that reflects a correct understanding of necessary self-management skills to care for a newly created colostomy is, "I will apply a non-alcoholic sealant around the stoma and allow it to dry prior to putting the bag on." Teach the patient and family to apply a skin sealant (preferably without alcohol) and allow it to dry before application of the appliance (colostomy bag) to facilitate less painful removal of the tape or adhesive.It is not realistic that the spouse will always change the patient's bag and does not reflect correct understanding of self-management skills. A towel is not an acceptable or effective way to cope with leakage. Putting an aspirin in the pouch will not reduce odor and can lead to ulcers in the stoma.

The nurse is teaching a patient who has undergone a hemorrhoidectomy about a follow-up plan of care. Which patient statement demonstrates a correct understanding of the nurse's instructions? "I would take Ex-Lax after the surgery to 'keep things moving'." "I will need to eat a diet high in fiber." "Limiting my fluids will help me with constipation." "To help with the pain, I'll apply ice to the surgical area."

"I will need to eat a diet high in fiber." **The statement that shows that the hemorrhoidectomy patient correctly understands the nurse's instruction is, "I will need to eat a diet high in fiber." A diet high in fiber serves as a natural stool softener and will prevent irritation to hemorrhoids caused by painful bowel movements.Ex-lax is a stimulant laxative. Stimulant laxatives are discouraged because they are habit-forming. Increased amounts of fluids are needed to prevent constipation. Moist heat (sitz baths) will be more effective with postoperative discomfort than cold applications. Cold therapy is sometimes recommended and useful before surgery for inflamed hemorrhoids.

A patient has been newly diagnosed with ulcerative colitis (UC). What does the nurse teach the patient about diet and lifestyle choices? "Drinking carbonated beverages will help with your abdominal distress." "It's OK to smoke cigarettes, but you should limit them to ½ pack per day." "Lactose-containing foods should be reduced or eliminated from your diet." "Raw vegetables and high-fiber foods may help to diminish your symptoms."

"Lactose-containing foods should be reduced or eliminated from your diet." **The nurse teaches the newly diagnosed patient with ulcerative colitis that lactose-containing foods are often poorly tolerated and need to be reduced or eliminated from the diet.Carbonated beverages are GI stimulants that can cause discomfort and must be used rarely or completely eliminated from the diet. Cigarette smoking is a stimulant that can cause GI distress symptoms. Nurses would never advise patients that any amount of cigarette smoking is "OK." Raw vegetables and high-fiber foods can cause GI symptoms in patients with UC.

Nurse talking to a group of people able colorectal cancer risk factors. Which person is at highest risk for development of CRC?

30yr old with Crohn's disease

A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What is the nurse's best response? "Every injury is different, and it is too soon to have any real answers right now." "Only time will tell." "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." "Please request a meeting with the health care provider. I will help set that up."

"Please request a meeting with the health care provider. I will help set that up." **The nurse's best response to a family member of a client with a recent spinal cord injury is, "Please request a meeting with the primary health care provider. I will set that up." Questions concerning prognosis and potential for recovery would be referred to the primary health care provider. The nurse can help facilitate the meeting however.The timing and extent of recovery are different for each client, but it is not the nurse's role to inform the client and family members of the client's prognosis. Telling the family that "only time will tell" is too vague and minimizes the family's concern. The client was informed of Health Insurance Portability and Accountability Act (HIPAA) rights on admission or when consciousness was established, so permission has already been granted by the client.

The daughter of a client who has had a stroke asks the nurse for additional resources. What is the nurse's best response? "Call hospice." "Check the Internet." "The National Stroke Association has resources available." "The charge nurse at the desk has all of the information."

"The National Stroke Association has resources available." **The nurse's best response about additional resources for stroke is the National Stroke Association. The National Stroke Association is a specific and reliable resource that can be recommended. Additional resources are frequently provided as part of the discharge teaching the nurse will provide.Hospice care is appropriate for clients who are terminally ill, not a client who has had a stroke necessarily. Sources on the Internet may be very broad and unreliable or lack evidence to support their recommendations. The role of the client's nurse is to advocate for the client and not to refer all questions to the charge nurse.

A client diagnosed with acalculous cholecystitis asks the nurse how the gallbladder inflammation developed when there is no history of gallstones. What is the nurse's best response? "This may be an indication that you are developing sepsis." "The gallstones are present, but have become fibrotic and contracted." "This type of gallbladder inflammation is associated with hypovolemia." "This may be an indication of pancreatic disease."

"This type of gallbladder inflammation is associated with hypovolemia." **The nurse's best response about acalculous cholecystitis is that "This type of gallbladder inflammation is associated with hypovolemia."Although this type of gallbladder inflammation is associated with sepsis, it is not an indicator that sepsis is developing. Fibrotic and contracted gallstones are associated with chronic cholecystitis and this scenario states that there is no history of gallstones. The presence of acalculous cholecystitis is not an indicator that pancreatic disease has developed.

Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit? A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis A 36-year-old who needs teaching about an endoscopic retrograde cholangiopancreatography A 40-year-old who will need administration of IV midazolam hydrochloride (Versed) during an upper endoscopy A 46-year-old who was recently admitted with abdominal cramping and diarrhea of unknown causes

A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis **Nasogastric tube insertion is included in LPN/LVN education and is an appropriate task for an experienced LPN/LVN.Assessment and client teaching would be done by an RN. IV hypnotic medications would be administered by an RN.

While working in the outpatient procedure unit, the RN is assigned to these clients. Which client does the nurse assess first? A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) A 54-year-old who is ready for discharge following a colonoscopy A 58-year-old who has just arrived for basal gastric secretion and gastric acid stimulation testing A 60-year-old with questions about an endoscopic ultrasound examination

A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) **ERCP requires conscious sedation, so the client needs immediate assessment of respiratory and cardiovascular status. The endoscopic procedure and nursing care for a client having an ERCP are similar to those for the EGD procedure, except that the endoscope is advanced farther into the duodenum and into the biliary tractA 54-year old client being discharged after a colonoscopy, a 58-year old client who is going to have a gastric acid test, and a 60-year old client with questions about an endoscopic ultrasound examination are not at risk for depressed respiratory status.

Peptic Ulcer Disease teaching

Avoid substances that increase gastric acid secretion (caffeine>>coffee, tea, cola) Seek immediate medical attention if experiencing any of these symptoms: -sharp sudden persistent and severe epigastric or abdominal pain -bloody or black stools Bloody vomit or vomit that looks like coffee grounds

Surgery for PUD teaching

Avoid any OTC product containing aspirin or other NSAID Stress importance of following treatment regimen for H.pylori infection and healing of ulcer and keeping of follow-up appts Help pt identify situations that cause stress, describe feelings during stressful situations and develop a plan for coping with stressors

A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? Measure intake and output every shift. Do not administer food or fluids by mouth. Administer opioid analgesic medication. Assist the client to assume a position of comfort.

Administer opioid analgesic medication. **Pain relief is the highest priority for the client with acute pancreatitis.Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority.

Oral cancer safety alert

After excision it resection for oral cancer, most important nursing intervention is maintains pt's airway to promote gas exchange

The nurse is caring for a client with a hiatal hernia who had an open fundoplication yesterday. Which task does the nurse delegate to unlicensed assistive personnel (UAP)? A. Using a pillow to support the incision when the client coughs Correct B. Adjusting the position of the nasogastric (NG) tube C. Assessing the level of postoperative pain using a 0-to-10 scale D. Giving the client sips of water once bowel sounds are heard

Assisting a client to cough is a task within the education and skill level of UAP. NG tube maintenance, pain assessment, and assessment of bowel sounds require more knowledge of the potential complications associated with this surgical procedure, and are actions best performed by licensed nursing staff.

The nurse is teaching a patient with a newly created colostomy about foods to limit or avoid because of flatulence or odors. Which foods are included? Select all that apply. Broccoli Buttermilk Mushrooms Onions Peas Yogurt

Broccoli Mushrooms Onions Peas **Foods the patient with a newly created colostomy needs to limit or avoid because of flatulence or odors include: Broccoli, mushrooms, onions, and peas.Buttermilk will help prevent odors. Yogurt can help prevent flatus.

A patient is diagnosed with irritable bowel syndrome (IBS). What factors does the nurse suspect as possibly contributing to the patient's condition? Select all that apply. Antihistamines Caffeinated drinks Stress Sleeping pills Combinations of genetic, immunological, and hormonal factors

Caffeinated drinks Stress Combinations of genetic, immunological, and hormonal factors **The factors that the nurse suspects may contribute to IBS include: caffeinated drinks, stress, and combinations of genetic, immunological and hormonal factors. The etiology of IBS remains unclear. Research suggests that a combination of environmental, immunologic, genetic, hormonal, and stress factors play a role in the development and course of the disorder. Examples of environmental factors include foods and fluids like caffeinated or carbonated beverages and dairy products. Infectious agents have also been identified. Several studies have found that patients with IBS often have small-bowel bacterial overgrowth, which causes bloating and abdominal distention.Antihistamines and sleeping pills are not suspected of causing IBS.

A home health patient has had severe diarrhea for the past 24 hours. Which nursing action does the RN delegate to the home health aide (unlicensed assistive personnel [UAP]) who assists the patient with self-care? Instructing the patient about the use of electrolyte-containing oral rehydration products Administering loperamide (Imodium) 4 mg from the patient's medicine cabinet Checking and reporting the patient's heart rate and blood pressure in lying, sitting, and standing positions Teaching the patient how to clean the perineal area after each loose stool

Checking and reporting the patient's heart rate and blood pressure in lying, sitting, and standing positions **The RN delegates to the UAP a home health patient with severe diarrhea who needs checking and reporting of the patient's heart rate and blood pressure in lying, sitting, and standing positions. Obtaining the patient's blood pressure and heart rate is included in the education of home health aides and other UAPs.Patient teaching and medication administration are complex skills that would be performed by licensed nurses who have the education and scope of practice needed to safely implement these actions.

A client reports ongoing episodes of heartburn. Nurse educated the client on prevention and control of reflux by recommending dietary elimination of which food item?

Chocolate candy

Obstruction of large intestine due to fecal impaction manifestations

Client having small frequent liquid stools

The nursing team consists of an RN, an LPN/LVN, and a nursing assistant. Which client should be assigned to the RN? Client who is taking lactulose and has diarrhea Client with hepatitis C who requires a dressing change Client with end-stage cirrhosis who needs teaching about a low-sodium diet Obtunded client with alcoholic encephalopathy who needs a blood draw

Client with end-stage cirrhosis who needs teaching about a low-sodium diet **The client with end-stage cirrhosis would be assigned to the RN. The RN is responsible for client teaching.Assisting a client with toileting and recording stool number and amount can be accomplished by nonprofessional staff. The LPN/LVN can provide dressing changes. Ancillary staff can perform venipuncture

A client who was awaiting liver transplantation is excluded from the procedure after the presence of which condition is discovered? Colon cancer with metastasis to the liver Hypertension Hepatic encephalopathy Ascites and shortness of breath

Colon cancer with metastasis to the liver **Clients with metastatic cancers are not candidates for liver transplant. Transplantation is performed for hepatitis and primary (not secondary) liver cancers.Hypertension is a controllable factor and would not preclude the client from a liver transplant. Encephalopathy is a consequence of advanced liver disease, consistent with the condition of a client awaiting transplantation. It can be treated with lactulose and nonabsorbable antibiotics. Ascites and resulting shortness of breath are also consequences of advanced liver disease, consistent with the client awaiting transplantation. They can be managed with diuretics and paracentesis.

The nurse is assessing a patient with gastroesophageal reflux disease (GERD). Which findings does the nurse expect to observe? Select all that apply. Blood-tinged sputum Dyspepsia Excessive salivation Flatulence Regurgitation

Dyspepsia Excessive salivation Flatulence Regurgitation **When assessing a patient for GERD, the nurse expects to find dyspepsia (heartburn), excessive salivation, flatulence which is common after eating, and regurgitation (backward flow of food and fluid into the throat).Blood-tinged sputum and excessive salivation are not symptoms of GERD.

The nurse is assessing a client with gastroesophageal reflux disease (GERD). Which findings does the nurse expect to observe? (Select all that apply.) A. Blood-tinged sputum B. Dyspepsia Correct C. Excessive salivation D. Flatulence Correct E. Regurgitation Correct

Dyspepsia, also known as heartburn, is one of the main symptoms of GERD. Flatulence is common after eating, as well as regurgitation (backward flow into the throat) of food and fluids. Blood-tinged sputum and excessive salivation are not symptoms of GERD.

A patient with a family history of colorectal cancer (CRC) regularly sees a primary health care provider for early detection of any signs of cancer. Which laboratory result may be an indication of CRC in this patient? Decrease in liver function test results Elevated carcinoembryonic antigen Elevated hemoglobin levels Negative test for occult blood

Elevated carcinoembryonic antigen **Carcinoembryonic antigen may be elevated in many patients diagnosed with CRC.Liver involvement may or may not occur in CRC. Hemoglobin will likely be decreased with CRC, not increased. An occult blood test is not reliable to affirm or rule out CRC.

The nurse suspects that a client may have acute pancreatitis as evidenced by which group of laboratory results? Deceased calcium, elevated amylase, decreased magnesium Elevated bilirubin, elevated alkaline phosphatase Elevated lipase, elevated white blood cell (WBC) count, elevated glucose Decreased blood urea nitrogen (BUN), elevated calcium, elevated magnesium

Elevated lipase, elevated white blood cell (WBC) count, elevated glucose **Elevated lipase, along with increased WBC and increased glucose, suggests acute pancreatitis. Also, increased are serum amylase, serum trypsin, and serum elastase.Many pancreatic and nonpancreatic disorders can cause increased serum amylase levels. Bilirubin and alkaline phosphatase levels will be increased only if pancreatitis is accompanied by biliary dysfunction. Usually, calcium and magnesium will be increased and BUN increased, not decreased, in acute pancreatitis.

small bowl obstruction from adhesion findings

Emesis greater than 500ml with a fecal odor Report of spasmodic abdominal pain High-pitched bowel sounds Abdominal distinction Metabolic alkalosis (loss of gastric acid)

Scope Procedures

Endoscopy: allow direct visualization of GI tract to evaluate bleeding/ulcers/inflammation/tumors and cancer Need informed consent

Acute gastritis plan of care

Evaluate I&O Monitor lab reports of electrolyte Observe stool characteristics Eat small frequent meals Avoid NSAIDs

A client who recently had laparoscopic surgery to treat a ruptured appendix has developed subsequent peritonitis. The client currently has two Jackson Pratt drains placed in the abdomen. Which finding(s) would the nurse report immediately to the surgeon?

Fever Cloudy drainage Painful abdominal distention

Nurse is assessing a client with a known inguinal hernia. Which assessment findings indicate that the hernia may have strangulated?

Fever Tachycardia Abdominal distention Nausea and vomiting

Anorectal Abscess nursing interventions

Focused on comfort and helping pt maintain optimal perineal hygiene Encourage use of warm sitz baths, analgesics, bulk producing agents, and stool softeners after surgery Stress importance of good perineal hygiene after all bowel movements and the maintenance of regular bowel pattern with a high-fiber diet

A client had an open partial colectomy and ascending colostomy 3days ago. Which assessment findings does the nurse expect?

Gas inside the pouch Pain controlled with analgesics Serosanguineous fluid draining from two Jackson-Pratt drains

A patient with a recent surgically created ileostomy refuses to look at the stoma and asks the nurse to perform all required stoma care. What does the nurse do next? Asks the patient whether family members could be trained in stoma care Has another patient with a stoma who performs self-care talk with the patient Requests that the primary health care provider request antidepressants and a psychiatric consult Suggests that the primary health care provider request a home health consultation so stoma care can be performed by a home health nurse

Has another patient with a stoma who performs self-care talk with the patient **When a patient with a recently created ileostomy refuses to look at the stoma and wants the nurse to perform all required stoma care, the nurse has another patient with a stoma who performs self-care talk with the patient.If at all possible, the patient would perform stoma care so that he or she can be as independent as possible. Although the patient may need medication for depression, the priority is to encourage the patient to look at, touch, and begin caring for the stoma. A home health nurse can be a support but cannot provide all of the care that the patient will need.

The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? Select all that apply. Alopecia Headaches Dizziness Diplopia Increased blood glucose

Headaches Dizziness Diplopia **Adverse effects the nurse must monitor for in a client taking carbamazepine for partial seizures after encephalitis include: headaches, dizziness, and diplopia. Carbamazepine affects the central nervous system, although it's mechanism of action is unclear.Carbamazepine does not cause alopecia and does not increase blood glucose. Divalproex (Depakote) and valproic acid (Depakene) may cause alopecia.

Which are risk factors for stroke? Select all that apply. High blood pressure Previous stroke or transient ischemic attack (TIA) Smoking Use of oral contraceptives Female gender

High blood pressure Previous stroke or transient ischemic attack (TIA) Smoking Use of oral contraceptives **Common modifiable risk factors for developing a stroke include smoking and the use of oral contraceptives. Other risk factors include high blood pressure and history of a previous TIA.Gender is not a known risk factor for stroke; however, the female client is at risk for delayed recognition of early stroke symptoms.

Dumping Syndrome teaching

High fat, high protein, low fiber, moderate-low carb diet

Abdominal assessment

If a bulging pulsating mass present during assessment of abdomen, DO NOT touch the area bc the patient may have an abdominal aortic aneurysm>>notify doctor immediately!! Peristaltic movement rarely seen unless or is thin and has increased peristalsis

H.pylori infection in older adults

In older adults usually undiagnosed bc of vague symptoms associated with physiologic changes in aging and comorbidities that mask dyspepsia Teach older adults about symptoms of PUD and consider H.pylori screening Early detection and treatment can prevent PUD and gastric cancer

Which diagnostic results lead the nurse to suspect that a client may have gallbladder disease? Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall Decreased WBC count, visualization of calcified gallstones, increased alkaline phosphatase Increased WBC count, visualization of noncalcified gallstones, edema of the gallbladder wall Decreased WBC count, visualization of noncalcified gallstones, increased alkaline phosphatase

Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall **An increased WBC count, calcified gallstones visualized on the abdominal X-ray, and edema of the gallbladder wall are the best diagnostic results to indicate gallbladder disease. Acute cholecystitis is seen as edema of the gallbladder wall and pericholecystic fluid. Ultrasonography of the right upper quadrant is the best diagnostic test for cholecystitis.An increased WBC count, not decreased, is evidence of inflammation. Only calcified gallstones, not noncalcified gallstones, will be visualized on abdominal X-ray. Alkaline phosphatase will be elevated if liver function is abnormal; this is not common in gallbladder disease.

A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? Select all that apply. Bite block at the bedside Intravenous access (IV) Continuous sedation Suction equipment at the bedside Siderails raised

Intravenous access (IV) Suction equipment at the bedside Siderails raised **Seizure precautions the nurse institutes for an admitted client with new-onset status epilepticus include IV access, suctioning equipment at the bedside and raised siderails. IV access is needed to administer medications. Suctioning equipment must be available to suction secretions and facilitate an open airway during a seizure. Raised, padded siderails may be used to protect the client from falling out of bed during a seizure.Bite blocks or padded tongue blades would not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway. Continuous sedation is a medical intervention and not a seizure precaution.

Which substance, produced in the stomach, facilitates the absorption of vitamin B12? Glucagon Hydrochloric acid Intrinsic factor Pepsinogen

Intrinsic factor **Intrinsic cells are produced by the parietal cells in the stomach. This substance facilitates the absorption of vitamin B12. Absence of intrinsic factor causes pernicious anemia.Glucagon, which is produced by the alpha cells in the pancreas, is essential for the regulation of metabolism. Parietal cells secrete hydrochloric acid, but this does not facilitate the absorption of vitamin B12. Pepsinogen is secreted by the chief cells; pepsinogen is a precursor to pepsin, a digestive enzyme.

PPIs

Long term use increases risk of hip fracture especially in older adults

A client is scheduled to undergo a liver transplantation. Which nursing intervention is most likely to prevent the complications of bile leakage and abscess formation? Preventing hypotension Keeping the T-tube in a dependent position Administering antibiotic vaccinations Administering immune-suppressant drugs

Keeping the T-tube in a dependent position **The nursing intervention most likely to prevent the complications of bile leakage and abscess formation is keeping the T-tube in a dependent position and secured to the client. This action will likely prevent bile leakage, abscess formation, and hepatic thrombosis.Preventing hypotension will help to prevent the complication of acute kidney injury. Administering antibiotic vaccinations will help to prevent infection. Administering immune-suppressant drugs will help to prevent graft rejection.

When caring for a client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)? Kidney failure Refractory ascites Fetor hepaticus Paracentesis scheduled for today

Kidney failure **The nurse would question the use of neomycin for a client with kidney failure. Aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and must not be taken by clients with hepatic encephalopathy.Cirrhosis and hepatic failure cause both ascites and encephalopathy; no contraindication for neomycin is known. Fetor hepaticus causes an ammonia smell to the breath when serum ammonia levels are elevated; neomycin is used to decrease serum ammonia levels. The client may be NPO for a few hours before paracentesis, but may take neomycin when the procedure is complete, or with less than 30 mL of water, depending on hospital policy.

The nurse is caring for a patient diagnosed with esophageal cancer who is experiencing diarrhea after conventional esophageal surgery. The nurse anticipates that the primary health care provider will request which medication to manage diarrhea? Loperamide (Imodium) Mesalamine (Pentasa) Minocycline (Minocin) Pantoprazole (Protonix)

Loperamide (Imodium) **The nurse anticipates that the primary health care provider will order Loperamide to manage the diarrhea. Diarrhea is thought to be the result of vagotomy syndrome, which develops as a result of interruption of vagal fibers to the abdominal viscera during surgery. It can occur 20 minutes to 2 hours after eating and can be symptomatically managed with loperamide.Mesalamine is used to treat patients with mild to moderate ulcerative colitis. Minocycline is an antibiotic used for treatment of infection. Pantoprazole is used to treat gastroesophageal reflux disease.

Which facial assessment finding in a pt with a salivary gland tumor prompts the nurse to notify the health care provider?

Loss of sensation in tongue

GERD expected finding

Loss of tooth enamel, hyper salivation, bitter taste in mouth, increased burping

Priory care of upper GI bleeding

Maintain A: airway, B:breathing, C:circulation Provide oxygen and other ventilatory support, 2 large bore IV lines for replacing fluids and blood, monitoring vital signs, hematocrit and oxygen saturation

The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range? Dexamethasone (Decadron) Hydrochlorothiazide (HydroDIURIL) Mannitol (Osmitrol) Phenytoin (Dilantin)

Mannitol (Osmitrol) **In a postoperative craniotomy client with ICP, the nurse expects Mannitol to be requested to keep the ICP within a certain range. Mannitol is an osmotic diuretic used specifically to treat cerebral edema.Glucocorticoids have no demonstrated benefit in reducing ICP. Hydrochlorothiazide is only a mild diuretic and is not beneficial in maintaining ICP. Dilantin is used to treat seizure activity caused by increased ICP.

A client has recently developed acute sialadenitis. Which intervention does the nurse include in this client's care? Applying cold compresses Avoiding the use of fruit or citrus-flavored candy Massaging the salivary gland Restrict fluids

Massaging the salivary gland **Sialadenitis (sialoadenitis) is inflammation of a salivary gland. The salivary gland is massaged to stimulate the flow of saliva. This is done by milking the edematous gland with the fingertips toward the ductal opening.To promote the flow of saliva, warm, not cold, compresses are applied to the affected salivary gland. Sialagogues such as lemon slices and fruit- or citrus-flavored candy are used to stimulate the flow of saliva. The client is kept well hydrated to promote salivary flow.

The nurse expects that which client will be discharged to the home environment first? Older obese adult who has had a laparoscopic cholecystectomy Middle-aged thin adult who has had a laparoscopic cholecystectomy Middle-aged thin adult with a heart murmur who has had a traditional cholecystectomy Older obese adult with chronic obstructive pulmonary disease (COPD) who has had a traditional cholecystectomy

Middle-aged thin adult who has had a laparoscopic cholecystectomy **A middle-aged client with a thin frame, who had a laparoscopic cholecystectomy, will be discharged first.Although the older obese client also had a laparoscopic cholecystectomy, the client's obesity and age probably will require a longer stay. A traditional cholecystectomy will always require a longer recovery time. The older obese client with a history of COPD will likely have a more lengthy recovery because of associated breathing problems.

A client is being discharged with paraplegia secondary to a motor vehicle crash and expresses concern over the ability to cope in the home setting after the injury. Which is the best resource for the nurse to provide for the client? Hospital library Internet National Spinal Cord Injury Association Provider's office

National Spinal Cord Injury Association **The best resource for the nurse to provide is the National Spinal Cord Injury Association. The National Spinal Cord Injury Association will inform the client of support groups in the area and will assist in answering questions regarding adjustment in the home setting.The hospital library is not typically consumer-oriented. Most information available in the library is targeted to health care professionals. The Internet is not the best resource simply because of the unlimited volume of information available and its questionable quality. Although the provider's office may have information, the information may not be as comprehensive and current as other options.

The nurse suspects that which client is at highest risk for developing gallstones? Obese male with chronic obstructive pulmonary disease Obese female receiving hormone replacement therapy Thin male with a history of coronary artery bypass grafting Thin female who has recently given birth

Obese female receiving hormone replacement therapy **The client at highest risk is the obese female receiving hormone replacement therapy. Both obesity and hormone replacement therapy have been found to increase a woman's risk for developing gallstones. Other risk factors for developing gallstones are type 2 diabetes, dyslipidemia, and insulin resistance.Men are at lower risk than women for developing gallstones. Although pregnancy increases the risk for a woman to develop gallstones, a woman's thin frame lessens that risk.

The nurse is caring for an older adult male patient who reports stomach pain and heartburn. Which sign/symptom is most significant suggesting the patient's ulceration is duodenal in origin and not gastric? Pain occurs 1½ to 3 hours after a meal, usually at night. Pain is worsened by the ingestion of food. The patient has a malnourished appearance. The patient is a man older than 50 years.

Pain occurs 1½ to 3 hours after a meal, usually at night. **A key symptom of duodenal ulcers is that pain usually awakens the patient between 1:00 a.m. and 2:00 a.m. and occurs 1½ to 3 hours after a meal.Pain that is worsened with ingestion of food and a malnourished appearance are key features of gastric ulcers. A male over 50 years is a finding that could apply to either type of ulcer.

CRC stat

People with first degree relative (parent, sibling, or child) dx with CRC have 3-4x risk for developing the disease

The nurse is reviewing admitting requests for a patient admitted to the intensive care unit with perforation of a duodenal ulcer. Which request does the nurse implement first? Apply antiembolism stockings. Place a nasogastric (NG) tube, and connect to suction. Insert an indwelling catheter, and check output hourly. Give famotidine (Pepcid) 20 mg IV every 12 hours.

Place a nasogastric (NG) tube, and connect to suction. **When caring for an ICU patient with a perforated duodenal ulcer, the nurse or primary care provider must first insert a nasogastric (NG) tube and connect it to suction. To decrease spillage of duodenal contents into the peritoneum, NG suction would be rapidly initiated. This will minimize the risk for peritonitis.Antiembolism stockings will need to be applied, monitoring urined output is important, and famotidine (Pepcid) will need to be administered, but these are done after the NG tube is inserted and connected to suction.

Priory care after EGD

Prevention of aspiration!! Do not offer fluids or food by mouth until you are sure the gag reflex is intact. Monitor for signs of perforation, such as pain, bleeding, or fever

When caring for a pt. Who has just had an upper GI endoscopy, the nurse assesses that the pt has developed a temperature of 101.8 degrees. What's the approval nursing intervention?

Prompt asses the pt for potential perforation

When caring for a client with oral cancer who has developed stomatitis as a complication of radiation and chemotherapy, which action does the nurse delegate to the unlicensed assistive personnel (UAP)? Provide oral care using disposable foam swabs. Inspect the oral mucosa for evidence of oral candidiasis. Instruct the client on how to use nystatin (Mycostatin) oral rinses. Teach the client how to make appropriate dietary choices.

Provide oral care using disposable foam swabs. **Providing oral care for a client with oral lesions is an appropriate assignment for a UAP.Assessments, client teaching, and assisting clients with oral problems in making appropriate dietary choices are the responsibilities of licensed nursing staff.

Seizure Nursing Actions

Provide privacy Ease client to floor if standing Move furniture away from client Loosen client's clothing Protect client's head with padding

Post-op esophageal surgery

Recognize if pt has signs of fever, fluid accumulation, signs of inflammation, and symptoms of early shock (tachycardia and tachypnea) Respond immediately by reporting any of hear finding to surgeon AND rapid response team!!

Perforation s&s

Rigid abdomen, tachycardia, hypotension, rebound tenderness

Seizure precautions

Safe environment; ensuring suction and oxygen are available; starting or maintaining IV access

Gastric Ulcer Assessment findings

Sensation of bloating, pain occurs 30min-1hr after meal, pain upon palpating of the epigastric region

The community nurse is discussing risk factors for esophageal cancer with clients. Which behavior requires further teaching?

Smokes one pack of cigarettes daily

A patient is experiencing bleeding related to peptic ulcer disease (PUD). Which nursing intervention is the highest priority? Starting a large-bore IV Administering IV pain medication Preparing equipment for intubation Monitoring the patient's anxiety level

Starting a large-bore IV **The nursing intervention that has the highest priority for a patient with a bleeding peptic ulcer is to start a large-bore IV. A large-bore IV is inserted so that blood products can be administered.IV pain medication is not a recommended treatment for gastrointestinal bleeding. Intubation is also not recommended. The mental status of the patient would be monitored, but it is not necessary to monitor the anxiety level of the patient.

A client who has been diagnosed recently with esophageal cancer states, "I'm not comfortable going to my father's birthday lunch at our family-owned restaurant because I'm afraid I'll choke in public." What is the nurse's best response? A. "I understand your concerns, but you can't give up your normal activities. You should go anyway and try not to worry about it." B. "Could you perhaps invite everyone over to cook at your home? That will allow you to be together and be more relaxed." Correct C. "Why not take one of your antianxiety pills before going? That will keep you from worrying about everything so much." D. "You need to talk to your doctor about your concerns. The doctor may recommend that you join a support group for cancer survivors." Incorrect

Suggesting that the client invite people over for a meal provides psychosocial support to the client and assists the client in finding a solution to the problem. Telling the client not to worry about it or to call the provider is evasive and unhelpful; it is used to placate the client and does not address the client's concerns. The client should use problem-solving and coping skills before resorting to the use of medication.

A nurse is providing discharge instructions to a female client who has a prescription for phenytoin. Which is the following info should the nurse include?

Take the medication at the same time every day

Colostomy skin care

Teach pt to apply a skin sealant and allow to dry beige application of the appliance (colostomy bag) to facilitate a less painful removal of the tape or adhesive If peristomal skin becomes raw, aroma powder or paste or a combination may be applied

Hemorrhoids post-op

Tell the or after hemorrhoids surgery that the first post-up bowel movement may be very painful!! Be sure that someone is with or near the pt when this happens...some become light-headed and diaphoretic and may have syncope r/t a vasovagal response

A client has been diagnosed with terminal esophageal cancer. The client is interested in obtaining support from hospice, but expresses concern that pain management will not be adequate. What is the nurse's best response? A. "Haven't you received adequate pain management in the hospital?" B. "Would you like me to get a nurse from hospice to come talk with you?" Correct C. "Do you want me to call the hospital chaplain to explain hospice to you?" D. "Talk to your health care provider about hospice services."

The best way to alleviate the client's concerns would be to have a hospice nurse talk with the client and answer any questions. Suggesting that the client has had adequate pain management sounds defensive. Referring the client to the chaplain or the health care provider is evasive and attempts to shift responsibility away from the nurse.

The nurse is caring for a client postoperatively after an anterior cervical diskectomy and fusion. Which assessment finding is of greatest concern to the nurse? Neck pain is at a level 7 on a 0-to-10 scale. Serosanguineous fluid oozes onto the neck dressing. The client is reporting difficulty swallowing secretions. The client has numbness and tingling bilaterally down the arms.

The client is reporting difficulty swallowing secretions. **The nursing assessment finding that is the greatest concern for a postoperative anterior cervical diskectomy client is the client reporting difficulty swallowing secretions. This may indicate swelling in the neck and the potential for compromise of the client's airway.Experiencing neck pain and numbness and tingling bilaterally down the arms are expected findings after this surgery. Serosanguineous fluid oozing onto the neck dressing is also a normal finding after this surgery.

The nurse prepares a teaching session regarding lifestyle changes needed to decrease the discomfort associated with a client's hiatal hernia. Which change does the nurse recommend to this client? A. Eat only two or three meals daily. B. Sleep flat in a left side-lying position. C. Drink tea instead of coffee. D. Avoid working while bent over the computer. Correct

The client should avoid working while bent over because this position presses on the diaphragm, causing discomfort. The client with a hiatal hernia should eat four to six meals a day. The head of the client's bed should be elevated approximately 6 inches. Both tea and coffee should be eliminated from this client's diet because of the caffeine content.

The nurse is caring for a client in the emergency department (ED) whose spinal cord was injured at the level of C7 1 hour prior to arrival. Which assessment finding requires the most rapid action? After two fluid boluses, the client's systolic blood pressure remains 80 mm Hg. Cardiac monitor shows a sinus bradycardia at a rate of 50 beats/min. The client's chest moves very little with each respiration. The client demonstrates flaccid paralysis below the level of injury.

The client's chest moves very little with each respiration. **The most rapid action is needed for a spinal cord injury client injured one hour prior to arrival whose chest moves very little with each respiration. Airway and breathing are always of major concern in a spinal cord injury, especially in an injury near C3 to C5, where the spinal nerves control the diaphragm.Bradycardia and hypotension are indications neurogenic shock due to disruption of autonomic pathways. This will need to be addressed rapidly however airway and breathing are always the top priority. Flaccid paralysis below the level of the injury is to be expected.

Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the health care provider (HCP)? The dressing has a 2-cm area of serous drainage. The client's platelet count is 135,000/mm3 (135 × 109/L). The client's albumin level is 2.8 g/dL (28 g/L). The client's heart rate is 122 beats/min.

The client's heart rate is 122 beats/min. **After a paracentesis with 2500 ml of fluid removed, the assessment finding of the client's heart rate is the most important finding to communicate to the HCP. Rapid removal of fluid may cause symptoms of shock, including tachycardia, and are especially associated with hypotension.A small amount of serous fluid may leak, so the dressing would be reinforced. Platelets will be checked before the procedure. These are slightly low, but this is not a cause for concern. An albumin level of 2.8 g/dL (28 g/L) is an expected finding for a client with cirrhosis and is not life threatening.

The nurse is caring for a client who has cirrhosis of the liver. The client has exhibited hand flapping and mental confusion for several weeks. Although the mental confusion is worsening, the client has stopped exhibiting hand flapping movements. How will the nurse interpret these findings? The client's symptoms are progressing and getting worse. The client's serum ammonia levels are decreasing. The client probably has a decrease in serum proteins. The client is showing signs of improvement.

The client's symptoms are progressing and getting worse. **The nurse interprets these findings as an indication that the client's is getting worse. Clients with cirrhosis who exhibit asterixis or hand flapping, may eventually stop exhibiting this sign as they worsen. The fact that the client's mental confusion is worsening indicates that this is the case.Increased mental confusion is related to elevated, not decreased, ammonia levels, as well as other serum proteins. The client is worsening, not improving.

A client in the outpatient clinic tells the nurse about experiencing heartburn and nighttime coughing episodes. Which action does the nurse take first? A. Teach the client about antacid effects and side effects. B. Ask the client about medications and dietary intake. Correct C. Suggest that the client sleep with the head elevated 6 inches. D. Tell the client to avoid drinking alcohol late in the evening. Incorrect

The nurse's initial action should be further assessment of the client's risk factors for gastroesophageal reflux disease. Before suggesting interventions or beginning client teaching, the nurse must elicit more information about the client's symptoms. The nurse needs additional data before telling the client to avoid drinking alcohol late in the evening.

Which of these assigned clients does the nurse assess first after receiving the change-of-shift report? A. Young adult admitted the previous day with abdominal pain who is scheduled for a computed tomography (CT) scan in 30 minutes B. Adult with gastroesophageal reflux disease (GERD) who is describing epigastric pain at a level of 6 (0-to-10 pain scale) C. Middle-aged adult with an esophagogastrectomy done 2 days earlier who has bright-red drainage from the nasogastric (NG) tube Correct D. Older adult admitted with an ileus who has absent bowel sounds and a prescription for metoclopramide (Reglan) on an as-needed (PRN) basis Incorrect

The presence of blood in NG drainage is an unexpected finding 2 days after esophagogastrectomy and requires immediate investigation. The young adult scheduled for a CT scan, the adult with GERD, and the older adult with an ileus are all stable and do not require the nurse's immediate attention.

The nurse administers lactulose (Evalose) to a client with cirrhosis for which purpose? To aid in digestion of dairy products To reduce portal pressure To promote gastrointestinal (GI) excretion of ammonia To reduce the risk of GI bleeding

To promote gastrointestinal (GI) excretion of ammonia **In a client with cirrhosis, the administration of lactulose reduces serum ammonia levels by causing the client to excrete ammonia through the GI tract.Lactase, not lactulose, is the enzyme that aids in the digestion of dairy products. The mechanism of action of lactulose is not to reduce portal pressure. Lactulose does not affect bleeding.

The nurse is teaching a client with gallbladder disease about diet modification. Which meal does the nurse suggest to the client? Steak and French fries Fried chicken and mashed potatoes Turkey sandwich on wheat bread Sausage and scrambled eggs

Turkey sandwich on wheat bread **Turkey is an appropriate low-fat selection for this client. High fiber, from the wheat bread, also helps reduce the risk. Typically, diets high in fat, high in calories, low in fiber, and high in refined white carbohydrates place clients at higher risk for developing gallstones.Steak, French fries, fried chicken and mashed potatoes, and sausage are too fatty. Eggs are too high in cholesterol for a client with gallbladder disease.

Migraine triggers

Tyramine in wine, pickled products, aged cheeses, nitrates and nitrites in processed and grilled meats, etc

A client who has undergone surgery and completed radiation therapy to treat oral cancer reports persistent dry mouth. What will the nurse teach this client about managing this symptom? Use saliva substitutes, especially when eating dry foods. This condition is common but is temporary. Use lozenges and hard candies to prevent dry mouth. This indicates a complication of therapy.

Use saliva substitutes, especially when eating dry foods. **Xerostomia is a common effect of oral irradiation and may be permanent. Clients should be advised to use saliva substitutes.The condition is common, but often permanent. Lozenges and hard candies are not as effective as saliva substitutes. Dry mouth is a side effect of therapy, not a symptom of complications. Frequent sips of water is the preferred method of treating xerostomia during radiation therapy.

A patient has an anal fissure. Which intervention most effectively promotes perineal comfort for the patient? Administering a Fleet's enema when needed Applying heat to acute inflammation for pain relief Avoiding the use of bulk-forming agents Using hydrocortisone cream to relieve pain

Using hydrocortisone cream to relieve pain **The intervention that most effectively promotes perineal comfort in a patient with anal fissure is using hydrocortisone skin cream to relieve perineal pain.Enemas would be avoided when an anal fissure is present. Cold packs would be applied to acute inflammation to diminish discomfort. Bulk-forming agents would be used to decrease pain associated with defecation.

A patient admitted with severe diarrhea is experiencing skin breakdown from frequent stools. What is an important comfort measure for this patient? Applying hydrocortisone cream Cleaning the area with soap and hot water Using sitz baths three times daily Wearing absorbent cotton underwear

Using sitz baths three times daily **An important comfort measure for a patient admitted with severe diarrhea experiencing skin breakdown is using sitz baths three times daily.Barrier creams, not hydrocortisone creams, may be used. The skin would be cleaned gently with soap and warm, not hot, water. Absorbent cotton underwear helps keep the skin dry but is not a comfort measure.

Oral fluid intake safety alert

When I rake is started, assess for and document signs of difficulty swallowing, aspiration, or leakage of saliva or fluids from the suture line Monitor daily weight and hydration

Aspiration with esophageal tumor

When eating or drinking, recognize you must monitor for signs and symptoms of aspiration (ex. Choking and coughing) Food aspiration can cause airway obstruction, pneumonia, or both

The nurse has received report on a group of clients. Which client requires the nurse's attention first? Adult who is lethargic after a generalized tonic-clonic seizure Young adult who has experienced four tonic-clonic seizures within the past 30 minutes Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)

Young adult who has experienced four tonic-clonic seizures within the past 30 minutes **After receiving report on a group of clients, the nurse first needs to attend to the young adult client who is experiencing repeated seizures over the course of 30 minutes. This client is in status epilepticus, which is a medical emergency and requires immediate intervention.The adult client who is lethargic and the middle-aged adult client with absence seizures do not require immediate attention. A fever of 101.9° F (38.8° C), although high, does not require immediate attention.

The nurse is caring for an older client who experiences an exacerbation of ulcerative colitis with severe diarrhea that have lasted a week. Which complications will the nurse assess?

dehydration, hypokalemia, skin breakdown

A patient with colorectal cancer was started on 5-fluorouracil (5-FU) and is experiencing fatigue, diarrhea, and mouth ulcers. What does the nurse tell the patient about the cause of diarrhea and mouth ulcers? "A combination of chemotherapeutic agents has caused them." "GI problems are symptoms of the advanced stage of your disease." "5-FU cannot discriminate between your cancer and your healthy cells and is causing your ulcers and diarrhea." "You have these as a result of the radiation treatment."

"5-FU cannot discriminate between your cancer and your healthy cells and is causing your ulcers and diarrhea." **The nurse tells the patient with colorectal cancer who is taking 5-fluorouracil and is having fatigue, diarrhea, and mouth ulcers that 5-FU cannot discriminate between cancer and healthy cells. Therefore, the side effects of 5-FU are diarrhea, mucositis, leukopenia, mouth ulcers, and skin ulcers.The 5-FU treatment, not a combination of chemotherapy drugs, radiation, or the stage of the disease, is what is causing the patient's GI problems.

A male patient with a long history of ulcerative colitis experienced massive bleeding and had emergency surgery for creation of an ileostomy. He is very concerned that sexual intercourse with his wife will be impossible because of his new ileostomy pouch. How does the nurse respond? "A change in position may be what is needed for you to have intercourse with your wife." "Have you considered going to see a marriage counselor with your wife?" "What has your wife said about your pouch system?" "You must get clearance from your primary health care provider before you attempt to have intercourse."

"A change in position may be what is needed for you to have intercourse with your wife." **The nurse tells the patient who had an emergency ileostomy that a simple change in positioning during intercourse may alleviate the patient's apprehension and facilitate sexual relations with his wife.Suggesting marriage counseling may address the patient's concerns, but it focuses on the wrong issue. The patient has not stated that he has relationship problems. Asking the patient what his wife has said about the pouch may address some of the patient's concerns, but it similarly focuses on the wrong issue. Telling the patient that he needs to get clearance from his primary health care provider is an evasive response that does not address the patient's primary concern.

The nurse has placed a nasogastric (NG) tube in a patient with upper gastrointestinal (GI) bleeding to administer gastric lavage. The patient asks the nurse about the purpose of the NG tube for the procedure. What is the nurse's best response? "A fluid solution goes down the tube to help clean out your stomach." "The medication goes down the tube to help clean out your stomach." "The primary health care provider requested the tube to be placed just in case it was needed." "We'll start feeding you through it once your stomach is cleaned out."

"A fluid solution goes down the tube to help clean out your stomach." **The nurse's best response to the patient with upper GI bleeding about the purpose of a NG tube for gastric lavage is that fluid is put down the tube to clean out the stomach. Gastric lavage involves the instillation of a room-temperature solution of water or saline in volumes of 200 to 300 mL through an NG tube to clear out stomach contents and blood clots.Gastric lavage does not involve the instillation of medication. An NG tube is not typically placed in a patient without a particular purpose in mind. Gastric lavage does not involve enteral feeding.

A patient has been diagnosed with mild gastroesophageal reflux disease (GERD) and asks the nurse about nonpharmacologic treatments to prevent symptoms. What does the nurse tell this patient? "Avoid caffeine-containing foods and beverages." "Eat three meals each day and avoid snacking between meals." "Peppermint lozenges help to reduce stomach upset." "Sleep on your left side with a pillow between your knees."

"Avoid caffeine-containing foods and beverages." **The nurse tells the patient to avoid caffeine-containing foods and beverages. The nurse also teaches the patient to limit or eliminate foods that decrease lower esophageal sphincter (LES) pressure and that irritate inflamed tissue, causing heartburn. These foods include peppermint, chocolate, alcohol, fatty foods (especially fried), caffeine, and carbonated beverages.The nurse also needs to remind the patient to eat four to six small meals each day rather than three large ones and avoid snacking between meals. Large meals increase the volume of and pressure in the stomach and delay gastric emptying. Peppermint decreases LES pressure and increases the risk of symptoms. Patients need to be taught to elevate the head by 6 to 12 inches (30 cm) for sleep to prevent nighttime reflux.

A nurse is teaching a patient with Crohn's disease about managing the disease with the drug adalimumab (Humira). Which instruction does the nurse emphasize to the patient? "Avoid large crowds and anyone who is sick." "Do not take the medication if you are allergic to foods with fatty acids." "Expect difficulty with wound healing while you are taking this drug." "Monitor your blood pressure and report any significant decrease in it."

"Avoid large crowds and anyone who is sick." **The nurse emphasizes that the patient taking adalimumab for Crohn's disease needs to avoid being around large crowds to prevent developing an infection. Adalimumab (Humira), a biologic response modifier (BRM), also known as a monoclonal antibody drug, has been approved for use in Crohn's disease when other drugs have been ineffective. BRMs are approved for refractory (not responsive to other therapies) cases. These drugs cause immunosuppression and should be used with caution. Patients must be taught to report any signs of a beginning infection, including a cold, and to also avoid others who are sick.The patient would not take the medication if he or she is allergic to certain proteins. Although immune suppression may occur to some degree, the patient would not experience difficulty with wound healing while taking adalimumab. Also, the patient would not experience a decrease in blood pressure from taking this drug.

A client is scheduled for a colonoscopy. What does the nurse tell the client to do before the procedure is performed? "Begin a clear liquid diet at least 24 hours before the test." "Do not eat or drink anything for 12 hours before the test." "Give yourself tap water enemas until the fluid returns are clear." "Be sure to take all currently prescribed medications prior to the procedure."

"Begin a clear liquid diet at least 24 hours before the test." **The nurse tells the client to be on a clear liquid diet for at least 24 hours to cleanse the bowel before a colonoscopy.The client must be NPO (except for water) 4 to 6 hours before a colonoscopy, not 12 hours. Also, the client needs to avoid aspirin, anticoagulants, and antiplatelet drugs for several days before the procedure. Diabetic clients need to check with their health care provider about drug therapy requirements on the day of the test because they are NPO. The client would not give him/herself a tap water enema. Clients must not take all currently prescribed medications without first checking with their doctor.

A Certified Wound, Ostomy, and Continence Nurse (CWOCN) is teaching a patient about caring for a new ileostomy. What information is most important to include? "After surgery, output from your ileostomy may be a loose, dark-green liquid with some blood present." "Call your primary health care provider if your stoma has a bluish or pale look." "Notify the primary health care provider if output from your stoma has a sweetish odor." "Remember that you must wear a pouch system at all times."

"Call your primary health care provider if your stoma has a bluish or pale look." **It is most important for the Certified Wound, Ostomy, and Continence nurse to tell the patient with a new ileostomy to call the primary health care provider if the stoma has a bluish or pale look. If the stoma has a bluish, pale, or dark look, its blood supply may be compromised and the primary health care provider must be notified immediately.It is true that output from the stoma after surgery may be a loose, greenish-colored liquid that may contain some blood, but this information is not the highest priority for instruction. It is normal for output from the stoma to have very little odor or a sweetish smell. Although it is true that the patient will be required to wear a pouch system at all times, this is not the highest priority for instruction.

A nurse is teaching a patient about dietary methods to help manage exacerbations (flare-ups) of diverticulitis. What does the nurse advice the patient? "Be sure to maintain an exclusively low-fiber diet to prevent pain on defecation." "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." "Maintain a high-fiber diet to prevent the development of hemorrhoids that frequently accompany this condition." "Make sure you consume a high-fiber diet while diverticulitis is active. When inflammation resolves, consume a low-fiber diet."

"Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." **The nurse teaches the patient that the most effective way to manage diverticulitis is to consume a low-fiber diet while inflammation is present, followed by a high-fiber diet once the inflammation has subsided.Neither an exclusively low-fiber diet nor an exclusively high-fiber diet will effectively manage diverticulitis. A high-fiber diet while diverticulitis is active will only worsen the disease and its symptoms.

A patient who developed viral gastroenteritis with vomiting and diarrhea is scheduled to be seen in the clinic the following day. What will the nurse teach the patient to do in the meantime? "Avoid all solid foods to allow complete bowel rest." "Consume extra fluids to replace fluid losses." "Take an over-the-counter antidiarrheal medication." "Contact your primary health care provider for an antibiotic medication."

"Consume extra fluids to replace fluid losses." **The nurse tells the patient to drink extra fluids to replace fluid lost through vomiting and diarrhea.It is not necessary to stop all solid food intake. Antidiarrheal medications are used if diarrhea is severe. Antibiotics are used if the infection is bacterial.

The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions does the nurse plan to include in teaching the client about preventing low back pain and injury? Select all that apply. "Do not wear high-heeled shoes." "Keep weight within 50% of ideal body weight." "Begin a regular exercise program." "When lifting something, the back should be straight and the knees bent." "Standing for long periods of time will help to prevent low back pain."

"Do not wear high-heeled shoes." "Begin a regular exercise program." "When lifting something, the back should be straight and the knees bent." **The nurse includes the following instructions into the low back pain client's teaching plan: don't wear high-heeled shoes, begin a regular exercise program, and keep the back straight and knees bent when lifting something. Wearing high-heeled shoes can increase back strain. Beginning a regular exercise program will help to promote back strengthening. Keeping the back straight while bending the knees is the proper way to lift objects and will help to prevent back injury.The client needs to avoid standing or sitting for long periods of time because this can cause further strain on the back. Weight needs to be kept within 10% of ideal body weight and not 50%.

The spouse of the client with Alzheimer's disease is listening to the home health nurse explain the client's drug regimen. Which statement by the spouse indicates an understanding of the nurse's instruction? "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." "Memantine (Namenda) is indicated for treatment of early symptoms of Alzheimer's disease. "Rivastigmine (Exelon) is used to treat depression." "Sertraline (Zoloft) will treat the symptoms of Alzheimer's disease."

"Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." **The comment that shows that the spouse understands the nurse's instructions is that Aricept will treat symptoms of Alzheimer's. Cholinesterase inhibitors (e.g., donepezil) are approved for the symptomatic treatment of Alzheimer's disease. This class of medication delays the destruction of acetylcholine (ACh) by the enzyme cholinesterase.Memantine (Namenda) is indicated for advanced Alzheimer's disease. Memantine blocks excess amounts of glutamate which can damage nerve cells. Rivastigmine (Exelon) is a cholinesterase inhibitor that is used to treat Alzheimer's symptoms. Selective serotonin reuptake inhibitors like sertraline (Zoloft) are antidepressants and may be used in Alzheimer's clients who develop depression.

The nurse's friend fears that something is wrong with his grandmother, saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response? "Have you taken her for a check-up?" "She has Alzheimer's disease." "That is a normal part of aging." "You should look into respite care."

"Have you taken her for a check-up?" **The best response by the nurse to a friend whose grandmother is forgetful and wandering is to ask her friend if he/she has taken the grandmother for a check-up. The grandmother's symptoms could indicate possible Alzheimer's disease or some other physiologic imbalance, and she needs to be assessed further by the primary care provider.The nurse's role is not to diagnose Alzheimer's disease but to advocate for the friend's grandmother to be evaluated. Becoming extremely forgetful, disoriented, and wandering is not normal age related behavior. Respite care is for caregivers, not for clients.

The nurse is caring for a patient who is to be discharged after a bowel resection and the creation of a colostomy. Which patient statement demonstrates that additional instruction from the nurse is needed? "I can drive my car in about 2 weeks." "I need to avoid drinking carbonated sodas." "It may take 6 weeks to see the effects of some foods on my bowel patterns." "Stool softeners will help me avoid straining."

"I can drive my car in about 2 weeks." **Additional instruction is needed from the nurse when the patient who is about to be discharged after a bowel resection and colostomy says, "I can drive my car in about 2 weeks." The patient who has had a bowel resection and colostomy would avoid driving for 4 to 6 weeks.The patient needs to avoid drinking sodas and other carbonated drinks because of the gas they produce. He or she may not be able to see the effects of certain foods on bowel patterns for several weeks. The patient must avoid straining at stool.

The nurse is teaching a patient about dietary choices to prevent dumping syndrome after gastric bypass surgery. Which statement by the patient indicates a need for further teaching? "I will need to avoid sweetened fruit juice beverages." "I can eat ice cream in moderation." "I cannot drink alcohol at all." "It is okay to have a serving of sugar-free pudding."

"I can eat ice cream in moderation." **A need for further teaching about dietary changes related to dumping syndrome is indicated when the patient says that ice cream can be eaten in moderation. Milk products such as ice cream must be eliminated from the diet of a patient with dumping syndrome.The patient with dumping syndrome can no longer consume sweetened drinks. Alcohol must also be eliminated from the diet. The patient can eat sugar-free pudding, custard, and gelatin but with caution.

A client is considering treatments for a malignant brain tumor. Which statement by the client indicates a need for further instruction by the nurse? "A combination of treatments might be necessary." "In a craniotomy, holes are cut in the skull to access the tumor." "I can go home the day of my craniotomy." "The goal is to decrease tumor size and improve survival time."

"I can go home the day of my craniotomy." **The nurse knows that further instruction is needed when a client considering treatment for malignant brain tumor says, "I can go home the day of my craniotomy." Craniotomies are inclient procedures. The client will be admitted to critical care for monitoring after the procedure and may be mechanically ventilated for 24-48 hours postprocedure.Chemotherapy, radiation, and surgery are often used in conjunction with each other to treat malignancies. For a craniotomy, several burr holes are drilled into the skull, and a saw is used to remove a piece of bone (bone flap) to expose the tumor area. The goals of treatment of brain tumor are to decrease tumor size, improve quality of life, and improve survival time.

A client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates a correct understanding of the nurse's instruction? "I can go home the day of the procedure." "I can go home 48 hours after the procedure." "I'll have a drain in place after the procedure." "I'll need to wear special stockings after the procedure."

"I can go home the day of the procedure." **The statement that indicates the client correctly understands preoperative teaching of a microdiskectomy is "I can go home the day of the procedure." A microdiskectomy is considered minimally invasive surgery (MIS) and does not typically require an inclient hospital stay.The client who undergoes a minimally invasive surgery does not have to wait 48 hours after the procedure to return home, will not have a drain in place after the procedure, and will not need to wear special stockings after the procedure. These steps are used in the case of traditional open laminectomy, not MIS.

A female client with newly diagnosed migraines is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions? "Birth control is not needed while taking sumatriptan." "I must report any chest pain right away." "St. John's wort can also be taken to help my symptoms." "Sumatriptan can be taken as a last resort."

"I must report any chest pain right away." **The client comment that shows that she understands the discharge instructions is that any chest pain must be reported right away. Chest pain must be reported immediately with the use of sumatriptan because triptans cause vasoconstriction.Remind the client to use contraception (birth control) while taking the drug because it may not be safe for women who are pregnant. Triptans would not be taken with selective serotonin reuptake inhibitors or St. John's wort, an herb used commonly for depression. Sumatriptan must be taken as soon as migraine symptoms appear.

The home health nurse is teaching a patient about the care of a new colostomy. Which patient statement demonstrates a correct understanding of the instructions? "A dark or purplish-looking stoma is normal and would not concern me." "If the skin around the stoma is red or scratched, it will heal soon." "I need to check for leakage underneath my colostomy." "I need to strive for a very tight fit when applying the barrier around the stoma."

"I need to check for leakage underneath my colostomy." **The patient's statement, "I need to check for leakage underneath my colostomy" shows that the patient correctly understands the instructions about how to care for a new colostomy. The pouch system must be checked frequently for evidence of leakage to prevent excoriation.A purplish stoma is indicative of ischemia and necrosis. Redness or scratched skin around the stoma must be reported to prevent it from beginning to break down. An overly tight fit may lead to necrosis of the stoma.

A patient with irritable bowel syndrome (IBS) is constipated. The nurse instructs the patient about a management plan. Which patient statement shows an accurate understanding of the nurse's teaching? "A cup (236 mL) of caffeinated coffee with cream & sugar at dinner is OK for me." "I need to go for a walk every evening." "Maintaining a low-fiber diet will manage my constipation." "Limiting the amount of fluid that I drink with meals is very important."

"I need to go for a walk every evening." **The patient statement, "I need to go for a walk every evening," shows that the patient accurately understands the nurse's management plan to treat IBS. Walking every day is an excellent exercise for promoting intestinal motility. Increased ambulation is part of the management plan for IBS, along with increased fluids and fiber and avoiding caffeinated beverages.Caffeinated beverages can cause bloating or diarrhea and need to be avoided in patients with IBS. Fiber is encouraged in patients with IBS because it produces a bulky soft stool and aids in establishing regular bowel habits. At least 8 to 10 cups (2 to 2.5 liters) of fluid need to be consumed daily to promote normal bowel function.

The nurse is teaching a patient how to prevent recurrent chronic gastritis symptoms before discharge. Which statement by the patient demonstrates a correct understanding of the nurse's instruction? "It is okay to continue to drink coffee in the morning when I get to work." "I will need to take vitamin B12 shots for the rest of my life." "I should avoid alcohol and tobacco." "I should eat small meals about six times a day."

"I should avoid alcohol and tobacco." **The patient's statement that he/she needs to avoid alcohol and tobacco shows that the patient correctly understands the nurse's instructions. The patient with chronic gastritis should avoid alcohol and tobacco.The patient also needs to eliminate caffeine from the diet. The patient will need to take vitamin B12 shots only if he/she has pernicious anemia. The patient would also not eat six small meals daily. This practice may actually stimulate gastric acid secretion.

The nurse is teaching a client and family about home care after a stroke. Which statement made by the client's spouse indicates a need for further teaching? "I should spend all my time with my husband in case I'm needed." "My husband may get depressed." "My husband must take his medicine every day to prevent another stroke." "The physical therapist will show us how to use the equipment so my husband can climb the stairs and get into and out of bed."

"I should spend all my time with my husband in case I'm needed." **Further home care teaching is needed when the stroke client's wife says that "I need to spend all my time with my husband in case I'm needed." Although well intentioned, family members can start to feel socially isolated when caring for a loved one. The family may need to plan for regular respite care in a structured day-care respite program or through relief provided by a friend or neighbor.The life changes associated with stroke often cause a change in the client's self-esteem. The client who has had a stroke needs to maintain a regular medication regimen to help prevent another stroke. If it is determined necessary after a home assessment, the physical and occupational therapist will show the client and family how to use equipment so they are able to mobilize and function in the home setting.

A patient has been diagnosed with terminal esophageal cancer. The patient is interested in obtaining support from hospice, but expresses concern that pain management will not be adequate. What is the nurse's best response? "Haven't you received adequate pain management in the hospital?" "Would you like me to get a nurse from hospice to come talk with you?" "Do you want me to call the hospital chaplain to explain hospice to you?" "Talk to your primary health care provider about hospice services."

"Would you like me to get a nurse from hospice to come talk with you?" **The best way to alleviate the patient's concerns would be to have a hospice nurse talk with the patient and answer any questions.Suggesting that the patient has had adequate pain management sounds defensive. Referring the patient to the chaplain or the primary health care provider is evasive and attempts to shift responsibility away from the nurse.

The nurse is educating a group of older adults about screening for colorectal cancer. Which statement by a group member indicates the need for further clarification about these guidelines? "A barium enema every 5 years is a screening option." "I will need to have a routine colonoscopy every 5 years." "My routine flexible sigmoidoscopy every 5 years is OK." "The 'virtual' colonoscopy every 5 years is acceptable."

"I will need to have a routine colonoscopy every 5 years." **The 2015 guidelines indicate that routine screening with colonoscopy is performed every 10 years, not every 5 years.Other options are performed at 5-year intervals. A barium enema every 5 years is a screening option. A flexible sigmoidoscopy and a "virtual" colonoscopy every 5 years are also acceptable for screening. A "virtual" colonoscopy or CT colonography is a noninvasive imaging procedure that takes multidimensional views of the entire colon.

A 24-year-old male is scheduled for a minimally invasive inguinal hernia repair (MIIHR). Which patient statement indicates a need for further teaching about this procedure? "I may have trouble urinating immediately after the surgery." "I will need to stay in the hospital overnight." "I will not eat after midnight the day of the surgery." "My chances of having complications after this procedure are slim."

"I will need to stay in the hospital overnight." **A need for further teaching about MIIHR is when the patient says, "I will need to stay in the hospital overnight." Usually, the patient is discharged 3 to 5 hours after MIIHR surgery.Male patients who have difficulty urinating after the procedure would be encouraged to force fluids and to assume a natural position when voiding. Patients undergoing MIIHR surgery must be NPO after midnight before the surgery. Most patients who have MIIHR surgery have an uneventful recovery.

A client has been discharged to home after being hospitalized with an acute episode of pancreatitis. The client, who is an alcoholic, is unwilling to participate in Alcoholics Anonymous (AA), and the client's spouse expresses frustration to the home health nurse regarding the client's refusal. What is the nurse's best response? "Your spouse will sign up for the meetings only when he is ready to deal with his problem." "Keep mentioning the AA meetings to your spouse on a regular basis." "I'll get you some information on the support group Al-Anon." "Tell me more about your frustration with your spouse's refusal to participate in AA."

"I'll get you some information on the support group Al-Anon." **The nurse's best response involves putting the client's spouse in contact with an Al-Anon support group. This action may help with the spouse's frustration and help both to cope with the situation.Telling the spouse that the client will sign up for AA meetings when the client is ready and telling the spouse to keep mentioning AA do not address the spouse's frustration with the client's refusal to participate in AA. Encouraging the spouse to say more about his or her frustration may allow the spouse to vent frustration, but it does not offer any options or solutions.

A patient suspected of having irritable bowel syndrome (IBS) is scheduled for a hydrogen breath test. What does the nurse tell the patient about this test? "During the test, you will drink small amounts of an antacid as directed by the technician." "If you have IBS, hydrogen levels may be increased in your breath samples and can be an indication that you have IBS." "The test will take between 30 and 45 minutes to complete." "You must have nothing to drink (except water) for 24 hours before the test."

"If you have IBS, hydrogen levels may be increased in your breath samples and can be an indication that you have IBS." **The nurse tells the patient with IBS who has a hydrogen breath test prescribed that "hydrogen levels may be increased in your breath samples and can indicate that you have IBS." Excess hydrogen levels in patients with IBS are due to bacterial overgrowth in the small intestine that accompanies the disease. The hydrogen travels to the lungs to be excreted.The patient will ingest small amounts of sugar during the test, not an antacid. The test takes longer than 45 minutes to complete. The patient has breath samples taken every 15 minutes for 1 to 2 hours. The patient needs to be NPO (except for water) for 12 hours before the test.

A patient with an exacerbation of ulcerative colitis has been prescribed Vivonex PLUS. The patient asks the nurse how this is helpful for improving signs/symptoms. How does the nurse reply? "It is absorbed quickly and allows the affected part of the GI tract to rest and heal." "It provides key nutrients and extra calories to promote healing." "It is bland and reduces the secretion of gastric acids." "It does not contain caffeine or other GI tract stimulants."

"It is absorbed quickly and allows the affected part of the GI tract to rest and heal." **Vivonex PLUS is an enteral elemental formula with components that are quickly absorbed in the small bowel that reduces bowel stimulation allowing the affected part of the GI tract to rest and heal. It helps to improve signs/symptoms of ulcerative colitis. For less severe exacerbations, a semielemental product of Vivonex PLUS may induce remission. These products are absorbed in the jejunum and therefore permit the distal small intestine and colon to rest.Nutritional supplements such as Ensure or Sustacal are added to provide nutrients and more calories. GI stimulants such as caffeinated beverages and alcohol need to be avoided, but this is not the reason for using Vivonex PLUS.

A patient with ulcerative colitis (UC) has stage 1 of a restorative proctocolectomy with ileo-anal anastomosis (RPC-IPAA) procedure performed. The patient asks the nurse, "How long do people with this procedure usually have a temporary ileostomy?" How does the nurse respond? "It is usually ready to be closed in about 1 to 2 months." "You need to talk to your primary health care provider about how long you will have this temporary ileostomy." "The period of time is indefinite—I am sorry that I cannot say." "You will probably have it for 6 months or longer, until things heal."

"It is usually ready to be closed in about 1 to 2 months." **The nurse tells the patient with a temporary ileostomy that it is usually ready to be closed in about 1 to 2 months. The RPC-IPAA has become the most effective alternate method for ulcerative colitis (UC) patients who have surgery to remove diseased portions of intestines. Stage 1 creates a temporary ileostomy to be used while an internally created pouch is healing. Stage 2 closes the ileostomy, and the patient begins to use the pouch for storage of stool. The time between the surgeries is generally 1 to 2 months.Telling the patient that he or she will have to discuss it with the primary health care provider evades the question. The nurse can give generalities to the patient based on past practice and available data. The time that the patient has the ileostomy is not "indefinite." The intent of this procedure is to eliminate the need to have a permanent ileostomy. The pouch would heal in 1 to 2 months, not 6 months. This estimate is not based on the expected outcome.

A client has been diagnosed with Primary Progressive MS (PPMS) and the nurse is providing education at the clinic. What statement by the client indicates the need for more teaching? "I can alternate wearing my eye patch between eyes for double vision." "I should keep my home clutter free so I don't fall." "It's important I work out in the afternoon so my muscles are warmed up." "I always keep my medications in the same place."

"It's important I work out in the afternoon so my muscles are warmed up." **More teaching is needed for the client with PPMS when the client says, "It's important I work out in the afternoon so my muscles are warmed up." Working out in the afternoon will increase body temperature and lead to fatigue. Fatigue is a key feature of MS. Working with a physical therapist to develop an appropriate exercise program tailored to the client's condition will be beneficial.If a client has diplopia, wearing an eye patch and alternating it between eyes every few hours may relieve the symptoms. Keeping the home organized and clutter free will decrease the risk of falls. Keeping medications and other important belongings in the same place and maintaining a routine may help with memory deficits that may occur with MS.

The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions? "Avoid using a pillow under the head while sleeping." "Begin driving 1 week after discharge." "Keep straws available for drinking fluids." "Swimming is recommended to keep active."

"Keep straws available for drinking fluids." **The instructions the nurse include for a client with a halo device is to keep straws available for drinking fluids. The halo device makes it difficult to bring a cup or a glass to the mouth.The head would be supported with a small pillow when sleeping to prevent unnecessary pressure and discomfort. Driving must be avoided because vision is impaired with the device. Swimming must be avoided to prevent the risk for infection.

A client is eating a soft diet while recovering from a stroke. The client reports food accumulating in the cheek of the affected side. What is the nurse's best response? "Next time you eat, try lifting your chin when you swallow." "Let's advance your diet to solid food." "Let's see if the dietitian can help." "Let's see if the speech-language pathologist can help."

"Let's see if the speech-language pathologist can help." **The nurse's best response about food gathering in the cheek of a stroke client is to see what the speech pathologist says may help. The speech-language pathologist identifies strategies to prevent food from accumulating in the cheek of the affected side of a client recovering from a stroke. The speech pathologist will assist the client with tongue exercises that will help move the food bolus to the unaffected side.Lifting the chin is not an appropriate technique. A solid diet would not necessarily be the best choice. The dietitian will be consulted to evaluate the nutritional status of the client as well as make recommendations regarding the correct diet.

The home health nurse is checking in on a client with dementia and the client's spouse. The spouse confides to the nurse, "I am so tired and worn out." What is the nurse's best response? "Can't you take care of your spouse?" "Establishing goals and a daily plan can help." "Make sure you take some time off and take care of yourself too." "That's not a very nice thing to say."

"Make sure you take some time off and take care of yourself too." **The nurse's best response to the spouse of the client with dementia is to encourage the wife to take some time off to take care of herself. This response is supportive and reminds the spouse that he or she cannot care for the client when exhausted.Questioning the spouse's ability to provide care is not supportive and may offend the spouse. Establishing goals and a daily plan may be helpful to the situation but is not responding to the spouse's need. Reprimanding the spouse does not validate his or her feelings and does not allow the nurse to further explore the statement.

Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? "Cirrhosis is a chronic disease that has scarred my liver." "The scars on my liver create problems with blood circulation." "Because of the scars on my liver, blood clotting and blood pressure are affected." "My liver is scarred, but the cells can regenerate themselves and repair the damage."

"My liver is scarred, but the cells can regenerate themselves and repair the damage." **The client's statement that, although his liver is scarred, the cells can regenerate and repair the damage indicates that further instruction is needed. Although cells and tissues will attempt to regenerate, destroyed liver cells will result in permanent scarring and irreparable damage.Cirrhosis is a chronic condition that leaves scars on the liver. Permanent scars form in response to attempts by the cells to regenerate and create problems in blood circulation moving through the liver. Liver scarring will create problems with blood clotting, cholesterol levels, and blood pressure, as well as with the metabolism of drugs and toxins.

The nurse is teaching a patient with peptic ulcer disease (PUD) about the prescribed drug regimen. Which statement made by the patient indicates a need for further teaching before discharge? "Nizatidine (Axid) needs to be taken three times a day to be effective." "Taking ranitidine (Zantac) at bedtime should decrease acid production at night." "Sucralfate (Carafate) should be taken 1 hour before and 2 hours after meals." "Omeprazole (Prilosec) should be swallowed whole and not crushed."

"Nizatidine (Axid) needs to be taken three times a day to be effective." **Further discharge teaching is needed when the patient says that Nizatidine works best when taken three times a day. Nizatidine is most effective if administered once daily.A dose of ranitidine at bedtime would decrease acid production throughout the night. Sucralfate is taken 1 hour before and 2 hours after meals. Because omeprazole is a delayed-release capsule, it needs to be swallowed whole and not crushed.

The nurse is teaching a client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates a correct understanding of the pathophysiology of the disease? "I will die early." "I will have gradual deterioration with no healthy times." "Parts of my nervous system have plaques." "This was caused by getting too many x-rays as a child."

"Parts of my nervous system have plaques." **The statement that demonstrates that the newly diagnosed client with MS correctly understands the pathophysiology of the disease is "parts of my nervous system have plaques." MS is characterized by an inflammatory response that results in diffuse random or patchy areas of plaque in the white matter of the central nervous system.The client with MS has no decrease in life expectancy. Frequent times of remission are common in clients with MS. There is no known cause for MS.

A patient with gastroesophageal reflux disease has undergone a laparoscopic Nissen fundoplication (LNF). What will the nurse include in postoperative home care instructions? "Consume carbonated beverages if you experience stomach upset." "Remain on a soft diet for about a week and avoid raw vegetables that are difficult to swallow." "You may resume running and weight lifting if you wish." "You may stop taking your antireflux medications after 1 week."

"Remain on a soft diet for about a week and avoid raw vegetables that are difficult to swallow." **After LNF, patients need to be taught to remain on a soft diet for 1 week and to avoid raw vegetables that are difficult to swallow.Carbonated beverages should be avoided. Patients may walk but need to avoid heavy lifting. Antireflux medications need to be taken for 1 month after the procedure.

A client has developed acute pancreatitis after also developing gallstones. Which is the highest priority nursing instruction for this client to avoid further attacks of pancreatitis? "You may need a surgical consult for removal of your gallbladder." "See your health care provider (HCP) immediately when experiencing symptoms of a gallbladder attack." "If you have a gallbladder attack and pain does not resolve within a few days, call your health care provider." "You'll need to drastically modify your alcohol intake."

"See your health care provider (HCP) immediately when experiencing symptoms of a gallbladder attack." **The highest priority nursing instruction for the client to avoid more attacks of pancreatitis is to report symptoms of gallbladder attacks immediately to the HCP.The client may not require removal of the gallbladder. That decision is made by the HCP. The client must see the provider promptly when experiencing gallbladder disease and should not wait. Because this client's acute pancreatitis is likely related to gallstones, alcohol consumption need not be restricted.

The outpatient clinic nurse is caring for a recovering client who had a colonoscopy. The client asks for a drink. How does the nurse respond to this request? "After I hear bowel sounds, you can have a drink." "Twenty minutes after the procedure was completed, you may have some liquids." "When you are able to pass flatus (gas), you can have a drink." "You can have fluids when you get home and are settled."

"When you are able to pass flatus (gas), you can have a drink." **Fluids are permitted after the client's peristalsis has returned, which is validated by the client's passing flatus (p. 34).Ability to pass flatus (gas) is more reliable than auscultation of bowel sounds when assessing a client's status to drink after a colonoscopy. There is no set time period after the procedure that is considered safe for the client to have something to drink. The client will not be discharged home without the nurse determining that peristalsis has returned. The client must report that he or she is passing flatus to go home; therefore, the client should be given a drink before being sent home.

A patient who has been diagnosed recently with esophageal cancer states, "I'm not comfortable going to my father's birthday lunch at our family-owned restaurant because I'm afraid I'll choke in public." What is the nurse's best response? "I understand your concerns, but you can't give up your normal activities. You should go anyway and try not to worry about it." "Tell me more about the lunch, what will be served and who is going with you." "Why not take one of your antianxiety pills before going? That will keep you from worrying about everything so much." "You need to talk to your doctor about your concerns. The doctor may recommend that you join a support group for cancer survivors."

"Tell me more about the lunch, what will be served and who is going with you." **The nurse's best response is to ask the patient for more information to help determine the specific fear and discuss possible alternatives so choking and/or fear of choking can be minimized or avoided in public.Telling the patient not to worry about it or to call the provider is evasive and unhelpful; it is used to placate the patient and does not address the patient's concerns. The patient should use problem-solving and coping skills before resorting to the use of medication.

A patient with colorectal cancer is scheduled for colostomy surgery. Which comment from the nurse is most therapeutic for this patient? "Are you afraid of what your spouse will think of the colostomy?" "Don't worry. You will get used to the colostomy eventually." "Tell me what worries you the most about this procedure." "Why are you so afraid of having this procedure done?"

"Tell me what worries you the most about this procedure." **The most therapeutic comment by the nurse to a patient scheduled for colostomy surgery is "Tell me what worries you the most about this procedure." Asking the patient about what worries him or her is the only question that allows the patient to express fears and anxieties about the diagnosis and treatment.Asking the patient if he or she is afraid is a closed question (i.e., it requires only a "yes" or "no" response). It closes the dialogue and is not therapeutic. Telling the patient not to worry offers reassurance and is a "pat" statement, making it nontherapeutic. "Why" questions place patients on the defense and are not therapeutic because they close the conversation.

The nurse is teaching the spouse and client who has had a brain attack about rehabilitation. Which statement by the spouse demonstrates understanding of the nurse's instruction? "Frequent stimulation will help with the rehabilitation process." "My spouse will no longer need to take blood pressure medication." "Rehabilitation and physical therapy are the same thing." "The rehabilitation therapist will help identify changes needed at home."

"The rehabilitation therapist will help identify changes needed at home." **Understanding instructions about brain attack is demonstrated by the statement that the rehabilitation therapist will help identify any needed home changes. The rehabilitation therapist and home health professionals assist the client and family in adapting the home environment to the client's needs and assess the client's need for therapy.An appropriate amount of stimulation based on the client's needs will be determined by the therapist and incorporated into a comprehensive plan. Any medication regimen established for the client after the brain attack must be maintained. Rehabilitation is much more comprehensive than physical therapy.

A patient with malabsorption syndrome asks the nurse, "What did I do to cause this disorder to develop?" How does the nurse respond? "An excessive intake of alcohol is associated with it, so your substance abuse could have contributed to its development." "It is inherited, so it could run in your family." "It might be caused by a virus, so you could have gotten it almost anywhere." "There are a variety of things that can cause malabsorption syndrome to occur. You may have a deficiency is certain enzymes, a bacteria or changes in the lining of your intestines."

"There are a variety of things that can cause malabsorption syndrome to occur. You may have a deficiency is certain enzymes, a bacteria or changes in the lining of your intestines." **The nurse responds to the patient with malabsorption syndrome who asks, "What did I do to cause this?", that there are many things that can cause this disorder. Malabsorption is a syndrome associated with a variety of disorders and intestinal surgical procedures. This syndrome can be caused by inflammation, intrinsic disease, or injury to the lining of the intestine.Malabsorption syndrome is not associated with an excessive intake of alcohol. It is not inherited, although a genetic immune defect is present in the related disease, celiac sprue. It is not caused by a virus but can be caused by some bacterias.

A client has just been diagnosed with pancreatic cancer. The client's upset spouse tells the nurse that they have recently moved to the area, have no close relatives, and are not yet affiliated with a church. What is the nurse's best response? "Maybe you should find a support group to join." "Would you like me to contact the hospital chaplain for you?" "Do you want me to try to find a therapist for you?" "Do you have any friends whom you want me to call?"

"Would you like me to contact the hospital chaplain for you?" **Suggesting to contact the hospital chaplain is the best and most appropriate response for the nurse to take when talking with the cancer client's spouse.Suggesting that the client find a support group does not assist the client and the family with the problem. It is inappropriate for the nurse to suggest that the client and the family need a therapist. The spouse has already told the nurse that they have recently moved to the area, so it is unlikely that they have already made close friends.

A patient with peptic ulcer disease (PUD) asks the nurse whether licorice and slippery elm might be useful in managing the disease. What is the nurse's best response? "No, they probably won't be useful. You should use only prescription medications in your treatment plan." "These herbs could be helpful. However, you should talk with your primary health care provider before adding them to your treatment regimen." "Yes, these are known to be effective in managing this disease but make sure you research the herbs thoroughly before taking them." "No, herbs are not useful for managing this disease. You can use any type of over-the-counter drugs though. They have been shown to be safe."

"These herbs could be helpful. However, you should talk with your primary health care provider before adding them to your treatment regimen." **The nurse's best response is that although licorice and slippery elm may be helpful in managing PUD, the patient must consult his or her primary health care provider before making a change in the treatment regimen.Alternative therapies may or may not be helpful in managing PUD. The patient must not use over-the-counter medications without first discussing it with his or her primary health care provider.

An older female patient is diagnosed with gastric cancer. Which statement made by the patient's family demonstrates a correct understanding of the disorder? "This may be related to her recurring ulcer disease." "This cancer is probably curable with surgery." "Gastric cancer has a strong genetic component." "Thank goodness she won't have to undergo surgery."

"This may be related to her recurring ulcer disease." **Correct understanding of a patient's diagnosis of gastric cancer is indicated when they family states that the diagnosis could be related to the patient's ulcer disease. Infection with Helicobacter pylori is the largest risk factor for gastric cancer because it carries the cytotoxin-associated antigen A (CagA) gene. Patients with chronic ulcers are probably infected with this organism.Surgery is often not curative because most gastric cancers do not present with symptoms until late in the disease and have a high fatality rate. There is no strong genetic predisposition to gastric cancer. Surgery is part of the treatment.

The nurse is caring for a client recently diagnosed with type 1 diabetes mellitus who has had an episode of acute pancreatitis. The client asks the nurse how he developed diabetes when the disease does not run in the family. What is the nurse's best response? "The diabetes could be related to your obesity." "Look online for general information about diabetes." "Do you consume alcohol on a frequent basis?" "Type 1 diabetes can occur when the pancreas is affected or destroyed by disease."

"Type 1 diabetes can occur when the pancreas is affected or destroyed by disease." **The nurse's best response is to tell the client that type 1 diabetes can occur when the pancreas is affected or destroyed by disease. This is the only response that accurately describes the relationship of the client's diabetes to pancreatic destruction.Type 2, not type 1, diabetes is usually related to obesity. Telling the client to look online for information is inappropriate because some information available online is incorrect at best.Many factors could produce acute pancreatitis other than alcohol consumption.

A client is being discharged home after surgery for brain cancer. Which statement by the client's spouse indicates a correct understanding of the nurse's discharge teaching? "I will have to quit my job to care for my spouse." "Life will be back to normal soon." "The case manager will provide home care." "We can find a support group through the local American Cancer Society."

"We can find a support group through the local American Cancer Society." **The statement by the spouse of a brain cancer client that shows correct understanding of discharge teaching is when the spouse says, "We can find a support group through the local American Cancer Society." The American Cancer Society is a good community resource for clients with malignant tumors and their families.It is not a requirement that the client's spouse quit his or her job but may need some assistance in home. A diagnosis of brain cancer is life changing and the client and spouse will find a "new normal"; however this will not happen immediately. The case manager helps coordinate care and will be able to locate home care but does not provide that care.

A patient has a long-term history of Crohn's disease and has recently developed acute gastritis. The patient asks the nurse whether Crohn's disease was a direct cause of the gastritis. What is the nurse's best response? "Yes, Crohn's disease is known to be a direct cause of the development of chronic gastritis." "We know that there can be an association between Crohn's disease and chronic gastritis, but Crohn's does not directly cause acute gastritis to develop." "What has your doctor told you about how your gastritis developed?" "Yes, a familial tendency to inherit Crohn's disease and gastritis has been reported. Have your other family members been tested for Crohn's disease?"

"We know that there can be an association between Crohn's disease and chronic gastritis, but Crohn's does not directly cause acute gastritis to develop." **The nurse's best response is that Crohn's disease may be an underlying disease process when chronic gastritis develops, but not when acute gastritis occurs. It is not known to be a direct cause of the disease.Although Crohn's disease tends to run in families, gastritis is a symptom of other disease processes. It is not a disease process in and of itself. Asking the patient what the doctor has said is an evasive response on the part of the nurse and does not help answer the patient's question.

Hiatal hernia repair

Primary focus after conventional surgery for hernia repair is prevention of respiratory complications Elevate HOB at least 30 degrees to lower diaphragm and promote lung expansion Assist pt out of bed and begin ambulation ASAP Support incision during coughing to reduce pain and prevent excessive strain on suture line (especially obese pts)

A patient is admitted with severe viral gastroenteritis caused by norovirus. The patient asks the nurse, "How did I get this disease?" Which answer by the nurse is correct? "You may have contracted it from an infected infant." "You may have consumed contaminated food or water." "You may have come into contact with an infected animal." "You may have had contact with the blood of an infected person."

"You may have consumed contaminated food or water." **When a patient with severe viral gastroenteritis caused by norovirus asks, "How did I get this disease?", the nurse answers, "You may have consumed contaminated food or water." Norovirus is the leading foodborne disease that causes gastroenteritis. It is transmitted via the fecal-oral route from person to person and from contaminated food and water. Vomiting causes the virus to become airborne.Campylobacter, not novovirus, can be transmitted by contact with infected infants or animals. Escherichia coli, not novovirus, may be spread via animals and contaminated food, water, or fomites. HIV, not novovirus, may be spread via the blood. Campylobacter and E. coli both cause bacterial gastroenteritis, while norovirus causes viral gastroenteritis.

A patient newly diagnosed with ulcerative colitis (UC) is started on sulfasalazine (Azulfidine). What does the nurse tell the patient about why this therapy has been prescribed? "It is to stop the diarrhea and bloody stools." "This will minimize your GI discomfort." "With this medication, your cramping will be relieved." "Your intestinal inflammation will be reduced."

"Your intestinal inflammation will be reduced." **The nurse tells the newly diagnosed patient with UC who is started on sulfasalazine that, "Your intestinal inflammation will be reduced." Sulfasalazine (Azulfidine) is one of the primary treatments for UC. It is thought to inhibit prostaglandin synthesis and thereby reduce inflammation.Although it is hoped that reduction of inflammation will cause the diarrhea and bloody stools to stop, this is not the way that the drug works. Antidiarrheal drugs "stop" diarrhea. The drug's action as an anti-inflammatory will diminish the patient's pain as the inflammation subsides, but this is not the purpose of the drug. Sulfasalazine is an anti-inflammatory medication, not an analgesic.

Psychosocial Integrity

*Assess pt's and family's response to an oral cancer diagnosis, which may include anger, depression, anxiety, and/or fear *Help the pt and family identify and use strengths and coping mechanisms to deal with changes in the body image and altered self-esteem *Refer pts with oral cancer to support groups (ex. American Cancer Society)

Physiological Integrity

*Be aware that a strangulated hernia can cause ischemia and bowel obstruction, requiring immediate intervention *Monitor pts who have conventional open herniorrhaphy for ability to void *Recall that changes in bowel habits or stool characteristics and/or rectal bleeding are often associated with diagnosis of CRC *Keep the peristomal skin clean and dry; observe for leakage around the pouch seal *Recognize characteristics of the colostomy stoma, which should be reddish pink and moist; report abnormalities such as ischemia and necrosis (purple or black) or unusual bleeding to the surgeon *Recall that bowel sounds are altered in pts with obstruction; absent bowel sounds imply total obstruction *Assess pt's NGT for proper placement, patency, and output at least every 4 hrs *Monitor pts with bowel obstruction for signs and symptoms of fluid, electrolyte, and acid-base imbalances; pts with smaller bowel obstruction are at greater risk for problems with fluid and electrolyte balance *Teach pts having hemorrhoid surgery to take stool softeners before and after surgery to decrease discomfort during elimination *Provide comfort measures for the pt who has chronic diarrhea associated with malabsorption *Reinforce teaching regarding supplements or dietary restrictions needed for malabsorption management

Safe and Effective Care Environment

*Be aware that airway management is the prioroty of care for pts having surgery for oral cancer *Place pts having oral cancer surgery in high-fowler's position to facilitate breathing and prevent aspiration *Assess for swallowing ability to prevent aspiration by checking the gag reflex before offering liquids or food to the pt who has had oral cancer surgery

Physiological Integrity

*Perform a focused abdominal assessment using inspection, auscultation, and light palpation *Do not palpate or auscultate any abdominal pulsating mass because it could be a life-threatening aortic aneurysm *Assess pts who have endoscopies for bleeding, fever, and severe pain *For pts who have had a colonoscopy, check for passage of flatus before allowing fluids or food

Safe and Effective Care Environment

*Priority for care is to check for the return of the gag reflex after an upper endoscopic procedure before offering fluids or food; aspiration may occur if gag reflex is not intact *If an endoscopic procedure in an ambulatory care setting is scheduled, remind the patient to have someone available to drive him or her home because of the effects of moderate sedation

Physiological Integrity

*Provide gentle oral care for pts. with oral lesions by using chemobrushes and warm saline or sodium bicarbonate solution *Assess for facial nerve involvement for pts with salivary gland tumors

Physiological Integrity

*Pts with GERD, teach importance of strict adherence to anti-reflux agents in preventing esophageal damage *Frequently monitor nutrition status of pt with esophageal cancer *For pt with NGT, check the tube every 4-8hrs for proper placement and anchorage

Physiological Integrity

*Remember that pts with gastric ulcers may be malnourished and have pain that is worsened by ingestion of food; pts with duodenal ulcers are usually well nourished, have pain that is relieved by ingestion of food and awaken with pain during the night *Teach that hematemesis is a medical emergency and refer to emergency department for prompt treatment *Teach pt proper administration of antacids (1 or 2 after meals), reminding pts antacids can interfere with effectiveness of certain drugs, such as phenytoin (Dilantin) *Teach proper administration of H2 antagonists and explain that they should be taken at bedtime *Monitor pts with ulcers for s&s of upper GI bleeding *After an EGD, monitor vitals, heart rhythm, and oxygen saturation frequently until they return to baseline. Prevent aspiration by assessing the gag reflex and ensure it is intact before giving pt food or fluids *observe s&s of dumping syndrome after gastric surgery

Health Promotion and Maintenance

*Remind adults to visit their dentist regularly for dental hygiene and oral examinations and to seek medical or dental attention for oral lesions that do not heal *Instruct pts to avoid harsh commercial mouthwashes if they have oral lesions *Teach adults to avoid tobacco or offer a cessation plan, alcohol, and sun exposure to decrease their chance of having oral cancer

Health Promotion and Maintenance

*Teach pt oral exercises to improve swallowing *Stress the importance of controlling reflex through nutrition and drug therapy to avoid further esophageal damage that could lead to Barrett's esophagus *Teach pt to elevate head of bed by 6 inches for sleep and to lie in the right die-lying position to minimize or prevent nighttime reflux *Teach pt with esophageal cancer to monitor body weight and to notify provider of weight loss *Teach pt to avoid alcoholic beverages, smoking, etc. that lead to increased GERD *Teach pt to prevent gas bloat syndrome by avoiding carbonated beverages and gas-producing foods, chewing gum, and drinking with a straw

Health Promotion and Maintenance

*Teach pts having invasive colon diagnostic procedures to follow instructions carefully for the bowel preparation before testing; the bowel must be clear to allow visualization of the colon *Instruct pt to drink plenty of fluids and take laxative as prescribed to eliminate barium if used during diagnostic testing

EGD (esophagogastroduodenoscopy)

- NPO 6-8hrs before - precent aspiration!! HOB elevates up, no food or drink until gag reflex returns -sedation: do not drive for 12-18hrs after -Avoid NSAIDs, aspirin, and anticoagulants -bits lock guard to prevent biting tube or doctor

A nurse is providing teaching to pt for prescription of aluminum hydroxide. What should nurse include in the teaching?

-Wait 1hr before taking other oral medications -take on empty stomach -can cause constipation, so increase dietary fiber

Nurse is giving meds and recognizes which drugs contribute to signs and symptoms of gastritis?

-aspirin taken once daily to prevent cardiac concerns -naproxen taken once daily for joint pain associated with arthritis -prednisone tapered over a 14day period to decrease inflammation associated with acute sinus infection

Aspiration Precautions

-assess pt's LOC, gag reflex, and ability to swallow -pace pt in upright position (90 degrees or high Fowler's -keep suction equipment nearby -provide thickened liquids -referral to speech/language pathologist for those experiencing aspiration with swallowing

A client who has undergone surgery and completed radiation therapy to treat oral cancer reports persistent dry mouth. What will the nurse teach this client about managing this symptom? a. Use saliva substitutes, especially when eating dry foods. b. This condition is common but is temporary. c. Use lozenges and hard candies to prevent dry mouth. d. This indicates a complication of therapy.

A

When caring for a client with oral cancer who has developed stomatitis as a complication of radiation and chemotherapy, which action does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Provide oral care using disposable foam swabs. b. Inspect the oral mucosa for evidence of oral candidiasis. c. Instruct the client on how to use nystatin (Mycostatin) oral rinses. d. Teach the client how to make appropriate dietary choices.

A

Which practice does the nurse include when teaching a client about proper oral care? a. Perform self-examination of the mouth every week, and report any unusual findings. b. Brush the teeth daily and floss as needed. c. Use drugs that reduce the flow of saliva unless lesions are present. d. Regularly rinse mouth with alcohol-based agent.

A

The RN receives a change-of-shift report about four patients. Which patient does the nurse assess first? A 20-year-old with ulcerative colitis (UC) who had six liquid stools during the previous shift A 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102°F (37.9°C) A 56-year-old who had a colon resection earlier in the day and whose colostomy bag does not have any stool in it A 60-year-old admitted with acute gastroenteritis who is reporting severe cramping and nausea

A 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102°F (37.9°C) **After a change-of-shift report the RN first assess a 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102°F (37.9°C). This patient with possible appendicitis may have developed a perforation and may be at risk for peritonitis. Rapid assessment and possible surgical intervention are needed.The patient with UC who had six liquid stools, the patient whose colostomy bag does not have any stool in it, and the patient who was admitted with acute gastroenteritis all need assessment and intervention by an RN, but they are not at immediate risk for life-threatening complications.

Which patient does the charge nurse assign to an experienced LPN/LVN? A 28-year-old who requires teaching about how to catheterize a Kock ileostomy A 30-year-old who must receive neomycin sulfate (Mycifradin) before a colectomy A 34-year-old with ulcerative colitis (UC) who has a white blood cell count of 23,000/mm3 (23 × 109/L) A 38-year-old with gastroenteritis who is receiving IV fluids at 250 mL/hr

A 30-year-old who must receive neomycin sulfate (Mycifradin) before a colectomy **The charge nurse assigns to an experienced LPN/LVN a 30-year-old who needs to receive neomycin sulfate before a colectomy. The LPN/LVN would be familiar with the purpose, adverse effects, and patient teaching required for neomycin.Teaching about how to catheterize a Kock ileostomy, assessing the patient with UC with a high white blood cell count, and monitoring the patient with gastroenteritis receiving IV fluids present complex problems that require assessment or intervention by an RN.

The RN on the medical-surgical unit receives a shift report about four patients. Which patient does the nurse assess first? A 34-year-old who has returned to the unit after a colon resection with a new colostomy stoma, which is pink and moist. A 36-year-old admitted after a motor vehicle collision (MVC) with areas of ecchymosis on the abdomen in a "lap-belt" pattern A 40-year-old with a reducible inguinal hernia asking questions about surgery. A 51-year-old with familial adenomatous polyposis (FAP) who is scheduled for a colonoscopy

A 36-year-old admitted after a motor vehicle collision (MVC) with areas of ecchymosis on the abdomen in a "lap-belt" pattern **After the shift-report, the RN first assesses the 36-year-old admitted after a MVC with areas of ecchymosis on the area in a "lap-belt" pattern. Ecchymosis in the abdominal area may indicate intraperitoneal or intraabdominal bleeding. This patient requires rapid assessment and interventions.The patient who is post colon resection, the patient with preoperative questions, and the patient with FAP do not have an urgent need for further assessment or intervention.

An intensive care unit (ICU) RN is "floated" to the medical-surgical unit. Which patient does the charge nurse assign to the float nurse? A 28-year-old with an exacerbation of Crohn's disease (CD) who has a draining enterocutaneous fistula A 32-year-old with ulcerative colitis (UC) who needs discharge teaching about the use of hydrocortisone enemas A 34-year-old who has questions about how to care for a newly created ileo-anal reservoir A 36-year-old with peritonitis who just returned from surgery with multiple drains in place

A 36-year-old with peritonitis who just returned from surgery with multiple drains in place **The charge nurse assigns to the ICU nurse who was floated to the medical-surgical unit a 36-year-old patient with peritonitis who just returned from surgery with multiple drains in place. The ICU nurse is familiar with the care of a patient with peritonitis, including monitoring for complications such as sepsis and kidney failure.The patient with CD who has a draining enterocutaneous fistula, the patient with UC who needs discharge teaching, and the patient with questions about an ileo-anal reservoir are best assigned to a medical-surgical nurse who is more familiar with the care and teaching needed for patients with their respective disorders.

Which client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) clinic? A 38-year-old who needs discharge instructions after having an endoscopic retrograde cholangiopancreatography (ERCP) A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy A 43-year-old recently admitted with nausea, abdominal pain, and abdominal distention A 50-year-old with epigastric pain who needs conscious sedation during a scheduled endoscopy procedure

A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy **A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy is the least complicated client. This client would be assigned to the float nurse who would have the experience and training to adequately care for this client. A clinic nurse typically cares for clients with chronic conditions.Discharge instructions following an ERCP, assessment of an admitted acutely ill client, and monitoring a client who is receiving conscious sedation would be accomplished best by nurses with experience in caring for adults with acute GI problems.

Psychosocial Integrity

Recognize that having a chronic bowel disease or an ileostomy impacts pt's body image and self-esteem; assess for coping strategies that pt. Has previously used, and identify personal support systems, such as family, to assist in coping

The nurse is instructing a patient with recently diagnosed diverticular disease about diet. What food does the nurse suggest the patient include? A slice of 5-grain bread Chuck steak patty (6 ounces [170 grams]) Strawberries (1 cup [160 grams]) Tomato (1 medium)

A slice of 5-grain bread **The nurse suggests to the patient with recently diagnosed diverticular disease to include a slice of 5-grain bread in the diet. Whole-grain breads are recommended to be included in the diet of patients with diverticular disease because cellulose and hemicellulose types of fiber are found in them. Dietary fat would be reduced in patients with diverticular disease.If the patient wants to eat beef, it must be of a leaner cut. Foods containing seeds, such as strawberries, must be avoided. Tomatoes would also be avoided unless the seeds are removed. The seeds may block diverticula in the patient and present problems leading to diverticulitis.

Colon resection

A stool softener may be prescribed to keep stools in soft consistency for ease of passage Teach pts to not the frequency, amount, and character of the stools Those with colon resections need to watch and report s&s of intestinal obstruction and perforation (abdominal pain, cramping, nausea, vomiting) Teach or to avoid gas producing foods and carbonated beverages Pt may require 4-6 weeks to establish the effects of certain foods on bowel patterns

The nurse is instructing a client on measures to maintain effective oral health. Which measures does the nurse include in the client's teaching plan? (Select All That Apply) a. Regular dental checkups b. Use of mouthwashes containing alcohol c. Ensuring that dentures are slightly loose-fitting d. Managing stress as much as possible e. Eating a balanced diet

A, D, E

A patient is scheduled for discharge after surgery for inflammatory bowel disease. The patient's spouse will be assisting home health services with the patient's care. What is most important for the home health nurse to assess in the patient and the spouse with regard to the patient's home care? Ability of the patient and spouse to perform incision care and dressing changes Effective coping mechanisms for the patient and spouse after the surgical experience Knowledge about the patient's requested pain medications Understanding of the importance of keeping scheduled follow-up appointments

Ability of the patient and spouse to perform incision care and dressing changes **It is most important for the home health nurse to assess the patient's and spouse's ability to carry out incision care and dressing changes. This assessment is essential to avoid further development of the infectious process, as well as infection of the surgical incision itself.Assessing coping mechanisms and knowledge of the patient's pain medication are important but are not the priority. Understanding the importance of scheduled follow-up appointments is important but is also not the priority.

The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client? Achieving the highest level of functioning Increasing cerebral perfusion Preventing further injury Preventing skin breakdown

Achieving the highest level of functioning **The most important nurse's goal for the client with TBI is to help him or her achieve the highest level of functioning possible.The nurse assesses cerebral perfusion, such as oxygenation status, but cannot increase cerebral perfusion. Prevention of injury from falls, infection, or further impairment of cerebral perfusion is part of a larger goal for this client. Prevention of skin breakdown is a goal for the care of any client.

The nurse is reviewing the history of a client who has been prescribed topiramate (Topamax) for prevention of migraines. The nurse plans to contact the primary care provider (PCP) if the client has which condition? Bipolar disorder Diabetes mellitus Glaucoma Hypothyroidism

Bipolar disorder **The nurse contacts the PCP after reviewing the history of a client with bipolar disorder who has been prescribed topiramate. Cases of suicide have been associated with topiramate when it is used in larger doses of 400 mg daily, most often in clients with bipolar disorder.Topiramate is not contraindicated in clients with diabetes mellitus, glaucoma, or hypothyroidism.

The nurse is teaching a group of patients with irritable bowel syndrome (IBS) about complementary and alternative therapies. What does the nurse suggest as possible treatment modalities? Select all that apply. Acupuncture Decreasing physical activities Meditation Peppermint oil capsules Yoga

Acupuncture Meditation Peppermint oil capsules Yoga **Possible treatment modalities the nurse suggests for a patient with IBS include: acupuncture, meditation, peppermint oil capsules, and yoga. Acupuncture is recommended as a complementary therapy for IBS. Meditation, yoga, and other relaxation techniques help many patients manage stress and their IBS symptoms. Research has shown that peppermint oil capsules may be effective in reducing symptoms of IBS. Regular exercise is important for managing stress and promoting bowel elimination.The nurse would not suggest decreasing physical activity. Regular exercise is important for managing stress and promoting bowel elimination.

The nurse admits an immunocompromised client who has contracted herpes simplex stomatitis. The nurse anticipates that the health care provider will request which medication? Acyclovir (Zovirax) Diphenhydramine (Benadryl) Nystatin (Mycostatin) Tetracycline syrup (Sumycin syrup)

Acyclovir (Zovirax) **The nurse anticipates that the health care provider will request acyclovir for the client. Acyclovir (Zovirax) is an antiviral agent that is prescribed for immunocompromised clients who contract herpes simplex stomatitis.Diphenhydramine is an antihistamine that is not indicated for treating this condition. Nystatin is indicated for treatment of fungal infection. Tetracycline syrup is indicated for treatment of recurrent aphthous ulcers (canker sores).

Fistula Care

Adequate nutrition and fluid and electrolyte balance are priorities Pt. at high risk for malnutrition, dehydration, and hypoglycemia Monitor urinary output and daily weights Preserving and protecting skin is priority!! Be sure wound drainage is not in direct contact with skin bc intestinal fluid enzymes are caustic!! Clean skin promptly to prevent skin breakdown or fungal infection

Suspected Appendicitis pt

Administer IV fluids as prescribed to maintain F&E balance and replace fluid volume If tolerated, have pt in semi-Fowler's so abd. Drainage can be contained in lower abdomen Administer opioid analgesics and antibiotics as prescribed after surgery Pt with suspects/confirmed appendicitis should not receive laxatives or enemas (can cause perforation of appendix) Do not apply heat to the abdomen bc May increase circulation to appendix and result in increased inflammation and perforation!!

A client newly diagnosed with Parkinson disease (PD) is being discharged. Which instruction is best for the nurse to provide to the client's spouse? Administer medications promptly on schedule to maintain therapeutic drug levels. Complete activities of daily living for the client. Provide high-fiber, high-carbohydrate foods. Speak loudly for better understanding.

Administer medications promptly on schedule to maintain therapeutic drug levels. **Administering medications promptly on schedule is a correct statement.The best instruction the nurse can give to the spouse of a PD client about to be discharged is to give schedule medications promptly in order to keep drug levels therapeutic.

The nurse finds a patient vomiting coffee-ground emesis. On assessment, the patient has a blood pressure of 100/74 mm Hg, is acutely confused, and has a weak and thready pulse. Which intervention is the nurse's first priority? Administering a histamine2 (H2) antagonist Initiating enteral nutrition Administering intravenous (IV) fluids Administering antianxiety medication

Administering intravenous (IV) fluids **The nurse's first priority is to administer intravenous (IV) fluids. Administering IV fluids is necessary to treat the hypovolemia caused by acute gastrointestinal (GI) bleeding.Administration of an H2 antagonist will not treat the basic problem, which is upper GI bleeding. Enteral nutrition will not be part of the treatment plan for acute GI bleeding. Administration of antianxiety medication will not treat the acute confusion. The patient's change in mental status is due to hypovolemia caused by acute GI bleeding.

A client with gastroesophageal reflux disease has undergone a laparoscopic Nissen fundoplication (LNF). What will the nurse include in postoperative home care instructions? A. "Consume carbonated beverages if you experience stomach upset." B. "Remain on a soft diet for about a week and avoid raw fruits and vegetables." Correct C. "You may resume running and weight lifting if you wish." D. "You may stop taking your anti-reflux medications after 1 week."

After LNF, clients should be taught to remain on a soft diet for 1 week. Carbonated beverages should be avoided. Clients may walk, but should avoid heavy lifting. Anti-reflux medications should be taken for 1 month after the procedure.

It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication? Right shoulder pain Polyuria Bone marrow suppression Bleeding

Bleeding **A potential complication of hepatic artery embolization for hepatic cancer is bleeding. Prompt detection of hemorrhage is the priority.Discomfort such as right shoulder pain may be present, but the priority is to assess for hemorrhage. The nurse must assess for signs of shock, not polyuria. Embolization does not suppress the bone marrow. If chemotherapy or immune modulators are used, the nurse then assesses for bone marrow suppression.

A client presents to the clinic with a migraine and is lying in a darkened room with a wet cloth on the head after receiving treatment. In preparation for dismissal home, what does the nurse do next? Allow the client to remain undisturbed. Assess the client's vital signs. Remove the cloth because it can harbor microorganisms. Turn on the lights for a neurologic assessment.

Allow the client to remain undisturbed. **The next action by the nurse is to allow the client to remain undisturbed. The client may be able to alleviate pain by lying down in a darkened room with a cool cloth on his or her forehead. If the client falls asleep, he or she would remain undisturbed until awakening.Assessing the client's vital signs, although important, will disturb the client unnecessarily. A cool cloth is helpful for the client with a migraine and does not present enough of a risk that it would be removed. Turning on the lights for a neurologic assessment is not appropriate because light can cause the migraine to worsen.

When assessing a client for hepatic cancer, the nurse anticipates finding an elevation in which laboratory test result? Hemoglobin and hematocrit Leukocytes Alpha-fetoprotein Serum albumin

Alpha-fetoprotein **The nurse anticipates finding an elevation in the laboratory test for alpha-fetoprotein. Fetal hemoglobin (alpha-fetoprotein) is abnormal in adults, and is a tumor marker indicative of cancers.Although anemia may be present, elevated hemoglobin and hematocrit are not diagnostic of hepatic cancer. White blood cells (leukocytes) are not used to specifically diagnose cancers. Serum albumin levels may be low in liver cancer and in malnutrition.

A client has undergone a partial glossectomy for cancer. What community resource does the nurse refer the client to when dressing supplies will be needed at home? Oral Cancer Foundation American Cancer Society (ACS) Client Advocate Foundation American Medical Supply Foundation

American Cancer Society (ACS) **The ACS supplies dressings and transportation to and from follow-up visits or medical treatments for clients with cancer. A partial glossectomy is removal of part of the tongue (see Chapter 29).The Oral Cancer Foundation is an organization for local support groups and resources. The Client Advocate Foundation provides education, legal counseling, and referrals to clients with cancer and survivors concerning managed care, insurance, financial issues, job discrimination, and debt crisis matters. The American Medical Supply Foundation does not exist.

Aside from chemotherapeutic agents, what other medications does the nurse expect to administer to a patient with advanced colorectal cancer for relief of symptoms? Analgesics and antiemetics Analgesics and benzodiazepines Steroids and analgesics Steroids and anti-inflammatory medications

Analgesics and antiemetics **Besides chemotherapeutic agents, the nurse expects to administer analgesics and antiemetics to a patient with advanced colorectal cancer for relief of symptoms related to pain and nausea.Benzodiazepines, steroids, and anti-inflammatory medications are not routinely requested for these patients.

The nurse is teaching a patient who recently began taking sulfasalazine (Azulfidine) about the drug. What side effects does the nurse tell the patient to report to the primary health care provider? Select all that apply. Anorexia Depression Drowsiness Frequent urination Headache Vomiting

Anorexia Headache Vomiting **Anorexia, headache, and nausea/vomiting are side effects of sulfasalazine that must be reported to the primary health care provider.Depression, drowsiness, and urinary problems are not side effects of sulfasalazine.

When preparing a client to undergo paracentesis, which action is necessary to reduce potential injury as a result of the procedure? Encourage the client to take deep breaths and cough Ask the client to void prior to the procedure Position the client with the head of the bed flat Assist the physician to insert a trocar catheter into the abdomen

Ask the client to void prior to the procedure **To avoid injury to the bladder during a paracentesis, the client would be asked to void prior to the procedure (Chart 58-1).Taking deep breaths and coughing does not prevent complications or injury as a result of paracentesis. Clients would be positioned with the head of the bed elevated. The trocar catheter is used to drain the ascetic fluid and does not reduce the risk of damage to the bladder.

A patient in the outpatient clinic tells the nurse about experiencing heartburn and nighttime coughing episodes. Which action does the nurse take first? Teach the patient about antacid effects and side effects. Ask the patient about oral intake, current medications and description of episodes. Suggest that the patient sleep with the head elevated 6 inches (15 cm). Tell the patient to avoid drinking alcohol late in the evening.

Ask the patient about oral intake, current medications and description of episodes. **The nurse's first action would be further assessment of the patient's risk factors for gastroesophageal reflux disease (GERD). Before suggesting interventions or beginning patient teaching, the nurse must elicit more information about the patient's symptoms.The nurse needs additional data before telling the patient about antacid effects, sleeping with the head elevated, or not drinking alcohol late in the evening.

A patient with gastric cancer is scheduled to undergo surgery to remove the tumor once 5 pounds (2.3 kg) of body weight has been regained. The patient is not drinking the vanilla-flavored enteral supplements that have been prescribed. Which is the highest priority nursing intervention for this patient? Explain to the patient the importance of drinking the enteral supplements prescribed. Ask the patient's family to try to persuade the patient to drink the supplements. Inform the patient that a nasogastric tube may be necessary if he or she fails to comply. Ask the patient if a change in flavor would make the supplement more palatable.

Ask the patient if a change in flavor would make the supplement more palatable. **The highest priority nursing intervention for this patient is to ask the patient if a change in flavor would make the supplement more palatable. This action helps show that the nurse is attempting to determine why the patient is not drinking the supplements. Many patients don't like certain supplement flavors.The nurse would not assume that the patient does not understand the importance of drinking the supplements or that the patient requires persuasion to drink the supplements. The problem may be entirely different. Telling the patient that a nasogastric tube may be necessary could be construed as threatening the patient.

The nurse is assessing an alert client who had abdominal surgery yesterday. What method provides the most accurate data about resumption of peristalsis in the client? Asking the client whether he or she has passed flatus (gas) within the previous 12 to 24 hours. (p. 17) Auscultating bowel sounds in all abdominal quadrants Counting the number of bowel sounds in each abdominal quadrant over one minute. Observing the abdomen for symmetry and distention

Asking the client whether he or she has passed flatus (gas) within the previous 12 to 24 hours. (p. 17) **The best and most reliable method for assessing the return of peristalsis following abdominal surgery is the client's report of passing flatus within the past 8 hours or stool within the past 12 hours.Although auscultation and counting the number of sounds was once a method of assessing for bowel activity, it is no longer considered the most effective method. Observing the abdomen is one method of examining a client's abdomen, but it is not a reliable way to assess for resumption of activity after surgery.

Fluid volume overload

Asses for edema, crackles in lungs, increased jugular venous pressure

Safety Priority for Peritonitis pts

Assess for abdominal wall rigidity (board like abdomen!!!) Monitor pt. For a high fever bc of infectious process Assess for tachycardia occurring in response to the fever and decreased circulatory blood volume Observe whether they have dry mucous membranes and a low urine output Nausea and vomiting may be present Hiccups can occur as a result of diaphragmatic irritation Be sure to document all assessment findings

Physiological Integrity

Assess for s&s of appendicitis: abdominal pain, N/V, abdominal tenderness on palpation..some pts have leukocytosis Perforation of appendix can result it peritonitis Be alert for GI bleeding in pt with chronic IBD Crohn's pts at high risk for malnutrition as result of inability to absorb nutrients via small intestine Priority problems for pts with UC include diarrhea, pain, and potential for lower GI bleeding Teach pts with IBD to avoid alcohol and caffeine Instruct diverticulosis pts not to eat food with seeds, nuts, and GI stimulants

Stoma assessment

Assess stoma frequently after stoma placement. It should be pinkish to cherry red to ensure an adequate amount of blood supply If stoma looks pale, bluish, or dark respond by reporting to health care provider immediately!!

A client with oral carcinoma has a priority problem of risk for airway blockage related to obstruction by the tumor. At the beginning of the shift, which action will the nurse take first? Suction the client's oral secretions to clear the airway. Place the client on humidified oxygen per nasal cannula. Assist the client to an upright position to facilitate breathing. Assess the respiratory effort and quantities and types of oral secretions.

Assess the respiratory effort and quantities and types of oral secretions. **The nurse would first assess the client's respiratory effort and quantities and types of oral secretions. Assessment is the first step of the nursing process.Suctioning the client, placing the client on humidified oxygen, and assisting the client to an upright position are not the first steps in the nursing process. These interventions may or may not be necessary if the nurse follows the nursing process.

A client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What does the nurse do first? Assesses airway, breathing, and circulation Calls the provider Performs a neurologic check Assists the client to a sitting position

Assesses airway, breathing, and circulation **When a client reports "feeling funny" and then starts slurring words and has right-sided weakness, the nurse must first assess for airway, breathing, and circulation. The priority is assessment of the "ABCs"—airway, breathing, and circulation.Calling the Rapid Response Team, not the provider, after assessing ABCs would be appropriate. The first 10 minutes after onset of symptoms is crucial. A neurologic check will be performed rapidly but is not the top priority. The client would be placed in bed, easily accessible for healthcare providers to assess and begin treatment. This does not need to be a seated position.

A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? Assessing neurologic status at least every 2-4 hours Decreasing environmental stimuli Managing pain through drug and nondrug methods Strict monitoring of hourly intake and output

Assessing neurologic status at least every 2-4 hours **The highest priority nursing intervention for the newly admitted client with bacterial meningitis is to accurately monitor and record the client's neurologic status every 2-4 hours. The neurologic status, vital signs, and vascular status must be assessed at least every 4 hours or more often, if clinically indicated, to rapidly determine any deterioration in status.Decreasing environmental stimuli is helpful for the client with bacterial meningitis but is not the highest priority. Clients with bacterial meningitis report severe headaches requiring pain management which may be accomplished through both pharmacologic and nonpharmacologic methods. Assessing fluid balance while preventing overload is not the highest priority however intake and output must be monitored.

A client is being discharged to home with progressing stage I Alzheimer's disease. The family expresses concern to the nurse about caring for their parent. What is the priority for best continuity of care? Assigning a case manager Ensuring that all family questions are answered before discharge Providing a safe environment Referring the family to the Alzheimer's Association

Assigning a case manager **The priority for the best continuity of care for a client about to be discharged with progressing Stage I Alzheimer's disease is to assign a case manager to the client and family. Whenever possible, the client and family need the services of a case manager who can assess their needs for health care resources and facilitate appropriate placement throughout the continuum of care. Continuity of care is important through all stages of Alzheimer's disease.Ensuring all questions are answered and providing a safe environment are necessary for family support. The Alzheimer's Association will also be able to help provide information and support to the family.

The nurse is monitoring a patient with gastric cancer for signs and symptoms of upper gastrointestinal bleeding. Which change in vital signs is most indicative of bleeding? Respiratory rate from 24 to 20 breaths/min Apical pulse from 80 to 72 beats/min Temperature from 97.9° F to 98.9° F (36.6°C to 37.2°C) Blood pressure from 140/90 to 110/70 mm Hg

Blood pressure from 140/90 to 110/70 mm Hg **A decrease in blood pressure from 140/90 to 110/70 is the most indicative sign of bleeding.A slight decrease in respiratory rate, apical pulse, and temperature is not the primary indication of bleeding.

A male patient in a long-term care facility is 2 days postoperative after an open repair of an indirect inguinal hernia. Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)? Assessing the patient's incision for signs of infection Assisting the patient to stand to void Instructing the patient in how to deep-breathe Monitoring the patient's pain level

Assisting the patient to stand to void **The RN delegates the UAP to assist the 2 day postoperative open repair of an indirect inguinal hernia patient to stand and void. Assisting the patient with activities is part of the UAP role.Assessment of the patient's incision and monitoring the patient's pain level requires broader education and scope of practice than a UAP and would be performed by licensed nursing personnel. Patient teaching—even about something as fundamental as taking "deep breaths"—likewise requires broader education and scope of practice and would be done by licensed nursing personnel.

The nurse is caring for a client with advanced Alzheimer's disease. Which communication technique is best to use with this client? Assuming that the client is not totally confused Providing the client with several options to choose from Waiting for the client to express a need Writing down instructions for the client

Assuming that the client is not totally confused **The best communication technique to use for a client with advanced Alzheimer's disease is to not assume that the client is totally confused and cannot understand what is being said.Choices need to be limited. Too many choices cause frustration and increased confusion in the client. Rather than waiting for the client to express a need, try to anticipate the client's needs and interpret nonverbal communication. Just writing down instructions may be confusing for the client. It is better to provide the client instructions with pictures, and put them in a highly visible place.

The nurse asks a client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record? Positive Babinski's sign Hyperreflexia Kehr's sign Asterixis

Asterixis **The nurse documents asterixis when the client's dorsiflexed hands begin to flap upward and downward when outstretched for a few moments. Liver flap or asterixis is related to increased serum ammonia levels.Babinski's sign is positive when, as the sole of the foot is stroked, the great toe points up and the toes fan out. Hyperreflexia refers to deep tendon reflexes that are overactive. Kehr's sign is reflected by increased abdominal pain, exaggerated by deep breathing, and referred to the right shoulder.

The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which sign/symptom is the nurse most concerned about? Amnesia Asymmetric pupils Headache Head laceration

Asymmetric pupils **The nurse is most concerned about asymmetric pupils in the client with traumatic brain injury. Asymmetric (uneven) pupils are treated as herniation of the brain from increased intracranial pressure (ICP) until proven otherwise. The nurse must report and document any changes in pupil size, shape, and reactivity to the primary health care provider immediately.Amnesia, a headache and a head laceration, can be signs of mild traumatic brain injuries and need to be investigated more thoroughly.

NGT assessment

At least every 4hrs, assess pt for proper placement of tube, tube patency, and output (quality and quantity) Monitor nasal skin around tube for irritation UE device the secures tube to nose Assess for peristalsis by auscultating for bowel sounds with the suction disconnected

Irritable bowel syndrome teaching

Avoid foods that trigger exacerbation Drink at least 2-3L fluids each day Increase daily fiber intake to 30-40g daily Eat small frequent meals

Trigger factors of seizures/teaching

Avoid overwhelming fatigue Remove caffeinated products from the diet Limit looking at flashing lights

The nurse prepares a teaching session regarding lifestyle changes needed to decrease the discomfort associated with a patient's gastroesophageal reflux disease (GERD). Which change does the nurse recommend to this patient? Eat only two or three meals daily. Sleep flat in a left side-lying position. Drink tea instead of coffee. Avoid working while bent over the computer.

Avoid working while bent over the computer. **The patient should avoid working while bent over because this position presses on the diaphragm, causing discomfort.The patient with GERD needs to eat four to six meals a day. The head of the patient's bed would be elevated approximately 6 inches (15 cm). Both tea and coffee need to be eliminated from this patient's diet because of the caffeine content.

A client has undergone a partial glossectomy for cancer. What community resource does the nurse refer the client to when dressing supplies will be needed at home? a. Oral Cancer Foundation b. American Cancer Society (ACS) c. Client Advocate Foundation d. American Medical Supply Foundation

B

The nurse is working with the dietitian to plan a menu for a client who has persistent difficulty swallowing. What is a suitable breakfast selection for this client? A. Scrambled eggs and toast B. Oatmeal and orange juice C. Puréed fruit and English muffin D. Cream of wheat and applesauce Correct

Both cream of wheat and applesauce are foods of semi-solid consistency and are appropriate for this client. The client who is having difficulty swallowing should be given semi-solid foods and thickened liquids. Toast would not be appropriate, and orange juice would have to be thickened before it is given to this client. An English muffin would be inappropriate for this client because it is not a semi-solid food.

Client developed dysphasia and stomatitis. What teaching will nurse provide?

Brush teeth twice daily with chemobrush Rinse mouth with mild saline and water mix before and after eating Plan to eat soft foods such as cheese, well cooked legumes, peanut butter, and pudding

What does the nurse advice a patient diagnosed with irritable bowel syndrome (IBS) to take during periods of constipation? Bulk-forming laxatives Saline laxatives Stimulant laxatives Stool-softening agents

Bulk-forming laxatives **The nurse advises the patient diagnosed with IBS to take bulk-forming laxatives during periods of constipation. For treatment of constipation-predominant IBS, bulk-forming laxatives are generally taken at mealtimes with a glass of water.Saline and stimulant laxatives are not used for the treatment of constipation-predominant IBS. Stool-softening agents are not effective.

A client has recently developed acute sialadenitis. Which intervention does the nurse include in this client's care? a. Applying cold compresses b. Avoiding the use of fruit or citrus-flavored candy c. Massaging the salivary gland d. Restrict fluids

C

Which food does the nurse instruct a client undergoing chemotherapy for oral cancer with secondary stomatitis to avoid? a. Broiled fish b. Ice cream c. Salted pretzels d. Scrambled eggs

C

The nurse is caring for a client diagnosed with aphthous ulcers. The nurse instructs the client to avoid which foods? (Select All That Apply) a. Apples b. Bananas c. Cheese d. Nuts e. Potatoes

C, D, E

Pernicious anemia

Caused by damage to parietal cells and caused decrease in intrinsic factor by the stomach parietal cells -client will receive monthly injections of Vitamin B12

A patient who has colorectal cancer is scheduled for a colostomy. Which referral is initially of greatest value to this patient? Certified Wound, Ostomy, and Continence Nurse (CWOCN) Home health nursing agency Hospice Hospital chaplain

Certified Wound, Ostomy, and Continence Nurse (CWOCN) **A CWOCN (or an enterostomal therapist) will be of greatest value to the patient with colorectal cancer because the patient is scheduled to receive a colostomy.The patient is newly diagnosed, so it is not yet known whether home health nursing will be needed. A referral to hospice may be helpful for a terminally ill patient. Referral to a chaplain may be helpful later in the process of adjusting to the disease.

A client with a traumatic brain injury from a motor vehicle crash is monitored for signs/symptoms of increased intracranial pressure (ICP). Which sign/symptoms does the nurse monitor for? Changes in breathing pattern Dizziness Increasing level of consciousness Reactive pupils

Changes in breathing pattern **The nurse monitors for changes in breathing pattern. This may be indicative of increased intracranial pressure secondary to compression of areas of the brain responsible for respiratory control.Dizziness is a symptom of brain injury, not increased intracranial pressure. Increasing level of consciousness and reactive pupils are desired outcomes for this client.

The nurse is reviewing the medication history for a patient diagnosed with gastroesophageal reflux disease (GERD) who has been prescribed esomeprazole (Nexium) once daily. The patient reports that this proton pump inhibitor medication doesn't completely control the symptoms. The nurse contacts the primary health care provider to discuss which intervention? Adding a second proton pump inhibitor medication Increasing the dose of esomeprazole Changing to a twice-daily dosing regimen Switching to omeprazole (Prilosec)

Changing to a twice-daily dosing regimen **The nurse contacts the primary health care provider about changing the Proton pump inhibitor to twice daily. These medications are usually effective when given once daily but can be given twice daily if symptoms are not well controlled.Adding a second medication, increasing the dose, or switching to another proton pump inhibitor is not recommended.

A client with oral cancer is depressed over the diagnosis and tells the nurse of plans to have a radical neck dissection. What is the nurse's best reaction? a. Listen to the client and then explain that it is normal to feel depressed about the diagnosis. b. Explain the grieving process and listen to what the client has to say. c. Suggest that the client talk with friends and family and seek their support. d. Listen to the client's concerns and feelings and then suggest that the client join a community group of cancer survivors.

D

A client has undergone the Whipple procedure (radical pancreaticoduodenectomy) for pancreatic cancer. Which precautionary measures does the nurse implement to prevent potential complications? Select all that apply. Check blood glucose often. Check bowel sounds and stools. Ensure that drainage color is clear. Monitor mental status. Place the client in the supine position.

Check blood glucose often. Check bowel sounds and stools. Monitor mental status. **To prevent potential complications after a Whipple procedure, the nurse would check the client's glucose often to monitor for diabetes mellitus. Bowels sounds and stools would be checked to monitor for bowel obstruction. A change in mental status or level of consciousness could be indicative of hemorrhage.Clear, colorless, bile-tinged drainage or frank blood with increased output may indicate disruption or leakage of a site of anastomosis but is not a precautionary action for the nurse to implement. The client should be placed in semi-Fowler's and not supine position to reduce tension on the suture line and the anastomosis site and to optimize lung expansion.

The nurse is observing a coworker who is caring for a patient with a nasogastric tube following esophageal surgery. Which actions by the coworker require the nurse to intervene? Select all that apply. Checking tube placement every 12 hours Keeping the bed flat Placing the patient upright when taking sips of water Providing mouth care every 8 hours Securing the tube

Checking tube placement every 12 hours Keeping the bed flat Providing mouth care every 8 hours **The nurse would intervene to make sure the nasogastric tube is checked every 4 to 8 hours and not every 12 hours. Also, the head of the bed needs to be elevated at least 30 degrees and not kept flat. Oral hygiene would be provided every 2 to 4 hours and not every 8 hours.The patient should be placed upright when taking sips or small amounts of water to prevent choking and to allow observation of the patient for dysphagia. The tube should be secured to prevent dislodgment.

The nurse is caring for a client diagnosed with aphthous ulcers. The nurse instructs the client to avoid which foods? Select all that apply. Apples Bananas Cheese Nuts Potatoes

Cheese Nuts Potatoes **Aphthous ulcers (canker sores) are small, shallow lesions that develop on the soft tissues in the mouth or at the base of the gums. The nurse tells the client that certain foods such as cheese, nuts, and potatoes may trigger allergic responses that cause aphthous ulcers and should be avoided.Apples and bananas are not acidic and do not trigger allergic responses that cause aphthous ulcers.

A patient has vague symptoms that indicate an acute inflammatory bowel disorder. Which signs/symptoms are most indicative of Crohn's disease (CD)? Abdominal pain relieved by bending the knees, constipation Chronic diarrhea, abdominal colicky pain, and fever Epigastric cramping & persistent rectal bleeding Hypotension with vomiting and headache

Chronic diarrhea, abdominal colicky pain, and fever **Signs/symptoms that are most indicative of Crohn's disease (CD) are: chronic diarrhea, abdominal colicky pain, and fever. These signs/symptoms are more specific to CD than any of the other acute inflammatory bowel disorders.Abdominal pain that is relieved by bending the knees is indicative of peritonitis or pancreatitis. Epigastric cramping is a sign/symptom more indicative of appendicitis. Hypotension with vomiting is not characteristic of CD.

A client is admitted into the emergency department (ED) with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? Classic migraine Meningitis Stroke West Nile virus

Classic migraine **The nurse suspects that a classic migraine could be present when an ED client complains of frontal-temporal pain preceded by a visual disturbance. These symptoms are most typical of a classic migraine.Meningitis may present with a headache and visual disturbance but is usually accompanied by nuchal rigidity (neck stiffness) and fever. The symptoms of stroke will vary depending upon the area affected. Mild cases of West Nile virus may be asymptomatic or present with flu-like symptoms, whereas severe cases may lead to loss of consciousness and death.

The RN has just received the change-of-shift report for the medical unit. Which client should the RN see first? Client with ascites who had a paracentesis 2 hours ago and is reporting a headache Client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse Client with hepatic cirrhosis and jaundice who has hemoglobin of 10.9 g/dL (109 mmol/l) and thrombocytopenia Client with hepatitis A who has elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST)

Client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse **The nurse would first see the client with PSE who is now difficult to arouse. A change in the level of consciousness (LOC) of the client with PSE is the greatest concern. Actions to improve the client's LOC must be rapidly implemented.Although uncomfortable, a headache in the client with ascites is not likely related to liver disease and does not pose an immediate threat or complication. A hemoglobin of 10.9 g/dL (109 mmol/L) and thrombocytopenia are expected findings in a client with cirrhosis and do not pose an immediate threat. Elevated ALT and AST levels are expected for the client with hepatitis A and do not indicate a risk for severe complications.

The nurse is caring for clients in the outclient clinic. Which of these phone calls would the nurse return first? Client with hepatitis A reporting severe and ongoing itching Client with severe ascites who has a temperature of 101.4°F (38°C) Client with cirrhosis who has had a 3-pound (1.4 kg) weight gain over 2 days Client with esophageal varices and mild right upper quadrant pain

Client with severe ascites who has a temperature of 101.4°F (38°C) **The nurse will first call the client with severe ascites and a temperature of 101.4 (38°C).This client may have spontaneous bacterial peritonitis.Itching is anticipated with jaundice, so this client may be called last. Weight gain with cirrhosis is not uncommon owing to low albumin levels. Cirrhosis may cause mild right upper quadrant pain. This client would be called after the client with severe ascites.

A client with oral carcinoma has a priority problem of risk for airway blockage related to obstruction by the tumor. At the beginning of the shift, which action will the nurse take first? a. Suction the client's oral secretions to clear the airway. b. Place the client on humidified oxygen per nasal cannula. c. Assist the client to an upright position to facilitate breathing. d. Assess the respiratory effort and quantities and types of oral secretions.

D

The nurse is reviewing orders for a client with possible esophageal trauma after a car crash. Which request does the nurse implement first? A. Give total parenteral nutrition (TPN) through a central venous catheter. B. Administer cefazolin (Kefzol) 1 g intravenously. C. Obtain a computed tomography (CT) scan of the chest and abdomen. D. Keep the client nothing by mouth (NPO) for possible surgery. Correct

Clients with possible esophageal tears should be NPO until diagnostic testing is completed, because leakage of anything taken orally into the sterile mediastinum could occur. In addition, esophageal rest is maintained for about 10 days after esophageal trauma to allow time for mucosal healing. TPN is prescribed to provide calories and protein for wound healing; although this is important, it is not a priority for the nurse to implement first. Antibiotics may be requested to prevent possible infection, but this is not the priority. A CT of the chest and abdomen will be needed, but is not the nurse's initial action.

A nurse is preparing a health teaching session about early detection of colorectal cancer. What should the nurse include?

Colonoscopy every 10 years Flexible sigmoidoscopy every 5 years Stool DNA test every 3 years Double contract barium enema every 5 years Take home yearly guise fecal occult blood test

A patient with a bowel obstruction is ordered a Salem sump nasogastric tube (NGT). After the nurse inserts the tube, which nursing intervention is the highest priority for this patient? Attaching the tube to low intermittent suction Auscultating for bowel sounds and peristalsis while the suction runs Connecting the tube to low continuous suction Flushing the tube with 30 mL of normal saline every 24 hours

Connecting the tube to low continuous suction **Most patients with an obstruction have an NGT unless the obstruction is mild. A Salem sump tube is inserted through the nose and placed into the stomach. It is attached to low continuous suction unless otherwise requested by the primary health care provider. This tube has a vent (pigtail) that prevents the stomach mucosa from being pulled away during suctioning. This tube does not require intermittent suctionLevin tubes (no pigtail) do not have a vent and therefore should only be connected to low intermittent suction. They are used much less often than the Salem sump tubes. Bowel sounds would not be auscultated with suction on and running. After appropriate placement is established, the contents are aspirated and the tube is irrigated with 30 mL of normal saline every 4 hours or as requested by the primary health care provider.

When providing dietary teaching to a client with hepatitis, what practice does the nurse recommend? Having a larger meal early in the morning Consuming increased carbohydrates and moderate protein Restricting fluids to 1500 mL/day Limiting alcoholic beverages to once weekly

Consuming increased carbohydrates and moderate protein **To repair the liver, the nurse recommends that the client adopt a high-carbohydrate and moderate-protein diet. Fats may cause dyspepsia.The client with hepatitis feels full easily and needs to have four to six small meals daily. Fluids are restricted with ascites caused by cirrhosis. Not all clients with hepatitis progress to cirrhosis. Complete abstention from alcohol is necessary until the liver enzymes return to normal.

A patient with ulcerative colitis (UC) is prescribed sulfasalazine (Azulfidine) and corticosteroid therapy. As the disease improves, what change does the nurse expect in the patient's medication regimen? Corticosteroid therapy will be stopped. Sulfasalazine (Azulfidine) will be stopped. Corticosteroid therapy will be tapered. Sulfasalazine (Azulfidine) will be tapered.

Corticosteroid therapy will be tapered. **The nurse expects that corticosteroid therapy will be tapered as the UC improves in the patient who was taking both sulfasalazine and corticosteroids. Once clinical improvement has been established, corticosteroids are tapered over a 2- to 3-month period.Stopping corticosteroid therapy abruptly is unsafe—steroids must be gradually decreased in patients. Usually the amount that they have been taking dictates how quickly or slowly they can be stopped. Sulfasalazine therapy will be taken on a long-term basis. It may be increased or decreased, depending on the patient's symptoms, but will likely never be stopped. These decisions are made over a long period of therapy.

The nurse is caring for a patient with esophageal cancer who has received photodynamic therapy using porfimer sodium (Photofrin). What instructions does the nurse include in teaching the patient about porfimer sodium? Select all that apply. Avoid sunlight for 2 weeks. Cover or shield all exposed body areas from sunlight. Follow a clear liquid diet for 3 to 5 days after the procedure. Monitor for hypertension. Tissue particles may be found in the sputum.

Cover or shield all exposed body areas from sunlight. Follow a clear liquid diet for 3 to 5 days after the procedure. Tissue particles may be found in the sputum. **The nurse teaches the patient that porfimer sodium causes photosensitivity, and sunglasses and protective clothing covering all exposed body areas are essential. Also, a clear liquid diet would be followed for 3 to 5 days after the procedure and then advanced to full liquids as tolerated. In addition, the patient would be warned that tissue particles may be released from the tumor site and may be present in the sputum.Sunlight needs to be avoided for 1 to 3 months, and not for 2 weeks. Side effects are rare and may include nausea, fever, and constipation. Hypertension is not a side effect of porfimer sodium.

A client recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living. How does the nurse help the client compensate? Approaches the client on the affected side Covers the affected eye Encourages turning the head from side to side Places objects in the client's field of vision

Covers the affected eye **The nurse helps the stroke client compensate with double vision by covering the affected eye. Covering the client's affected eye with a patch prevents diplopia.The client who is recovering from a stroke would always be approached on the unaffected side. The nurse may encourage side-to-side head turning for clients with hemianopsia (blindness in half of the visual field). Objects would be placed in the field of vision for the client with a decreased visual field.

The nurse is monitoring a client after supratentorial surgery. Which sign/symptom does the nurse report immediately to the provider? Periorbital edema Bilateral ecchymoses of both eyes Moderate amount of serosanguineous drainage on the head dressing Decorticate positioning

Decorticate positioning **In a postoperative supratentorial client, the nurse must immediately report decorticate positioning to the provider. The major complications of supratentorial surgery are increased intracranial pressure from cerebral edema or hydrocephalus and hemorrhage. Decorticate positioning indicates damage to the pathway between the brain and the spinal cord.Periorbital edema and a small-to-moderate amount of serosanguineous drainage are expected after a craniotomy. Ecchymoses in the facial region, especially around the eyes, are expected after a craniotomy.

As a result of being treated with radiation for oral cancer, a client is experiencing xerostomia. What collaborative resource does the nurse suggest for this client's care? Dentist Occupational therapist Psychiatrist Speech therapist

Dentist **Xerostomia is the subjective feeling of oral dryness, which is often (but not always) associated with hypofunction of the salivary glands. It is a long-term effect of radiation therapy and requires ongoing oral care such as the use of saliva substitutes and follow-up dental visits.Occupational therapists, psychiatrists, and speech therapists are not the appropriate resource for a client with xerostomia.

A client has undergone conventional esophageal surgery. The client's diet has been advanced to semi-solid, and feedings are well tolerated. The client reports experiencing diarrhea about 1 hour after each meal. What is the priority nursing intervention to help prevent further diarrhea? A. Ensure that the client takes adequate amounts of fluids with meals. Incorrect B. Advance the diet to solid food and encourage eating as much as possible at meals. C. Give the client a dose of magnesium hydroxide (Milk of Magnesia) after each meal. D. Encourage the client to take fluids between meals rather than with meals. Correct

Diarrhea is believed to be the result of vagotomy syndrome and can be managed by taking fluids between meals rather than with meals. For this client, fluids with meals can lead to the development of diarrhea immediately after eating. The client may not be physically ready to advance to a solid diet. The client should eat six to eight small meals daily. Magnesium hydroxide is a magnesium-based antacid that can cause diarrhea.

The nurse is caring for a client diagnosed with esophageal cancer who is experiencing diarrhea after conventional esophageal surgery. The nurse anticipates that the health care provider will request which medication to manage diarrhea? A. Loperamide (Imodium) Correct B. Mesalamine (Pentasa) C. Minocycline (Minocin) D. Pantoprazole (Protonix)

Diarrhea is thought to be the result of vagotomy syndrome, which develops as a result of interruption of vagal fibers to the abdominal viscera during surgery. It can occur 20 minutes to 2 hours after eating and can be symptomatically managed with loperamide. Mesalamine is used to treat clients with mild to moderate ulcerative colitis. Minocycline is an antibiotic used for treatment of infection. Pantoprazole is used to treat gastroesophageal reflux disease.

A nurse is planning care for a client who has a small bowel obstruction and a NG tube. Which interventions should nurse include in plan of care?

Document the NG drainage with client's output Assess bowel sounds Provide oral hygiene every 2hrs Monitor NG tube placement Irrigate the NG tube every 4hrs

Which activity by the nurse will best relieve symptoms associated with ascites? Administering oxygen Elevating the head of the bed Monitoring serum albumin levels Administering intravenous fluids

Elevating the head of the bed **The best action by the nurse caring for a client with ascites is to elevate the head of the bed. The enlarged abdomen of ascites limits respiratory excursion. Fowler's position will increase excursion and reduce shortness of breath.The client may need oxygen, but first the nurse would raise the head of the bed to improve respiratory excursion and oxygenation. Monitoring serum albumin levels will detect anticipated decreased levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.

A patient with colorectal cancer had colostomy surgery performed yesterday. The patient is very anxious about caring for the colostomy and states that the primary health care provider's instructions "seem overwhelming." What does the nurse do first for this patient? Encourage the patient to look at and touch the colostomy stoma Instruct the patient about complete care of the colostomy Schedule a visit from a patient who has a colostomy and is successfully caring for it Suggest that the patient involve family members in the care of the colostomy

Encourage the patient to look at and touch the colostomy stoma **The first action the nurse does for the postoperative colostomy patient who is very anxious about caring for the colostomy is to encourage the patient to look at and touch the colostomy stoma. The initial intervention is to get the patient comfortable looking at and touching the stoma before providing instructions on its care.Instructing the patient about colostomy care will be much more effective after the patient's anxiety level has stabilized. Talking with someone who has gone through a similar experience may be helpful to the patient only after his or her anxiety level has stabilized. The patient has begun to express feelings regarding the colostomy and its care. It is too soon to involve others. The patient must get comfortable with this body image change before attempting to involve family members in colostomy care.

When caring for a client with portal hypertension, the nurse assesses for which potential complications? Select all that apply. Esophageal varices Hematuria Fever Ascites Hemorrhoids

Esophageal Varices Ascites Hemorrhoids **Potential complications of portal hypertension include esophageal varices, ascites, and hemorrhoids. Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid).Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.

A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What does the nurse do first? Administer phenytoin (Dilantin). Draw the client's blood. Establish an airway. Start an intravenous (IV) line.

Establish an airway. **When a client admitted with cerebral edema begins to have a seizure, the nurse must first establish an airway. The primary goal is to open and maintain an airway and then assess the client for the need of additional support during the seizure.Phenytoin (Dilantin) is administered to prevent the recurrence of seizures, not to treat a seizure already underway. Drawing blood or starting an IV is not the priority in this situation. Remember the ABCs during an emergency situation.

The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? Apple juice Grape juice Grapefruit juice Prune juice

Grapefruit juice **The nurse instructs the client taking phenytoin for epilepsy to avoid taking grapefruit juice. Some citrus fruits and juices, like grapefruit juice, can interfere with the metabolism of phenytoin potentially leading to an increased blood level and toxicity.Apple, grape, and prune juices are not contraindicated for a client taking phenytoin (Dilantin).

A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client? Assesses the abdomen in the following sequence: inspection, palpation, percussion, auscultation Examines the RUQ of the abdomen last following all other assessment techniques. Have the client lie in a supine position with legs straight and arms at the sides Gently palpates any bulging mass and documents findings.

Examines the RUQ of the abdomen last following all other assessment techniques. **If the client reports pain in the RUQ, the nurse would examine this area last in the examination sequence. This sequence prevents the client from tensing abdominal muscles because of the pain, which would make the examination difficult.The sequence for examining the abdomen is inspection, auscultation, percussion, and then palpation. This sequence prevents the increase in intestinal activity and bowel sounds caused by palpation and percussion. The client would be positioned supine with the knees bent, while keeping the arms at the sides to prevent tensing of the abdominal muscles. If a bulging, pulsating mass is present during assessment of the abdomen, do not touch the area because the client may have an abdominal aortic aneurysm, a life-threatening problem. Notify the health care provider of this finding immediately!

A client had a routine sigmoidoscopy with a tissue biopsy. What postprocedure complication would the nurse report to the health care provider? Gas and flatulence Excessive bleeding Nausea and vomiting Severe rectal pain

Excessive bleeding **Excessive or heavy bleeding is a possible complication following a sigmoidoscopy. It must be reported immediately to the health care provider.Nausea, vomiting, and severe rectal pain are not common complications of sigmoidoscopy. Gas and flatulence are expected assessment findings post-sigmoidoscopy (p. 36)

A client is being discharged home after treatment for a brain attack. What is the mnemonic that the nurse can teach the family and client to help recognize and act on another stroke? A-V-P-U F-A-S-T K-I-N-D O-P-Q-R-S-T

F-A-S-T **The mnemonic F-A-S-T is utilized to teach the client, family, and community how to recognize and respond to a stroke. The purpose is to observe the Face, Arms, Speech, and then Time of onset and knowing it's Time to call 9-1-1.A-V-P-U is the mnemonic for level of awareness (alert, verbal, painful, and unresponsive). K-I-N-D is a mnemonic for treatment of hyperkalemia (kayexalate, insulin, NaHCO3, diuretics). O-P-Q-R-S-T is a mnemonic for assessing pain (onset, provokes, quality, radiates, severity, time).

A client on the neurosurgical floor who had a lumbar laminectomy is confused, agitated, and complaining of difficulty breathing. The client is normally alert and oriented. The nurse notices a pinpoint rash over the client's chest. What condition is the nurse concerned has occurred? Autonomic dysreflexia CSF leak Fat embolism syndrome Paralytic ileus

Fat embolism syndrome **The nurse is concerned that fat embolism syndrome has occurred. Fat embolism syndrome (FES) is characterized by chest pain, dyspnea, anxiety, and mental status changes. Petechiae may develop around the neck, over the upper chest, buccal mucosa, and conjunctiva. This is an emergency. The nurse must notify the primary health care provider immediately.Autonomic dysreflexia is not associated with lumbar laminectomies. It is seen in spinal cord injuries. A cerebrospinal fluid (CSF) leak is a concern with laminectomy but would not present with these symptoms. Paralytic ileus may occur but is associated with abdominal pain and distention.

Which is the most effective way for a college student to minimize the risk for bacterial meningitis? Avoid large crowds. Get the meningococcal vaccine. Take a high dose vitamin C daily. Take prophylactic antibiotics.

Get the meningococcal vaccine. **The most effective way for a college student to minimize the risk for bacterial meningitis is to get the meningococcal vaccine. Individuals ages 16-21 years have the highest rates of meningococcal infection and need to be immunized against the virus.Avoiding large crowds is helpful, but is not practical for a college student. Taking a high dose of vitamin C every day does not minimize the risk of bacterial meningitis. However, maintaining a healthy lifestyle, with adequate sleep and nutrition, can improve immunity. Taking prophylactic antibiotics is inappropriate because it leads to antibiotic-resistant strains of microorganisms.

A patient with a history of osteoarthritis has a 10-inch (25.5 cm) incision following a colon resection. The incision has become infected, and the wound requires extensive irrigation and packing. What aspect of the patient's care does the nurse make certain to discuss with the primary health care provider before the patient's discharge? Having a home health consultation for wound care Requesting an antianxiety medication Requesting pain medication for the patient's osteoarthritis Placing the patient in a skilled nursing facility for rehabilitation

Having a home health consultation for wound care **The nurse makes sure to discuss an order for a home health consultation for wound care with the primary health care provider. Home health services are most appropriate for this patient because wound care will be extensive and the patient's mobility may be limited.No indication suggests that the patient is experiencing anxiety regarding postoperative care. Pain medication may be needed for the patient's osteoarthritis, but this is not the highest priority. A skilled nursing facility is not necessary if the patient can remain in his or her home with sufficient support services.

hiatal hernia

Heath teaching is most important -encourage or to avoid eating in late evening and avoid food associated with reflux -follow restricted diet and exercise regularly -reducing body weight is beneficial bc obesity increases intraabdomibal pressure -teach positioning: sleep with HOB elevated 6inches, remain upright for several hours after eating, avoid straining or excessive vigorous exercise, refrain from wearing tight clothing or constrictive around abdomen

A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? Check for fecal impaction. Help the client sit up. Insert a straight catheter. Loosen the client's clothing.

Help the client sit up. **The nurse's first action for a T6 spinal cord injury client suddenly developing facial flushing and severe headache is to help the client sit up. The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the client to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain.Checking for fecal impaction, inserting a straight catheter, and loosening the clothing are important but will not immediately reduce blood pressure.

A client has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? Aphasia and cautiousness Impulsiveness and smiling Inability to discriminate words Quick to anger and frustration

Impulsiveness and smiling **Impulsiveness and smiling are signs and symptoms indicative of a right hemisphere stroke.Aphasia, cautiousness, the inability to discriminate words, quick to anger, and frustration are signs and symptoms indicative of a left hemisphere stroke.

The admission assessment for a patient with acute gastric bleeding indicates blood pressure 82/40 mm Hg, pulse 124 beats/min, and respiratory rate 26 breaths/min. Which admission request does the nurse implement first? Type and crossmatch for 4 units of packed red blood cells. Infuse 0.9% normal saline solution at 200 mL/hr. Give pantoprazole (Protonix) 40 mg IV now and then daily. Insert a nasogastric tube and connect to low intermittent suction.

Infuse 0.9% normal saline solution at 200 mL/hr. **The nurse must first infuse 0.9% normal saline solution at 200 mL/hr for the patient with acute gastric bleeding and hypotension associated with volume loss. The most rapidly available volume expanders are crystalloids to treat hypovolemia.A type and crossmatch, administration of pantoprazole, and insertion of a nasogastric tube must all be done, but the nurse's immediate concern is correcting the patient's hypovolemia.

A patient has developed gastroenteritis while traveling outside the country. What is the likely cause of the patient's symptoms? Bacteria on the patient's hands Ingestion of parasites in the water Insufficient vaccinations Overcooked food

Ingestion of parasites in the water **The likely cause of gastroenteritis when a patient travels outside the country is ingestion of water that is infested with parasites.Bacteria on the patient's hands will not produce gastroenteritis unless food or water is contaminated with the bacteria. Insufficient vaccinations may cause other disease processes, but not gastroenteritis. Undercooked, not overcooked, food may produce gastroenteritis.

The nurse practitioner is performing an abdominal assessment on a newly admitted client. In which order should the nurse proceed with assessment technique? Auscultation, percussion, palpation, inspection Inspection, auscultation, percussion, palpation Palpation, percussion, inspection, auscultation Percussion, auscultation, palpation, inspection

Inspection, auscultation, percussion, palpation **The assessment technique proceeds as inspection, auscultation, percussion, palpation. This sequence is different from that used for other body systems. It is used so that palpation and percussion do not increase intestinal activity and bowel sounds. Nurse generalists may perform inspection, auscultation, and light palpation; percussion and deep palpation may be done by advanced practice nurses.Inspection must be the first assessment technique. Options beginning with auscultation, palpation, or percussion are incorrect.

The nurse is assessing a client who has come to the emergency department with acute abdominal pain. The client is very thin and the nurse observes visible peristaltic movements when inspecting the abdomen. What does the nurse suspect? Acute diarrhea Aortic aneurysm Intestinal obstruction Pancreatitis

Intestinal obstruction **The nurse would suspect an intestinal obstruction related to peristaltic movements. Peristaltic movements are rarely seen except in thin clients. This needs to be reported to the HCP.Acute diarrhea does not cause visible peristaltic movements. Aortic aneurysm may cause a bulging, pulsatile mass. Pancreatitis is characterized by severe pain.

A client with Parkinson disease (PD) is being discharged home with his wife. To ensure success with the management plan, which discharge action is most effective? Involving the client and his wife in developing a plan of care Setting up visitations by a home health nurse Telling his wife what the client needs Writing up a detailed plan of care according to standards

Involving the client and his wife in developing a plan of care **The discharge plan most effective when discharging a client home with his spouse is to involve both the client and his wife in developing the plan of care. Involving the client and spouse in drawing up a plan of care is the best way to ensure success with the management plan.Home health nurse visitations are generally helpful but may not be needed for this client. The management plan must be collaborative and include not only the spouse but the client to ensure buy-in. Evidence-based guidelines would be utilized.

What is the mechanism of action for the chemotherapeutic drug cetuximab (Erbitux)? It destroys the cancer's cell wall, which will kill the cell. It decreases blood flow to rapidly dividing cancer cells. It stimulates the body's immune system and stunts cancer growth. It blocks factors that promote cancer cell growth.

It blocks factors that promote cancer cell growth. **The mechanism of action for the chemotherapeutic drug cetuximab is that it blocks factors that promote cancer cell growth. Cetuximab, a monoclonal antibody, may be given for advanced disease. This drug works by binding to a protein (epidermal growth factor receptor) to slow cell growth.Cetuximab does not destroy the cancer's cell walls and does not stimulate the body's immune system or stunt cancer growth in that manner. Cetuximab also does not decrease blood flow to rapidly dividing cancer cells.

A pt with rectal bleeding preparing for colonoscopy tells the nurse, "I'm very afraid of having polyps and cancer" most appropriate response?

It's understandable that you are fearful. Tell me what frightens you most

Nurse caring for pt. experiences seizure. Which action should nurse perform first?

Keep pt in side-lying position

The nurse is reviewing orders for a patient with possible esophageal trauma after a car crash. Which request does the nurse implement first? Give total parenteral nutrition (TPN) through a central venous catheter. Administer cefazolin (Kefzol) 1 g intravenously. Obtain a computed tomography (CT) scan of the chest and abdomen. Keep the patient nothing by mouth (NPO) to prevent further leakage of esophageal contents.

Keep the patient nothing by mouth (NPO) to prevent further leakage of esophageal contents. **The nurse first implements the request to keep the patient NPO, because patients with possible esophageal tears need to be NPO until diagnostic testing is completed. Leakage of anything taken orally into the sterile mediastinum could occur. In addition, esophageal rest is maintained for about 10 days after esophageal trauma to allow time for mucosal healing.TPN is prescribed to provide calories and protein for wound healing. Although TPN is important, it is not a priority for the nurse to implement first. Antibiotics may be requested to prevent possible infection, but this is not the priority. A CT of the chest and abdomen will be needed but is not the nurse's initial action.

A client who had been hospitalized with pancreatitis is being discharged with home health services. The client is severely weakened after this illness. Which nursing intervention is the highest priority in conserving the client's strength? Limiting the client's activities to one floor of the home Instructing the client to take an as-needed (PRN) sleeping medication at night Arranging for the client to have a nutritional consult to assess the client's diet Asking the health care provider for a request for PRN nasal oxygen

Limiting the client's activities to one floor of the home **Limiting the client's activities to one floor of the home is the highest priority nursing intervention. This will prevent tiring the client unnecessarily with stair climbing.A PRN sleeping medication will not increase the client's strength level or conserve strength.Arranging for a nutritional consult or placing the client on PRN nasal oxygen will not necessarily result in an increase in the client's strength level or conserve strength. No information suggests that the client has any history of breathing difficulties.

A client with oral cancer is depressed over the diagnosis and tells the nurse of plans to have a radical neck dissection. What is the nurse's best reaction? Listen to the client and then explain that it is normal to feel depressed about the diagnosis. Explain the grieving process and listen to what the client has to say. Suggest that the client talk with friends and family and seek their support. Listen to the client's concerns and feelings and then suggest that the client join a community group of cancer survivors.

Listen to the client's concerns and feelings and then suggest that the client join a community group of cancer survivors. **The nurse's best reaction is to listen to the client and suggest a community support group of those with similar diagnoses who can offer support to the client.Telling the client that his or her feelings are normal or explaining the grieving process to the client are not helpful or therapeutic; the client needs more guidance. The nurse should not assume that the client's family and friends are an appropriate support group, because this may not be the case.

A client who has just undergone spinal surgery must be moved. How does the nurse plan to move this client? Getting the client up in a chair Keeping the client in the Trendelenburg position Lifting the client in unison with other health care personnel Log rolling the client

Log rolling the client **Log rolling the client who has undergone spinal surgery is the best way to keep the spine in alignment. The client who has undergone spinal surgery must remain straight and turned as a unit.The Trendelenburg position is not indicated for the client who has undergone spinal surgery, nor should the client be lifted or encouraged to get up in a chair.

A patient admitted with severe gastroenteritis has been started on an IV, but the patient continues having excessive diarrhea. Which medication does the nurse expect the primary health care provider to prescribe? Balsalazide (Colazal) Loperamide (Imodium) Mesalamine (Asacol) Milk of Magnesia (MOM)

Loperamide (Imodium) **The nurse expects the primary health care provider to prescribe loperamide for a patient with severe gastroenteritis who still has excessive diarrhea. If the primary health care provider determines that antiperistaltic agents are necessary, an initial dose of loperamide (Imodium) 4 mg can be administered orally, followed by 2 mg after each loose stool, up to 16 mg daily.Balsalazide is not the best choice for control of diarrhea in this scenario. Mesalamine is used for patients with ulcerative colitis for long-term therapy. MOM is a laxative.

A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)? Assessing for Grey Turner's sign Maintaining neutral head position Placing the client in the Trendelenburg position Suctioning the client frequently

Maintaining neutral head position **To prevent ICP in a client with traumatic brain injury who is being mechanically ventilated, the nurse needs to maintain the patent's head in a neutral position. Maintaining the head in neutral alignments prevents obstruction of blood flow and is an important component of ICP.Grey Turner's sign is a bluish gray discoloration in the flank region caused by retroperitoneal hemorrhage. The head of the bed needs to be at 30 degrees. The Trendelenburg position will cause the client's ICP to increase. Although some suctioning is necessary, frequent suctioning would be avoided because it increases ICP.

What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? The client must not consume alcohol. Avoid sharing the bathroom with the client. Members of the household must not share toothbrushes. Drink only bottled water and avoid ice.

Members of the household must not share toothbrushes. **The nurse teaches the family of a client with Hepatitis C that toothbrushes, razors, towels, and any other items may spread blood and body fluids and must not be shared.The client should not consume alcohol, but abstention will not prevent spread of the virus. The client may share a bathroom if he or she is continent. To prevent hepatitis A when traveling to foreign countries, bottled water should be consumed and ice made from tap water needs to be avoided.

When providing community education, the nurse emphasizes that which group needs to receive immunization for hepatitis B? Clients who work with shellfish Men who engage in sex with men Clients traveling to a third-world country Clients with elevations of aspartate aminotransferase and alanine aminotransferase

Men who engage in sex with men **Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity.Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A. Hepatitis B is not of concern, unless the client is exposed to blood and body fluids during travel. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B.

Which of these assigned patients does the nurse assess first after receiving the change-of-shift report? Young adult admitted the previous day with abdominal pain who is scheduled for a computed tomography (CT) scan in 30 minutes Adult with gastroesophageal reflux disease (GERD) who is describing epigastric pain at a level of 6 (0-to-10 pain scale) Middle-aged adult with an esophagectomy done 2 days earlier who has bright-red drainage from the nasogastric (NG) tube Older adult admitted with an ileus who has absent bowel sounds and a prescription for metoclopramide (Reglan) on an as-needed (PRN) basis

Middle-aged adult with an esophagectomy done 2 days earlier who has bright-red drainage from the nasogastric (NG) tube **The nurse must first assess the postoperative esophagectomy patient with bright red NG tube drainage. The presence of blood in NG drainage is an unexpected finding 2 days after esophagectomy and requires immediate investigation.The young adult scheduled for a CT scan, the adult with GERD, and the older adult with an ileus are all stable and do not require the nurse's immediate attention.

The nurse reviews a medication history for a patient newly diagnosed with peptic ulcer disease (PUD) who has a history of using ibuprofen (Advil) frequently for chronic knee pain. The nurse anticipates that the primary health care provider will request which medication for this patient? Bismuth subsalicylate (Pepto-Bismol) Magnesium hydroxide (Maalox) Metronidazole (Flagyl) Misoprostol (Cytotec)

Misoprostol (Cytotec) **The nurse expects that the primary health care provider will request that Misoprostol be given to the patient. Misoprostol is a prostaglandin analogue that protects against nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers.Bismuth subsalicylate is an antidiarrheal drug that contains salicylates, which can cause bleeding and would be avoided in patients who have PUD. Magnesium hydroxide is an antacid that may be used to neutralize stomach secretions but is not used specifically to help prevent NSAID-induced ulcers. Metronidazole is an antimicrobial agent used to treat Helicobacter pylori infection.

After abdominal surgery

Monitor pt's LOC, vital signs, respiratory status, and I&O at least hourly immediately after abdominal surgery Maintain or on semi-Fowler's position to promote drainage of peritoneal contents into the lower region of abdominal cavity>>also helps increase lung expansion

After EGD

Monitor vitals, heart rhythm, and oxygen saturation frequently until return to baseline Assess pt'a ability to swallow saliva Pt gag reflex may initially be absent after bc of numbing the throat with spray before procedure After procedure, DO NOT let pt have food or liquids until gag reflex is intact!!!!

A client has Parkinson's disease (PD). Which nursing intervention best protects the client from injury? Discouraging the client from activity Encouraging the client to watch the feet when walking Monitoring the client's sleep patterns Suggesting that the client obtain assistance in performing activities of daily living (ADLs)

Monitoring the client's sleep patterns **The nursing intervention that best protects the PD client from injury is to monitor the client's sleep patterns. Clients with PD tend to not sleep well at night because of drug therapy and the disease itself. Some clients nap for short periods during the day and may not be aware that they have done so. This sleep misperception could put the client at risk for injury (e.g., falling asleep while driving).Active and passive range-of-motion exercises, muscle stretching, and activity are important to keep the client with PD mobile and flexible. The client with PD needs to avoid watching his or her feet when walking to prevent falls and would be encouraged to participate as much as possible in self-management, including ADLs. Occupational and physical therapists can provide training in ADLs and the use of adaptive devices, as needed, to facilitate independence.

ulcerative colitis

More common among Askenazki Jewish individuals and among whites Important to monitor stools for blood loss>> may be bright red or black and tarry Monitor H&H and electrolyte values and assess vitals Prolonged slow bleeding can lead to anemia Observe for fever, tachycardia, and signs of fluid volume depletion Changes in mental status may occur, especially among older adults (maybe first indication of dehydration or anemia) If symptoms of GI bleeding begin, respond by notifying the health care provider immediately

The nurse is caring for a postoperative client who had an extensive oral and neck surgery. The client is now describing throbbing pain in the head. The nurse anticipates that the health care provider will request which medication for this client? Diphenhydramine (Benadryl) Midazolam (Versed) intravenously Morphine sulfate intravenously Oxycodone plus acetaminophen (Percocet, Tylox)

Morphine sulfate intravenously **Intravenous morphine sulfate is indicated for severe pain and is given initially. Clients undergoing surgery for oral cancer describe their pain as throbbing or pounding.Diphenhydramine is an anti-inflammatory agent and is not indicated for treatment of pain. Midazolam is used for conscious sedation and is not indicated for pain. Oxycodone/acetaminophen is given for systematic relief of moderate pain. This client may also have trouble swallowing.

A client is admitted with a stroke (brain attack). Which tool does the nurse use to facilitate a focused neurologic assessment of the client? Glasgow Coma Score (GCS) Intracranial pressure monitor Mini-Mental State Examination (MMSE; mini-mental status examination) National Institutes of Health Stroke Scale (NIHSS)

National Institutes of Health Stroke Scale (NIHSS) **The nurse uses the NIHSS tool to perform a focused neurologic assessment. Health care providers and nurses at designated stroke centers use a specialized stroke scale such as the NIHSS to assess clients.The Glasgow Coma Score (GCS) provides a non-specific indication of level of consciousness. An intracranial pressure monitor would be requested by the health care specialist if signs and symptoms indicated increased intracranial pressure. The MMSE is used primarily to differentiate among dementia, psychosis, and affective disorders.

The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the primary health care provider will prescribe which medication? Dopamine hydrochloride (Inotropin) Methylprednisolone (Solu-Medrol) Nifedipine (Procardia) Ziconotide (Prialt)

Nifedipine (Procardia) **The nurse anticipates that the primary health care provider will prescribe nifedipine for a spinal cord injury client who has an elevated blood pressure and severe headache. This client is experiencing autonomic dysreflexia (AD). Nifedipine (Procardia), a calcium channel blocker, can be administered to treat AD and lower blood pressure. If AD is not treated, a hemorrhagic stroke can occur.Dopamine hydrochloride (Inotropin) is an inotropic agent used to treat severe hypotension. Methylprednisolone (Solu-Medrol) is a glucocorticoid and is not indicated because it may further increase blood pressure. Ziconotide (Prialt) is an N-type calcium channel blocker on those nerves that usually transmit pain signals to the brain.

When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? Vitamin K-containing products Potassium-sparing diuretics Nonabsorbable antibiotics Nonsteroidal anti-inflammatory drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) **The nurse must emphasize avoidance of NSAIDs when providing discharge teaching to a client with cirrhosis. The client with cirrhosis has an increased risk of hemorrhage. Clients who have cirrhosis must not take NSAIDs because they may predispose to bleeding.Products containing vitamin K can decrease bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics are used to reduce ascites. Nonabsorbable antibiotics are used to decrease ammonia levels.

Gastroenteritis pts

Note any abdominal distention and listen for hyperactive bowel sounds. Depending on amount of fluids and electrolytes lost through diarrhea and vomiting, pts May have varying degrees of dehydration manifested by: Poor skin turgor Fever (most common in elderly) Dry mucous membranes Orthostatic BP changes (can result in a fall) Hypotension Oliguria (decreased or absent urinary output) Monitor mental status changes (ex. acute confusion that results from hypoxia)

The nurse is assessing a client who comes to the emergency department with acute abdominal pain. The nurse notes a bulging, pulsating mass when inspecting the abdomen. Which action by the nurse is correct? Auscultate the abdomen to determine the presence of bowel sounds. Notify the provider about this finding immediately. Palpate the client's abdomen to determine the outlines of the mass. Question the client about recent stool habits.

Notify the provider about this finding immediately. **The nurse needs to immediately notify the health care provider because a bulging, pulsating mass may indicate an abdominal aortic aneurysm requiring emergency actions.Palpating the abdomen or even touching the abdomen with a stethoscope may cause this to rupture, which would be a life-threatening emergency. Because this is a potential life-threatening situation, questioning the client about stool habits is not appropriate.

A client with a history of esophageal varices has just been admitted to the emergency department after vomiting a large quantity of blood. Which action does the nurse take first? Obtain the charts from the previous admission. Listen for bowel sounds in all quadrants. Obtain pulse and blood pressure. Ask about abdominal pain.

Obtain pulse and blood pressure. **When caring for a newly admitted client with esophageal varices and vomiting of blood, the nurse would first assess vital signs to detect hypovolemic shock caused by hemorrhage. Assessment for adequate perfusion is the highest priority at this time.Obtaining charts from the previous admission, assessing bowel sounds, and pain assessment can be delayed until the client has stabilized.

A client with acute cholecystitis is admitted to the medical-surgical unit. Which nursing activity associated with the client's care will be appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Assessing dietary risk factors for cholecystitis Checking for bowel sounds and distention Determining precipitating factors for abdominal pain Obtaining the admission weight, height, and vital signs

Obtaining the admission weight, height, and vital signs **Obtaining admission height, weight, and vital signs is included in the education for UAPs and usually is included in the job description for these staff members.Assessing for risk factors, checking bowel sounds, and determining precipitating factors for abdominal pain require assessment skills. Assessment skills require broader education and are within the scope of practice of licensed nursing staff and not UAPs.

Adults at risk for AD

Older adults and those who experience traumatic brain injury including war veterans

GERD medications

PPIs, antacids, histamine 2 receptor antagonists

Which is a correct statement differentiating Crohn's disease (CD) from ulcerative colitis (UC)? Patients with CD experience about 20 loose, bloody stools daily. Patients with UC may experience hemorrhage. The peak incidence of UC is between 15 and 40 years of age. Very few complications are associated with CD.

Patients with UC may experience hemorrhage. **A correct statement about differentiating Crohn's disease (CD) from ulcerative colitis (UC) is that patients with UC may experience hemorrhage. Patients with CD can have 5-6 soft, loose stools per day, but they are nonbloody.Five to six stools daily is common with CD, not 20 loose, bloody stools. The peak incidences of UC are between 30 and 40 years and again at 55 to 65 years of age, and not just 15 to 40 years of age. Fistulas commonly occur as a complication of CD.

Appendicitis

Perforation more common in older adults>> increasing mortality rate Symptoms of pain and tenderness may not be as pronounced in this age group For pt with suspected appendicitis, administer IV fluids as prescribed to maintain fluid and electrolyte balance and replace fluid volume If tolerated, advise pt to maintain semi-Fowler's so abdominal drainage to lower abdomen Once dx is confirmed and surgery is scheduled, administer opioid analgesics and antibiotics prescribed Pt with appendicitis should NOT receive laxatives or enemas (can cause perforation of the appendix Do not apply heat to abdomen bc may increase circulation to the appendix and result in increased inflammation and perforation!!!

When caring for a client with Laennec's cirrhosis, which of these does the nurse expect to find on assessment? Select all that apply. Prolonged partial thromboplastin time Icterus of skin Swollen abdomen Elevated magnesium Currant jelly stool Elevated amylase level

Prolonged partial thromboplastin time Icterus of skin Swollen abdomen **Clients with Laennec's cirrhosis have damaged clotting factors, so prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The client with cirrhosis may develop ascites, or fluid in the abdominal cavity.Elevated magnesium is not related to cirrhosis. Amylase is typically elevated in pancreatitis. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. The client with cirrhosis may develop hypocalcemia and/or hypokalemia. It is also consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase.

Which practice does the nurse include when teaching a client about proper oral care? Perform self-examination of the mouth every week, and report any unusual findings. Brush the teeth daily and floss as needed. Use drugs that reduce the flow of saliva unless lesions are present. Regularly rinse mouth with alcohol-based agent.

Perform self-examination of the mouth every week, and report any unusual findings. **The nurse needs to teach the client that proper oral care involves self-examination of the mouth every week and reporting any unusual findings to the Health Care Provider.Clients need to brush teeth and floss every day. Clients would be instructed to avoid, if possible, drugs that can cause inflammation of the mouth or that can reduce the flow of saliva, and to avoid contact with agents that may cause inflammation of the mouth (such as alcohol based mouthwashes).

Nurse is assessing manifestation of Parkinson's..expected findings?

Pin-rolling tremor of the fingers Shuffling gait Drooling Lack of facial expression

The nurse is reinforcing the instructions on swallowing provided by the speech-language pathologist to a patient diagnosed with esophageal cancer. Which of the following instructions should be included in the teaching? Place food at the back of the mouth as you eat. Do not be overly concerned with tongue or lip movements. Before swallowing, tilt the head back to straighten the esophagus. Do not attempt to reach food particles that are on the lips or around the mouth.

Place food at the back of the mouth as you eat. **The nurse should instruct the patient to place food at the back of the mouth when eating. This will help the patient avoid aspiration of food. Food aspiration can cause airway obstruction, pneumonia, or both, especially in older adults.Both tongue movements and sealing of the lips should be monitored in this patient. The patient's head should be tilted forward in the chin-tuck position and not back. The patient needs to be able to reach food particles on her or his lips and around the mouth with the tongue.

A nurse is caring for a pt who has AD an dfalls frequently. Which actions should the nurse take first to keep the client safe?

Place the client in a room near the nurse's station

The RN is caring for a client with end-stage liver disease who has ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)? Assessing skin integrity and abdominal distention Drawing blood from a central venous line for electrolyte studies Evaluating laboratory study results for the presence of hypokalemia Placing the client in a semi-Fowler's position

Placing the client in a semi-Fowler's position **The nurse delegates the client who needs to be placed in a semi-Fowler's position to the UAP. Positioning the client in this position is included within UAP education and scope of practice, although the RN will need to supervise the UAP in providing care and will evaluate the effect of the semi-Fowler's position on the client's comfort and breathing.Assessment of skin integrity and abdominal distention, obtaining blood from a central line, and evaluation of laboratory results must be done by the RN.

Nurse teaching client about nutrition and diverticulosis. Which food will the nurse tell the pt to avoid? Popcorn Oatmeal Bran Lettuce

Popcorn

The nurse is caring for a client with esophageal cancer who has received photodynamic therapy using porfimer sodium (Photofrin). What instructions does the nurse include in teaching the client about porfimer sodium? (Select all that apply.) A. Avoid sunlight for 2 weeks. Incorrect B. Cover all exposed body areas. Correct C. Follow a clear liquid diet for 3 to 5 days after the procedure. Correct D. Monitor for hypertension. E. Tissue particles may be found in the sputum. Correct

Porfimer sodium causes photosensitivity, and sunglasses and protective clothing covering all exposed body areas are essential. A clear liquid diet should be followed for 3 to 5 days after the procedure and then should be advanced to full liquids as tolerated. The client should be warned that tissue particles may be released from the tumor site and may be present in the sputum. Sunlight should be avoided for 1 to 3 months. Side effects are rare and may include nausea, fever, and constipation. Hypertension is not a side effect of porfimer sodium.

A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? Auscultating bowel sounds every 2 hours Beginning a bladder retraining program Monitoring nutritional status Positioning the client to maximize ventilation potential

Positioning the client to maximize ventilation potential **The priority nursing intervention for a client with a spinal cord injury at the seventh cervical vertebra is to position the client to maximize ventilation potential. Airway management is the priority for the client with a spinal cord injury. The client with a cervical spinal cord injury is at high risk for respiratory compromise because the cervical spinal nerves (C3-C5) innervate the phrenic nerve, controlling the diaphragm.Auscultating bowel sounds is important since paralytic ileus can develop from a SCI; however this is not the priority intervention. Beginning bladder retraining and monitoring the nutritional status will be important for adequate healing and progress to rehabilitation. However, these interventions can be delayed until major life threats are addressed.

A client presents to the Emergency Department from an assisted living facility after a ground level fall with a head strike. The client has a Glasgow Coma Score (GCS) of 12, which is decreased for this client, and has projectile vomiting. What is the priority intervention for this client? Calling the Stroke Team Establishing an IV Positioning the client to prevent aspiration Preparing for thrombolytic administration

Positioning the client to prevent aspiration **Positioning the client while maintaining cervical spine immobilization to prevent aspiration is the nurse's priority intervention. Maintaining a patent airway is essential especially since this client is vomiting.Calling the Stroke Team would not be necessary. Establishing an IV is important for this client but it is not the first priority. If this client was having a stroke, thrombolytics would be contraindicated because of the fall with head strike.

The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? Documents the length and time of the seizure. Forces a tongue blade in the mouth. Positions the client on the side. Restrains the client.

Positions the client on the side. **When a newly admitted client with a history of seizures begins to seize, the nurse must turn the client on his/her side. Turning the client on the side during a generalized tonic-clonic or complex partial seizure is indicated because he or she may lose consciousness resulting in potential loss of a patent airway.Documenting the length and time of seizures is important, but not the priority intervention. Both forcing a tongue blade in the mouth and restraining the client can cause injury.

A client with early-stage Alzheimer's disease is admitted to the surgical unit for a biopsy. Which client problem is the priority? Potential for injury related to chronic confusion and physical deficits Risk for reduced mobility related to progression of disability Potential for skin breakdown related to immobility and/or impaired nutritional status Lack of social contact related to personality and behavior changes

Potential for injury related to chronic confusion and physical deficits **The priority client problem related to a client admitted to the surgical unit for biopsy is the potential for injury due to chronic confusion and physical deficits. The most important intervention for interdisciplinary care is safety. Chronic confusion and physical deficits place the client with Alzheimer's disease at high risk for injury.Reduced mobility, skin breakdown, and lack of social contact, although potential problems in this population, are more frequently observed in the long-term setting and not the top priority.

Which problem for a client with cirrhosis takes priority? Insufficient knowledge related to the prognosis of the disease process Discomfort related to the progression of the disease process Potential for injury related to hemorrhage Inadequate nutrition related to an inability to tolerate usual dietary intake

Potential for injury related to hemorrhage **Potential for injury related to hemorrhage is the priority client problem because this complication could be life threatening.Insufficient knowledge of the prognosis of the disease process, discomfort, and inadequate nutrition are not priorities because these issues are not immediately life threatening.

A patient with an intestinal obstruction has pain that changes from a "colicky" intermittent type to constant discomfort. What does the nurse do first? Administers medication for pain Changes the nasogastric suction level from "intermittent" to "constant" Positions the patient in high-Fowler's position Prepares the patient for emergency surgery

Prepares the patient for emergency surgery **The first action the nurse takes for a patient with intestinal obstruction whose pain changes from "colicky" intermittent type to constant discomfort is to prepare the patient for emergency surgery. The change in pain type could be indicative of perforation or peritonitis and will require immediate surgical intervention.Pain medication may mask the patient's symptoms but will not address the root cause. A change in the nasogastric suction rate will not resolve the cause of the patient's pain and could be particularly ineffective if a nonvented tube is in use. A high-Fowler's position will have no effect on an intestinal perforation or peritonitis, which this patient is likely experiencing.

Which set of assessment findings indicates to the nurse that a client may have acute pancreatitis? Absence of jaundice, pain of gradual onset Absence of jaundice, pain in right abdominal quadrant Presence of jaundice, pain worsening when sitting up Presence of jaundice, pain worsening when lying supine

Presence of jaundice, pain worsening when lying supine **Pain that worsens when lying supine and the presence of jaundice are the only assessment findings indicative of acute pancreatitis.Pain associated with acute pancreatitis usually has an abrupt onset, is located in the mid-epigastric or upper left quadrant, and lessens with sitting up. Also, jaundice is present.

A client has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the client about this therapy, the nurse advises the client not to mix enzyme preparations with foods containing which element? Carbohydrates High fat High fiber Protein

Protein **The nurse tells the client not to mix enzyme preparations with foods containing protein because the enzymes will dissolve the food into a watery substance. Pancreatic-enzyme replacement therapy (PERT) is the standard of care to prevent malnutrition, malabsorption, and excessive weight loss (Chart 59-3). Pancrelipase is usually prescribed in capsule or tablet form and contains varying amounts of amylase, lipase, and protease.No evidence suggests that enzyme preparations should not be mixed with carbohydrates, food with high fat content, and food with high fiber content.

After a colonoscopy, a client reports severe abdominal pain. The nurse obtains these data: temperature 100.2°F (37.9°C), pulse 122 beats/min, blood pressure 100/45 mm Hg, respirations 44 breaths/min, and O2 saturation 89%. Which request from the health care provider does the nurse implement first? Give cefazolin (Ancef) 500 mg IV. Infuse normal saline at 200 mL/hr. Give morphine sulfate 2 mg IV. Provide oxygen at 6 L/min per nasal cannula.

Provide oxygen at 6 L/min per nasal cannula. **The first request the nurse complies with is to place the client on oxygen. This is the most immediate concern because it involves the client's respiratory status. Based on the data given, the client may be experiencing complications of colonoscopy such as bleeding or perforation.An antibiotic request is important but is not the first priority. Fluid supplementation is important, but the client's oxygen saturation level places the client's respiratory status as the priority. The client's need for analgesia should be delayed until respiratory status is addressed. Morphine depresses respiratory status and therefore might not be the right choice for this client.

The nurse is assessing a client who has recurrent attacks of pancreatitis and is concerned about possible alcohol abuse as an underlying cause of these attacks. To elicit this information, what will the nurse do initially? Ask the client about binge drinking. Question the client whether drinking increases on weekends. Provide privacy and use the CAGE questionnaire (Cut down, Annoyed by criticism, Guilt about drinking, and Eye-opener drinks) Ask the client's spouse to describe the client's drinking

Provide privacy and use the CAGE questionnaire (Cut down, Annoyed by criticism, Guilt about drinking, and Eye-opener drinks) **Initially, the nurse needs to provide privacy and establish a trusting relationship to help obtain information from the client about alcohol use. The CAGE questionnaire is useful as well.Topics such as binge drinking or tending to drink more on holidays or weekends may put the client on the defensive rather than provide the desired information. It has not yet been determined whether the client engages in binge drinking. Asking the client client's spouse will decrease nurse-client trust.

A patient is scheduled to be discharged home after a gastrectomy and will need to perform daily dressing changes on the surgical wound. What is the nurse's highest priority intervention? Providing both oral and written instructions to the patient and his spouse on changing the dressing and on symptoms of infection that must be reported to the provider Asking the primary health care provider for a referral for home health services to assist with dressing changes Asking the spouse if any other family members are in the medical profession and could help change the dressing Offer literature on dressing changes and schedule follow-up phone calls with the patient and spouse to talk them through dressing changes when at home.

Providing both oral and written instructions to the patient and his spouse on changing the dressing and on symptoms of infection that must be reported to the provider **The nurse's highest priority intervention for a post-op gastrectomy patient about to be discharged with daily dressing changes is to provide the patient and spouse with both oral and written instructions on what to report to the provider, and how to perform the dressing changes. This will reinforce important points needed about what information to report to the provider as well as properly caring for the wound.Obtaining a referral and recruiting other family members prevents the patient and spouse from taking responsibility for the patient's care. Follow-up phone calls and written literature won't provide assurance that wound care is being done properly or that teaching was effective.

A client arrives at the emergency department with acute abdominal pain in the left lower quadrant. In which order does the nurse examine and assess the client's abdomen? (left lower quadrant (LLQ), left upper quadrant (LUQ), right lower quadrant (RLQ), and right upper quadrant (RUQ))? LLQ, RLQ, LUQ, RUQ LUQ, LLQ, RUQ, RLQ RLQ, LLQ, RUQ, LUQ RUQ, LUQ, RLQ, LLQ

RUQ, LUQ, RLQ, LLQ **The LLQ would be the last area assessed for this client. Abdominal examination usually begins at the client's right side and proceeds in a systematic fashion: RUQ, LUQ, RLQ, LLQ. However, if the client is experiencing pain in a specific quadrant, that area should be assessed last in the examination sequence. This action prevents the client from tensing abdominal muscles because of the pain, which would make the examination difficult.The options that do not assess the quadrant where the pain presents last are incorrect.

A 67-year-old male patient, with no surgical history, reports pain in the inguinal area that occurs when he coughs. A bulge that can be pushed back into the abdomen is found in his inguinal area. What type of hernia does he have? Femoral Reducible Strangulated Incarcerated

Reducible **The hernia is reducible because its contents can be pushed back into the abdominal cavity.Femoral hernias tend to occur more frequently in obese and pregnant women. A hernia is considered to be strangulated when the blood supply to the herniated segment of the bowel is cut off. An incarcerated or irreducible hernia cannot be reduced or placed back into the abdominal cavity. Any hernia that is not reducible requires immediate surgical evaluation.

The nurse is instructing a client on measures to maintain effective oral health. Which measures does the nurse include in the client's teaching plan? Select all that apply. Regular dental checkups Use of mouthwashes containing alcohol Ensuring that dentures are slightly loose-fitting Managing stress as much as possible Eating a balanced diet

Regular dental checkups Managing stress as much as possible Eating a balanced diet **Regular dental checkups are important so potential problems can be prevented or attended to promptly. Stress suppresses the immune system, which can increase the client's risk for infections such as Candida albicans. Eating a balanced diet can reduce the risk for dental caries and infections such as C. albicans or stomatitis.Mouthwashes that contain alcohol may cause inflammation and should be avoided. Dentures must be in good repair and need to fit properly. (Chart 53-1)

Which nursing action is best for the charge nurse to delegate to an experienced LPN/LVN? Retape the nasogastric tube for a patient who has had a subtotal gastrectomy and vagotomy. Reinforce the teaching previously done by the RN about avoiding alcohol and caffeine for a patient with chronic gastritis. Document instructions for a patient with chronic gastritis about how to use "triple therapy." Assess the gag reflex for a patient who has arrived from the post anesthesia care unit after a laparoscopic gastrectomy.

Reinforce the teaching previously done by the RN about avoiding alcohol and caffeine for a patient with chronic gastritis. **The best nursing action to delegate to the experienced LPN/LVN is to reinforce patient teaching previously done by the RN to a patient with chronic gastritis about avoiding alcohol and caffeine. Reinforcement of teaching done by the RN is within the scope of practice for an LPN/LVN.Retaping the nasogastric tube for a patient who has had a subtotal gastrectomy and vagotomy is a complex task that would be done by the RN. Documenting instructions about how to use triple therapy are nursing functions that would be done by the RN. Assessment of a patient's gag reflex is also an RN nursing function.

A patient with an inoperable esophageal tumor is receiving swallowing therapy. Which task does the home health nurse delegate to an experienced home health aide? Teaching family members how to determine whether the patient is obtaining adequate nutrition Assessing lung sounds for possible aspiration when the patient is swallowing clear liquids Reminding the patient to use the chin-tuck technique each time the patient attempts to swallow Instructing family members about symptoms that may indicate a need to call the primary health care provider

Reminding the patient to use the chin-tuck technique each time the patient attempts to swallow **The role of a home health aide when caring for a patient with swallowing difficulty includes reinforcement of previously taught swallowing techniques.Teaching and providing instructions to family members are not within the scope of practice of a home health aide and would be done by the home health nurse. Likewise, assessing lung sounds is part of the nursing process and would be done by the nurse.

AD pt. Safety precautions

Remove floor rugs Provide increased lighting in stairwells Install handrails in the bathroom Place the mattress on the floor

A health care worker believes that he may have been exposed to hepatitis A. Which intervention is the highest priority to prevent him from developing the disease? Requesting vaccination for hepatitis A Using a needleless system in daily work Getting the three-part hepatitis B vaccine Requesting an injection of immunoglobulin

Requesting an injection of immunoglobulin **The highest priority intervention to help prevent the health care worker from developing Hepatitis A after exposure to the disease is requesting the administration of immunoglobulin, antibodies to hepatitis A.The vaccine for hepatitis A will take several weeks to stimulate the development of antibodies. Passive immunity in the form of immunoglobulin is needed. Implementing a needleless system and getting the three-part vaccine may prevent the development of hepatitis B, not hepatitis A.

How does the home care nurse best modify the client's home environment to manage side effects of lactulose (Evalose)? Provides small frequent meals for the client Suggests taking daily potassium supplements Elevates the head of the bed in high-Fowler's position Requests a bedside commode for the client

Requests a bedside commode for the client **The home care nurse best modifies the client's home environment to manage side effects of lactulose by making a bedside commode available to the client. Lactulose therapy increases the frequency of stools. A bedside commode is especially necessary if the client has difficulty reaching the toilet.Small frequent meals and elevating the head of the bed will not have any effect on the side effects of lactulose. Although lactulose produces excessive stools and could potentially result in loss of potassium, it is inappropriate for the nurse to suggest that the client take potassium supplements.

Post-op for esophagectomy

Respiratory care is highest priority!! Intubation needed for at least first 16-24hrs Pulmonary complications: atelectasis and pneumonia Once pt is extubated: begin deep breathing, turning, coughing every 1-2 hrs Assess or for decreased breath sounds and SOB every 1-2 hrs Provide incisional support and adequate analgesia for effective coughing

The nurse is providing instructions to a client who has a history of stomatitis. Which instructions does the nurse include in the client's teaching plan? Encourage the client to eat acidic foods to decrease bacteria. Mouth care should be performed twice daily. Rinse the mouth with warm saline or sodium bicarbonate. Use a medium-bristled toothbrush for oral care.

Rinse the mouth with warm saline or sodium bicarbonate. **Rinsing the mouth with warm saline or sodium bicarbonate or a combination of the two decreases inflammation and pain.Acidic foods increase inflammation and should be avoided. Mouth care should be done after each meal and as often as needed. If stomatitis is not controlled, mouth care may have to be done every 2 hours or more frequently. A soft toothbrush not medium-bristled one would be used for oral care.

Crohn's disease

Risk factors: tobacco use, Jewish ethnicity, and living in urban areas, genetics, environmental More common in Ashkenazi Jewish than any other group Be especially alert for s&s of peritonitis, small bowel obstruction, and nutritional and fluid imbalances

A client with dementia and Alzheimer's disease is discharged to home. The client's daughter says, "He wanders so much, I am afraid he'll slip away from me." What resource does the nurse suggest? Alzheimer's Wandering Association Lost Family Members Tracking Association National Alzheimer's Group Safe Return Program

Safe Return Program **The discharge nurse suggests the Safe Return Program to the daughter of a client who wanders at home. The Safe Return Program, a national, government-funded program of the Alzheimer's Association assists in the identification and safe, timely return of those with dementia who wander off and become lost.The Alzheimer's Wandering Association, National Alzheimer's Group, and Lost Family Members Tracking Association do not exist.

Question 4 of 14 Which food does the nurse instruct a client undergoing chemotherapy for oral cancer with secondary stomatitis to avoid? Broiled fish Ice cream Salted pretzels Scrambled eggs

Salted pretzels **Salty foods like pretzels can further irritate ulcers in the client's mouth, causing pain.Cool or cold foods and foods high in protein, such as fish, eggs, and ice cream, may be included in the diet of the client with stomatitis.

A patient has been discharged home after surgery for gastric cancer, and a case manager will follow up with the patient. To ensure a smooth transition from the hospital to the home setting, which information provided by the hospital nurse to the case manager is given the highest priority? Schedule of the patient's follow-up examinations and diagnostic testing Information on family members' progress in learning how to perform dressing changes Copy of the diet plan prepared for the patient by the hospital dietitian Detailed account of what occurred during the patient's surgical procedure

Schedule of the patient's follow-up examinations and diagnostic testing **The highest priority information the hospital nurse would give to the home case manager is a schedule of the patient's follow-up exams and diagnostic testing. Because recurrence of gastric cancer is common, it is important for the patient to have follow-up examinations and x-rays so that a recurrence can be detected quickly.It may take family members a long time to become proficient at tasks such as dressing changes. Although the case manager must be aware of the diet, family members will likely be preparing the patient's daily diet, and they would be provided with this information. It is not necessary for the case manager to have details of the patient's surgical procedure unless a significant event occurred during the procedure.

A patient returns to the unit after having an exploratory abdominal laparotomy. How does the nurse position this patient after the patient is situated in bed? High Fowler's Lateral Sims' (side-lying) Semi-Fowler's Supine

Semi-Fowler's **The nurse places the postoperative abdominal laparotomy patient in the semi-Fowler's position in bed. The patient is maintained in this position to facilitate the drainage of peritoneal contents into the lower region of the abdominal cavity after an abdominal laparotomy. This position also helps increase lung expansion.High-Fowler's position would be too high for the patient postoperatively. It would place strain on the abdominal incision(s), and, if the patient was still drowsy from anesthesia, this position would not enhance the patient's ability to rest. Sims' position does not promote drainage to the lower abdomen. The supine position does not facilitate drainage to the abdomen or increased lung expansion. The patient would be more likely to develop complications (wound drainage stasis and atelectasis) in the supine position.

In assessing a client with back pain, the nurse uses a paper clip bilaterally on each limb. What is the nurse assessing? Gait Mobility Sensation Strength

Sensation **The nurse uses a paper clip bilaterally on each limb of the client with back pain to assess sensation. Both extremities may be checked for sensation by using a paper clip and a cotton ball for comparison of light and deep touch. The client may feel sensation in both limbs but may experience a stronger sensation on the unaffected side.Gait is assessed by having the client walk. Mobility is assessed by determining the client's ability to move on his/her own, turn or perform ADLs. Strength is measured by having the client perform bilateral grips.

The nurse is attempting to position a client having an acute attack of pancreatitis in the most comfortable position possible. In which position does the nurse place this client? Supine, with a pillow supporting the abdomen Up in a chair between frequent periods of ambulation High-Fowler's position, with pillows used as needed Side-lying position, with knees drawn up to the chest

Side-lying position, with knees drawn up to the chest **The side-lying position with the knees drawn up has been found to be the most comfortable possible position to relieve abdominal discomfort related to acute pancreatitis.No evidence suggests that supine position, sitting up in a chair, or high-Fowler's position has any effect on abdominal discomfort related to acute pancreatitis.

Report any of these problems r/t colostomy to the surgeon

Signs of ischemia and necrosis (dark red, purplish, and black color, dry) Unusual bleeding Mucocutaneous separation (breakdown of the suture line securing the stoma to the abdominal wall Also assess the condition of the peristomal skin (skin around atoms) and check pouch system for proper fit and signs of leakage>>skin should be intact, smooth, and without redness or excoriation

A client receiving propranolol (Inderal) as a preventative for migraine headaches is experiencing side effects after taking the drug. Which side effect is of greatest concern to the nurse? Dry mouth Slow heart rate Tingling feelings Warm sensation

Slow heart rate **The side effect that is the greatest concern for a client taking propranolol for migraine headaches is a slow heart rate. Beta blockers such as propranolol (Inderal) may be prescribed as a preventive medication for migraines. Propranolol causes blood vessels to relax and improves blood flow although the exact mechanism of action in migraines is unclear. The client would be taught how to monitor his or her heart rate and appropriately report any deviations to the primary care provider.Dry mouth is typically associated with tricyclic antidepressants such as nortriptyline. Skin flushing, tingling feelings, and a warm sensation are common side effects with triptan medications and are not indications to avoid using this group of drugs. Nortriptyline may be used as a preventive medication. Triptans are utilized as abortive medications after a migraine begins.

Which factors place a client at risk for gastrointestinal (GI) problems? Select all that apply. Eating a high-fiber diet Smoking a half-pack of cigarettes per day Socioeconomic status Some herbal preparations Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

Smoking a half-pack of cigarettes per day Socioeconomic status Some herbal preparations Use of nonsteroidal anti-inflammatory drugs (NSAIDs) **Smoking or any tobacco use places a client in a higher-risk category for GI problems. Socioeconomic status can also influence the risk for GI problems; clients may not be able to afford to seek care or treatment and may put off seeking help. Some herbal preparations contribute to GI problems, such as Ayurvedic herbs, which can affect appetite, absorption, and elimination. NSAIDs can predispose clients to peptic ulcer disease or GI bleeding.High-fiber diets are generally believed to be healthy for most clients.

The nurse is caring for a client who has been diagnosed with esophageal cancer. Client appears anxious and asks the nurse, "Does this mean I'm going to die?" Which nursing response are appropriate?

Sounds like death frightens you Let me sit with you for awhile and we can discuss how you're feeling about this

An 80-year-old patient with a 2-day history of myalgia, nausea, vomiting, and diarrhea is admitted to the medical-surgical unit with a diagnosis of gastroenteritis. Which primary health care provider request does the nurse implement first? Administer acetaminophen (Tylenol) 650 mg rectally. Draw blood for a complete blood count and serum electrolytes. Obtain a stool specimen for culture and sensitivity. Start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr.

Start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr. **The request the nurse implements first is to start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr. Although the dextrose 5% in 0.45% sodium chloride is hypertonic in the IV bag, once it is infused, the glucose is rapidly metabolized and the fluid is really hypotonic. Fluid therapy is the focus of treatment for patients with gastroenteritis. Older patients are at increased risk for the complications of dehydration such as hypovolemia and acute kidney failure.Acetaminophen 650 mg should be administered rectally soon, and blood draws and stool specimen collection would also be implemented soon, but prevention and treatment of dehydration are the priorities for this patient.

An obese patient is discharged 10 days after being hospitalized for peritonitis, which resulted in an exploratory laparotomy. Which assessment finding by the patient's home health nurse requires immediate action? Pain when coughing States, "I am too tired to walk very much" States, "I feel like the incision is splitting open" Temperature of 100.8°F (38.2°C).

States, "I feel like the incision is splitting open" **The assessment finding of a patient who had an exploratory laparotomy that requires immediate action by the home health nurse is the patient stating, "I feel like the incision is splitting open." The patient feeling like the incision is splitting open is at risk for poor wound healing and possible wound dehiscence. The nurse must immediately assess the wound and notify the primary health care provider.Reports of pain when coughing, being too tired to ambulate, and a temperature of 100.8°F (38.2°C) all require further assessment or intervention but are not as great a concern as the possibility of wound dehiscence for this patient.

A patient at risk for colorectal cancer asks the nurse, "Can you tell me some foods to include in my diet so that I can reduce my chances of getting this disease?" Which dietary selection does the nurse suggest? Steak with pasta Spaghetti with tomato sauce Steamed broccoli with turkey Tuna salad with wheat crackers

Steamed broccoli with turkey **The nurse suggests steamed broccoli and turkey to the patient who wants to know what foods to include in his/her diet to reduce the chance of getting colorectal cancer.Animal fat from red meats is carcinogenic, and pasta is high in refined carbohydrates, which are known to contribute to colon cancer. Spaghetti and wheat crackers also contain large amounts of refined carbohydrates.

"A patient is being discharged, 8 days postoperatively following a total esophagectomy." Which teaching point does the nurse consider to be of the highest priority during the transition to home? Instruct the patient to eat three meals daily. Emphasize the importance of lying down after meals. Encourage the patient to ask his or her health care provider for antidepressant medication. Stress the importance of notifying the primary health care provider if leaking is noted at the incision site.

Stress the importance of notifying the primary health care provider if leaking is noted at the incision site. **The teaching point with the highest priority is to notify the primary health care provider (PHCP) immediately if leaking is noted at the incision site. Leakage from the site of anastomosis is a dreaded complication that can appear 2 to 10 days after surgery. Wound management and prevention of infection are major concerns because the patient who has had an esophagectomy typically has multiple drains and incisions.The patient should eat six to eight small meals daily, and should sit up after meals to encourage satisfactory swallowing. The patient's coping skills should be assessed, as well as his or her level of anxiety and/or depression, before antidepressant medication is prescribed.

A 21-year-old with a stab wound to the abdomen has come to the emergency department (ED). Once stabilized, the patient is admitted to the medical-surgical unit. What does the admitting nurse do first for this patient? Administer pain medication. Assess skin temperature and color. Check on the amount of urine output. Take vital signs.

Take vital signs. **The admitting nurse needs to first take the vital signs of a patient who was just transferred from the ED with a stab wound to the abdomen. Assessment of vital signs must be done first to determine the adequacy of the airway and circulation. Vital signs initially reveal the most about the patient's condition.The patient would not be medicated for pain until his or her alertness level is determined. Skin temperature and color are not specifically indicative of the patient's overall condition. If the patient is in shock, urine output will be scant and will not be an accurate assessment variable.

When assessing a client with hepatitis B, the nurse anticipates which assessment findings? Select all that apply. Recent influenza infection Brown stool Tea-colored urine Right upper quadrant tenderness Itching

Tea-colored urine Right upper quadrant tenderness Itching **Assessment findings the nurse expects to find in a client with Hepatitis B include brown, tea-, or cola-colored urine, right upper quadrant pain due to inflammation of the liver, and itching, irritating skin caused by deposits of bilirubin on the skin secondary to high bilirubin levels and jaundice.Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored, and not typically brown. Question 27 of 27

sulfasalazine

Teach pts to report nausea, vomiting, anorexia, rash, and headache to the health care provider With higher doses, hemolytic anemia, hepatitis, male infertility, or agranulocytosis can occur Assess pt for allergy to drugs that contain sulfa before pt takes drug

A client has been diagnosed with mild gastroesophageal reflux disease and asks the nurse about nonpharmacologic treatments to prevent symptoms. What does the nurse tell this client? A. "Avoid caffeine-containing foods and beverages." Correct B. "Eat three meals each day and avoid snacking between meals." C. "Peppermint lozenges help to reduce stomach upset." D. "Sleep on your left side with a pillow between your knees."

Teach the client to limit or eliminate foods that decrease lower esophageal sphincter (LES) pressure and that irritate inflamed tissue, causing heartburn, such as peppermint, chocolate, alcohol, fatty foods (especially fried), caffeine, and carbonated beverages. Large meals increase the volume of and pressure in the stomach and delay gastric emptying. Remind the client to eat four to six small meals each day rather than three large ones. Peppermint decreases LES pressure and increases the risk of symptoms. Clients should be taught to elevate the head by 6 to 12 inches for sleep to prevent nighttime reflux.

The nurse is observing a co-worker who is caring for a client with a nasogastric tube following esophageal surgery. Which actions by the co-worker require the nurse to intervene? (Select all that apply.) A. Checking tube placement every 12 hours Correct B. Keeping the bed flat Correct C. Placing the client upright when taking sips of water D. Providing mouth care every 8 hours Correct E. Securing the tube

The nasogastric tube should be checked every 4 to 8 hours. The head of the bed should be elevated at least 30 degrees. Oral hygiene should be provided every 2 to 4 hours. The client should be placed upright when taking sips or small amounts of water to prevent choking and to allow observation of the client for dysphagia. The tube should be secured to prevent dislodgment.

The nurse is reviewing the medication history for a client diagnosed with gastroesophageal reflux disease who has been prescribed esomeprazole (Nexium) once daily. The client reports that the drug doesn't completely control the symptoms. The nurse contacts the provider to discuss which intervention? A. Adding a second proton pump inhibitor medication B. Increasing the dose of esomeprazole Incorrect C. nging to a twice-daily dosing regimen Correct D. Switching to omeprazole (Prilosec)

The proton pump inhibitors are usually effective when given once daily, but can be given twice daily if symptoms are not well controlled. Adding a second medication, increasing the dose, or switching to another proton pump inhibitor is not recommended.

A client with an inoperable esophageal tumor is receiving swallowing therapy. Which task does the home health nurse delegate to an experienced home health aide? A. Teaching family members how to determine whether the client is obtaining adequate nutrition B. Assessing lung sounds for possible aspiration when the client is swallowing clear liquids C. Reminding the client to use the chin-tuck technique each time the client attempts to swallow Correct D. Instructing family members about symptoms that may indicate a need to call the provider

The role of a home health aide when caring for a client with swallowing difficulty includes reinforcement of previously taught swallowing techniques. Client teaching and providing instructions to family members are not within the scope of practice of a home health aide and should be done by the nurse. Likewise, assessment is part of the nursing process and should be done by a nurse.

A client in the emergency department (ED) has slurred speech, confusion, and visual problems and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What does the nurse suspect that the client is probably experiencing? Embolic stroke Hemorrhagic stroke Thrombotic stroke Transient ischemic attack

Thrombotic stroke **The client's signs and symptoms fit the description of a thrombotic stroke due to its gradual onset.Signs and symptoms of embolic stroke have a sudden onset, unlike this client's symptoms. Hemorrhagic strokes more frequently present with sudden, severe headache. Intermittent episodes of slurred speech, confusion, and visual problems are transient ischemic attacks, which often are warning signs of an impending ischemic stroke.

Antacids

To achieve a therapeutic effect, must be ingested to neutralize hourly production of acid Optimal effect: take about 2hrs after meals to reduce hydrogen ion load in duodenum May be effective from 30min-3hrs after ingestion Do not take on empty stomach

A patient is being evaluated in the emergency department (ED) for a possible small bowel obstruction. Which signs/symptoms does the nurse expect to assess? Cramping intermittently, metabolic acidosis, and minimal vomiting Intermittent lower abdominal cramping, obstipation, and metabolic alkalosis Metabolic acidosis, upper abdominal distention, and intermittent cramping Upper abdominal distention, metabolic alkalosis, and a great amount of vomiting

Upper abdominal distention, metabolic alkalosis, and a great amount of vomiting **A small bowel obstruction is characterized by upper or epigastric abdominal distention, metabolic alkalosis, and a great amount of vomiting.Intermittent lower abdominal cramping and metabolic acidosis are all symptoms of a large bowel obstruction.

The nurse is preparing to instruct a client with chronic pancreatitis who is to begin taking pancrelipase (Cotazym). Which instruction does the nurse include when teaching the client about this medication? Administer pancrelipase before taking an antacid. Chew tablets before swallowing. Take pancrelipase before meals. Wipe your lips after taking pancrelipase.

Wipe your lips after taking pancrelipase. **The nurse will instruct the client to wipe the lips after taking pancrelipase. Pancrelipase is a pancreatic enzyme used for enzyme replacement for clients with chronic pancreatitis. To avoid skin irritation and breakdown from residual enzymes, the lips should be wiped.Pancrelipase should be administered after, and not before, antacids or histamine2 blockers are taken. It should not be chewed to minimize oral irritation and allow the drug to be released more slowly. It should be taken with meals and snacks, and not before, and followed with a glass of water.

A client is being discharged after a minimally invasive esophagectomy. Which teaching point does the nurse consider to be of the highest priority during the predischarge teaching session? A. Instruct the client to eat three meals daily. B. Emphasize the importance of lying down after meals. C. Encourage the client to ask his or her health care provider for antidepressant medication. D. Report the presence of fever and a swollen, painful neck incision. Correct

Wound management and prevention of infection are major concerns because the client who has had an esophagectomy typically has multiple drains and incisions. The client should eat six to eight small meals daily, and should sit up after meals to encourage satisfactory swallowing. The client's coping skills should be assessed, as well as his or her level of anxiety and/or depression, before antidepressant medication is prescribed.

A patient who had surgery for inflammatory bowel disease is being discharged. The case manager will arrange for home health care follow-up. The patient tells the nurse that family members will also be helping with care. What information is critically important for the nurse to provide to these collaborating members? A list of medical supply facilities where wound care supplies may be purchased Proper handwashing techniques to avoid cross-contamination of the patient's wound The amount of pain medication that the patient is allowed to take in each dose Written and oral instructions regarding signs/symptoms to report to the primary health care provider

Written and oral instructions regarding signs/symptoms to report to the primary health care provider **It is critically important to provide the patient and case manager with both written and oral instructions on reportable signs/symptoms to avoid the development of complications.It will be the home health nurse's responsibility to bring supplies to the patient's home. Although instruction on proper handwashing and the patient's medication regimen are important, they are not the highest priority.

After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain Middle-aged client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL (13.1 mmol/L)

Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min **The nurse would first assess the young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. Airway and breathing are the two most important criteria the nurse will use to determine which client to assess first. The dyspneic client is at greatest risk for rapid deterioration and requires immediate assessment and intervention. Acute respiratory distress syndrome is a possible complication of acute pancreatitis.The client with cholecystitis and the client with an elevated temperature will require further assessment and intervention, but these are not medical emergencies requiring the nurse's immediate attention. The older adult client's glucose level will require intervention but, again, is not a medical emergency.

The nurse working during the day shift on the medical unit has just received report. Which patient does the nurse plan to assess first? Young adult with epigastric pain, hiccups, and abdominal distention after having a total gastrectomy Adult who had a subtotal gastrectomy and is experiencing dizziness and diaphoresis after each meal Middle-aged patient with gastric cancer who needs to receive omeprazole (Prilosec) before breakfast Older adult with advanced gastric cancer who is scheduled to receive combination chemotherapy

Young adult with epigastric pain, hiccups, and abdominal distention after having a total gastrectomy **After receiving shift report, the nurse would first assess the post-op total gastrectomy young adult with epigastric pain, hiccups and abdominal pain. This patient is experiencing symptoms of acute gastric dilation, which can disrupt the suture line. The surgeon must be notified immediately because the nasogastric tube may need irrigation or repositioning.The patient who had a subtotal gastrectomy is not in a life-threatening situation and does not require immediate assessment. The patient with gastric cancer and the older adult with advanced gastric cancer are in stable condition and do not require immediate assessment.