Chapter 59 Iggy Practice Questions, Chapter 58 Iggy Practice Questions, Med-Surg Chapters 59 & 60, Gastro Nclex Questions, Nclex Review: Lower GI Problems - Intestinal Obstruction, Nclex Review: Lower GI Problems- ileostomy, Total Parenteral Nutritio...

After insertion of a nasoenteric tube, the nurse should place the client in which position? 1. Supine. 2. Right side-lying. 3. Semi-Fowler's. 4. Upright in a bedside chair.

2. The client is placed in a right side-lying position to facilitate movement of the mercury-weighted tube through the pyloric sphincter. After the tube is in the intestine, the client is turned from side to side or encouraged to ambulate to facilitate tube movement through the intestinal loops. Placing the client in the supine or semi-Fowler's position, or having the client sitting out of bed in a chair will not facilitate tube progression.

Radiation therapy is used to treat colon cancer before surgery for which of the following reasons? A. Reducing the size of the tumor B. Eliminating the malignant cells C. Curing the cancer D. Helping the bowel heal after surgery

A. Radiation therapy is used to treat colon cancer before surgery to reduce the size of the tumor, making it easier to be resected. Radiation therapy isn't curative, can't eliminate the malignant cells (though it helps define tumor margins), can could slow postoperative healing.

A client has a percutaneous endoscopic gastrostomy tube inserted for tube feedings. Before starting a continuous feeding, the nurse should place the client in which position? A. Semi-Fowlers B. Supine C. Reverse Trendelenburg D. High Fowler's

A. To prevent aspiration of stomach contents, the nurse should place the client in semi-Fowler's position. High Fowler's position isn't necessary and may not be tolerated as well as semi-Fowler's.

54. Which information will the nurse teach a 23-year-old patient with lactose intolerance? a. Ice cream is relatively low in lactose. b. Live-culture yogurt is usually tolerated. c. Heating milk will break down the lactose. d. Nonfat milk is a better choice than whole milk.

ANS: B Lactose-intolerant individuals can usually eat yogurt without experiencing discomfort. Ice cream, nonfat milk, and milk that has been heated are all high in lactose.

The patient is on a continuous tube feeding. The tube placement should be checked every a) 24 hours. b) 12 hours. c) hour. d) shift.

D) Shift Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding. Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities. Checking for placement every 12 or 24 hours does not meet the standard of care due the patient receiving continuous tube feedings.

What is a key etiologic factor in the incidence of nonalcoholic fatty liver disease (NAFLD)? A. Smoking B. Inadequate bulk C. Use of illegal drugs D. Obesity

D. Obesity

The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? A. Has completed a college education B. Has been able to stop smoking cigarettes C. Has well-controlled type 1 diabetes mellitus D. The chest x-ray showed another lung cancer lesion.

D. The chest x-ray showed another lung cancer lesion. Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug and/or alcohol abuse, and the inability to comprehend or comply with the rigorous post-transplant course.

A nurse assesses a client who is hospitalized with an exacerbation of Crohn's disease. Which clinical manifestation should the nurse expect to find?

High-pitched, rushing bowel sounds in the right lower quadrant

A client attending a summer camp develops an Escherichia coli infection. What does the camp nurse tell campers about how to prevent this infection?

If you are swimming, avoid swallowing the water

The nurse is monitoring a client admitted to the hospital with a dx of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is appropriate nursing intervention? "A. Notify the physician B. Administer the prescribe pain medication C. Call and ask the operating room team to perform the surgery as soon as possible D. Reposition the client and apply a heating pad on warm setting to the clients abdomen"

Answer A The health-care provider should be noti-fied when the nurse has the needed infor-mation.`

The nurse is monitoring a female client for the early signs and symptoms of dumping syndrome. Which of the following indicate this occurrence? a. Sweating and pallor b. Bradycardia and indigestion c. Double vision and chest pain d. Abdominal cramping and pain

Answer A. Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

Dr. Smith has determined that the client with hepatitis has contracted the infection form contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? a. Hepatitis A ,b. hep b, C Hep C, D. Hep D

Answer A. Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.

The doctor ordered for a complete blood count. After the test, Nurse Ray received the result from the laboratory. Which laboratory values will confirm the diagnosis of appendicitis? a. RBC 5.5 x 106/mm3 b. Hct 44 % c. WBC 13, 000/mm3 d. Hgb 15 g/dL"

Answer C "Rationale: Increase in WBC counts is suggestive of appendicitis because of bacterial invasion and inflammation. Normal WBC count is 5, 000 - 10, 000/mm3. Other options are normal values."

What is the best indication that the intravenous (IV) fluid replacement is adequate during the treatment of a patient with intestinal obstruction? A. Serum sodium: 155 mEq/L B. Urine specific gravity: 1.050 C. Urine output: 0.5 ml/kg/ hour D. Bowel sounds: 4 times/minute

C. Urine output: 0.5 ml/kg/ hour Adequate fluid replacement results in urine output of 0.5 mL/kg/ hour. The first two options indicate dehydration. Bowel sounds (peristalsis) are not used to determine rehydration.

A 35-year-old man with a family history of adenomatous polyposis had a colonoscopy with removal of multiple polyps. Which signs and symptoms should the nurse teach the patient to report immediately? a. Fever and abdominal pain b. Flatulence and liquid stool c. Loudly audible bowel sounds d. Sleepiness and abdominal cramps

Correct answer: a Rationale: The patient should be taught to observe for signs of rectal bleeding and peritonitis. Fever, malaise, and abdominal pain and distention could indicate a perforated bowel with peritonitis.

A patient is admitted to the hospital with left upper quadrant (LUQ) pain. What may be a possible source of the pain? a. Liver b. Pancreas c. Appendix d. Gallbladder

Correct answer: b Rationale: The pancreas is located in the left upper quadrant, the liver is in the right upper quadrant, the appendix is in the right lower quadrant, and the gallbladder is in the right upper quadrant.

A normal physical assessment finding of the GI system is/are (select all that apply) a. nonpalpable liver and spleen. b. borborygmi in upper right quadrant. c. tympany on percussion of the abdomen. d. liver edge 2 to 4 cm below the costal margin. e. finding of a firm, nodular edge on the rectal examination.

Correct answers: a, c Rationale: Normal assessment findings for the gastrointestinal system include a nonpalpable liver and spleen and generalized tympany on percussion. Normally, bowel sounds are high pitched and gurgling; loud gurgles indicate hyperperistalsis and are called borborygmi (stomach growling). If the patient has chronic obstructive pulmonary disease, large lungs, or a low-set diaphragm, the liver may be palpated 0.4 to 0.8 inch (1 to 2 cm) below the right costal margin. On palpation, the rectal wall should be soft and smooth and should have no nodules.

"The health care team is assessing a patient for acute pancreatitis after he presented to the emergency department with severe abdominal pain. Which laboratory value is the best diagnostic indicator of acute pancreatitis? A. Gastric pH B. Blood glucose C. Serum amylase D. Serum potassium

Correct: C Serum amylase levels indicate pancreatic function, and they are used to diagnose acute pancreatitis. Blood glucose, gastric pH, and potassium levels are not direct indicators of acute pancreatic dysfunction.

After teaching a client who was hospitalized for Salmonella food poisoning, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?

"I'll take the ciprofloxacin until the diarrhea has resolved."

A nurse is reviewing the history and physical of a client admitted for a hemorrhoidectomy. Which predisposing condition does the nurse expect to see? a) Constipation b) Hypoglycemia c) Lactic acidosis d) Hyperkalemia

A) Constipation Orthostatic hypertension and other conditions associated with persistently high intra-abdominal pressure (such as pregnancy) can lead to hemorrhoids. The passing of hard stools, not diarrhea, can aggravate hemorrhoids. Diverticulosis has no relationship to hemorrhoids. Rectal bleeding is a symptom of hemorrhoids, not a predisposing condition.

The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which of the following instructions would be most helpful to prevent further episodes of constipation? A) Maintain a high intake of fluid and fiber in the diet. B) Reduce intake of medications causing constipation. C) Eat several small meals per day to maintain bowel motility. D) Sit upright during meals to increase bowel motility by gravity.

A) Maintain a high intake of fluid and fiber int he diet Increased fluid intake and a high-fiber diet reduce the incidence of constipation caused by immobility, medications, and other factors. Fluid and fiber provide bulk that in turn increases peristalsis and bowel motility.

A client with which of the following conditions may be likely to develop rectal cancer? A. Adenomatous polyps B. Diverticulitis C. Hemorrhoids D. Peptic ulcer disease

A. A client with adenomatous polyps has a higher risk for developing rectal cancer than others do. Clients with diverticulitis are more likely to develop colon cancer. Hemorrhoids don't increase the chance of any type of cancer. Clients with peptic ulcer disease have a higher incidence of gastric cancer.

The nurse is teaching the client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do? A. Increase fluid intake B. Reduce the amount of irrigation solution C. Perform the irrigation in the evening D. Place heat on the abdomen

A. To enhance effectiveness of the irrigation and fecal returns, the client is instructed to increase fluid intake and prevent constipation.

Nursing management of the patient with acute pancreatitis includes (select all that apply) A. checking for signs of hypocalcemia B. providing a diet low in carbohydrates C. giving insulin based on a sliding scale D. observing stools for signs of steatorrhea E. monitoring for infection, particularly respiratory infection

A. checking for signs of hypocalcemia D. observing stools for signs of steatorrhea Rationale During the acute phase, it is important to monitor vital signs. Hemodynamic stability may be compromised by hypotension, fever, and tachypnea. IV fluids are ordered, and the response to therapy is monitored. Fluid and electrolyte balance is closely monitored. Frequent vomiting, along with gastric suction, may result in decreased chloride, sodium, and potassium levels. Because hypocalcemia can occur in acute pancreatitis, you should observe for symptoms of tetany, such as jerking, irritability, and muscular twitching. Numbness or tingling around the lips and in the fingers is an early indicator of hypocalcemia. The patient should be assessed for a positive Chvostek sign or Trousseau sign. Observe for fever and other manifestations of infection in the patient with acute pancreatitis. Respiratory infections are common because the retroperitoneal fluid raises the diaphragm, which causes the patient to take shallow, guarded abdominal breaths. Reference: 1090, 1092

The nurse is teaching a patient about postoperative care following an ileostomy. Which of the following, if stated by the patient, demonstrates correct understanding? A) "My new stoma should appear dullish pink in nature" B) "Fecal drainage should begin about 4 days after the surgery" C) "I will need to be on bed rest immediately following the surgery" D) "I will have a nasogastric tube put in place immediately after the surgery"

Answer: D. The nasogastric tube will be put in place following the surgery to prevent a buildup of gastric contents. Then it will be removed and diet will progress as tolerated. The stoma will appear shiny pink or bright, beefy red in color. NOT dull. Fecal drainage should begin within 72 hours. Ambulation should begin as soon as possible postoperatively

What laboratory finding is the primary diagnostic indicator for pancreatitis? a. Elevated blood urea nitrogen (BUN) b. Elevated serum lipase c. Elevated aspartate aminotransferase (AST) d. Increased lactate dehydrogenase (LD)

B. Elevation of serum lipase is the most reliable indicator of pancreatitis because this enzyme is produced solely by the pancreas. A client's BUN is typically elevated in relation to renal dysfunction; the AST, in relation to liver dysfunction; and LD, in relation to damaged cardiac muscle

Compared with a colostomy, which complication is a patient with an ileostomy at an increased risk for? A. Constipation B. Obstruction C. Flatus D. Polyps

B. Obstruction The ileostomy patient is susceptible to obstruction because the lumen is less than an inch in diameter and may narrow further at the point where the bowel passes through the fascia-muscle layer of the abdomen. Ileostomies have loose drainage because fluid is not absorbed in the large colon.

Which is a complication in patients with ulcerative colitis? A. Hyperkalemia B. Toxic megacolon C. Pancreatitis D. Barrett's esophagus

B. Toxic megacolon Colonic dilation (toxic megacolon) can occur as a result of decreased tissue function, with lack of peristalsis and enlargement of the colon. The patient is at risk for perforation.

The nurse is caring for a client who has been newly diagnosed with colon cancer. The client has become withdrawn from family members. Which strategy does the nurse use to assist the client at this time? a. Ask the health care provider for a psychiatric consult for the client. b. Explain the improved prognosis for colon cancer with new treatment. c. Encourage the client to verbalize feelings about the diagnosis. d. Allow the client to remain withdrawn as long as he or she wishes.

C The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the client's feelings with a generalization about cancer prognosis and treatment. The nurse should not ignore the client's withdrawal behavior.

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? a) Dyspnea and fatigue b) Ascites and orthopnea c) Purpura and petechiae d) Gynecomastia and testicular atrophy

C) Purpura and petechiae A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

The nurse is caring for a patient with Diverticulitis. The patient asks what foods should be included in the diet. What is the best response by the nurse? Select all that apply: a. Raspberries b. Corn c. Cooked pears d. Broiled chicken e. Steamed green beans

C, D, E

What is the reason for steatorrhea in a patient with chronic pancreatitis? A. Infection by Streptobacillus moniliformis B. Co-infection with the hepatitis B virus C. Fat intolerance because of inadequate enzymes D. Dumping syndrome

C. Fat intolerance because of inadequate enzymes

A female college student goes to the university health clinic complaining of pain that started at the umbilicus and moved to the right lower quadrant over the last 12 hours. You notice muscle guarding on examination. What action should you take? A. Administer a PRN laxative per standing orders. B. Ask about the last menstrual period. C. Make the student NPO. D. Assess bowel sounds.

C. Make the student NPO. This is a classic description of appendicitis. At the very least, it is an acute abdomen, and the student should be kept NPO until a need for surgery is ruled out. The student should be referred to an emergency department.

A client with gastric cancer may exhibit which of the following symptoms? A. Abdominal cramping B. Constant hunger C. Feeling of fullness D. Weight gain

C. The client with gastric cancer may report a feeling of fullness in the stomach, but not enough to cause him to seek medical attention. Abdominal cramping isn't associated with gastric cancer. Anorexia and weight loss (not increased hunger or weight gain) are common symptoms of gastric cancer.

Which of the following position should the client with appendicitis assume to relieve pain ? A. Prone B. Sitting C. Supine D. Lying with legs drawn up

Correct Answer: D Lying still with legs drawn up towards chest helps relive tension on the abdominal muscle, which helps to reduce the amount of discomfort felt. Lying flat or sitting may increase the amount of pain experienced

In preparing a patient for a colonoscopy, the nurse explains that a. a signed permit is not necessary. b. sedation may be used during the procedure. c. only one cleansing enema is necessary for preparation. d. a light meal should be eaten the day before the procedure.

Correct answer: b Rationale: Sedation is induced during a colonoscopy. A signed consent form is necessary for a colonoscopy. A cathartic or enema is administered the night before the procedure, and more than one enema may be necessary. Patients may need to be kept on clear liquids 1 to 2 days before the procedure.

You explain to the patient with acute pancreatitis that the most common pathogenic mechanism of the disorder is A. Cellular disorganization B. Overproduction of enzymes C. Lack of secretion of enzymes D. Autodigestion of the pancreas

D. Autodigestion of the pancreas

What is the main cause of primary liver cancer? A. Toxic levels of metal B. Parasites C. Untreated trichomoniasis D. Hepatitis C

D. Hepatitis C

What is the proper understanding of how esophageal varices develop? A. Faulty valves in the veins allow vein distention. B. Lower esophageal sphincter weakness allowing fluid backup. C. Obstruction from cholelithiasis causes enzyme backup. D. Pressure increases in the portal vein.

D. Pressure increases in the portal vein.

The patient has an obstruction high in the small intestine. What patient assessment do you anticipate finding? A. No bowel sounds B. Metabolic acidosis C. Flank pain D. Vomiting

D. Vomiting A patient with a high small intestinal obstruction is likely to have vomiting, which can be profuse. Lower intestinal obstruction is associated with a greater risk of metabolic acidosis. In small intestinal obstructions bowel sounds can still be heard in the large intestine.

A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, and weak, thready pulses. The nurse should do which of the following first? 1. Encourage the client to drink at least 1,000 mL per day. 2. Provide parenteral rehydration therapy ordered by the physician. 3. Turn and reposition every 2 hours. 4. Monitor vital signs every shift.

2. Initially, the extracellular fluid (ECF) volume with isotonic I.V. fluids until adequate circulating blood volume and renal perfusion are achieved. Vital signs should be monitored as parenteral and oral rehydration are achieved. Oral fluid intake should be greater than 1,000 mL/ day. Turning and repositioning the client at regular intervals aids in the prevention of skin breakdown, but it is first necessary to rehydrate this client.

A physician has ordered a liver biopsy for a client whose condition is deteriorating. Which of the following places the client at high risk due to her altered liver function during the biopsy? a) Low platelet count b) Low hemoglobin c) Decreased prothrombin time d) Low sodium level

A) Low platelet count Certain blood tests provide information about liver function. Prolonged prothrombin time (PT) and low platelet count place the client at high risk for hemorrhage. The client may receive intravenous (IV) administration of vitamin K or infusions of platelets before liver biopsy to reduce the risk of bleeding.

A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge? a) The client is free from esophagitis and achalasia. b) The client doesn't exhibit rectal tenesmus. c) The client has normal gastric structures. d) The client reports diminished duodenal inflammation.

A) The client is free from esophagitis and achalasia Dysphagia may be the reason why a client with esophagitis or achalasia seeks treatment. Therefore, when the client is free of esophagitis or achalasia, he is ready for discharge. Dysphagia isn't associated with rectal tenesmus, duodenal inflammation, or abnormal gastric structures.

You are preparing to insert a nasogastric tube into a 68-year-old patient with an abdominal mass and suspected bowel obstruction. The patient asks you why this procedure is necessary. Which response is most appropriate? A. "The tube will help to drain the stomach contents and prevent further vomiting." B. "The tube will push past the area that is blocked and help to stop the vomiting." C. "The tube is just a standard procedure before many types of surgery of the abdomen." D. "The tube will let us measure your stomach contents, so that we can plan what type of intravenous fluid replacement would be best."

A. "The tube will help to drain the stomach contents and prevent further vomiting." The nasogastric tube is used to decompress the stomach by draining stomach contents and thereby prevent further vomiting.

When teaching a community group about measures to prevent colon cancer, which instruction should the nurse include? A. "Limit fat intake to 20% to 25% of your total daily calories." B. "Include 15 to 20 grams of fiber into your daily diet." C. "Get an annual rectal examination after age 35." D. "Undergo sigmoidoscopy annually after age 50."

A. To help prevent colon cancer, fats should account for no more than 20% to 25% of total daily calories and the diet should include 25 to 30 grams of fiber per day. A digital rectal examination isn't recommended as a stand-alone test for colorectal cancer. For colorectal cancer screening, the American Cancer society advises clients over age 50 to have a flexible sigmoidoscopy every 5 years, yearly fecal occult blood tests, yearly fecal occult blood tests PLUS a flexible sigmoidoscopy every 5 years, a double-contrast barium enema every 5 years, or a colonoscopy every 10 years.

27. A 42-year-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia. Which patient teaching will the nurse provide before discharge? a. Soak in sitz baths several times each day. b. Cough 5 times each hour for the next 48 hours. c. Avoid use of acetaminophen (Tylenol) for pain. d. Apply a scrotal support and ice to reduce swelling.

ANS: D A scrotal support and ice are used to reduce edema and pain. Coughing will increase pressure on the incision. Sitz baths will not relieve pain and would not be of use after this surgery. Acetaminophen can be used for postoperative pain.

"Several children at a daycare center have been infected with hepatitis A virus. Which instruction by the nurse would reduce the risk of hepatitis A to the other children and staff members? "1. Hand washing after diaper changes 2. Isolation of the sick children 3. Use of masks during contact with the children 4. Sterilization of all eating utensils"

Answer 1: Rationale: children in day care centers are at risk for hepatits A infection which is transmitted via fecal-oral route due to poor hand hygeine practices and poor sanitation. Isolation of sick children, use of mask during contact, and sterilization of all eating utensils would not be useful in breaking the chain of infection.

A patient arrives to the ED complaining of pain in their abdomen. He says, "My cousin died from a blockage in their intestine! I think I have one too!" The nurse knows that the main symptoms of small bowel obstruction are: A) Severe distention, elevated sodium levels, and dark spaces in X-Ray of abdomen B) Severe pain in abdomen, metabolic acidosis, and dehydration C) Crampy, wave-like pain in abdomen, no passage of stool, and vomiting D) RLQ pain, rebound tenderness, and distention

Answer: C. See page 679

A nurse is caring for a client newly diagnosed with hepatitis A. Which statement by the client indicates the need for further teaching? a) "I'll wash my hands often." b) "How did this happen? I've been faithful my entire marriage." c) "I'll take all my medications as ordered." d) "I'll be very careful when preparing food for my family."

B) How did this happen? I've been faithful my entire marriage The client requires further teaching if he suggests that he acquired the virus through sexual contact. Hepatitis A is transmitted by the oral-fecal route or through ingested food or liquid that's contaminated with the virus. Hepatitis A is rarely transmitted through sexual contact. Clients with hepatitis A need to take every effort to avoid spreading the virus to other members of their family with precautions such as preparing food carefully, washing hands often, and taking medications as ordered.

What sign or symptom in a patient with cirrhosis and esophageal varices is most important for you to follow-up? A. Dark urine and whitish stool B. Coughing for 30 minutes C. Lipase and amylase values are four times the normal values D. Telangiectasia and palmar erythema

B. Coughing for 30 minutes

A nurse is receiving report from the emergency room regarding a new client being admitted to the medical-surgical unit with a diagnosis of peptic ulcer disease. The nurse expects the age of the client will be between a) 20 and 30 years b) 15 and 25 years c) 40 and 60 years d) 60 and 80 years

C) 40 to 60 years Peptic ulcer disease occurs with the greatest frequency in people 40 to 60 years old. It is relatively uncommon in women of childbearing age, but it has been observed in children and even in infants.

The nurse is to obtain a stool specimen from a client who reported that he is taking iron supplements. The nurse would expect the stool to be which color? a) Dark brown b) Red c) Black d) Green

C) Black Ingestion of iron can cause the stool to turn black. Meat protein causes stool to appear dark brown. Ingestion of large amounts of spinach may turn stool green while ingestion of carrots and beets may cause stool to turn red.

What is most important to teach a patient to prevent chronic pancreatitis? A. Monitor temperature. B. Eat a low-residue diet. C. Avoid all alcohol. D. Watch for melena.

C. Avoid all alcohol.

A female client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should: a. place the client in a private room. b. wear a mask when handling the client's bedpan. c. wash the hands after touching the client. d. wear a gown when providing personal care for the client.

C. To maintain enteric precautions, the nurse must wash the hands after touching the client or potentially contaminated articles and before caring for another client. A private room is warranted only if the client has poor hygiene — for instance, if the client is unlikely to wash the hands after touching infective material or is likely to share contaminated articles with other clients. For enteric precautions, the nurse need not wear a mask and must wear a gown only if soiling from fecal matter is likely.

Which of the following would indicate that Bobby's appendix has ruptured? " a) diaphoresis b) anorexia c) pain at Mc Burney's point d) relief from pain

Correct D all are normal signs of having appendicits and once you have relief from pain means you could have a rupture.

As gastric contents move into the small intestine, the bowel is normally protected from the acidity of gastric contents by the a. inhibition of secretin release. b. release of bicarbonate by the pancreas. c. release of pancreatic digestive enzymes. d. release of gastrin by the duodenal mucosa.

Correct answer: b Rationale: The hormone secretin stimulates the pancreas to secrete fluid with a high concentration of bicarbonate. This alkaline secretion enters the duodenum and neutralizes acid in the chyme.

Inspection of an older patient's mouth reveals the presence of white, curd-like lesions on the patient's tongue. What is the most likely etiology for this abnormal assessment finding? a. Herpesvirus b. Candida albicans c. Vitamin deficiency d. Irritation from ill-fitting dentures

Correct answer: b Rationale: White, curd-like lesions surrounded by erythematous mucosa are associated with oral candidiasis. Herpesvirus causes benign vesicular lesions in the mouth. Vitamin deficiencies may cause a reddened, ulcerated, swollen tongue. Irritation from ill-fitting dentures will cause friable, edematous, painful, bleeding gingivae.

Which digestive substances are active or activated in the stomach (select all that apply)? a. Bile b. Pepsin c. Gastrin d. Maltase e. Secretin f. Amylase

Correct answer: b, c Rationale: Pepsinogen is changed to pepsin by acidity of the stomach, where it begins to break down proteins. Gastrin stimulates gastric acid secretion and motility and maintains lower esophageal sphincter tone. The stomach also secretes lipase for fat digestion.Bile is secreted by the liver and stored in the gallbladder for emulsifying fats. Maltase is secreted in the small intestine and converts maltose to glucose. Secretin is secreted y the duodenal mucosa and inhibits gastric motility and acid secretion. Amylase is secured in the small intestine and by the pancreas for carbohydrate digestion.

A patient's serum liver enzyme tests reveal an elevated aspartate aminotransferase (AST). The nurse recognizes what about the elevated AST? a. It eliminates infection as a cause of liver damage. b. It is diagnostic for liver inflammation and damage. c. Tissue damage in organs other than the liver may be identified. d. Nervous system symptoms related to hepatic encephalopathy may be the cause.

Correct answer: c Rationale: The aspartate aminotransferase (AST) level is elevated in liver disease but it is important to note that it is also elevated in damage to the heart and lungs and is not a specific test for liver function. Measurements of most of the transaminases involves nonspecific tests unless isoenzyme fractions are determined. Hepatic encephalopathy is related to elevated ammonia levels.

After eating, a patient with an inflamed gallbladder experiences pain caused by contraction of the gallbladder. What is the mechanism responsible for this action? a. Production of bile by the liver b. Production of secretin by the duodenum c. Release of gastrin from the stomach antrum d. Production of cholecystokinin by the duodenum

Correct answer: d Rationale: Cholecystokinin is secreted by the duodenal mucosa when fats and amino acids enter the duodenum and stimulate the gallbladder to release bile to emulsify the fats for digestion. The bile is produced by the liver but stored in the gallbladder. Secretin is responsible for stimulating pancreatic bicarbonate secretion and gastrin increases gastric motility and acid secretion.

"A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? a) Left lower quadrant b) Left upper quadrant c) Right upper quadrant d) Right lower quadrant

Correct answer: d) Right lower quadrant" Rationale: The pain of acute appendicitis localizes in the right lower quadrant (RLQ) at McBurney's point, an area midway between the umbilicus and the right iliac crest. Often, the pain is worse when manual pressure near the region is suddenly released, a condition called rebound tenderness.

To prevent the spread of hepatitis A virus (HAV) infection the nurse is especially careful when: A) Disposing of food trays B) Emptying the bed pan C)Taking an oral temperature D) changing IV tubing

Correct: B.... Rationale: HAV is transmitted primarily person-to-person by the fecal-oral route. Food can be a method of transmission but needs to be fecally contaminated. Since the transmission of hepatitis A is fecal-oral and not saliva or blood like hepatitis B, taking a temperature and changing IV tubing would not spread hepatitis A

The nurse who inserted a nasogastric tube for a 68-year-old patient with suspected bowel obstruction should write which of the following priority nursing diagnoses on the patient's problem list? A) Anxiety related to nasogastric tube placement B) Abdominal pain related to nasogastric tube placement C) Risk for deficient knowledge related to nasogastric tube placement D) Altered oral mucous membrane related to nasogastric tube placement

D) Altered oral mucous membrane related to nasogastric tube placement With nasogastric tube placement, the patient is likely to breathe through the mouth and may experience irritation in the affected nares. For this reason, the nurse should plan preventive measures based on this nursing diagnosis.

The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing which of the following? A) Relief of constipation B) Relief of abdominal pain C) Decreased liver enzymes D) Decreased ammonia levels

D) Decreased ammonia levels Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy.

The nurse asks a 68-year-old patient scheduled for colectomy to sign the operative permit as directed in the physician's preoperative orders. The patient states that the physician has not really explained well what is involved in the surgical procedure. Which of the following is the most appropriate action by the nurse? A) Ask family members whether they have discussed the surgical procedure with the physician. B) Have the patient sign the form and state the physician will visit to explain the procedure before surgery. C) Explain the planned surgical procedure as well as possible, and have the patient sign the consent form. D) Delay the patient's signature on the consent and notify the physician about the conversation with the patient.

D) Delay the patient's signature on the consent and notify the physician about the conversation with the patient. The patient should not be asked to sign a consent form unless the procedure has been explained to the satisfaction of the patient. The nurse should notify the physician, who has the responsibility for obtaining consent.

Which type of jaundice seen in adults is the result of increased destruction of red blood cells? a) Obstructive b) Nonobstructive c) Hepatocellular d) Hemolytic

D) Hemolytic Hemolytic jaundice results because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease.

The nurse is providing care to a client who has had a percutaneous liver biopsy. The nurse would monitor the client for which of the following? a) Intake and output b) Passage of stool c) Return of the gag reflex d) Signs and symptoms of bleeding

D) Signs and symptoms of bleeding A major complication after a liver biopsy is bleeding so it would be important for the nurse to monitor the client for signs and symptoms of bleeding. Return of the gag reflex would be important for the client who had an esophagogastroduodenoscopy to prevent aspiration. Monitoring the passage of stool would be important for a client who had a barium enema or colonoscopy. Monitoring intake and output is a general measure indicated for any client. It is not specific to a liver biopsy.

The nurse would instruct the patient to do which of the following to best enhance the effectiveness of a daily dose of docusate sodium (Colace)? A) Take a dose of mineral oil at the same time. B) Add extra salt to food on at least one meal tray. C) Ensure dietary intake of 10 g of fiber each day. D) Take each dose with a full glass of water or other liquid.

D) Take each dose with a full glass of water or other liquid Docusate lowers the surface tension of stool, permitting water and fats to penetrate and soften the stool for easier passage. The patient should take the dose with a full glass of water and should increase overall fluid intake, if able, to enhance effectiveness of the medication. Dietary fiber intake should be a minimum of 20 g daily to prevent constipation.

What is most indicative of end-stage cirrhosis? A. ALT and AST levels five times the normal value B. Palmar erythema C. Pitting pedal edema D. Asterixis

D. Asterixis

When planning care for a patient with cirrhosis, you will give highest priority to which nursing diagnosis? A. Imbalanced nutrition: less than body requirements B. Impaired skin integrity related to edema, ascites, and pruritus C. Excess fluid volume related to portal hypertension and hyperaldosteronism D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient's plan of care? Immediately start enteral feeding to prevent malnutrition. Insert an NG and maintain NPO status to allow pancreas to rest. Initiate early prophylactic antibiotic therapy to prevent infection. Administer acetaminophen (Tylenol) every 4 hours for pain relief.

Insert an NG and maintain NPO status to allow pancreas to rest. Correct Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.

The nursing management of the patient with cholecystitis associated with cholelithiasis is based on the knowledge that a. shock-wave therapy should be tried initially. b. once gallstones are removed, they tend not to recur. c. the disorder can be successfully treated with oral bile salts that dissolve gallstones. d. laparoscopic cholecystectomy is the treatment of choice in most patients who are symptomatic. (Lewis 1042)

d Rationale: Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis.

A patient with type 2 diabetes and cirrhosis asks you if it would be okay to take silymarin (milk thistle) to help minimize liver damage. On what do you base your response? A. Milk thistle may affect liver enzymes and alter drug metabolism. B. Milk thistle is generally safe in recommended doses for up to 10 years. C. There is unclear scientific evidence for the use of milk thistle in treating cirrhosis. D. Milk thistle may elevate the serum glucose levels and is contraindicated in diabetes.

A. Milk thistle may affect liver enzymes and alter drug metabolism.

Which symptom would most indicate a patient was experiencing an exacerbation of chronic pancreatitis? A. Retroperitoneal "gnawing," cramplike back pain B. Epigastric burning pain relieved by food C. Periumbilical pain migrating to the right lower quadrant (RLQ) D. Sudden onset of unilateral flank pain rated 10 on a pain scale

A. Retroperitoneal "gnawing," cramplike back pain Rationale Pain from chronic pancreatitis is located in the same area as acute pancreatitis: often retroperitoneal because of the location of pancreas. Although pain in the acute form is sharp and knifelike, pain in the chronic form is described as "heavy, gnawing, burning, or cramplike." It is not relieved with food or antacids. Epigastric burning pain relieved by food classically indicates a stomach ulcer. Periumbilical pain migrating to RLQ is a classic manifestation of appendicitis. Sudden, unilateral flank pain is more typical of renal calculi. Reference: 1093

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse would assess the client for which of the following most frequent symptom(s) of duodenal ulcer? A. Pain that is relieved by food intake B. Pain that radiated down the right arm C. N/V D. Weight loss

A. The most frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as burning, heavy, sharp, or "hungry" pain that often localizes in the midepigastric area. The client with duodenal ulcer usually does not experience weight loss or N/V. These symptoms are usually more typical in the client with a gastric ulcer.

A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, "The stool in my pouch is still liquid." How should the nurse respond? a. "The stool will always be liquid with this type of colostomy." b. "Eating additional fiber will bulk up your stool and decrease diarrhea." c. "Your stool will become firmer over the next couple of weeks." d. "This is abnormal. I will contact your health care provider."

ANS: A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet or with the passage of time.

Nurse Berlinda is assigned to a 41-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of: a. 45 units/L b. 100 units/L c. 300 units/L d. 500 units/L

Answer C. The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Options A and B are within normal limits. Option D is an extremely elevated level seen in acute pancreatitis.

The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What should the nurse expect to do for this patient? A. Prevent all oral intake. B. Control abdominal pain. C. Provide enteral feedings. D. Avoid dietary cholesterol.

B. Control abdominal pain. Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated. NPO status may be needed if the patient will have surgery but will not be used for all patients with cholelithiasis. Enteral feedings should not be needed, and avoiding dietary cholesterol is not used to treat cholelithiasis

The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient's plan of care? A. Immediately start enteral feeding to prevent malnutrition. B. Insert an NG and maintain NPO status to allow pancreas to rest. C. Initiate early prophylactic antibiotic therapy to prevent infection. D. Administer acetaminophen (Tylenol) every 4 hours for pain relief.

B. Insert an NG and maintain NPO status to allow pancreas to rest. Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.

The nurse is caring for a 55-year-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect the patient to exhibit? A. Hematochezia B. Left upper abdominal pain C. Ascites and peripheral edema D. Temperature over 102o F (38.9o C)

B. Left upper abdominal pain Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations of acute pancreatitis include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration).

A client is being treated for prolonged diarrhea. Which of the following foods should the nurse encourage the client to consume? a) Protein-rich foods b) High-fiber foods c) Potassium-rich foods d) High-fat foods

C) Potassium rich foods The nurse should encourage the client with diarrhea to consume potassium-rich foods. Excessive diarrhea causes severe loss of potassium. The nurse should also instruct the client to avoid high-fiber or fatty foods because these foods stimulate gastrointestinal motility. The intake of protein foods may or may not be appropriate depending on the client's status.

During the incubation period of viral hepatitis, the nurse would expect the patient to report a. pruritus and malaise b. dark urine and easy fatigability c. anorexia and right upper quadrant discomfort d. constipation or diarrhea with light colored stools

C- Incubation symptoms occur before the onset of jaundice and include a variety of GI symptoms as well as discomfort and heaviness in the upper right quadrant of the abdomen. Pruritus, dark urine, and light colored stools occur with the onset of jaundice in the acute phase.

A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings? A. Malnutrition B. Osteomyelitis C. Alcohol abuse D. Diabetes mellitus

C. Alcohol Use The patient with alcohol abuse could develop pancreatitis as a complication, which would increase the serum amylase (normal 30-122 U/L) and serum lipase (normal 31-186 U/L) levels as shown.

Which of the following associated disorders may the client with Crohn's disease exhibit? A. Ankylosing spondylitis B. Colon cancer C. Malabsorption D. Lactase deficiency

C. Because of the transmural nature of Crohn's disease lesions, malaborption may occur with Crohn's disease. Ankylosing spondylitis and colon cancer are more commonly associated with ulcerative colitis. Lactase deficiency is caused by a congenital defect in which an enzyme isn't present.

Which of the following definitions best describes gastritis? A. Erosion of the gastric mucosa B. Inflammation of a diverticulum C. Inflammation of the gastric mucosa D. Reflux of stomach acid into the esophagus

C. Gastritis is an inflammation of the gastric mucosa that may be acute (often resulting from exposure to local irritants) or chronic (associated with autoimmune infections or atrophic disorders of the stomach). Erosion of the mucosa results in ulceration. Inflammation of a diverticulum is called diverticulitis; reflux of stomach acid is known as gastroesophageal disease.

What is important in the management of a patient with esophageal varices? A. Teach consumption of raw vegetables for adequate vitamins. B. Teach foods high in protein for adequate healing. C. Have suction available in the room. D. Administer oxygen continuously by nasal cannula.

C. Have suction available in the room. Rationale Bleeding esophageal varices is a life-threatening complication, and suction to maintain an open airway is a priority. Raw fruits and vegetables are contraindicated with varices because they can cause bleeding in the delicate, torturous veins. Esophageal varices are seen later in the continuum of cirrhosis, and then large amounts of high-protein foods are contraindicated because the liver can no longer metabolize the protein. Continuous oxygen is not required with esophageal varices. Reference: 1078, 1084

Primary biliary cirrhosis is characterized by which finding? A. Elevated lipase and amylase B. Elevated troponin C. Low levels of vitamins A and D D. Low levels of iron

C. Low levels of vitamins A and D Rationale Patients have signs of fat malabsorption, including low levels of fat-soluble vitamins (A, D, E, and K). Elevated lipase and amylase levels are seen in pancreatitis. Elevated troponin levels are associated with acute myocardial infarction. Low levels of iron are not related to this condition. Reference: 1071

A client with rectal cancer may exhibit which of the following symptoms? A. Abdominal fullness B. Gastric fullness C. Rectal bleeding D. Right upper quadrant pain

C. Rectal bleeding is a common symptom of rectal cancer. Rectal cancer may be missed because other conditions such as hemorrhoids can cause rectal bleeding. Abdominal fullness may occur with colon cancer, gastric fullness may occur with gastric cancer, and right upper quadrant pain may occur with liver cancer.

A nurse is making a home health visit and finds the client experiencing right lower quadrant abdominal pain, which has decreased in intensity over the last day. The client also has a rigid abdomen and a temperature of 103.6 F. The nurse should intervene by: a) administer Tylenol (acetaminophen) for the elevated temperature b) advising the client to increase oral fluids c) asking the client when she last had a bowel movement d) notifying the physician

Correct D D. The client symptoms indicate appendicitis which requires immediate attention

When assessing a patient's abdomen, what would be most appropriate for the nurse to do? a. Palpate the abdomen before auscultation. b. Percuss the abdomen before auscultation. c. Auscultate the abdomen before palpation. d. Perform deep palpation before light palpation.

Correct answer: c Rationale: During examination of the abdomen, auscultation is done before percussion and palpation because these latter procedures may alter the bowel sounds.

When the nurse is assessing the health perception-health maintenance pattern as related to GI function, an appropriate question to ask is a. "What is your usual bowel elimination pattern?" b. "What percentage of your income is spent on food?" c. "Have you traveled to a foreign country in the last year?" d. "Do you have diarrhea when you are under a lot of stress?"

Correct answer: c Rationale: When assessing gastrointestinal function in relation to the health perception-health management pattern, the nurse should ask the patient about recent foreign travel with possible exposure to hepatitis, parasitic infestation, or bacterial infection.

The patient with suspected pancreatic cancer is having many diagnostic studies done. Which one can be used to establish the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment? A. Spiral CT scan B. A PET/CT scan C. Abdominal ultrasound D. Cancer-associated antigen 19-9

D. Cancer-associated antigen 19-9 The cancer-associated antigen 19-9 (CA 19-9) is the tumor marker used for the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment. Although a spiral CT scan may be the initial study done and provides information on metastasis and vascular involvement, this test and the PET/CT scan or abdominal ultrasound do not provide additional information.

Combined with clinical manifestations, the laboratory finding that is most commonly used to diagnose acute pancreatitis is a. increased serum calcium b. increased serum amylase c. increased urinary amylase d. decreased serum glucose

b. increased serum amylase

After teaching a client with a parasitic gastrointestinal infection, a nurse assesses the client's understanding. Which statements made by the client indicate that the client correctly understands the teaching? (Select all that apply.)

- "I must take a shower or bathe every day." - "I should have my well water tested." - "I will ask my sexual partner to have a stool test."

What are the first signs of fulminant hepatic failure? A. Cushing's triad B. Fetor hepaticus C. Narrow pulse pressure D. Change in mentation

D. Change in mentation

A nurse assesses a client with Crohn's disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider?

Distended abdomen

D

During the assessment of a patient with acute abdominal pain, the nurse should: A. perform deep palpation before auscultation B. obtain pulse rate and blood pressure to determine hypovolemic changes C. auscultate bowel sounds because hyperactive bowel sounds suggest paralytic ileus D. measure body temperature because an elevated temp may indicate an inflammatory or infectious process

A nurse cares for a client who has a Giardia infection. Which medication should the nurse anticipate being prescribed for this client?

Metronidazole (Flagyl)

A client is being evaluated in the emergency department (ED) for a possible small bowel obstruction. Which symptoms does the nurse expect to assess?

Upper abdominal distention, metabolic alkalosis, and great amount of vomiting

A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider?

pale and bluish stoma

The nurse is caring for a client with a parasitic gastrointestinal infection. What statement by the client indicates a need for further teaching? a. "I will have my housekeeper keep my toilet very clean." b. "I need to shower or bathe every day." c. "I need to have my well water tested." d. "My sexual partner needs to have a stool test."

A Parasitic infections can be transmitted to other people. The client himself or herself should keep the toilet area clean instead of possibly exposing another person to the disease. The other statements are accurate

The client with Crohn's disease has a nursing diagnosis of acute pain. The nurse would teach the client to avoid which of the following in managing this problem? A. Lying supine with the legs straight B. Massaging the abdomen C. Using antispasmodic medication D. Using relaxation techniques

A. The pain associated with Crohn's disease is alleviated by the use of analgesics and antispasmodics and also is reduced by having the client practice relaxation techniques, applying local cold or heat to the abdomen, massaging the abdomen, and lying with the legs flexed. Lying with the legs extended is not useful because it increases the muscle tension in the abdomen, which could aggravate the inflamed intestinal tissues as the abdominal muscles are stretched.

48. A female patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care? a. Position patient with the knees flexed. b. Avoid use of opioids or sedative drugs. c. Offer frequent small sips of clear liquids. d. Assist patient to breathe deeply and cough.

ANS: A There is less peritoneal irritation with the knees flexed, which will help decrease pain. Opioids and sedatives are typically given to control pain and anxiety. Preoperative patients with peritonitis are given IV fluids for hydration. Deep breathing and coughing will increase the patient's discomfort.

The nurse is caring for a male client with a diagnosis of chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency? a. Vitamin A b. Vitamin B12 c. Vitamin C d. Vitamin E

Answer B. Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of the function of the parietal cells. The source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia. The client is not at risk for vitamin A, C, or E deficiency.

A male client with pancreatitis complains of pain. The nurse expects the physician to prescribe meperidine (Demerol) instead of morphine to relieve pain because: a. meperidine provides a better, more prolonged analgesic effect. b. morphine may cause spasms of Oddi's sphincter. c. meperidine is less addictive than morphine. d. morphine may cause hepatic dysfunction.

B. For a client with pancreatitis, the physician will probably avoid prescribing morphine because this drug may trigger spasms of the sphincter of Oddi (a sphincter at the end of the pancreatic duct), causing irritation of the pancreas. Meperidine has a somewhat shorter duration of action than morphine. The two drugs are equally addictive. Morphine isn't associated with hepatic dysfunction.

Which of the following terms is used to refer to intestinal rumbling? a) Diverticulitis b) Tenesmus c) Borborygmus d) Azotorrhea

C) Borborygmus Borborygmus is the intestinal rumbling that accompanies diarrhea. Tenesmus is the term used to refer to ineffectual straining at stool. Azotorrhea is the term used to refer to excess of nitrogenous matter in the feces or urine. Diverticulitis refers to inflammation of a diverticulum from obstruction (by fecal matter) resulting in abscess formation.

Which is the best method for evaluation and treatment of large intestine polyps? A. Sigmoidoscopy B. Barium enema C. Digital examination D. Colonoscopy

D. Colonoscopy Colonoscopy is preferred because it allows evaluation of the total colon and polyps can be immediately removed. Only polyps in the distal colon and rectum can be detected and removed during sigmoidoscopy.

The patient underwent liver transplantation. Which finding is of most concern to you 5 days after the operation? A. Glucose: 140 mg/dL B. Reports feeling weakness C. Reports nausea D. Temperature: 100.4° F (38° C).

D. Temperature: 100.4° F (38° C).

During the assessment of a client with acute pancreatitis the nurse notes a decrease in breath sounds bilaterally in the lung bases. What should the nurse do with this information? a Document the finding. b Increase the client's intravenous fluids. c Report the information to the physician. d Encourage the client to use the incentive spirometer.

c Atelectasis may result from decreased diaphragmatic excursion because of abdominal distention or from direct injury from exposure to pancreatic enzymes.

Which of the following interventions should the nurse include in the client's plan of care to prevent complications associated with TPN administered through a central line? 1. Use a clean technique for all dressing changes. 2. Tape all connections of the system. 3. Encourage bed rest. 4. Cover the insertion site with a moisture-proof dressing.

2. Complications associated with administration of TPN through a central line include infection and air embolism. To prevent these complications, strict aseptic technique is used for all dressing changes, the insertion site is covered with an air-occlusive dressing, and all connections of the system are taped. Ambulation and activities of daily living are encouraged and not limited during the administration of TPN.

The nurse is changing the subclavian dressing of a client who is receiving total parenteral nutrition. When assessing the catheter insertion site, the nurse notes the presence of yellow drainage from around the sutures that are anchoring the catheter. Which action should the nurse take first? 1. Clean the insertion site and redress the area. 2. Document assessment findings in the client's chart. 3. Obtain a culture specimen of the drainage. 4. Notify the physician.

3. The nurse should first obtain a culture specimen. The presence of drainage is a potential indication of an infection and the catheter may need to be removed. A culture specimen should be obtained and sent for analysis so that treatment can be promptly initiated. Since removing the catheter will be required in the presence of an infection, the nurse would not clean and redress the area. After the culture report is obtained, the nurse should notify the physician and document all assessments and client care activities in the client's record.

Which of the following medications used for the treatment of obesity prevents the reuptake of serotonin and norepinephrine? a) Sibutramine hydrochloride (Meridia) b) Orlistat (Xenical) c) Bupropion hydrochloride (Wellbutrin) d) Fluoxetine hydrochloride (Prozac)

A) Sibutramine hydrochloride (Meridia) Sibutramine hydrochloride (Meridia) inhibits the reuptake of serotonin and norepinephrine. Meridia decreases appetite. Orlistat (Xenical) prevents the absorption of triglycerides. Side effects of Xenical may include increased bowel movements, gas with oily discharge, decreased food absorption, decreased bile flow, and decreased absorption of some vitamins. Bupropion hydrochloride (Wellbutrin) is an antidepressant medication. Fluoxetine hydrochloride (Prozac) has not been approved by the FDA for use in the treatment of obesity.

The nurse is reviewing the record of a female client with Crohn's disease. Which stool characteristics should the nurse expect to note documented in the client's record? a. Diarrhea b. Chronic constipation c. Constipation alternating with diarrhea d. Stools constantly oozing form the rectum

Answer A. Crohn's disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options B, C, and D are not characteristics of Crohn's disease.

A female client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurse's best response? "A. "You may have eaten contaminated restaurant food." b. "You could have gotten it by using I.V. drugs." c. "You must have received an infected blood transfusion." d. "You probably got it by engaging in unprotected sex.""

Answer A. Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming food contaminated by infected food handlers. The virus isn't transmitted by the I.V. route, blood transfusions, or unprotected sex. Hepatitis B can be transmitted by I.V. drug use or blood transfusion. Hepatitis C can be transmitted by unprotected sex.

"When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? "a. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. b. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. c. The appendix may develop gangrene and rupture, especially in a middle-aged client. d. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage."

Answer B. A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Geriatric, not middle-aged, clients are especially susceptible to appendix rupture.

The nurse is preparing a discharge teaching plan for the male client who had umbilical hernia repair. What should the nurse include in the plan? a. Irrigating the drain b. Avoiding coughing c. Maintaining bed rest d. Restricting pain medication

Answer B. Coughing is avoided following umbilical hernia repair to prevent disruption of tissue integrity, which can occur because of the location of this surgical procedure. Bed rest is not required following this surgical procedure. The client should take analgesics as needed and as prescribed to control pain. A drain is not used in this surgical procedure, although the client may be instructed in simple dressing changes.

Nurse Joy is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse would: a. Position the client supine to assist in medication absorption b. Aspirate the nasogastric tube after medication administration to maintain patency c. Clamp the nasogastric tube for 30 minutes following administration of the medication d. Change the suction setting to low intermittent suction for 30 minutes after medication administration

Answer C. If a client has a nasogastric tube connected to suction, the nurse should wait up to 30 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered. The client should not be placed in the supine position because of the risk for aspiration.

A nurse is preparing to remove a nasogartric tube from a female client. The nurse should instruct the client to do which of the following just before the nurse removes the tube? a. Exhale b. Inhale and exhale quickly c. Take and hold a deep breath d. Perform a Valsalva maneuver

Answer C. When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep breath. This will close the epiglottis. This allows for easy withdrawal through the esophagus into the nose. The nurse removes the tube with one smooth, continuous pull.

A client post-hemorrhoidectomy feels the need to have a bowel movement. Which action by the nurse is best? a. Have the client use the bedside commode. b. Stay with the client, providing privacy. c. Make sure toilet paper and the call light are in reach. d. Plan to send a stool sample to the laboratory.

B The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure needed items are within reach is an important nursing action too, but it does not take priority over client safety. The other two actions are not needed in this situation.

Patients with chronic liver dysfunction have problems with insufficient vitamin intake. Which of the following may occur as a result of vitamin C deficiency? a) Hypoprothrombinemia b) Scurvy c) Beriberi d) Night blindness

B) Scurvy Scurvy may result from a vitamin C deficiency. Night blindness, hypoprothrombinemia, and beriberi do not result from a vitamin C deficiency.

A client with appendicitis is experiencing excruciating abdominal pain. An abdominal X-ray film reveals intraperitoneal air. The nurse should prepare the client for: a) colonoscopy. b) surgery. c) nasogastric (NG) tube insertion. d) barium enema.

B) Surgery The client should be prepared for surgery because his signs and symptoms indicate bowel perforation. Appendicitis is the most common cause of bowel perforation in the United States. Because perforation can lead to peritonitis and sepsis, surgery wouldn't be delayed to perform other interventions, such as colonoscopy, NG tube insertion, or a barium enema. These procedures aren't necessary at this point.

The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate post-op period for which of the following most frequent complications of this type of surgery? A. Intestinal obstruction B. Fluid and electrolyte imbalance C. Malabsorption of fat D. Folate deficiency

B. A major complication that occurs most frequent following an ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from happening. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.

During the first few days of recovery from ostomy surgery for ulcerative colitis, which of the following aspects should be the first priority of client care? A. Body image B. Ostomy care C. Sexual concerns D. Skin care

B. Although all of these are concerns the nurse should address, being able to safely manage the ostomy is crucial for the client before discharge.

A male client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note: a. severe abdominal pain radiating to the shoulder. b. anorexia, nausea, and vomiting. c. eructation and constipation. d. abdominal ascites.

B. Hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and weakness. Abdominal pain may occur but doesn't radiate to the shoulder. Eructation (belching) and constipation are common in gallbladder disease, not hepatitis A. Abdominal ascites is a sign of advanced hepatic disease, not an early sign of hepatitis A.

Which preoperative teaching is the highest priority for a 68-year-old patient scheduled for a colectomy? A. How to care for the wound B. How to breathe deeply and cough C. The location and care of drains after surgery D. Which medications will be used during surgery

B. How to breathe deeply and cough Because anesthesia, an abdominal incision, and pain can impair the patient's respiratory status in the postoperative period, it is essential to teach the patient to cough and breathe deeply.

Which assessment finding in a patient with acute pancreatitis is most important for you to follow-up? A. Gray Turner's sign B. Positive Trousseau's sign C. White blood cell count 11,000/μL D. Elevated lipase levels

B. Positive Trousseau's sign Rationale Positive Trousseau's sign indicates systemic hypocalcemia, which should be treated emergently with calcium gluconate (as ordered). Gray Turner's sign is a bluish flank discoloration or ecchymoses from the bloody exudate of the pancreatic autodigestion. Although it is an indication of more severe pancreatitis, the symptom of systemic calcium deficiency takes priority. Signs of systemic inflammation are anticipated with pancreatitis and do not require specific treatment for that finding. Elevated amylase and lipase levels are how the disease is diagnosed and do not require a direct intervention. Reference: 1092

15. Which of the following factors is believed to cause ulcerative colitis? A. Acidic diet B. Altered immunity C. Chronic constipation D. Emotional stress

B. Several theories exist regarding the cause of ulcerative colitis. One suggests altered immunity as the cause based on the extraintestinal characteristics of the disease, such as peripheral arthritis and cholangitis. Diet and constipation have no effect on the development of ulcerative colitis. Emotional stress can exacerbate the attacks but isn't believed to be the primary cause.

The nurse is caring for a client who is scheduled to have fecal occult blood testing. Which instructions does the nurse give to the client? a. "You must fast for 12 hours before the test." b. "You will be given a cleansing enema the morning of the test." c. "You must avoid eating meat for 48 hours before the test." d. "You will be sedated and will require someone to accompany you home."

C The client is instructed to avoid meat, aspirin, vitamin C, and anti-inflammatory drugs for 48 hours before the test. The other directions are not accurate for this test.

A patient is scheduled to receive "Colace 100 mg PO." The patient asks to take the medication in liquid form, and the nurse obtains an order for the interchange. Available is a syrup that contains 150 mg/15 ml. How many milliliters does the nurse administer? A) 3 B) 5 C) 10 D) 12

C) 10 mL The concentration of the syrup is 10 mg/ml. Therefore, a 100-mg dose necessitates 10 ml.

Which of the following factors is believed to be linked to Crohn's disease? A. Constipation B. Diet C. Hereditary D. Lack of exercise

C. Although the definite cause of Crohn's disease is unknown, it's thought to be associated with infectious, immune, or psychological factors. Because it has a higher incidence in siblings, it may have a genetic cause.

Which of the following medications is most effective for treating the pain associated with irritable bowel disease? A. Acetaminophen B. Opiates C. Steroids D. Stool softeners

C. The pain with irritable bowel disease is caused by inflammation, which steroids can reduce. Stool softeners aren't necessary. Acetaminophen has little effect on the pain, and opiate narcotics won't treat its underlying cause (I feel this is untrue—dilaudid will help anything!)

The physician has determined that the client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? 1. Hep A, 2. Hep B, 3. Hep C, 4. Hep D

Correct 1: Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, D are transmitted more commonly via infected blood or bloody fluids.

"The nurse is caring for a pt. in the emergency department with complaints of acute abdominal pain, nausea, and vomiting. When the nurse palpates the patient's left lower abdominal quadrant, the pt. complains of pain in the right lower quadrant. The nurse will document this as which of the following signs of appendicitis? A. Rovsing sign B. Referred pain C. Chvostek's sign D. Rebound tenderness"

Correct Answer A In patients with suspected appendicitis, Rovsing sign may be elicited by palpation of the left lower quadrant, causing pain to be felt in the right lower quadrant.

The nurse is caring for the following clients on a surgical unit. Which client would the nurse assess first? 1.The client who had an inguinal hernia repair and has not voided in four (4) hours. 2.The client who was admitted with abdominal pain who suddenly has no pain. 3.The client four (4) hours postoperative abdominal surgery with no bowel sounds. 4.The client who is one (1) day postoperative appendectomy who is being discharged"

Correct: 2 "1. A client who has not voided within four (4)hours after any surgery would not be priority. This is an acceptable occurrence, but if the client hasn't voided for eight (8) hours, then the nurse would assess further. 2.This could indicate a ruptured appendix, which could lead to peritonitis, a life-threatening complication; therefore, thenurse should assess this client first. 3.Bowel sounds should return within 24 hoursafter abdominal surgery. Absent bowel soundsat four (4) hours postoperative would not beof great concern to the nurse 4.The client being discharged would be stableand not a priority for the nurse"

A female client is admitted with an exacerbation of ulcerative colitis. Which laboratory value does the nurse correlate with this condition? a. Potassium, 5.5 mEq/L b. Hemoglobin, 14.2 g/dL c. Sodium, 144 mEq/L d. Erythrocyte sedimentation rate (ESR), 55 mm/hr

D The erythrocyte sedimentation rate (ESR) is an indicator of inflammation, which is elevated during an exacerbation of ulcerative colitis. The normal range for the ESR is 0 to 33 mm/hr. Diarrhea caused by ulcerative colitis will result in loss of potassium and hypokalemia with levels lower than 3.5 mEq/L. Bloody diarrhea will lead to anemia, with hemoglobin levels lower than 12 g/dL in females. The sodium level is normal.

The nurse is preparing to administer a scheduled dose of docusate sodium (Colace) when the patient reports an episode of loose stool and does not want to take the medication. What is the appropriate action by the nurse? A. Write an incident report about this untoward event. B. Attempt to have the family convince the patient to take the ordered dose. C. Withhold the medication at this time and try to administer it later in the day. D. Chart the dose as not given on the medical record and explain in the nursing progress notes.

D Whenever a patient refuses medication, the dose should be charted as not given with an explanation of the reason documented in the nursing progress notes. In this instance, the refusal indicates good judgment by the patient, and the patient should not be encouraged to take it today

Which area of the alimentary canal is the most common location for Crohn's disease? A. Ascending colon B. Descending colon C. Sigmoid colon D. Terminal ileum

D. Studies have shown that the terminal ileum is the most common site for recurrence in clients with Crohn's disease. The other areas may be involved but aren't as common.

A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B? a. A 20-year-old college student who has had several sexual partners b. A 46-year-old woman who takes acetaminophen daily for headaches c. A 63-year-old businessman who travels frequently across the country d. An 82-year-old woman who recently ate raw shellfish for dinner

Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route. A person with multiple sexual partners has more opportunities to contract the infection. Hepatitis B is not transmitted through medications, casual contact with other travelers, or raw shellfish. Although an overdose of acetaminophen can cause liver cirrhosis, this is not associated with hepatitis B. Hepatitis E is found most frequently in international travelers. Hepatitis A is spread through ingestion of contaminated shellfish.

A patient who has hepatitis B surface antigen (HBsAg) in the serum is being discharged with pain medication after knee surgery. Which medication order should the nurse question because it is most likely to cause hepatic complications? Tramadol (Ultram) Hydromorphone (Dilaudid) Oxycodone with aspirin (Percodan) Hydrocodone with acetaminophen (Vicodin)

Hydrocodone with acetaminophen (Vicodin) The analgesic with acetaminophen should be questioned because this patient is a chronic carrier of hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage.

The nurse is preparing to insert a nasogastric (NG) tube into a 68-year-old female patient who is nauseated and vomiting. She has an abdominal mass and suspected small intestinal obstruction. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate? a. "The tube will help to drain the stomach contents and prevent further vomiting." b. "The tube will push past the area that is blocked and thus help to stop the vomiting." c. "The tube is just a standard procedure before many types of surgery to the abdomen." d. "The tube will let us measure your stomach contents so that we can plan what type of IV fluid replacement would be best."

a. "The tube will help to drain the stomach contents and prevent further vomiting." The NG tube is used to decompress the stomach by draining stomach contents and thereby prevent further vomiting. The NG tube will not push past the blocked area. Potential surgery is not currently indicated. The location of the obstruction will determine the type of fluid to use, not measure the amount of stomach contents.

Which of the following diagnostic tests may be performed to determine if a client has gastric cancer? a Barium enema b Colonoscopy c Gastroscopy d Serum chemistry levels

c A gastroscopy will allow direct visualization of the tumor. A colonoscopy or a barium enema would help diagnose colon cancer. Serum chemistry levels don't contribute data useful to the assessment of gastric cancer.

After eating, a patient with an inflamed gallbladder experiences pain caused by contraction of the gallbladdder. The mechanism responsible for this action is a) production of bile by the liver b) production of secretin by the duodenum c) release of gastrin from the stomach antrum d) production of cholecystokinin by the duodenum

d) production of cholecystokinin by the duodenum Cholecystokinin is secreted by the duodenal mucosa when fats and amino acids enter the duodenum and stimulates the gallbladder to release bile and emulsify the fats for digestion. The bile is produced by the liver but stored in the gallbladder. Secretin is responsible for stimulating pancreatic bicarbonate secretion, and gastrin increases gastric motility and acid secretion.

A nurse cares for a client with ulcerative colitis. The client states, "I feel like I am tied to the toilet. This disease is controlling my life." How should the nurse respond?

"Let's discuss potential factors that increase your symptoms."

A nurse cares for a client with a new ileostomy. The client states, "I don't think my friends will accept me with this ostomy." How should the nurse respond?

"tell me more about your concerns"

A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.)

- Distended abdomen - Inability to pass flatus - Decreased urine output

A patient is hospitalized with metastatic cancer of the liver. The nurse plans care for the patient based on the knowledge that a. chemotherapy is highly successful in the treatment of liver cancer b. the patient will undergo surgery to remove the involved portions of the liver c. supportive care that is appropriate for all patient with severe liver damage is indicated. d. metastatic cancer of the liver is more responsive to treatment than primary carcinoma of the liver

...

You're caring for Jane, a 57 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Before her paracentesis, you instruct her to: 1 Empty her bladder. 2 Lie supine in bed. 3 Remain NPO for 4 hours. 4 Clean her bowels with an enema

1. A full bladder can interfere with paracentesis and be punctured inadvertently

A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient's blood pressure because of which change that is associated with the liver failure? 1 Hypoalbuminemia 2 Increased capillary permeability 3 Abnormal peripheral vasodilation 4 Excess rennin release from the kidneys

1. Blood pressure decreases as the body is unable to maintain normal oncotic pressure with liver failure, so patients with liver failure require close blood pressure monitoring. Increased capillary permeability, abnormal peripheral vasodilation, and excess rennin released from the kidney's aren't direct ramifications of liver failure.

Which of the following statements about nasoenteric tubes is correct? 1. The tube cannot be attached to suction. 2. The tube contains a soft rubber bag filled with mercury. 3. The tube is taped securely to the client's cheek after insertion. 4. The tube can have its placement determined only by auscultation.

2. A nasoenteric tube has a small balloon at its tip that is weighted with mercury. The weight of the mercury helps advance the tube by gravity through the intestine. Nasoenteric tubes are attached to suction. A nasoenteric tube is not taped in position until it has reached the obstruction. Because the tube has a radiopaque strip, its progress through the intestinal tract can be followed by fluoroscopy.

Which client does the charge nurse assign to an experienced LPN/LVN?

30 year old who needs to receive neomycin sulfate before colectomy

An intensive care unit (ICU) RN is "floated" to the medical-surgical unit. Which client does the charge nurse assign to the float nurse?

36 year old with peritonitis who just returned from surgery with multiple drains in place

The nurse has an order to administer sulfasalazine (Azulfidine) 2 g. The medication is available in 500-mg tablets. How many tablets should the nurse administer? ________________________ tablets.

4 tablets To administer 2 g sulfasalazine (Azulfidine), the nurse will need to administer 4 tablets.

The school nurse is discussing ways to prevent an outbreak of hepatitis A with a groupof high school teachers. Which action is the most important intervention that theschool nurse must explain to the school teachers? "1.Do not allow students to eat or drink after each other.2.Drink bottled water as much as possible.3.Encourage protected sexual activity.4.Thoroughly wash hands."

4. Thoroughly wash hands.

Which is the most common cause of fulminant hepatic failure? A. Alcohol with acetaminophen (Tylenol) B. Food poisoning C. Hepatitis A D. SIRS and sepsis

A. Alcohol with acetaminophen (Tylenol)

53. The nurse is admitting a 67-year-old patient with new-onset steatorrhea. Which question is most important for the nurse to ask? a. "How much milk do you usually drink?" b. "Have you noticed a recent weight loss?" c. "What time of day do your bowels move?" d. "Do you eat meat or other animal products?"

ANS: B Although all of the questions provide useful information, it is most important to determine if the patient has an imbalance in nutrition because of the steatorrhea.

A nurse cares for an older adult client who has Salmonella food poisoning. The client's vital signs are heart rate: 102 beats/min, blood pressure: 98/55 mm Hg, respiratory rate: 22 breaths/min, and oxygen saturation: 92%. Which action should the nurse complete first?

Administer intravenous fluids.

A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings? Malnutrition Osteomyelitis Alcohol abuse Diabetes mellitus

Alcohol abuse The patient with alcohol abuse could develop pancreatitis as a complication, which would increase the serum amylase (normal 30-122 U/L) and serum lipase (normal 31-186 U/L) levels as shown.

Which priority teaching information should the nurse discuss with the client to help prevent contracting hep. B? 1.Explain the importance of good hand washing. 2.Tell the client to take the hepatitis B vaccine in three (3) doses. 3.Tell the client not to ingest unsanitary food or water. 4.Discuss how to implement standard precautions.

Answer 1 would be appropriate for prevention of hepatitis A.

The nurse is caring for a female client following a Billroth II procedure. Which postoperative order should the nurse question and verify? a. Leg exercises b. Early ambulation c. Irrigating the nasogastric tube d. Coughing and deep-breathing exercises

Answer C. In a Billroth II procedure, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically ordered by the physician. In this situation, the nurse should clarify the order. Options A, B, and D are appropriate postoperative interventions.

A school-aged child has an emergency appendectomy. The nurse should report which of the following to the HCP if notes in the immediate postoperative period. 1. abdominal pain, 2. tugging at the incision line, 3. thirst, 4 a rigid abdomen

Answer: 4 Rationale: A tense, rigid abdomen is an early symptom of peritonitis. The other findings are expected in the immediate postoperative period.

"A patient with hepatitis A is in the acute phase. The nurse plans to care for the patient based on the knowledge that "A. pruritus is a common problem with jaundice in this phase. B. the patient is most likely to transmit the disease in this phase. C. gastrointestinal symptoms are not as severe in hepatitis A as they are in hepatitis B. D. extrahepatic manifestations of glomerulonephritis and polyarteritis are common in this phase.

Answer: A" The acute phase of jaundice may be icteric (i.e., symptomatic, including jaundice) or anicteric. Jaundice results when bilirubin diffuses into the tissues. Pruritus sometimes accompanies jaundice. Pruritus is the result of an accumulation of bile salts beneath the skin.

A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, "I am having trouble swallowing this pill." Which action should the nurse take?

Ask the health care provider to prescribe the medication as an enema instead.

A male client 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)?

Assisting the client to stand to void

A nurse is teaching a client with Crohn's disease (CD) about managing the disease with the drug adalimumab (Humira). Which instruction does the nurse emphasize to the client?

Avoid large crowds and anyone who is sick

A patient has been told that she has elevated liver enzymes caused by NAFLD. What should the nursing teaching plan include? A. Having genetic testing done B. Recommending a heart-healthy diet C. The necessity to reduce weight rapidly D. Avoiding alcohol until liver enzymes return to normal

B. Recommending a heart-healthy diet

A client with irritable bowel syndrome is being prepared for discharge. Which of the following meal plans should the nurse give the client? A. Low fiber, low-fat B. High fiber, low-fat C. Low fiber, high-fat D. High-fiber, high-fat

B. The client with irritable bowel syndrome needs to be on a diet that contains at least 25 grams of fiber per day. Fatty foods are to be avoided because they may precipitate symptoms.

After teaching a client with diverticular disease, a nurse assesses the client's understanding. Which menu selection made by the client indicates the client correctly understood the teaching?

Baked fish with steamed carrots and a glass of apple juice

After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I cannot drink any alcohol at all anymore." b. "I need to avoid protein in my diet." c. "I should not take over-the-counter medications." d. "I should eat small, frequent, balanced meals."

Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client

When patients undergo diagnostic tests of the GI system The nurse is aware that the elderly patient must be closely monitored for : a. diarrhea b. nausea and vomiting c. electrolyte imbalances and dehydration d. constipation.

C

The patient receiving chemotherapy rings the call bell and reports an onset of nausea. The nurse should prepare a prn dose of which of the following medications? A) Morphine sulfate B) Zolpidem (Ambien) C) Ondansetron (Zofran) D) Dexamethasone (Decadron)

C) Ondansetron (Zofran) Ondansetron is a 5-HT3 receptor antagonist antiemetic that is especially effective in reducing cancer chemotherapy-induced nausea and vomiting.

Following bowel resection, a patient has a nasogastric tube to suction, but complains of nausea and abdominal distention. The nurse irrigates the tube prn as ordered, but the irrigating fluid does not return. Which of the following should be the priority action by the nurse? A) Notify the physician. B) Auscultate for bowel sounds. C) Reposition the tube and check for placement. D) Remove the tube and replace it with a new one.

C) Reposition the tube and check for placement The tube may be resting against the stomach wall. The first action by the nurse, since this intestinal surgery (not gastric surgery), is to reposition the tube and check it again for placement.

Which of the following diagnostic tests may be performed to determine if a client has gastric cancer? A. Barium enema B. Colonoscopy C. Gastroscopy D. Serum chemistry levels

C. A gastroscopy will allow direct visualization of the tumor. A colonoscopy or a barium enema would help diagnose colon cancer. Serum chemistry levels don't contribute data useful to the assessment of gastric cancer.

The patient had an ileostomy 4 days earlier and has a daily drainage of 1800 mL. What action should you take? A. Notify the primary provider. B. Send a specimen to the laboratory. C. Document the findings. D. Test the stool for occult blood.

C. Document the findings. With an ileostomy, the volume of drainage is high (1000 to 1800 mL/day) after peristalsis returns because the adsorptive functions provided by the colon and the delay provided by the ileocecal valve have been altered.

"When planning care for a patient with cirrhosis, the nurse will give highest priority to which of the following nursing diagnoses? A: Imbalanced nutrition: less than body requirements B: Impaired skin integrity related to edema, ascites, and pruritis C: Ecess fluid volume related to portal hypertension and hyperaldosteronism D: Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

CORRECT: D Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, AIRWAY and BREATHING are always the highest priorities.

A client with a bowel obstruction is requested a nasogastric (NG) tube. After the nurse inserts the tube, which nursing intervention is the highest priority for this client?

Connecting the tube to low intermittent suction

Colon cancer is most closely associated with which of the following conditions? A. Appendicitis B. Hemorrhoids C. Hiatal hernia D. Ulcerative colitis

D. Chronic ulcerative colitis, granulomas, and familial polposis seem to increase a person's chance of developing colon cancer. The other conditions listed have no known effect on colon cancer risk.

True or False? Obsruction of the biliary tract is indicated by increased unconjugated (indirect) bilirubin levels in the blood.

False Obsruction of the biliary tract is indicated by increased conjugated (direct) bilirubin levels in the blood.

True or False? The structure that prevents reflux of stomach contents into the esophagus is the upper esophageal sphincter.

False The structure that prevents reflux of stomach contents into the esophagus is the lower esophageal sphincter.

A client 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?

Has another client with a stoma who performs self care come and talk with the client

A client with irritable bowel syndrome (IBS) is constipated. The nurse instructs the client about a management plan. Which client statement shows an accurate understanding of the nurse's teaching?

I need to go for a walk every evening

B

In contrast to diverticulitis, the patient with diverticulosis: A. has rectal bleeding B. often has no symptoms C. has localized cramping pain D. frequently develops peritonitis

C

In planning care for the patient with Crohn's disease, the nurse recognizes that a major difference between ulcerative colitis and Crohn's disease is that Crohn's disease: A. frequently results in toxic megacolon B. causes fewer nutritional deficiencies than does ulcerative colitis C. often recurs after surgery, whereas ulcerative colitis is curable with a colectomy D. is manifested by rectal bleeding and anemia more frequently than is ulcerative colitis

When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? Impaired skin integrity related to edema, ascites, and pruritus Imbalanced nutrition: less than body requirements related to anorexia Excess fluid volume related to portal hypertension and hyperaldosteronism Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.

A nurse is reviewing laboratory test results from a client. The report indicates that the client has jaundice. What serum bilirubin level must the client's finding exceed? Enter the correct number only.

Jaundice becomes clinically evident when the serum bilirubin level exceeds 2.5 mg/dL (43 fmol/L).

A client has newly diagnosed ulcerative colitis (UC). What does the nurse tell the client about diet and lifestyle choices?

Lactose containing foods should be reduced or eliminated from your diet

patient with type 2 diabetes and cirrhosis asks the nurse if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge? Milk thistle may affect liver enzymes and thus alter drug metabolism. Milk thistle is generally safe in recommended doses for up to 10 years. There is unclear scientific evidence for the use of milk thistle in treating cirrhosis. Milk thistle may elevate the serum glucose levels and is thus contraindicated in diabetes.

Milk thistle may affect liver enzymes and thus alter drug metabolism. There is good scientific evidence that there is no real benefit from using milk thistle to protect the liver cells from toxic damage in the treatment of cirrhosis. Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore patients will need to be monitored for drug interactions. It is noted to be safe for up to 6 years, not 10 years, and it may lower, not elevate, blood glucose levels.

A client with malabsorption syndrome asks the nurse, "What did I do to cause this disorder to develop?" How does the nurse respond?

Nothing you did could have caused it; it is the result of flattening of the mucosa of your large intestine

A nurse cares for a client who is recovering from an open Whipple procedure. Which action should the nurse take? a. Clamp the nasogastric tube. b. Place the client in semi-Fowler's position. c. Assess vital signs once every shift. d. Provide oral rehydration.

Postoperative care for a client recovering from an open Whipple procedure should include placing the client in a semi-Fowler's position to reduce tension on the suture line and anastomosis sites, setting the nasogastric tube to low suction to remove free air buildup and pressure, assessing vital signs frequently to assess fluid and electrolyte complications, and providing intravenous fluids.

A client with an intestinal obstruction has pain that changes from a "colicky" intermittent type to constant discomfort. What does the nurse do first?

Prepares the client for emergency surgery. The change in pain type could be indicative of perforation or peritonitis and will require immediate surgical intervention

After an abdominoperineal resection, a 75-year-old client is referred to a home health agency. Which staff member does the nurse manager assign to perform the initial assessment on this client?

RN who is new to the agency with 5 years experience in the ED

A 67-year-old male client 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?

Reducible

A nurse cares for a client who has food poisoning resulting from a Clostridium botulinum infection. Which assessment should the nurse complete first?

Respiratory rate

A client with an exacerbation of ulcerative colitis (UC) has been prescribed a low-residue diet. Which meal does the nurse help the client select?

Scrambled eggs, white toast with margarin

A nurse reviews the chart of a client who has Crohn's disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions?

Serum potassium of 2.6 mEq/L

A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find?

Severe, steady right lower quadrant pain

After an automobile accident, a client is admitted to the emergency department (ED) with possible abdominal trauma. Which health care provider request does the nurse implement first?

Starts an IV line and infuses normal saline at 200 mL/hr

A nurse assesses a client who is hospitalized for botulism. The client's vital signs are temperature: 99.8° F (37.6° C), heart rate: 100 beats/min, respiratory rate: 10 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take?

Stay with the client while another nurse calls the provider.

A 21-year-old with a stab wound to the abdomen has come to the emergency department (ED). Once stabilized, the client is admitted to a medical-surgical unit. What does the admitting nurse do first for this client?

Take vital signs

A client with colorectal cancer (CRC) is scheduled for colostomy surgery. Which comment from the nurse is most therapeutic for this client?

Tell me what worries you the most about this procedure

A

The nurse determines that the goals of dietary teaching have been met when the patient with celiac disease selects from the menu: A. scrambled eggs and sausage B. buckwheat pancake and syrup C. oatmeal, skim milk, and OJ D. yogurt, strawberries and rye toast with butter

A

The nurse explains to the patient undergoing ostomy surgery that the procedure that maintain the most normal functioning of the bowel is: A. a sigmoid colostomy B. a transverse colostomy C. a descending colostomy D. an ascending colostomy

A, C

The nurse performs a detailed assessment of the abdomen of a patient with a possible bowel obstruction, knowing that a manifestation of an obstruction in the large intestine is (select all that apply): A. a largely distended abdomen B. diarrhea that is loose or liquid C. persistent, colicky abdominal pain D. profuse vomiting that relieves abdominal pain

B

The nurse would increase the comfort of a patient with appendicitis by: A. having the patient lie prone B. flexing the patient's right knee C. sitting the patient upright in a chair D. turning the patient onto his left side

A client has an anal fissure. Which nursing intervention most effectively promotes perineal comfort for the client?

Using witch hazel wipes to relieve pain

When a 35-year-old female patient is admitted to the emergency department with acute abdominal pain, which possible diagnosis should you consider that may be the cause of her pain (select all that apply)? a. Gastroenteritis b. Ectopic pregnancy c. GI bleeding d. Irritable bowel syndrome e. Inflammatory bowel disease

a, b, c, d & e Rationale: All these conditions could cause acute abdominal pain.

The nurse is concerned that a 45-year-old female client with cholelithiasis will develop acute pancreatitis. Why is the nurse concerned? select all that apply a Because the client is a female. b The nurse is wrong because acute pancreatitis is seen in alcoholic syndrome. c Because the client has gallstones. d A triglyceride level should be drawn before coming to this conclusion. e A calcium level should be drawn before coming to this conclusion. f The nurse is wrong because acute pancreatitis is more prevalent in males.

a, c Gallstone-produced pancreatitis is more common in women.

Which of the following diets is most commonly associated with colon cancer? a Low-fiber, high fat b Low-fat, high-fiber c Low-protein, high-carbohydrate d Low carbohydrate, high protein

a. A low-fiber, high-fat diet reduced motility and increases the chance of constipation. The metabolic end products of this type of diet are carcinogenic. A low-fat, high-fiber diet is recommended to prevent colon cancer.

Assessment findings suggestive of peritonitis include a. rebound abdominal pain b. a soft, distended abdomen c. dull, continuous abdominal pain d. observing that the patient is restless

a. rebound abdominal pain Rationale: With peritoneal irritation, the abdomen is hard, like a board, and the patient has severe abdominal pain that is worse with any sudden movement. The patient lies very still. Palpating the abdomen and releasing the hands suddenly causes sudden movement within the abdomen and severe pain. This is called rebound tenderness.

Excessive fluid continues to be reabsorbed from the kidney because of the altered kidney perfusion and because ___________ is not metabolized by the impaired liver

aldosterone

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate? a Notify the physician b Document the findings c Irrigate the T-tube d Clamp the T-tube

b. Following cholecystectomy, drainage from the T-tube is initially bloody and then turns to green-brown. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 ml per day. The nurse would document the output.

A risk factor associated with cancer of the pancreas is a. alcohol intake b. cigarette smoking c. exposure to asbestos d. increased dietary intake of milk and milk products

b. cigarette smoking

A client with gastric cancer may exhibit which of the following symptoms? a Abdominal cramping b Constant hunger c Feeling of fullness d Weight gain

c. The client with gastric cancer may report a feeling of fullness in the stomach, but not enough to cause him to seek medical attention. Abdominal cramping isn't associated with gastric cancer. Anorexia and weight loss (not increased hunger or weight gain) are common symptoms of gastric cancer.

Following laparoscopic cholecystectomy, the nurse would expect the patient to a. return to work in 2 to 3 weeks b. be hospitalized for 3 to 5 days postoperatively c. have four small abdominal incisions covered with small dressings d. have a T tube placed in the common bile duct to provide bile drainage

c. have four small abdominal incisions covered with small dressings

A client is diagnosed with an infected pancreatic abscess. Which of the following procedures should the nurse prepare this client for? a Surgery b Pancreatic angiography c ERCP d Percutaneous drainage

d Pancreatic abscess is treated by percutaneous drainage.

The nurse is preparing to administer a scheduled dose of docusate sodium (Colace) when the patient reports an episode of loose stool and does not want to take the medication. What is the appropriate action by the nurse? a. Write an incident report about this untoward event. b. Attempt to have the family convince the patient to take the ordered dose. c. Withhold the medication at this time and try to administer it later in the day. d. Chart the dose as not given on the medical record and explain in the nursing progress notes.

d. Chart the dose as not given on the medical record and explain in the nursing progress notes. Whenever a patient refuses medication, the dose should be charted as not given with an explanation of the reason documented in the nursing progress notes. In this instance, the refusal indicates good judgment by the patient, and the patient should not be encouraged to take it today.

When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend? a. White bread, cheese, and green beans b. Fresh tomatoes, pears, and corn flakes c. Oranges, baked potatoes, and raw carrots d. Dried beans, All Bran (100%) cereal, and raspberries

d. Dried beans, All Bran (100%) cereal, and raspberries A high fiber diet is recommended for diverticular disease. Dried beans, All Bran (100%) cereal, and raspberries all have higher amounts of fiber than white bread, cheese, green beans, fresh tomatoes, pears, corn flakes, oranges, baked potatoes, and raw carrots.

The nurse would question the use of which cathartic agent in a patient with renal insufficiency? a. Bisacodyl (Dulcolax) b. Lubiprostone (Amitiza) c. Cascara sagrada (Senekot) d. Magnesium hydroxide (Milk of Magnesia)

d. Magnesium hydroxide (Milk of Magnesia) Milk of Magnesia may cause hypermagnesemia in patients with renal insufficiency. The nurse should question this order with the health care provider. Bisacodyl, lubiprostone, and cascara sagrada are safe to use in patients with renal insufficiency as long as the patient is not currently dehydrated.

What should the nurse instruct the patient to do to best enhance the effectiveness of a daily dose of docusate sodium (Colace)? a. Take a dose of mineral oil at the same time. b. Add extra salt to food on at least one meal tray. c. Ensure dietary intake of 10 g of fiber each day. d. Take each dose with a full glass of water or other liquid.

d. Take each dose with a full glass of water or other liquid. Docusate lowers the surface tension of stool, permitting water and fats to penetrate and soften the stool for easier passage. The patient should take the dose with a full glass of water and should increase overall fluid intake, if able, to enhance effectiveness of the medication. Dietary fiber intake should be a minimum of 20 g daily to prevent constipation. Mineral oil and extra salt are not recommended.

Fluid moves into the abdominal cavity, producing ascited because of decreased serum oncotic coloidal pressure. The decreased serum oncotic pressure is cause by __________________

decreased albumin production

The change in CO results in ___________ kidney perfusion and secretion of _________ and ___________, both of which increased fluid retention.

decreased, aldosterone, antidiuretic hormone (ADH)

A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this client's plan of care?

skin protection

An 80-year-old client with a 2-day history of myalgia, nausea, vomiting, and diarrhea is admitted to a medical-surgical unit with a diagnosis of gastroenteritis. Which health care provider request does the nurse implement first?

start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr

The nurse would assess the client experiencing an acute episode of cholecysitis for pain that is located in the right a Upper quadrant and radiates to the left scapula and shoulder b Upper quadrant and radiates to the right scapula and shoulder c Lower quadrant and radiates to the umbilicus d Lower quadrant and radiates to the back

b. During an acute "gallbladder attack," the client may complain of severe right upper quadrant pain that radiates to the right scapula and shoulder. This is governed by the pattern on dermatones in the body.

"Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? "1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D"

"Correct answer: 1 Rationale: 1. The hepatitis A virus is in the stool of infected people for up to 2 weeks before symptoms develop 2. Hepatitis B is spread through contact with infected blood and body fluids 3. Hepatitis C is transmitted through contact with infected blood and body fluids 4. Hepatitis D infection only causes infection in people who are also infected with Hepatitis B or C"

A client has a total colectomy, and a continent ileostomy is created. Which postoperative instruction does the nurse emphasize to this client?

A small dressing must be worn over the stoma at all times

A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first? a. Sedate the client to prevent tube dislodgement. b. Maintain balloon pressure at 15 and 20 mm Hg. c. Irrigate the gastric lumen with normal saline. d. Assess the client for airway patency.

ANS: D Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration and occlusion of the airway. The client usually is intubated and mechanically ventilated during this treatment. The client should be sedated, balloon pressure should be maintained between 15 and 20 mm Hg, and the lumen can be irrigated with saline or tap water. However, these are not a higher priority than airway patency.

What information would have the highest priority to be included in preoperative teaching for a 68-year-old patient scheduled for a colectomy? a. How to care for the wound b. How to deep breathe and cough c. The location and care of drains after surgery d. Which medications will be used during surgery

b. How to deep breathe and cough Because anesthesia, an abdominal incision, and pain can impair the patient's respiratory status in the postoperative period, it is of high priority to teach the patient to cough and deep breathe. Otherwise, the patient could develop atelectasis and pneumonia, which would delay early recovery from surgery and hospital discharge. Care for the wound and location and care of the drains will be briefly discussed preoperatively, but done again with higher priority after surgery. Knowing which drugs will be used during surgery may not be meaningful to the patient and should be reviewed with the patient by the anesthesiologist.

The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." "I need to take good care of my belly and ankle skin where it is swollen." "A scrotal support may be more comfortable when I have scrotal edema." "I can use pillows to support my head to help me breathe when I am in bed."

"If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." Correct If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider, as this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.

A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications? 1. Deficient fluid volume. 2. Intestinal obstruction. 3. Bowel ischemia. 4. Peritonitis.

4. Complications of acute appendicitis are perforation, peritonitis, and abscess development. Signs of the development of peritonitis include abdominal pain and distention, tachycardia, tachypnea, nausea, vomiting, and fever. Because peritonitis can cause hypovolemic shock, hypotension can develop. Deficient fluid volume would not cause a fever. Intestinal obstruction would cause abdominal distention, diminished or absent bowel sounds, and abdominal pain. Bowel ischemia has signs and symptoms similar to those found with intestinal obstruction.

The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation? A. Maintain a high intake of fluid and fiber in the diet. B. Reduce intake of medications causing constipation. C. Eat several small meals per day to maintain bowel motility. D. Sit upright during meals to increase bowel motility by gravity.

A Increased fluid intake and a high-fiber diet reduce the incidence of constipation caused by immobility, medications, and other factors. Fluid and fiber provide bulk that in turn increases peristalsis and bowel motility. Analgesics taken for lung cancer probably cannot be reduced. Other medications may decrease constipation, but it is best to avoid laxatives. Eating several small meals per day and position do not facilitate bowel motility. Defecation is easiest when the person sits on the commode with the knees higher than the hips.

A patient newly diagnosed with acute hep B asks about drug therapy to treat the disease. The most appropriate response by the nurse is informing the patient that a. there are no specific drugs that are effective for treating acute viral hepatitis b, only chronic hep C is treatable, primarily with antiviral agents and alpha interferon. c. no drugs can be used for treatment of viral hepatitis because of the risk of additional liver damage. d. alpha interferon combined with lamivudine (EPivir) will decrease viral load and liver damage if taken for 1 year

A- No specific drugs are effective in treating acute viral hepatitis, although supportive drugs, such as anti-emetics, sedative, or atipruritics, may be used for symptom control. Antiviral agents, such as lamivudine or ribavirin, and alpha interferon may be used for treating chronic hepatitis B or C.

The patient has hepatic encephalopathy. The patient has the laxative lactulose prescribed but had a bowel movement today. What action should you take? A. Administer medication as prescribed. B. Hold the medication. C. Consult the primary health care provider. D. Check bilirubin before making decision.

A. Administer medication as prescribed. Rationale The goal of management of hepatic encephalopathy is the reduction of ammonia formation. Lactulose traps the ammonia in the gut, and the laxative effect of the drug expels the ammonia. The medication is held only if there is copious diarrhea. Reference: 1078-1079

The client has been admitted with a diagnosis of acute pancreatitis. The nurse would assess this client for pain that is: A. Severe and unrelenting, located in the epigastric area and radiating to the back. B. Severe and unrelenting, located in the left lower quadrant and radiating to the groin. C. Burning and aching, located in the epigastric area and radiating to the umbilicus. D. Burning and aching, located in the left lower quadrant and radiating to the hip.

A. The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back.

32. The nurse is assessing a 31-year-old female patient with abdominal pain. Th nurse,who notes that there is ecchymosis around the area of umbilicus, will document this finding as a. Cullen sign. b. Rovsing sign. c. McBurney sign. d. Grey-Turner's signt.

ANS: B Cullen sign is ecchymosis around the umbilicus. Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. Deep tenderness at McBurney's point (halfway between the umbilicus and the right iliac crest), known as McBurney's sign, is a sign of acute appendicitis.

24. The nurse will determine that teaching a 67-year-old man to irrigate his new colostomy has been effective if the patient a. inserts the irrigation tubing 4 to 6 inches into the stoma. b. hangs the irrigating container 18 inches above the stoma. c. stops the irrigation and removes the irrigating cone if cramping occurs. d. fills the irrigating container with 1000 to 2000 mL of lukewarm tap water.

ANS: B The irrigating container should be hung 18 to 24 inches above the stoma. If cramping occurs, the irrigation should be temporarily stopped and the cone left in place. Five hundred to 1000 mL of water should be used for irrigation. An irrigation cone, rather than tubing, should be inserted into the stoma; 4 to 6 inches would be too far for safe insertion.

4. A 26-year-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient's symptoms? a. "What type of foods do you eat?" b. "Is it possible that you are pregnant?" c. "Can you tell me more about the pain?" d. "What is your usual elimination pattern?"

ANS: C A complete description of the pain provides clues about the cause of the problem. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms.

A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client? a. "Eat low-fiber and low-residual foods." b. "White rice and bread are easier to digest." c. "Add vegetables such as broccoli and cauliflower to your new diet." d. "Foods high in animal fat help to protect the intestinal mucosa."

ANS: C The client should be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer.

39. A 19-year-old female is brought to the emergency department with a knife handle protruding from the abdomen. During the initial assessment of the patient, the nurse should a. remove the knife and assess the wound. b. determine the presence of Rovsing sign. c. check for circulation and tissue perfusion. d. insert a urinary catheter and assess for hematuria.

ANS: C The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. A patient with a knife in place will be taken to surgery and assessed for bladder trauma there.

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

ANS: D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse should not medicate the client until the provider has been notified of the change in his or her condition. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse need not insert a nasogastric tube for decompression.

7. A 27-year-old female patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? a. Encourage the patient to sip clear liquids. b. Assess the abdomen for rebound tenderness. c. Assist the patient to cough and deep breathe. d. Apply an ice pack to the right lower quadrant.

ANS: D The patient's clinical manifestations are consistent with appendicitis, and application of an ice pack will decrease inflammation at the area. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient should be NPO in case immediate surgery is needed. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.

A male client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse would offer which full liquid item to the client? a. Tea b. Gelatin c. Custard d. Popsicle

Answer C. Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, and strained vegetable juices. A clear liquid diet consists of foods that are relatively transparent. The food items in options A, B, and D are clear liquids.

Your patient has an X-Ray and has been diagnosed with having a large bowel obstruction. What is the nurse's priority? A) Start an IV NS with potassium at 100 ml/hr B) Prepare the client for immediate surgery C) Monitor for worsening obstruction D) Provide emotional support

Answer: C. Large bowel obstruction often occurs slower and has less complications than small bowel obstruction. The nurse would never start an IV with potassium without first checking potassium levels. Surgery may be needed, but not necessarily (depending on severity). Nonsurgical interventions should be used first. Although providing emotional support is important, it is not as important for watching for worsening obstruction

Your patient is experiencing a GI bleed. You are teaching your patient about the condition. Your patient demonstrates the need for FURTHER teaching when he says: A) I need to sip water as an NG tube is inserted to allow it to go down B) The NG tube will help stop the bleeding in my duodenum C) I will need to drink plenty of fluids in order to stay hydrated while I'm bleeding D) I would like to talk with the chaplain

Answer: C. The client should remain NPO while having a GI bleed. A sip of water is ok, as the NG suction will suck it right back out. The NG is being inserted to help with the bleeding ulcer, and wanting to see the chaplain is irrelevant to the conversation

The nurse is caring for a client with severe ulcerative colitis who has been prescribed adalimumab (Humira). Which client statement indicates that additional teaching about the medication is needed? a. "I will avoid large crowds and people who are sick." b. "I will take this medication with food or milk." c. "Nausea and vomiting are common side effects." d. "I will wash my hands after I play with my dog."

B Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing.

The nurse provides discharge teaching for a client who was hospitalized for Salmonella food poisoning. Which client statement indicates that additional teaching is needed? a. "I will let my husband do the cooking for my family." b. "I will take the ciprofloxacin (Cipro) until the diarrhea has resolved." c. "I will wash my hands with antibacterial soap before and after each meal." d. "I will make sure that my dishes go straight into the dishwasher after each meal."

B Cipro should be taken for 10 to 14 days to treat Salmonella infection, and should not be stopped once the diarrhea has cleared. Clients should be advised to take the entire course of medication. People with Salmonella should not prepare foods for others because the infection may be spread in this way. Dishes and eating utensils should not be shared and should be cleaned thoroughly. Hands should be washed with antibacterial soap before and after eating to prevent spread of the bacteria. Clients can be carriers for up to 1 year.

2. A patient who is hospitalized with abdominal pain and watery, incontinent diarrhea is diagnosed with Clostridium difficile. In planning care for the patient, the nurse will a. order a diet with no dairy products for the patient. b. place the patient in a private room with contact isolation. c. explain to the patient why antibiotics are not being used. d. teach the patient about proper food handling and storage.

B Rationale: Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile. Cognitive Level: Application Text Reference: p. 1038 Nursing Process: Planning NCLEX: Safe and Effective Care Environment

A client comes into the emergency department with complaints of abdominal pain. Which of the following should the nurse ask first? a) Family history of ruptured appendix b) Characteristics and duration of pain c) Concerns about impending hospital stay d) Medications taken in the last 8 hours

B) Characteristics and duration of pain A focused abdominal assessment begins with a complete history. The nurse must obtain information about abdominal pain. Pain can be a major symptom of gastrointestinal disease. The character, duration, pattern, frequency, location, distribution, and timing of the pain vary but require investigation immediately.

Which of the following complications of gastric resection should the nurse teach the client to watch for? A. Constipation B. Dumping syndrome C. Gastric spasm D. Intestinal spasms

B. Dumping syndrome is a problem that occurs postprandially after gastric resection because ingested food rapidly enters the jejunum without proper mixing and without the normal duodenal digestive processing. Diarrhea, not constipation, may also be a symptom. Gastric or intestinal spasms don't occur, but antispasmidics may be given to slow gastric emptying.

Which is the best understanding of colon irrigation? A. It is taught to patients with ascending colostomies. B. The tip should be inside a cone to prevent perforation. C. Use cold water to promote peristalsis. D. Administer 2000 mL of sterile saline.

B. The tip should be inside a cone to prevent perforation. The tip is inside a cone to control the depth of insertion, prevent water from leaking out, and prevent perforation. Irrigation is used only in the distal colon or rectum because the stool is solid there.

A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 pounds since the exacerbation of his ulcerative colitis. The nurse should anticipate that the physician will order which of the following treatment approaches to help the client meet his nutritional needs? A. Initiate continuous enteral feedings B. Encourage a high protein, high-calorie diet C. Implement total parenteral nutrition D. Provide six small meals a day.

C. Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the bowel. To maintain the client's nutritional status, the client will be started on TPN. Enteral feedings or dividing the diet into 6 small meals does not allow the bowel to rest. A high-calorie, high-protein diet will worsen the client's symptoms.

The client is in the preicteric phase of hepatitis. Which signs/symptoms would thenurse expect the client to exhibit during this phase? 1.Clay-colored stools and jaundice.2.Normal appetite and pruritus.3.Being afebrile and left upper quadrant pain.4.Complaints of fatigue and diarrhea.

Correct Answer 4 "Flu-like" symptoms are the first com-plaints of the client in the preicteric phase of hepatitis, which is the initial phase and may begin abruptly or insidiously

"A client is admitted with ongoing sypmtoms of the flu. There are no other obvious signs of illness. This client should be tested for hepatitis because: "A. She has a blood pressure of 90/50 B. whe has an allergy to shellfish C. She could have anicteric hepatitis, which means no jaundice D. She was living with a roommate who had similar symptoms"

Correct C Rationale: Only about 25 percet of people with acute hepatitis develop jaundice. Patients with anicteric hepatitis may have severely compromised liver function that is overlooked due to lack of jaundice. A roommate with the same symptoms could mean a communicable disease such as the flu.

"1. A health care provider who has not been immunized for hepatitis B is exposed to the hepatitis B virus (HBV) through a needle stick from an infected patient. The infection control nurse informs the individual that treatment for the exposure should include: a. baseline hepatitis B antibody testing now and in 2 months. b. active immunization with hepatitis B vaccine. c. hepatitis B immune globulin (HBIG) injection. d. both the hepatitis B vaccine and HBIG injection.

Correct D The recommended treatment for exposure to hepatitis B in unvaccinated individuals is to receive both HBIG and the hepatitis B vaccine, which would provide temporary passive immunity and promote active immunity. Antibody testing may also be done, but this would not provide protection from the exposure.

What characterizes auscultation of the abdomen? a. The presence of borborygmi indicates hyper peristalsis. b. The bell of the stethoscope is used to auscultate high-pitched sounds. c. High-pitched, rushing, and tinkling bowel sounds are heard after eating. d. Absence of bowel sounds for 1 minute in each quadrant is reported as abnormal.

Correct answer: a Rationale: Borborygmi are loud gurgles (stomach growling) that indicate hyper peristalsis. Normal bowel sounds are relatively high-pitched and are heard best with the diaphragm of the stethoscope. High-pitched, tinkling bowel sounds occur when the intestines are under tension, as in bowel obstructions. Absent bowel sounds may be reported when no sounds are heard for 2 to 3 minutes in each quadrant.

An 80-year-old man states that, although be adds a lot of salt to his food, it still does not have much taste. The nurse's response is based on the knowledge that the older adult a. should not experience changes in taste. b. has a loss of taste buds, especially for sweet and salty. c. has some loss of taste but no difficulty chewing food. d. loses the sense of taste because the ability to smell is decreased.

Correct answer: b Rationale: Older adults have decreased numbers of taste buds and a decreased sense of smell. These age-related changes diminish the sense of taste (especially of salty and sweet substances).

A 62-year-old woman patient is scheduled for a percutaneous transhepatic cholangiography to restore biliary drainage. The nurse discusses the patient's health history and is most concerned if the patient makes which statement? a."I am allergic to bee stings." b. "My tongue swells when I eat shrimp." c. "I have had epigastric pain for 2 months." d. "I have a pacemaker because my heart rate was slow."

Correct answer: b Rationale: The percutaneous transhepatic cholangiography procedure will include the use of radiopaque contrast medium. Patients allergic to shellfish and iodine are also allergic to contrast medium. Having a pacemaker will not affect the patient during this procedure. It would be expected that the patient would have some epigastric pain given the patient's condition.

An 85-year-old woman seen in the primary care provider's office for a well check complains of difficulty swallowing. What common effect of aging should the nurse assess for as a possible cause? a. Anosmia b. Xerostomia c. Hypochlorhydria d. Salivary gland tumor

Correct answer: b Rationale: Xerostomia (decreased saliva production), or dry mouth, affects many older adults and may be associated with difficulty swallowing (dysphagia). Anosmia is loss of sense of smell. Hypochlorhydria, a decrease in stomach acid, does not affect swallowing. Salivary gland tumors are not common.

The nurse should recognize that the liver performs which functions (select all that apply) a. Bile storage b. Detoxification c. Protein metabolism d. Steroid metabolism e. Red blood cell (RBC) destruction

Correct answer: b, c, d Rationale: The liver performs multiple major functions that aid in the maintenance of homeostasis. These include metabolism of proteins and steroids as well as detoxification of drugs and metabolic waste products. The Kupffer cells of the liver participate in the breakdown of old RBCs. The liver produces bile, but storage occurs in the gall bladder.

A patient who is scheduled for surgery with general anesthesia in 1 hour is observed with a moist, but empty water glass in his hand. Which assessment finding may indicate that the patient drank a glass of water? a. Flat abdomen without movement upon inspection b. Tenderness at left upper quadrant upon palpation c. Easily heard, loud gurgling in the right upper quadrant d. High-pitched, hollow sounds in the left upper quadrant

Correct answer: c Rationale: If the patient drank water on an empty stomach, gurgling can be assessed without a stethoscope or assessed with auscultation. High-pitched, hollow sounds are tympanic and indicate an empty cavity. A flat abdomen and tenderness do not indicate that the patient drank a glass of water.

Nathaniel has severe pruritus due to having hepatitis B. What is the best intervention for his comfort? a Give tepid baths. b Avoid lotions and creams. c Use hot water to increase vasodilation. d Use cold water to decrease the itching.

D Rest periods and small frequent meals is indicated during the acute phase of hepatitis B.

A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? a) Left lower quadrant b) Left upper quadrant c) Right upper quadrant d) Right lower quadrant

D) Right lower quadrant The pain of acute appendicitis localizes in the right lower quadrant (RLQ) at McBurney's point, an area midway between the umbilicus and the right iliac crest. Often, the pain is worse when manual pressure near the region is suddenly released, a condition called rebound tenderness.

A 24-year-old male is scheduled for a minimally invasive inguinal hernia repair (MIIHR). Which client statement indicates a need for further teaching about this procedure?

I will need to stay in the hospital overnight

The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons (select all that apply)? There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. Osmoreceptors in the hypothalamus stimulate thirst, which causes the stimulation to take in fluids orally. Overactivity of the enlarged spleen results in increased removal of blood cells from the circulation, which decreases the vascular pressure.

There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. Correct Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. Correct Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. Correct The ascites related to cirrhosis are caused by decreased colloid oncotic pressure from the lack of albumin from liver inability to synthesize it and the portal hypertension that shifts the protein from the blood vessels to the peritoneal cavity, and hyperaldosteronism which increases sodium and fluid retention. The intake of fluids orally and the removal of blood cells by the spleen do not directly contribute to ascites.

After teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?

"I will take a laxative nightly at bedtime to avoid becoming constipated."

"The nurse is caring for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST? "A.) "Take three deep breaths, hold your incision, and then cough." B.) "That was good. Do that again and soon it won't hurt as much." C.) "It won't hurt as much if you hold your incision when you cough." D.) "Take another deep breath, hold it, and then cough deeply."

"(1) correct-most effective way of deep breathing and coughing, dilates airway and expands lung surface area (2) should splint incision before coughing to reduce discomfort and increase efficiency (3) partial answer, should take three deep breaths before coughing (4) implies coughing routine is adequate, incision needs to be splinted"

"A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, the nurse would expect serologic testing to reveal... a. hepatitis B surface antigen (HBsAg). b. anti-hepatitis B core immunoglobulin M (anti-HBc IgM). c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG). d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)."

"ANSWER: D Rationale: Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen or antibodies for hepatitis B. Anti-HAV IgG would indicate past infection and lifelong immunity."

A college student is required to be inoculated for hepatitis before entering college. The nurse reognizes that this client will be inoculated to prevent the development of...? "1. Hepatits D 2. Hepatits B 3, Hepatitis C 4.Hepatits E"

"Answer: 2 - Hepatits B Ratioinale: Sexually transmitted and is seen in all age groups. There is a vaccine for this type of Hepatitis

"A client with appendicitis is experiencing excruciating abdominal pain. An abdominal X-ray film reveals intraperitoneal air. The nurse should prepare the client for: a) colonoscopy. b) surgery. c) nasogastric (NG) tube insertion. d) barium enema."

"B) Surgery The client should be prepared for surgery because his signs and symptoms indicate bowel perforation. Appendicitis is the most common cause of bowel perforation in the United States. Because perforation can lead to peritonitis and sepsis, surgery wouldn't be delayed to perform other interventions, such as colonoscopy, NG tube insertion, or a barium enema. These procedures aren't necessary at this point."

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill. Which of the following responses by the nurse is most appropriate? "A) The hepatitis vaccine will provide immunity from this exposure and future exposures."" B) I am afraid there is nothing you can do since the patient was infectious before admission."" C) You will need to be tested first to make sure you don't have the virus before we can treat you."" D) An injection of immunoglobulin will need to be given to prevent or minimize the effects of this exposure."""

"Correct Answer: D Rationale: Immunoglobulin provides temporary (1-2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks of exposure. It may not prevent an infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis."

A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this client's teaching?

"Drink plenty of fluids to prevent dehydration."

The nurse provides discharge instructions for a 64-year-old woman with ascites and peripheral edema related to cirrhosis. Which statement, if made by the patient, indicates teaching was effective? "It is safe to take acetaminophen up to four times a day for pain." "Lactulose (Cephulac) should be taken every day to prevent constipation." "Herbs and other spices should be used to season my foods instead of salt." "I will eat foods high in potassium while taking spironolactone (Aldactone)."

"Herbs and other spices should be used to season my foods instead of salt." A low-sodium diet is indicated for the patient with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices. Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided as these medications may be toxic to the liver. The patient should avoid potentially hepatotoxic over-the-counter drugs (e.g., acetaminophen) because the diseased liver is unable to metabolize these drugs. Spironolactone is a potassium-sparing diuretic. Lactulose results in the acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.

After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?

"I will take this medication with my breakfast each morning."

A nurse cares for a teenage girl with a new ileostomy. The client states, "I cannot go to prom with an ostomy." How should the nurse respond?

"Let's talk to the enterostomal therapist about options for ostomy supplies and dress styles."

The nurse instructs a 50-year-old woman about cholestyramine to reduce pruritis caused by gallbladder disease. Which statement by the patient to the nurse indicates she understands the instructions? "This medication will help me digest fats and fat-soluble vitamins." "I will apply the medicated lotion sparingly to the areas where I itch." "The medication is a powder and needs to be mixed with milk or juice." "I should take this medication on an empty stomach at the same time each day."

"The medication is a powder and needs to be mixed with milk or juice." For treatment of pruritus, cholestyramine may provide relief. This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Cholestyramine is in powder form and should be mixed with milk or juice before oral administration.

Which foods should the nurse encourage a client with diverticulosis to incorporate into the diet? Select all that apply. 1. Bran cereal. 2. Broccoli. 3. Tomato juice. 4. Navy beans. 5. Cheese.

1, 2, 4. Clients with diverticulosis are encouraged to follow a high-fiber diet. Bran, broccoli, and navy beans are foods high in fiber. Tomato juice and cheese are low-residue foods.

A client with diverticular disease is receiving psyllium hydrophilic mucilloid (Metamucil). The drug has been effective when the client tells the nurse that he: 1. Passes stool without cramping. 2. Does not have diarrhea any longer. 3. Is not as anxious as he was. 4. Does not expel gas like he used to.

1. Diverticular disease is treated with a high-fiber diet and bulk laxatives such as psyllium hydrophilic mucilloid (Metamucil). Fiber decreases the intraluminal pressure and makes it easier for stool to pass through the colon. Bulk laxatives do not manage diarrhea, anxiety or relieve gas formation.

A client who is scheduled for an ileostomy has an order for oral neomycin (Mycifradin) to be administered before surgery. The intended outcome of administering oral neomycin before surgery is to: 1. Prevent postoperative bladder infection. 2. Reduce the number of intestinal bacteria. 3. Decrease the potential for postoperative hypostatic pneumonia. 4. Increase the body's immunologic response to the stressors of surgery.

2. The rationale for the administration of oral neomycin is to decrease intestinal bacteria and thereby decrease the potential for peritonitis and wound infection postoperatively. Neomycin will not alter the client's potential for developing a urinary or respiratory infection. Neomycin does not affect the body's immune system.

Which of the following adverse effects would the nurse expect the client to exhibit in the event of too rapid an infusion of TPN solution? 1. Negative nitrogen balance. 2. Circulatory overload. 3. Hypoglycemia. 4. Hypokalemia.

2. Too rapid infusion of a TPN solution can lead to circulatory overload. The client should be assessed carefully for indications of excessive fluid volume. A negative nitrogen balance occurs in nutritionally depleted individuals, not when TPN fluids are administered in excess. When TPN is administered too rapidly the client is at risk for receiving an excess of dextrose and electrolytes. Therefore, the client is at risk for hyperglycemia and hyperkalemia.

Arthur has a family history of colon cancer and is scheduled to have a sigmoidoscopy. He is crying as he tells you, "I know that I have colon cancer, too." Which response is most therapeutic? 1 "I know just how you feel." 2 "You seem upset." 3 "Oh, don't worry about it, everything will be just fine." 4"Why do you think you have cancer?"

2. Making observations about what you see or hear is a useful therapeutic technique. This way, you acknowledge that you are interested in what the patient is saying and feeling.

Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? a) Hypotension b) Bradycardia c) Warm moist skin d) Polyuria

A) Hypotension Signs of potential hypovolemia include cool, clammy skin, tachycardia, decreased blood pressure, and decreased urine output.

A nurse is assisting with preoperative care for a client who requires an appendectomy. The nurse is aware that the surgery will involve which abdominal quadrant? A) RLQ B) RUQ C) LLQ D) LUQ

A) RLQ The appendix is in the right lower quadrant.

A client's ulcerative colitis signs and symptoms have been present for longer than 1 week. The nurse should assess the client for signs and symptoms of which of the following complications? 1. Heart failure. 2. Deep vein thrombosis. 3. Hypokalemia. 4. Hypocalcemia.

3. Excessive diarrhea causes significant depletion of the body's stores of sodium and potassium as well as fluid. The client should be closely monitored for hypokalemia and hyponatremia. Ulcerative colitis does not place the client at risk for heart failure, deep vein thrombosis, or hypocalcemia.

Which client does the medical-surgical unit charge nurse assign to an LPN/LVN?

47 year old who needs to receive whole gut lavage before a colon resection

A client who is recently has been started on enteral feedings begins to complain of abdominal cramping, followed by the passage of two liquid stools. A nurse notes that the client has abdominal distention as well. The nurse reviews the nutritional content on the label of the can of feeding to see if it has which of the following ingredients? a) lactose b) sucrose c) fructose d) maltose

A - several tube feeding formulas contain lactose. A client with an unreported history of lactose intolerance would develop symptoms such as abdominal cramping, distention, and the passage of liquid stool in response to nutritional therapy with these formulas. If the client is diagnosed as lactose intolerant, a lactose-free formula should be prescribed by the physician. This will resolve the client's symptoms and promote adequate nutrition for the client.

A nurse is preparing a client for surgery. During preoperative teaching, the client asks where is bile stored. The nurse knows that bile is stored in the: a) Cystic duct b) Duodenum c) Gallbladder d) Common bile duct

C) Gallbladder The gallbladder functions as a storage depot for bile.

Which of the following is an accurate statement regarding cancer of the esophagus? a) Chronic irritation of the esophagus is a known risk factor. b) It is three times more common in women in the U.S. than men. c) It is seen more frequently in Caucasian Americans than in African Americans. d) It usually occurs in the fourth decade of life.

A) Chronic irritation of the esophagus is a known risk factor In the United States, cancer of the esophagus has been associated with the ingestion of alcohol and the use of tobacco. In the United States, carcinoma of the esophagus occurs more than three times more often in men as in women. It is seen more frequently in African Americans than in Caucasian Americans. It usually occurs in the fifth decade of life

A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test? a) Encourage plenty of fluids. b) Order a high-fiber diet. c) Serve dairy products. d) Serve the client his usual diet.

A) Encourage plenty of fluids The nurse should encourage plenty of fluids because adequate fluid intake is necessary to avoid dehydration that may be caused by the bowel preparation and to prevent fecal impaction after the procedure. The client may be placed on a low-residue diet 1 to 2 days before the procedure to reduce the contents in the GI tract. Fiber intake is limited in a low-residue diet. Because dairy products leave a residue, they aren't allowed the evening before the test. Clear liquids only are allowed the evening before the test.

A physician plans to send a client home with supplies to complete a hemoccult test on all stools for 3 days. During the client education, the nurse informs the client to avoid which of the following medications while collecting stool for the test? a) ibuprofen (Advil) b) ciprofloxacin (Cipro XR) c) docusate sodium (Colace) d) acetaminophen (Tylenol)

A) Ibprofen (Advil) Fecal occult blood testing (FOBT) is one of the most commonly performed stool tests. FOBT can be done at the bedside, in the physician's office, or at home. The client is taught to avoid aspirin, red meats, nonsteroidal antiinflammatory agents, and horseradish for 72 hours prior to the examination. Advil is an anti-inflammatory drug and should be avoided with FOBT.

30. A 50-year-old female patient calls the clinic to report a new onset of severe diarrhea. The nurse anticipates that the patient will need to a. collect a stool specimen. b. prepare for colonoscopy. c. schedule a barium enema. d. have blood cultures drawn.

ANS: A Acute diarrhea is usually caused by an infectious process, and stool specimens are obtained for culture and examined for parasites or white blood cells. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema.

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

ANS: A In obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excess bile salts to accumulate on the skin. This leads to itching, or pruritus. The other statements are not accurate.

45. A 51-year-old woman with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider? a. Fever b. Nausea c. Joint pain d. Headache

ANS: A Since infliximab suppresses the immune response, rapid treatment of infection is essential. The other patient complaints are common side effects of the medication, but they do not indicate any potentially life-threatening complications.

46. A 33-year-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching? a. Stool will be expelled from both stomas. b. This type of colostomy is usually temporary. c. Soft, formed stool can be expected as drainage. d. Irrigations can regulate drainage from the stomas.

ANS: B A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible.

20. A 74-year-old patient preparing to undergo a colon resection for cancer of the colon asks about the elevated carcinoembryonic antigen (CEA) test result. The nurse explains that the test is used to a. identify any metastasis of the cancer. b. monitor the tumor status after surgery. c. confirm the diagnosis of a specific type of cancer. d. determine the need for postoperative chemotherapy.

ANS: B CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help to determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA.

A client with CRC had colostomy surgery performed yesterday. The client is very anxious about caring for the colostomy and states that the health care provider's instructions "seem to be overwhelming." What does the nurse do first for this client?

Encourage the client to look at and touch the colostomy stoma

A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially causing complications of this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)

ANS: B, E, F Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the client's confusion. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.

40. Which activity in the care of a 48-year-old female patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)? a. Document the appearance of the stoma. b. Place a pouching system over the ostomy. c. Drain and measure the output from the ostomy. d. Check the skin around the stoma for breakdown.

ANS: C Draining and measuring the output from the ostomy is included in UAP education and scope of practice. The other actions should be implemented by LPNs or RNs.

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

ANS: C Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen equally with both chronic and acute cholecystitis.

A nurse assesses clients at a community health center. Which client is at highest risk for pancreatic cancer? a. A 32-year-old with hypothyroidism b. A 44-year-old with cholelithiasis c. A 50-year-old who has the BRCA2 gene mutation d. A 68-year-old who is of African-American ethnicity

ANS: C Mutations in both the BRCA2 and p16 genes increase the risk for developing pancreatic cancer in a small number of cases. The other factors do not appear to be linked to increased risk.

After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the client's understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for additional teaching? a. "I should drink bottled water during my travels." b. "I will not eat off another's plate or share utensils." c. "I should eat plenty of fresh fruits and vegetables." d. "I will wash my hands frequently and thoroughly."

ANS: C The client should be advised to avoid fresh, raw fruits and vegetables because they can be contaminated by tap water. Drinking bottled water, and not sharing plates, glasses, or eating utensils are good ways to prevent illness, as is careful handwashing.

28. Which breakfast choice indicates a patient's good understanding of information about a diet for celiac disease? a. Oatmeal with nonfat milk b. Whole wheat toast with butter c. Bagel with low-fat cream cheese d. Corn tortilla with scrambled eggs

ANS: D Avoidance of gluten-containing foods is the only treatment for celiac disease. Corn does not contain gluten, while oatmeal and wheat do.

A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer? a. A 37-year-old who drinks eight cups of coffee daily b. A 44-year-old with irritable bowel syndrome (IBS) c. A 60-year-old lawyer who works 65 hours per week d. A 72-year-old who eats fast food frequently

ANS: D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer.

The nurse is caring for a patient with a stress ulcer. The nurse understands thus ulcer is caused by : a. The body's response to psychosocial stressors. b. Lack of blood supply to the gastric mucosa. c. H. pylori infection. d. Suppression of stomach acid

B

The nurse is planning care for a 68-year-old patient with an abdominal mass and suspected bowel obstruction. Which factor in the patient's history increases the patient's risk for colorectal cancer? A. Osteoarthritis B. History of colorectal polyps C. History of lactose intolerance D. Use of herbs as dietary supplements

B A history of colorectal polyps places this patient at risk for colorectal cancer. This tissue can degenerate over time and become malignant. Osteoarthritis, lactose intolerance, and the use of herbs do not pose additional risk to the patient.

The nurse is caring for a client who is brought to the emergency department following a motor vehicle crash. The nurse notes that the client has ecchymotic areas across the lower abdomen. Which is the priority action of the nurse? a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Ask whether the client was riding in the front or back seat of the car.

B On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present; this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or asking about seating in the car is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity.

36. The nurse explains to a patient with a new ileostomy that after the bowel adjusts to the ileostomy, the usual drainage will be about a. 1 cup. b. 2 cups. c. 3 cups. d. 1 quart.

B Rationale: After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 ml daily. Cognitive Level: Comprehension Text Reference: p. 1073 Nursing Process: Implementation NCLEX: Physiological Integrity

What part of the GI tract begins the digestion of food? a) Stomach b) Mouth c) Duodenum d) Esophagus

B) Mouth Food that contains starch undergoes partial digestion when it mixes with the enzyme salivary amylase, which the salivary glands secrete.

The nurse is caring for a client who is hospitalized with exacerbation of Crohn's disease. What does the nurse expect to find during the physical assessment? a. Positive Murphy's sign with rebound tenderness b. Dullness in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Abdominal cramping that the client says is worse at night

C The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn's disease. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohn's disease. Nightly worsening of abdominal cramping is not consistent with Crohn's disease. A positive Murphy's sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis.

Brenda, a 36 y.o. patient is on your floor with acute pancreatitis. Treatment for her includes: a Continuous peritoneal lavage. b Regular diet with increased fat. c Nutritional support with TPN. d Insertion of a T tube to drain the pancreas.

C With acute pancreatitis, you need to rest the GI tract by TPN as nutritional support.

A nurse is teaching an elderly client about good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required? a) "I need to drink 2 to 3 liters of fluids every day." b) "I should exercise four times per week." c) "I need to use laxatives regularly to prevent constipation." d) "I should eat a fiber-rich diet with raw, leafy vegetables, unpeeled fruit, and whole grain bread."

C) "I need to use laxatives regularly to prevent constipation." The client requires more teaching if he states that he'll use laxatives regularly to prevent constipation. The nurse should teach this client to gradually eliminate the use of laxatives because using laxatives to promote regular bowel movements may have the opposite effect. A high-fiber diet, ample amounts of fluids, and regular exercise promote good bowel health.

Which of the following indicates an overdose of lactulose? a) Hypoactive bowel sounds b) Constipation c) Watery diarrhea d) Fecal impaction

C) Watery diarrhea The patient receiving lactulose is monitored closely for the development of watery diarrheal stool, which indicates a medication overdose.

Which teaching is provided to help a patient manage chronic pancreatitis? A. Eat an acid-ash diet. B. Take antacids before meals. C. Eat a bland, high-carbohydrate diet. D. Take iron supplement daily.

C. Eat a bland, high-carbohydrate diet.

Which of the following conditions is most likely to directly cause peritonitis? A. Cholelithiasis B. Gastritis C. Perforated ulcer D. Incarcerated hernia

C. The most common cause of peritonitis is a perforated ulcer, which can pour contaminates into the peritoneal cavity, causing inflammation and infection within the cavity. The other conditions don't by themselves cause peritonitis. However, if cholelithiasis leads to rupture of the gallbladder, gastritis leads to erosion of the stomach wall, or an incarcerated hernia leads to rupture of the intestines, peritonitis may develop.

A home health client has had severe diarrhea for the past 24 hours. Which nursing action does the RN delegate to a home health aide (unlicensed assistive personnel [UAP]) who assists the client with self-care?

CHecking and reporting the clients heart rate and BP in lying, sitting, and standing positions

A certified wound, ostomy, continence nurse (CWOCN) nurse is teaching a client about caring for a new ileostomy. What information is most important to include?

Call the health care provider if your stoma has a bluish or pale look

"A college student is required to be inoculated for hepatitis before beginning college. The nurse realizes that this client will be inoculated to prevent the development of... A: Hepatitis B B: Hepatitis C C: Hepatitis E D: Hepatitis D"

Correct A: Hepatitis B is considered a significant sexually transmitted disease and is seen in all age groups. A vaccine is available for this type of hepatitis.

A college student is required to be inoculated for hepatitis before beginning college. The nurse realizes this client will be inoculated to prevent the development of: "A) Hep B B) Hep D C) Hep C D) Hep E"

Correct A: Hepatitis B is considered a significant sexually transmitted disease and is seen in all age groups. A vaccine is available for this type of hepatitis

Priority Decision: Following auscultation of the abdomen, what should the nurse's next action be? a. Lightly percuss over all four quadrants b. Have the patient empty his or her bladder c. Inspect perianal and anal areas for color, masses, rashes, and scars d. Perform deep palpation to delineate abdominal organs and masses

Correct answer: a Rationale: The abdomen should be assessed in the following sequence: inspection, auscultation, percussion, palpation. The patient should empty his or her bladder before assessment begins.

"A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? "A) Left lower quadrant B) Left upper quadrant C) Right upper quadrant D) Right lower quadrant"

Correct: 4 - no rationale

The nurse is assessing for stoma prolapse in a client with a colostomy. The nurse would observe which of the following if stoma prolapse occurred? A. Sunken and hidden stoma B. Dark- and bluish-colored stoma C. Narrowed and flattened stoma D. Protruding stoma

D. A prolapsed stoma is one which the bowel protruded through the stoma. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with dusky or bluish color. A stoma with a narrowed opening at the level of the skin or fascia is said to be stenosed.

Pancreatitis is primarily diagnosed by which diagnostic tests? A. AST and ALT B. Glucose and triglycerides C. Bilirubin and alkaline phosphatase D. Amylase and lipase

D. Amylase and lipase

The patient tells a nurse that she has been diagnosed with a 2-cm cancerous tumor in the liver. The patient is asking questions about the types of treatment to anticipate. Your response should reflect what information? A. Chemotherapy is the first-line treatment for liver cancer. B. It is not possible to have surgery because of the liver's vascularity. C. Liver transplantation is not an option for patients with cancer. D. Radiofrequency ablation is an option for tumors that size.

D. Radiofrequency ablation is an option for tumors that size.

Surgical management of ulcerative colitis may be performed to treat which of the following complications? A. Gastritis B. Bowel herniation C. Bowel outpouching D. Bowel perforation

D. Perforation, obstruction, hemorrhage, and toxic megacolon are common complications of ulcerative colitis that may require surgery. Herniation and gastritis aren't associated with irritable bowel diseases, and outpouching of the bowel is diverticulosis.

A client with a family history of colorectal cancer (CRC) regularly sees a health care provider for early detection of any signs of cancer. Which laboratory result may be an indication of CRC in this client?

Elevated carcinoembryonic antigen

True or False? A drug that clocks the release of secretions from the stomach's chief cells will decrease gastric acidity.

False A drug that clocks the release of secretions from the stomach's parietal cells will decrease gastric acidity.

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first?

Heart rate and rhythm

A nurse is instructing a client with recently diagnosed diverticular disease about diet. What food does the nurse suggest the client include?

a slice of 5 grain bread

A client has just had surgery for colon cancer. Which of the following disorders might the client develop? a Peritonitis b Diverticulosis c Partial bowel obstruction d Complete bowel obstruction

a. Bowel spillage could occur during surgery, resulting in peritonitis. Complete or partial bowel obstruction may occur before bowel resection. Diverticulosis doesn't result from surgery or colon cancer.

In contrast to diverticulitis, the patient with diverticulosis: a. has rectal bleeding b. often has no symptoms c. has localized cramping pain d. frequently develops peritonitis

b. often has no symptoms Rationale: Many people with diverticulosis have no symptoms. Patients with diverticulitis have symptoms of inflammation. Diverticulitis can lead to obstruction or perforation.

Which of the following symptoms is a client with colon cancer most likely to exhibit? a A change in appetite b A change in bowel habits c An increase in body weight d An increase in body temperature

b. The most common complaint of the client with colon cancer is a change in bowel habits. The client may have anorexia, secondary abdominal distention, or weight loss. Fever isn't associated with colon cancer.

Management of the patient with acute pancreatitis include a. surgery to remove the inflamed pancreas b. pancreatic enzymes administered with meals c. NG suction to prevent gastric contents from entering the duodenum d. endoscopic pancreatic sphncterectomy using ERCP

c. NG suction to prevent gastric contents from entering the duodenum

A patient with stage I colorectal cancer is scheduled for surgery. Patient teaching for this patient would include an explanation that: a. chemotherapy will begin after the patient recovers from the surgery b. both chemotherapy and radiation can be used as palliative treatments c. follow-up colonoscopies will be needed to ensure that the cancer does not occur d. a wound, ostomy, and continence nurse will visit the patient to identify an abdominal site for the ostomy

c. follow-up colonoscopies will be needed to ensure that the cancer does not occur Rationale: Stage 1 colorectal cancer is treated with surgical removal of the tumor and reanastomosis, and so there is no ostomy. Chemotherapy is not recommended for stage I tumors. Follow-up colonoscopy is recommended because colorectal cancer can recur.

A patient with acute pancreatitis has a nursing diagnosis of pain related to distention of pancreas and peritoneal irritation. In addition to effective use of analgesics, the nurse should a. provider diversional activities to distract the patient from pain b. provide small frequent meals to increase the patient's tolerance of food c. position the patient on the side with the head of the bed elevated 45 degrees for pain relief d. ambulate the patient every 3 to 4 hours to increase circulation and decrease abdominal congestion

c. position the patient on the side with the head of the bed elevated 45 degrees for pain relief

During discharge instructions for a patient following a laparoscopic cholecystectomy, the nurse advises the patient to a. keep the incision areas clean and dry for at least a week b. report the need to take pain medication for shoulder pain c. report any bile colored or purulent drainage from the incisions d. expect some postoperative nausea and vomiting for a few days

c. report any bile colored or purulent drainage from the incisions

A client has acute pancreatitis due to a gallstone blocking a bile duct. Which diagnostic test would be the most useful to expedite the recovery of this client? a Pancreatic ultrasound b CT scan of the pancreas c Aspiration biopsy d ERCP

d ERCP provides the opportunity to remove mechanical obstructions such as a gallstone or pancreatic stone.

The nurse is reviewing the physician's orders written for a client admitted with acute pancreatitis. Which physician order would the nurse question if noted on the client's chart? a NPO status b Insert a nasogastric tube c An anticholinergic medication d Morphine for pain

d. Meperidine (Demerol) rather than morphine is the medication of choice because morphine can cause spasm in the sphincter of Oddi.

A nursing intervention that is most appropriate to decrease post-operative edema and pain after an inguinal herniorrhaphy is: a. applying a truss to the hernia site b. allowing the patient to stand to void c. supporting the incision during coughing d. applying a scrotal support with ice bag

d. applying a scrotal support with ice bag Rationale: Scrotal edema is a painful complication after an inguinal hernia repair. Scrotal support with application of an ice bag may help relieve pain and edema.

The changes in laboratory test results that relate to this process are _______________ and _________________

hypoalbuminemia, hypokalemia (from hyperaldosteronism)

"A patient with hepatitis B is being discharged in 2 days. In the discharge teaching plan the nurse should include instructions to "a. avoid alcohol for the first 3 weeks. B. use a condom during sexual intercourse. c. have family members get an injection of immunoglobulin. d. follow a low-protein, moderate-carbohydrate, moderate-fat diet."

"3. Correct answer: b Rationale: Hepatitis B virus may be transmitted by mucosal exposure to infectious blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Hepatitis B is a sexually transmitted disease that is acquired through unprotected sex with an infected person. Condom use should be taught to patients to prevent transmission of hepatitis B."

The nurse is performing an assessment on a client bein evaluated for viral hepatitis. Which symptom will the nurse most likely assess on this client? 1. Arthralgia 2. Excitability 3. Headache 4. Polyphagia

"ANSWER: 1 Rationale: arthralgia is common in clients with viral hepatitis. Other symptoms of viral hepatits include lethargy, flulike symptoms, anorexia, N/V, abdominal pain, diarrhea, constipation, and fever. The others are not symptoms of viral hepatitis."

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which response by the nurse is most appropriate? "The hepatitis vaccine will provide immunity from this exposure and future exposures." "I am afraid there is nothing you can do since the patient was infectious before admission." "You will need to be tested first to make sure you don't have the virus before we can treat you." "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure."

"An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure." Immunoglobulin provides temporary (1-2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.

A client is admitted with right lower quadrant pain, anorexia, nausea, low-grade fever, and elevated white blood cell count. Which complication is most likely the cause? 1. A. fecalith 2. Bowel Kinking 3. Internal blowel occlusion 4. Abdominal wall swelling

"Answer 1 Rational: The client is experiencing appendicitis. A. fecalith is a fecal calculus, or stone, that occludes the lumen of the appendix and is the most common cause of appendicitis. Bowel wall swelling, kinking of the appendix, and external occlusion not internal occlusion, of the bowel by adhesions can also be cause of appendicitis."

"A female client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurse's best response? a. "You may have eaten contaminated restaurant food." b. "You could have gotten it by using I.V. drugs." c. "You must have received an infected blood transfusion." d. "You probably got it by engaging in unprotected sex.""

"Answer A. Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming food contaminated by infected food handlers. The virus isn't transmitted by the I.V. route, blood transfusions, or unprotected sex. Hepatitis B can be transmitted by I.V. drug use or blood transfusion. Hepatitis C can be transmitted by unprotected sex."

"The school nurse is discussing ways to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the most important intervention that the school nurse must explain to the school teachers? "1.Do not allow students to eat or drink after each other. 2.Drink bottled water as much as possible. 3.Encourage protected sexual activity. 4.Thoroughly wash hands."

"Answer is 4. 1.Eating after each other should be discouraged,but it is not the most important intervention. 2.Only bottled water should be consumed in Third World countries, but that precaution is not necessary in American high schools. 3.Hepatitis B and C, not hepatitis A, are transmitted by sexual activity. 4.Hepatitis A is transmitted via the fecal-oral route. Good hand washing helps to prevent its spread."

"The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which of the following responses by the nurse is most appropriate? A. The hepatitis vaccine will provide immunity from this exposure and future exposures. B. I am afraid there is nothing you can do since the paitent was infectious before admission C. You will need to be tested first to make sure you don't have the virus before we treat you D. An injection of immunoglobin will need to be given to minimize or prevent the effects of this exposure"

"Answer: D. Immunoglobulin provides temporary (1-2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis."

"A client with acute hepatitis is prescribed lactulose. The nurse knows this medication will: A. Prevent the absorption of ammonia from the bowel. B. Prevent hypoglycemia. C. Remove bilirubin from the blood. D. Mobilize iron stores from the liver"

"Correct Answer: A Rationale: Lactulose helps prevent the absorption of ammonia from the bowel because it will cause frequent bowel movements, which facilitates the removal of ammonia from the intestines."

A patient with hepatitis A is in the acute phase. The nurse plans care for the pateint based on the knowledge that: "a. pruritus is a common problem with jaundice in this phase. b. the pateint is most likely to transmit the disease during this phase. c. gastrointestinal symptoms are not severe in hepatitis A they are in hepatitis B. d. extrahepatic manifestations of glomerulonephritis and polyarteritis are common in this phase."

"Correct answer: a Rationale: The acute phase of jaundice may be icteric (i.e., symptomatic, including jaundice) or anicteric. Jaundice results when bilirubin diffuses into the tissues. Pruritus sometimes accompanies jaundice. Pruritus is the result of an accumulation of bile salts beneath the skin."

"During the assessment of a patient with acute abdominal pain, the nurse should: a. Perform deep palpation before ascultation b. Obtain blood pressure and pulse rate to determine hypervolemic changes c. Ascultate bowel sounds because hyperactive bowel sounds suggest paralytic ileus d. Measure body temperature because an elevated temperature may indicate an inflammatory or infectious process"

"Correct answer: d Rationale: For the patient complaining of acute abdominal pain, the nurse should take vital signs immediately. Increased pulse and decreasing blood pressure (BP) are indicative of hypovolemia. An elevated temperature suggests an inflammatory or infectious process. Intake and output measurements provide essential information about the adequacy of vascular volume. Inspect the abdomen first and then auscultate bowel sounds. Palpation is performed next and should be gentle."

After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching?

"I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel."

When teaching the patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement? "I will use care when kissing my wife to prevent giving it to her." "I will need to take adofevir (Hepsera) to prevent chronic HCV." "Now that I have had HCV, I will have immunity and not get it again." "I will need to be checked for chronic HCV and other liver problems."

"I will need to be checked for chronic HCV and other liver problems." The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adofevir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.

After teaching a client who has a new colostomy, the nurse provides feedback based on the client's ability to complete self-care activities. Which statement should the nurse include in this feedback?

"You cleaned the stoma well. Now you need to practice putting on the appliance."

A nurse teaches a community group about food poisoning and gastroenteritis. Which statements should the nurse include in this group's teaching? (Select all that apply.)

- "Rotavirus is more common among infants and younger children." - "To prevent E. coli infection, don't drink water when swimming." - "Parasitic diseases may not show up for 1 to 2 weeks after infection."

A nurse teaches a client how to avoid becoming ill with Salmonella infection again. Which statements should the nurse include in this client's teaching? (Select all that apply.)

- "Wash leafy vegetables carefully before eating or cooking them." - "Wash your hands before and after using the bathroom." - "Be sure meat is cooked to the proper temperature." - "Avoid eating eggs that are sunny side up or undercooked."

A nurse teaches a community group ways to prevent Escherichia coli infection. Which statements should the nurse include in this group's teaching? (Select all that apply.)

- "Wash your hands after any contact with animals." - "Use separate cutting boards for meat and vegetables."

A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.)

- Lower gastrointestinal bleeding - Erosion of the bowel wall - Abscess formation - Localized pockets of infection develop in the ulcerated bowel lining - Nonmechanical bowel obstruction - Paralysis of colon resulting from colorectal cancer

After teaching a client with an anal fissure, a nurse assesses the client's understanding. Which client actions indicate that the client correctly understands the teaching? (Select all that apply.)

- Taking a warm sitz bath several times each day - Using bulk-producing agents to aid elimination - Self-administering anti-inflammatory suppositories

A patient with chronic cholecystitis asks the nurse whether she will need to continue a low fat diet after she has a cholecystectomy. The best response by the nurse is a. a low fat diet will prevent development of further gallstones and should be continued b. yes, because you will not have a gallbladder to store bile, you will not be able to digest fats adequately c. a low fat diet is recommended for a few weeks after surgery until the intestine adjusts to receiving a continuous flow of bile d. removal of the gallbladder will eliminate the source of your pain associated with fat intake, so you may eat whatever you like

...

To care for a T tube in a patient following cholecystectomy, the nurse a. keeps the tube supported and free of kinks b. attaches the tube to low continuous suction c. clamps the tube when ambulating the patient d. irrigates the tube with 10 mL sterile saline every 2 to 4 hours

...

When assessing a patient with acute pancreatitis, the nurse would expect to find a. hyperactive bowel sounds b. hypertension and tachycardia c. severe midepigastric pain or LUQ pain d. a temperature greater than 102 F

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A client with ulcerative colitis is to take sulfasalazine (Azulfidine). Which of the following instructions should the nurse provide for the client about taking this medication at home? Select all that apply. 1. Drink enough fluids to maintain a urine output of at least 1,200- 1,500 mL per day. 2. Discontinue therapy if symptoms of acute intolerance develop and notify the health care provider. 3. Stop taking the medication if the urine turns orange-yellow. 4. Avoid activities that require alertness. 5. If dose is missed, skip and continue with the next dose.

1, 2, 4. Sulfasalazine may cause dizziness and the nurse should caution the client to avoid driving or other activities that require alertness until response to medication is known. If symptoms of acute intolerance (cramping, acute abdominal pain, bloody diarrhea, fever, headache, rash) occur, the client should discontinue therapy and notify the health care provider immediately. Fluid intake should be sufficient to maintain a urine output of at least 1,200- 1,500 mL daily to prevent crystalluria and stone formation. The nurse can also inform the client that this medication may cause orange-yellow discoloration of urine and skin, which is not significant and does not require the client to stop taking the medication. The nurse should instruct the client to take missed doses as soon as remembered unless it is almost time for the next dose.

A client with diverticulitis has developed peritonitis following diverticular rupture. The nurse should assess the client to determine which of the following? Select all that apply. 1. Percuss the abdomen to note resonance and tympany. 2. Percuss the liver to note lack of dullness. 3. Monitor the vital signs for fever, tachypnea, and bradycardia. 4. Assess presence of polyphagia and polydipsia. 5. Auscultate bowel sounds to note frequency.

1, 2, 5. Assessment during peritonitis will reveal fever, tachypnea, and tachycardia. The abdomen becomes rigid with rebound tenderness and there will be absent bowel sounds. Percussion will show resonance and tympany indicating paralytic ileus; loss of liver dullness may indicate free air in the abdomen. There is anorexia, nausea, and vomiting as peristalsis decreases.

A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for? Select all that apply. 1. Projectile vomiting. 2. Significant abdominal distention. 3. Copious diarrhea. 4. Rapid onset of dehydration. 5. Increased bowel sounds.

1, 4, 5. Signs and symptoms of intestinal obstructions in the small intestine may include projectile vomiting and rapidly developing dehydration and electrolyte imbalances. The client will also have increased bowel sounds, usually high-pitched and tinkling. The client would not normally have diarrhea and would have minimal abdominal distention. Pain is intermittent, being relieved by vomiting. Intestinal obstructions in the large intestine usually evolve slowly, produce persistent pain, and vomiting is less common. Clients with a large-intestine obstruction may develop obstipation and significant abdominal distention.

A client is admitted with a bowel obstruction. The client has nausea, vomiting, and crampy abdominal pain. The physician has written orders for the client to be up ad lib, to have narcotics for pain, to have a nasogastric tube inserted if needed, and for I.V. Ringer's Lactate and hyperalimentation fluids. The nurse should do the following in order of priority from first to last: 1. Assist with ambulation to promote peristalsis 2. Administer Ringer's Lactate 3. Insert a nasogastric tube. 4. Start and infusion of hyperalimentation fluids.

1,2,3,4 The nurse should first help the client ambulate to try to induce peristalsis; this may be effective and require the least amount of invasive procedures. I.V. fluid therapy can be done to correct fluid and electrolyte imbalances (sodium and potassium), and normal saline or Ringer's Lactate to correct interstitial fluid deficit. Nasogastric (NG) decompression of G.I. tract to reduce gastric secretions and nasointestinal tubes may also be used. Hyperalimentation can be used to correct protein deficiency from chronic obstruction, paralytic ileus, or infection.

A client with ulcerative colitis expresses serious concerns about her career as an attorney because of the effects of stress on ulcerative colitis. Which of the following nursing interventions will be most helpful to the client? 1. Review her current coping mechanisms and develop alternatives, if needed. 2. Suggest a less stressful career in which she would still use her education and experience. 3. Suggest that she ask her colleagues to help decrease her stress by giving her the easier cases. 4. Prepare family members for the fact that she will have to work part-time.

1. A client with ulcerative colitis need not curtail career goals. Self-care is the cornerstone of long-term management, and learning to cope with and modify stressors will enable the client to live with the disease. Giving up a desired career could discourage and even depress the client. Placing the responsibility for minimizing stressors at work in the hands of others leads to a feeling of loss of control and decreases the sense of responsibility needed for sound self-care. Working part-time rather than full-time is unnecessary.

The nurse is aware that the diagnostic tests typically ordered for acute diverticulitis do not include a barium enema. The reason for this is that a barium enema: 1. Can perforate an intestinal abscess. 2. Would greatly increase the client's pain. 3. Is of minimal diagnostic value in diverticulitis. 4. Is too lengthy a procedure for the client to tolerate.

1. Barium enemas and colonoscopies are contraindicated in clients with acute diverticulitis because they can lead to perforation of the colon and peritonitis. A barium enema may be ordered after the client has been treated with antibiotic therapy and the inflammation has subsided. A barium enema is diagnostic in diverticulitis. A barium enema could increase the client's pain; however, that is not a reason for excluding this test. The client may be able to tolerate the procedure but the concern is the potential for perforation of the intestine.

The physician orders intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression the nurse should evaluate the client to determine if: 1. Fluid and gas have been removed from the intestine. 2. The client has had a bowel movement. 3. The client's urinary output is adequate. 4. The client can sit up without pain.

1. Intestinal decompression is accomplished with a Cantor, Harris, or Miller-Abbott tube. These 6- to 10-foot tubes are passed into the small intestine to the obstruction. They remove accumulated fluid and gas, relieving the pressure. The client will not have an adequate bowel movement until the obstruction is removed. The pressure from the distended intestine should not obstruct urinary output. While the client may be able to more easily sit up, and the pain caused by the intestinal pressure will be less, these are not the primary indicators for successful intestinal decompression.

A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors was most likely of greatest significance in causing an exacerbation of ulcerative colitis? 1. A demanding and stressful job. 2. Changing to a modified vegetarian diet. 3. Beginning a weight-training program. 4. Walking 2 miles every day.

1. Stressful and emotional events have been clearly linked to exacerbations of ulcerative colitis, although their role in the etiology of the disease has been disproved. A modified vegetarian diet or an exercise program is an unlikely cause of the exacerbation.

The nurse administers fat emulsion solution during TPN as ordered based on the understanding that this type of solution: 1. Provides essential fatty acids. 2. Provides extra carbohydrates. 3. Promotes effective metabolism of glucose. 4. Maintains a normal body weight.

1. The administration of fat emulsion solution provides additional calories and essential fatty acids to meet the body's energy needs. Fatty acids are lipids, not carbohydrates. Fatty acids do not aid in the metabolism of glucose. Although they are necessary for meeting the complete nutritional needs of the client, fatty acids do not necessarily help a client maintain normal body weight.

TPN is ordered for a client with Crohn's disease. Which of the following indicate the TPN soloution is having an intended outcome? 1. There is increased cell nutrition. 2. The client does not have metabolic acidosis. 3. The client is hydrated. 4. The client is in a negative nitrogen balance.

1. The goal of TPN is to meet the client's nutritional needs. TPN is not used to treat metabolic acidosis; ketoacidosis can actually develop as a result of administering TPN. TPN is a hypertonic solution containing carbohydrates, amino acids, electrolytes, trace elements, and vitamins. It is not used to meet the hydration needs of clients. TPN is administered to provide a positive nitrogen balance.

Using a sliding-scale schedule, the nurse is preparing to administer an evening dose of regular insulin to a client who is receiving total parenteral nutrition (TPN). Which action is most appropriate for the nurse to take to determine the amount of insulin to give? 1. Base the dosage on the glucometer reading of the client's glucose level obtained immediately before administering the insulin. 2. Base the dosage on the fasting blood glucose level obtained earlier in the day. 3. Calculate the amount of TPN fluid the client has received since the last dose of insulin and adjust the dosage accordingly. 4. Assess the client's dietary intake for the evening meal and snack and adjust the dosage accordingly.

1. When using a sliding-scale insulin schedule, the nurse obtains a glucometer reading of the client's blood glucose level immediately before giving the insulin and bases the dosage on those findings. The fasting blood glucose level obtained earlier in the day is not relevant to an evening sliding-scale insulin dosage. The nurse cannot calculate insulin dosage by assessing the amount of TPN intake or dietary intake.

When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistant? Select all that apply. 1. Assessing the client's bowel sounds. 2. Providing skin care following bowel movements. 3. Evaluating the client's response to antidiarrheal medications. 4. Maintaining intake and output records. 5. Obtaining the client's weight.

2, 4, 5. The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client's weight. Assessing the client's bowel sounds and evaluating the client's response to medication are registered nurse activities that cannot be delegated.

The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include? Select all that apply. 1. Monitoring vital signs once a shift. 2. Weighing the client daily. 3. Changing the central venous line dressing daily. 4. Monitoring the I.V. infusion rate hourly. 5. Taping all I.V. tubing connections securely.

2, 4, 5. When caring for a client who is receiving TPN, the nurse should plan to weigh the client daily, monitor the I.V. fluid infusion rate hourly (even when using an I.V. fluid pump), and securely tape all I.V. tubing connections to prevent disconnections. Vital signs should be monitored at least every 4 hours to facilitate early detection of complications. It is recommended that the I.V. dressing be changed once or twice per week or when it becomes soiled, loose, or wet.

The nurse is assigning clients for the evening shift. Which of the following clients are appropriate for the nurse to assign to a licensed practical nurse to provide client care? Select all that apply. 1. A client with Crohn's disease who is receiving total parenteral nutrition (TPN). 2. A client who underwent inguinal hernia repair surgery 3 hours ago. 3. A client with an intestinal obstruction who needs a Cantor tube inserted. 4. A client with diverticulitis who needs teaching about his take-home medications. 5. A client who is experiencing an exacerbation of his ulcerative colitis.

2, 5. The nurse should consider client needs and scope of practice when assigning staff to provide care. The client who is recovering from inguinal hernia repair surgery and the client who is experiencing an exacerbation of his ulcerative colitis are appropriate clients to assign to a licensed practical nurse as the care they require fall within the scope of practice for a licensed practical nurse. It is not within the scope of practice for the licensed practical nurse to administer TPN, insert nasoenteric tubes, or provide client teaching related to medications.

Which of the following should be a priority focus of care for a client experiencing an exacerbation of Crohn's disease? 1. Encouraging regular ambulation. 2. Promoting bowel rest. 3. Maintaining current weight. 4. Decreasing episodes of rectal bleeding.

2. A priority goal of care during an acute exacerbation of Crohn's disease is to promote bowel rest. This is accomplished through decreasing activity, encouraging rest, and initially placing client on nothing-by-mouth status while maintaining nutritional needs parenterally. Regular ambulation is important, but the priority is bowel rest. The client will probably lose some weight during the acute phase of the illness. Diarrhea is nonbloody in Crohn's disease, and episodes of rectal bleeding are not expected.

The client with ulcerative colitis is following orders for bed rest with bathroom privileges. When evaluating the effectiveness of this level of activity, the nurse should determine if the client has: 1. Conserved energy. 2. Reduced intestinal peristalsis. 3. Obtained needed rest. 4. Minimized stress.

2. Although modified bed rest does help conserve energy and promotes comfort, its primary purpose in this case is to help reduce the hypermotility of the colon. Remaining on bed rest does not by itself reduce stress, and if the client is having stress, the nurse can plan with the client to use strategies that will help the client manage the stress.

Which of the following diets would be most appropriate for the client with ulcerative colitis? 1. High-calorie, low-protein. 2. High-protein, low-residue. 3. Low-fat, high-fiber. 4. Low-sodium, high-carbohydrate.

2. Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid excess roughage. There is no need for clients with ulcerative colitis to follow low-sodium diets.

Which goal for the client's care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis? 1. Promoting self-care and independence. 2. Managing diarrhea. 3. Maintaining adequate nutrition. 4. Promoting rest and comfort.

2. Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and decreasing the frequency of stools is the first goal of treatment. The other goals are ongoing and will be best achieved by halting the exacerbation. The client may receive antidiarrheal agents, antispasmodic agents, bulk hydrophilic agents, or anti-inflammatory drugs.

A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to: 1. Provide access for wound irrigation. 2. Promote drainage of wound exudates. 3. Minimize development of scar tissue. 4. Decrease postoperative discomfort.

2. Drains are inserted postoperatively in appendectomies when an abscess was present or the appendix was perforated. The purpose is to promote drainage of exudate from the wound and facilitate healing. A drain is not used for irrigation of the wound. The drain will not minimize scar tissue development or decrease postoperative discomfort.

A client has been placed on long-term sulfasalazine (Azulfidine) therapy for treatment of his ulcerative colitis. The nurse should encourage the client to eat which of the following foods to help avoid the nutrient deficiencies that may develop as a result of this medication? 1. Citrus fruits. 2. Green, leafy vegetables. 3. Eggs. 4. Milk products.

2. In long-term sulfasalazine therapy, the client may develop folic acid deficiency. The client can take folic acid supplements, but the nurse should also encourage the client to increase the intake of folic acid in his diet. Green, leafy vegetables are a good source of folic acid. Citrus fruits, eggs, and milk products are not good sources of folic acid.

Postoperative nursing care for a client after an appendectomy should include which of the following? 1. Administering sitz baths four times a day. 2. Noting the first bowel movement after surgery. 3. Limiting the client's activity to bathroom privileges. 4. Measuring abdominal girth every 2 hours.

2. Noting the client's first bowel movement after surgery is important because this indicates that normal peristalsis has returned. Sitz baths are used after rectal surgery, not appendectomy. Ambulation is started the day of surgery and is not confined to bathroom privileges. The abdomen should be auscultated for bowel sounds and palpated for softness, but there is no need to measure the girth every 2 hours.

A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. The nurse shuld tell the client? 1. "Ulcerative colitis can be cured by the use of steroids." 2. "Steroids are used in severe flare-ups because they can decrease the incidence of bleeding." 3. "Long-term use of steroids will prolong periods of remission." 4.. "The side effects of steroids outweigh their benefits to clients with ulcerative colitis."

2. Steroids are effective in management of the acute symptoms of ulcerative colitis. Steroids do not cure ulcerative colitis, which is a chronic disease. Long-term use is not effective in prolonging the remission and is not advocated. Clients should be assessed carefully for side effects related to steroid therapy, but the benefits of short-term steroid therapy usually outweigh the potential adverse effects.

A client with inflammatory bowel disease is receiving total parenteral nutrition (TPN). The basic component of the client's TPN solution is most likely to be: 1. An isotonic dextrose solution. 2. A hypertonic dextrose solution. 3. A hypotonic dextrose solution. 4. A colloidal dextrose solution.

2. The TPN solution is usually a hypertonic dextrose solution. The greater the concentration of dextrose in solution, the greater the tonicity. Hypertonic dextrose solutions are used to meet the body's calorie demands in a volume of fluid that will not overload the cardiovascular system. An isotonic dextrose solution (e.g., 5% dextrose in water) or a hypotonic dextrose solution will not provide enough calories to meet metabolic needs. Colloids are plasma expanders and blood products and are not used in TPN.

The client with an intestinal obstruction continues to have acute pain even though the nasoenteric tube is patent and draining. Which action by the nurse would be most appropriate? 1. Reassure the client that the nasoenteric tube is functioning. 2. Assess the client for a rigid abdomen. 3. Administer an opioid as ordered. 4. Reposition the client on the left side.

2. The client's pain may be indicative of peritonitis, and the nurse should assess for signs and symptoms, such as a rigid abdomen, elevated temperature, and increasing pain. Reassuring the client is important, but accurate assessment of the client is essential. The full assessment should occur before pain relief measures are employed. Repositioning the client to the left side will not resolve the pain.

The nurse finds the client who has had an ileostomy crying. The client explains to the nurse, "I'm upset because I know I won't be able to have children now that I have an ileostomy." Which of the following would be the best response for the nurse? 1. "Many women with ileostomies decide to adopt. Why don't you consider that option?" 2. "Having an ileostomy does not necessarily mean that you can't bear children. Let's talk about your concerns." 3. "I can understand your reasons for being upset. Having children must be important to you." 4. "I'm sure you will adjust to this situation with time. Try not to be too upset."

2. The fact that the client has an ileostomy does not necessarily mean that she cannot get pregnant and bear children. It may be recommended, however, that the number of pregnancies be limited. Women of childbearing age should be encouraged to discuss their concerns with their physician. Discussing their concerns about sexual functioning and pregnancy will help decrease fears and anxiety. Empathizing or telling the woman that she can adopt does not address her concerns. Her current fears may be based on erroneous understanding. Telling the client that she will adjust to the situation ignores her concerns.

The nurse is teaching the client how to care for her ileostomy. The client asks the nurse how long she can wear her pouch before changing it. The nurse responds: 1. "The pouch is changed only when it leaks." 2. "You can wear the pouch for about 4 to 7 days." 3. "You should change the pouch every evening before bedtime." 4. "It depends on your activity level and your diet."

2. Unless the pouch leaks, the client can wear her ileostomy pouch for about 4 to 7 days. If leakage occurs, it is important to promptly change the pouch to avoid skin irritation. It is not necessary to change the pouch daily or in the evening. Diet and activity typically do not affect the schedule for changing the pouch.

You're caring for Lewis, a 67 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Relief of which symptom indicated that the paracentesis was effective? 1. Pruritus 2 Dyspnea 3 Jaundice 4 Peripheral Neuropathy

2. Ascites puts pressure on the diaphragm. Paracentesis is done to remove fluid and reducing pressure on the diaphragm. The goal is to improve the patient's breathing. The others are signs of cirrhosis that aren't relieved by paracentesis.

A nurse cares for a client who is prescribed 5 mg/kg of infliximab (Remicade) intravenously. The client weighs 110 lbs and the pharmacy supplies infliximab 100 mg/10 mL solution. How many milliliters should the nurse administer to this client? (Record your answer using a whole number.) ____ mL

25 mL (100 lb = 50 kg; 50 kg x 5 mg/kg = 250 mg; 250 mg x 10mg/100mL = 25mL)

An RN receives a change-of-shift report about four clients. Which client does the nurse assess first?

25 year old who has just been admitted with possible appendicitis and has a temperature of 102

The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should do the following in order of what priority from first to last? 1. Change dressing per institutional policy. 2. Culture drainage at insertion site. 3. Notify physician. 4. Position rolled towel under client's back, parallel to the spine.

3, 4, 2, 1. A potential complication of receiving TPN is leakage or catheter puncture; notify the physician immediately and prepare for changing of the catheter. If pneumothorax is suspected, position a rolled towel under the client's back. If there is drainage at the insertion site, culture the drainage and change the dressing using sterile technique.

After instructing a client with diverticulosis about appropriate self-care activities, which of the following client comments indicate effective teaching? Select all that apply. 1. "With careful attention to my diet, my diverticulosis can be cured." 2. "Using a cathartic laxative weekly is okay to control bowel movements." 3. "I should follow a diet that's high in fiber." 4. "It is important for me to drink at least 2,000 mL of fluid every day." 5. "I should exercise regularly."

3, 4, 5. Clients who have diverticulosis should be instructed to maintain a diet high in fiber and, unless contraindicated, should increase their fluid intake to a minimum of 2,000 mL/ day. Participating in a regular exercise program is also strongly encouraged. Diverticulosis can be controlled with treatment but cannot be cured. Clients should be instructed to avoid the regular use of cathartic laxatives. Bulk laxatives and stool softeners may be helpful to maintain regularity and decrease straining.

The client asks the nurse, "Is it really possible to lead a normal life with an ileostomy?" Which action by the nurse would be the most effective to address this question? 1. Have the client talk with a member of the clergy about these concerns. 2. Tell the client to worry about those concerns after surgery. 3. Arrange for a person with an ostomy to visit the client preoperatively. 4. Notify the surgeon of the client's question.

3. If the client agrees, having a visit by a person who has successfully adjusted to living with an ileostomy would be the most helpful measure. This would let the client actually see that typical activities of daily living can be pursued postoperatively. Someone who has felt some of the same concerns can answer the client's questions. A visit from the clergy may be helpful to some clients but would not provide this client with the information sought. Disregarding the client's concerns is not helpful. Although the physician should know about the client's concerns, this in itself will not reassure the client about life after an ileostomy.

A client has returned to the medical surgical unit after having surgery to create an ileostomy. Which goal has the highest priority at this time? 1. Providing relief from constipation. 2. Assisting the client with self-care activities. 3. Maintaining fluid and electrolyte balance. 4. Minimizing odor formation.

3. A high-priority outcome after ileostomy surgery is the maintenance of fluid and electrolyte balance. The client will experience continuous liquid to semiliquid stools. The client should be engaged in self-care activities, and minimizing odor formation is important; however, these goals do not take priority over maintaining fluid and electrolyte balance.

The physician prescribes sulfasalazine (Azulfidine) for the client with ulcerative colitis to continue taking at home. Which instruction should the nurse give the client about taking this medication? 1. Avoid taking it with food. 2. Take the total dose at bedtime. 3. Take it with a full glass (240 mL) of water. 4. Stop taking it if urine turns orange-yellow.

3. Adequate fluid intake of at least 8 glasses a day prevents crystalluria and stone formation during sulfasalazine therapy. Sulfasalazine can cause gastrointestinal distress and is best taken after meals and in equally divided doses. Sulfasalazine gives alkaline urine an orange-yellow color, but it is not necessary to stop the drug when this occurs.

The nurse should instruct the client with an ileostomy to report which of the following signs and symptoms immediately? 1. Passage of liquid stool from the stoma. 2. Occasional presence of undigested food in the effluent. 3. Absence of drainage from the ileostomy for 6 or more hours. 4. Temperature of 99.8 ° F (37.7 ° C).

3. Any sudden decrease in drainage or onset of severe abdominal pain should be reported to the physician immediately because it could mean that an obstruction has developed. The ileostomy drains liquid stool at frequent intervals throughout the day. Undigested food may be present at times. A temperature of 99.8 ° F is not necessarily abnormal or a cause for concern.

Three weeks after the client has had an ileostomy, the nurse is following up with instruction about using a skin barrier around the stoma at all times. The client has been applying the skin barrier correctly when: 1. There is no odor from the stoma. 2. The client is adequately hydrated. 3. There is no skin irritation around the stoma. 4. The client only changes the ostomy pouch once a day.

3. Because of high concentrations of digestive enzymes, ileostomy effluent is irritating to skin and can cause excoriation and ulceration. Some form of protection must be used to keep the effluent from contacting the skin. A skin barrier does not decrease odor formation; odor is controlled by diet. The barrier does not affect the client's hydration status, and the nurse can encourage the client to have an adequate daily intake of fluids. Pouches are usually worn for 4 to 7 days before being changed.

Which of the following laboratory findings would the nurse expect to find in a client with diverticulitis? 1. Elevated red blood cell count. 2. Decreased platelet count. 3. Elevated white blood cell count. 4. Elevated serum blood urea nitrogen concentration.

3. Because of the inflammatory nature of diverticulitis, the nurse would anticipate an elevated white blood cell count. The remaining laboratory findings are not associated with diverticulitis. Elevated red blood cell counts occur in clients with polycythemia vera or fluid volume deficit. Decreased platelet counts can occur as a result of aplastic anemias or malignant blood disorders, as an adverse effect of some drugs, and as a result of some heritable conditions. Elevated serum blood urea nitrogen concentration is usually associated with renal conditions.

A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 lb since the exacerbation of his ulcerative colitis. Which of the following will be most effective in helping the client meet his nutritional needs? 1. Continuous enteral feedings. 2. Following a high-calorie, high-protein diet. 3. Total parenteral nutrition (TPN). 4. Eating six small meals a day.

3. Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the bowel. To maintain the client's nutritional status, the client will be started on TPN. Enteral feedings or dividing the diet into six small meals does not allow the bowel to rest. A high-calorie, high-protein diet will worsen the client's symptoms.

A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for: 1. Hyperalbuminemia. 2. Thrombocytopenia. 3. Hypokalemia. 4. Hypercalcemia.

3. Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.

A client is scheduled for an ileostomy. Which of the following interventions would be most helpful in preparing the client psychologically for the surgery? 1. Include family members in preoperative teaching sessions. 2. Encourage the client to ask questions about managing an ileostomy. 3. Provide a brief, thorough explanation of all preoperative and postoperative procedures. 4. Invite a member of the ostomy association to visit the client.

3. Providing explanations of preoperative and postoperative procedures helps the client prepare and understand what to expect. It also provides an opportunity for the client to share concerns. Including family members in the teaching sessions is beneficial but does not focus on the client's psychological preparation. Encouraging the client to ask questions about managing the ileostomy may be rushing the client psychologically into accepting the change in body image and function. The client may need time to first handle the stress of surgery and then observe the care of the ileostomy by others before it is appropriate to begin discussing self-management. The nurse should gently explore whether the client is ready to ask questions about management throughout the hospitalization. The client should have the opportunity to express concerns and to agree to an ostomy association visitor before an invitation is extended.

The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should: 1. Contact the surgeon to request an order for a narcotic for the pain. 2. Maintain the client in a recumbent position. 3. Place the client on nothing-by-mouth (NPO) status. 4. Apply heat to the abdomen in the area of the pain.

3. The nurse should place the client on NPO status in anticipation of surgery. The nurse can initiate pain relief strategies, such as relaxation techniques, but the surgeon will likely not order narcotic medication prior to surgery. The nurse can place the client in a position that is most comfortable for the client. Heat is contraindicated because it may lead to perforation of the appendix.

The nurse evaluates the client's understanding of ileostomy care. Which of the following statements indicates that discharge teaching has been effective? 1. "I should be able to resume weight lifting in 2 weeks." 2. "I can return to work in 2 weeks." 3. "I need to drink at least 3,000 mL a day of fluid." 4. "I will need to avoid getting my stoma wet while bathing."

3. To maintain an adequate fluid balance, the client needs to drink at least 3,000 mL/ day. Heavy lifting should be avoided; the physician will indicate when the client can participate in sports again. The client will not resume working as soon as 2 weeks after surgery. Water does not harm the stoma, so the client does not have to worry about getting it wet.

A client who is experiencing an exacerbation of ulcerative colitis is receiving I.V. fluids that are to be infused at 125 mL/ hour. The I.V. tubing delivers 15 gtt/ mL. How quickly should the nurse infuse the fluids in drops per minute to infuse the fluids at the prescribed rate? ________________________ gtt/ minute.

31 gtt/ minute To administer I.V. fluids at 125 mL/ hour using tubing that has a drip factor of 15 gtt/ mL, the nurse should use the following formula: 125 mL/ 60 minutes × 15 gtt/ 1 mL = 31 gtt/ minute.

An RN on the medical-surgical unit receives shift report about four clients. Which client does the nurse assess first?

36 year old recently admitted after a MVA with areas of ecchymoses on the abdomen in a lap belt pattern

Which of the following should the nurse interpret as an indication of a complication after the first few days of TPN therapy? 1. Glycosuria. 2. A 1- to 2-pound weight gain. 3. Decreased appetite. 4. Elevated temperature.

4. An elevated temperature can be an indication of an infection at the insertion site or in the catheter. Vital signs should be taken every 2 to 4 hours after initiation of TPN therapy to detect early signs of complications. Glycosuria is to be expected during the first few days of therapy until the pancreas adjusts by secreting more insulin. A gradual weight gain is to be expected as the client's nutritional status improves. Some clients experience a decreased appetite during TPN therapy.

The nurse should teach the client with diverticulitis to integrate which of the following into a daily routine at home? 1. Using enemas to relieve constipation. 2. Decreasing fluid intake to increase the formed consistency of the stool. 3. Eating a high-fiber diet when symptomatic with diverticulitis. 4. Refraining from straining and lifting activities.

4. Clients with diverticular disease should refrain from any activities, such as lifting, straining, or coughing, that increase intra-abdominal pressure and may precipitate an attack. Enemas are contraindicated because they increase intestinal pressure. Fluid intake should be increased, rather than decreased, to promote soft, formed stools. A low-fiber diet is used when inflammation is present.

Before abdominal surgery for an intestinal obstruction, the nurse monitors the client's urine output and finds that the total output for the past 2 hours was 35 mL. The nurse then assesses the client's total intake and output over the last 24 hours and notes that he had 2,000 mL of I.V. fluid for intake, 500 mL of drainage from the nasogastric tube, and 700 mL of urine for a total output of 1,200 mL. This would indicate which of the following? 1. Decreased renal function. 2. Inadequate pain relief. 3. Extension of the obstruction. 4. Inadequate fluid replacement.

4. Considering that there is usually 1 L of insensible fluid loss, this client's output exceeds his intake (intake, 2,000 mL; output, 2,200 mL), indicating deficient fluid volume. The kidneys are concentrating urine in response to low circulating volume, as evidenced by a urine output of less than 30 mL/ hour. This indicates that increased fluid replacement is needed. Decreasing urine output can be a sign of decreased renal function, but the data provided suggest that the client is dehydrated. Pain does not affect urine output. There are no data to suggest that the obstruction has worsened.

A client is receiving Total Parenteral Nutrition (TPN) soulution. The nurse should assess a client's ability to metabolize the TPN solution adequately by monitoring the client for which of the following signs? 1. Tachycardia. 2. Hypertension. 3. Elevated blood urea nitrogen concentration. 4. Hyperglycemia.

4. During TPN administration, the client should be monitored regularly for hyperglycemia. The client may require small amounts of insulin to improve glucose metabolism. The client should also be observed for signs and symptoms of hypoglycemia, which may occur if the body overproduces insulin in response to a high glucose intake or if too much insulin is administered to help improve glucose metabolism. Tachycardia or hypertension is not indicative of the client's ability to metabolize the solution. An elevated blood urea nitrogen concentration is indicative of renal status and fluid balance.

A client who has ulcerative colitis says to the nurse, "I can't take this anymore! I'm constantly in pain, and I can't leave my room because I need to stay by the toilet. I don't know how to deal with this." Based on these comments, an appropriate nursing diagnosis for this client would be: 1. Impaired physical mobility related to fatigue. 2. Disturbed thought processes related to pain. 3. Social isolation related to chronic fatigue. 4. Ineffective coping related to chronic abdominal pain.

4. It is not uncommon for clients with ulcerative colitis to become apprehensive and upset about the frequency of stools and the presence of abdominal cramping. During these acute exacerbations, clients need emotional support and encouragement to verbalize their feelings about their chronic health concerns and assistance in developing effective coping methods. The client has not expressed feelings of fatigue or isolation or demonstrated disturbed thought processes.

A client with a well-managed ilesostomy calls the nurse to report the sudden onset of abdominal cramps, vomiting, and watery discharge from the ileostomy. The nurse should: 1. Tell the client to take an antiemetic. 2. Encourage the client to increase fluid intake to 3 L/ day to replace fluid lost through vomiting. 3. Instruct the client to take 30 mL of milk of magnesia to stimulate a bowel movement. 4. Advise the client to notify the physcian.

4. Sudden onset of abdominal cramps, vomiting, and watery discharge with no stool from an ileostomy are likely indications of an obstruction. It is imperative that the physician examine the client immediately. Although the client is vomiting, the client should not take an antiemetic until the physician has examined the client. If an obstruction is present, ingesting fluids or taking milk of magnesia will increase the severity of symptoms. Oral intake is avoided when a bowel obstruction is suspected.

A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care? 1. Remove the dressing and leave the incision open to air. 2. Remove the drain if wound drainage is minimal. 3. Gently irrigate the drain to remove exudate. 4. Clean the area around the drain moving away from the drain.

4. The nurse should gently clean the area around the drain by moving in a circular motion away from the drain. Doing so prevents the introduction of microorganisms to the wound and drain site. The incision cannot be left open to air as long as the drain is intact. The nurse should note the amount and character of wound drainage, but the surgeon will determine when the drain should be removed. Surgical wound drains are not irrigated.

A nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of: a) pork b) milk c) chicken d) broccoli

A - the client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plants and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Milk contains vitamin A, D, and B2. Poultry contains niacin. Broccoli contains vitamin C, E and K and folic acid.

The nurse is caring for a client who is to receive 5-fluorouracil (5-FU) chemotherapy IV for the treatment of colon cancer. Which assessment finding leads the nurse to contact the health care provider? a. White blood cell (WBC) count of 1500/mm3 b. Presence of fatigue with a headache c. Presence of slight nausea and no appetite d. Two diarrhea stools yesterday

A Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the client's WBC count is very low (normal range, 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately.

A client with Crohn's disease has a draining fistula. Which finding leads the nurse to intervene most rapidly? a. Serum potassium of 2.6 mEq/L b. The client not wanting to eat anything c. White blood cell count of 8200/mm3 d. The client losing 3 pounds in a week

A Fistulas place the client with Crohn's disease at risk for hypokalemia, which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium takes priority.

The nurse is caring for a client with Giardia lamblia infection. Which medication does the nurse anticipate teaching the client about? a. Metronidazole (Flagyl) b. Ciprofloxacin (Cipro) c. Sulfasalazine (Azulfidine) d. Ceftriaxone (Rocephin)

A Flagyl is the drug of choice for Giardia lamblia infection. Cipro and Rocephin are antibiotics used for bacterial infections. Azulfidine is used for ulcerative colitis and Crohn's disease.

The nurse notes a bulge in a client's groin that is present when the client stands and disappears when the client lies down. Which conclusion does the nurse draw from these assessment findings? a. Reducible inguinal hernia b. Indirect umbilical hernia c. Strangulated ventral hernia d. Incarcerated femoral hernia

A In a reducible hernia, the contents of the hernial sac can be replaced into the abdominal cavity by gentle pressure or by lying flat. The contents of irreducible, strangulated, or incarcerated hernias may not be replaced into the abdomen when the client lies down.

The wound, ostomy, and continence (WOC) nurse selects the site where the ostomy will be placed. What should be included in the consideration for the site? A. The patient must be able to see the site. B. Outside the rectus muscle area is the best site. C. It is easier to seal the drainage bag to a protruding area. D. The ostomy will need irrigation, so area should not be tender.

A In selection of the ostomy site, the WOC nurse will want a site visible to the patient so the patient can take care of it, within the rectus muscle to avoid hernias, and on a flat surface to more easily create a good seal with the drainage bag.

The nurse reviews a health teaching for a client with Crohn's disease. Which instruction does the nurse provide for the client? a. "You should have a colonoscopy every few years." b. "You should eat a diet that is high in protein and fiber." c. "You should avoid heavy lifting and tight-fitting clothes." d. "You should take the Asacol whenever you have loose stools."

A Long-term inflammatory bowel disease increases the risk of colon cancer, so regular colonoscopies are recommended. A high-fiber diet is not recommended for clients with Crohn's disease because fiber can further irritate the inner lining of the bowel. Asacol (mesalamine [5-aminosalicylic acid]) should be taken daily, not as needed. Avoiding heavy lifting and tight-fitting clothes is not necessary.

The nurse is caring for a client who has undergone removal of a benign colonic polyp. The client asks the nurse why a follow-up colonoscopy is necessary. Which is the nurse's best response? a. "You are at risk for developing more polyps in the future." b. "You may have other cancerous lesions that could not be seen right now." c. "The doctor can remove only a few of the polyps during each colonoscopy." d. "This test will ensure that you have healed where the polyp was removed."

A Once a person has developed a polyp, risk for occurrence of multiple polyps is present. The physician usually can remove all visible polyps during the colonoscopy procedure. Follow-up colonoscopy is not done to ensure that healing occurred where a polyp was removed, or to check for cancerous lesions that were not visible during the first procedure.

A stroke patient who primarily uses a wheelchair for mobility has diarrhea with fecal incontinence. What should the nurse assess first? A. Fecal impaction B. Perineal hygiene C. Dietary fiber intake D. Antidiarrheal agent use

A Patients with limited mobility are at risk for fecal impactions due to constipation that may lead to liquid stool leaking around the hardened impacted feces, so assessing for fecal impaction is the priority. Perineal hygiene can be assessed at the same time. Assessing the dietary fiber and fluid intake and antidiarrheal agent use will be assessed and considered next.

41. A patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as illustrated. The nurse explains to the patient that a. this type of colostomy is usually temporary. b. soft, formed stool can be expected as drainage. c. the drainage is liquid at this site but less odorous than at higher sites. d. colostomy irrigations can help regulate the drainage from the proximal stoma.

A Rationale: A loop or double-barrel stoma is usually temporary. Cognitive Level: Application Text Reference: p. 1069 Nursing Process: Implementation NCLEX: Physiological Integrity

37. When implementing the initial plan of care for a patient admitted with acute diverticulitis, the nurse will a. administer IV fluids. b. order a diet high in fiber and fluids. c. give stool softeners. d. prepare the patient for colonoscopy.

A Rationale: A patient with acute diverticulitis will be NPO with parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have colonoscopy because of the risk for perforation and peritonitis. Cognitive Level: Application Text Reference: p. 1077 Nursing Process: Implementation NCLEX: Physiological Integrity

8. Two days following an exploratory laparotomy with a resection of a short segment of small bowel, the patient complains of gas pains and abdominal distention. Which nursing action is most appropriate to take at this time? a. Assisting the patient to ambulate b. Administering the ordered IV morphine sulfate c. Giving a return-flow enema d. Inserting the ordered promethazine (Phenergan) suppository

A Rationale: Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. Morphine will further reduce peristalsis. A return-flow enema may decrease the patient's symptoms, but ambulation is less invasive and should be tried first. Promethazine (Phenergan) is used as an antiemetic rather than to decrease gas pains or distention. Cognitive Level: Application Text Reference: p. 1046 Nursing Process: Implementation NCLEX: Physiological Integrity

15. A patient hospitalized with an acute exacerbation of ulcerative colitis is having 14 to 16 bloody stools a day and crampy abdominal pain associated with the diarrhea. The nurse will plan to a. place the patient on NPO status. b. administer Cobalamin (vitamin B12) injections. c. start bowel preparation for colonoscopy. d. administer IV metoclopramide (Reglan).

A Rationale: An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. It is not appropriate to administer laxatives needed for colonoscopy to a patient with diarrhea. Metoclopramide increases peristalsis and will worsen symptoms. Cognitive Level: Application Text Reference: p. 1058 Nursing Process: Planning NCLEX: Physiological Integrity

40. In providing discharge teaching for a patient who has undergone a hemorrhoidectomy at an outpatient surgical center, the nurse instructs the patient to a. take prescribed pain medications before a bowel movement is expected. b. delay having a bowel movement for several days until healing has occurred. c. maintain a low-residue diet until the surgical area is healed. d. use ice packs on the perianal area to relieve pain and swelling.

A Rationale: Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. Delay of bowel movements is likely to lead to constipation. A high-residue diet will increase stool bulk and prevent constipation. Sitz baths are used to relieve pain and keep the surgical area clean. Cognitive Level: Application Text Reference: p. 1083 Nursing Process: Implementation NCLEX: Physiological Integrity

24. A patient newly diagnosed with Crohn's disease asks the nurse what to expect in the future. The best response by the nurse is, a. "You need to know that there is the probability of lifelong, unpredictable periods of remissions and recurrences." b. "You can expect to lead a normal life and may have long periods without episodes of diarrhea or other symptoms." c. "Most patients with Crohn's disease require an ostomy to control the disease, but you can adjust to that." d. "After about 10 years, patients with Crohn's disease have a high risk for colon cancer unless the colon is removed."

A Rationale: Crohn's disease has recurrent acute exacerbations that occur at unpredictable intervals. There are many lifestyle changes that patients need to make with regard to diet and medication use. The preference is to treat Crohn's disease with medications rather than with surgery. Patients with Crohn's disease are at high risk for cancer of the small intestine, but the risk for colon cancer is lower. Cognitive Level: Application Text Reference: pp. 1057-1058 Nursing Process: Implementation NCLEX: Physiological Integrity

35. After teaching a patient to irrigate a new colostomy, the nurse will determine that the teaching has been effective if the patient a. hangs the irrigating container about 18 inches above the stoma. b. stops the irrigation and removes the irrigating cone if cramping occurs. c. fills the irrigating container with 1000 to 2000 ml of lukewarm tap water. d. inserts the irrigation tubing no further than 4 to 6 inches into the stoma.

A Rationale: Irrigating container should be hung 18 to 24 inches above the stoma. Cognitive Level: Application Text Reference: p. 1075 Nursing Process: Evaluation NCLEX: Safe and Effective Care Environment

28. A recent colonoscopy revealed an increased number of polyps in a 22-year-old patient with a history of moderately severe familial adenomatous polyposis (FAP). In planning care for the patient, the nurse recognizes that the medical recommendation for patients with familial adenomatous polyposis includes a. a total colectomy with ileostomy. b. annual colonoscopy until age 40. c. routine periodic polypectomies via colonoscope to remove these abnormal growths. d. biannual colonoscopy for life because of a 50% chance of developing colon cancer.

A Rationale: Patients with FAP have a high likelihood of developing colorectal cancer by age 40; therefore, total colectomy with ileostomy is recommended for these patients. Frequent colonoscopy is required, but patients are encouraged to have a colectomy. Patients with FAP have too many polyps to be removed by polypectomy. The patient has an 80% chance of developing colorectal cancer. Cognitive Level: Application Text Reference: p. 1063 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

11. A patient is brought to the emergency department with a knife impaled in the abdomen following a domestic fight. During the initial assessment of the patient, it is important for the nurse to a. assess the BP and pulse. b. remove the knife to assess the wound. c. determine the presence of Rovsing's sign. d. insert a urinary catheter and assess for hematuria.

A Rationale: The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing's sign is assessed in the patient with suspected appendicitis. A patient with a knife in place will be taken to surgery and assessed for bladder trauma there. Cognitive Level: Application Text Reference: p. 1048 Nursing Process: Assessment NCLEX: Physiological Integrity

1. A patient with acute diarrhea of 24 hours' duration calls the clinic to ask for directions for care. In talking with the patient, the nurse should a. ask the patient to describe the character of the stools and any associated symptoms. b. advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility. c. inform the patient that laboratory testing of blood and stool specimens will be necessary. d. advise the patient to drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte.

A Rationale: The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment. Cognitive Level: Application Text Reference: p. 1037 Nursing Process: Assessment NCLEX: Physiological Integrity

6. A patient is admitted to the emergency department with severe abdominal pain with rebound tenderness, anorexia, and chills. The vital signs include temperature 101° F (38.3° C), pulse 130, respirations 34, and blood pressure (BP) 82/50. Of the following collaborative interventions, which one should the nurse implement first? a. Infuse 1000 ml of lactated Ringer's solution over 30 minutes. b. Administer IV ketorolac (Toradol) 15 mg. c. Give IV ceftriaxone (Rocephin) 1 g. d. Obtain a computed tomography (CT) scan of the abdomen with and without contrast.

A Rationale: The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion. Cognitive Level: Application Text Reference: pp. 1044-1045 Nursing Process: Implementation NCLEX: Physiological Integrity

33. During the initial postoperative assessment of a patient's stoma formed with a transverse colostomy, the nurse finds it to be red with moderate edema and a small amount of bleeding. The nurse should a. document the stoma assessment. b. notify the surgeon about the stoma appearance. c. monitor the stoma every 30 minutes. d. place an ice pack on the stoma to reduce swelling.

A Rationale: The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed. Cognitive Level: Application Text Reference: p. 1071 Nursing Process: Implementation NCLEX: Physiological Integrity

The nurse conducts a physical assessment for a client with abdominal pain. Which finding leads the nurse to suspect appendicitis? a. Severe, steady right lower quadrant (RLQ) pain b. Abdominal pain that started a day after vomiting began c. Abdominal pain that increases with knee flexion d. Marked peristalsis and hyperactive bowel sounds

A Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has a gastroenteritis. Abdominal pain due to appendicitis decreases with knee flexion. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis.

The nurse is caring for a client who has been diagnosed with a bowel obstruction. Which assessment finding leads the nurse to conclude that the obstruction is in the small bowel? a. Potassium of 2.8 mEq/L, with a sodium value of 121 mEq/L b. Losing 15 pounds over the last month without dieting c. Reports of crampy abdominal pain across the lower quadrants d. High-pitched, hyperactive bowel sounds in all quadrants

A Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range, 3.5 to 5.0 mEq/L) and hyponatremic (normal range, 136 to 145 mEq/L). Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched, hyperactive bowel sounds may be noted with large and small bowel obstructions. Crampy abdominal pain across the lower quadrants is associated with large bowel obstruction.

The nurse is preparing to insert a nasogastric (NG) tube into a 68-year-old female patient who is nauseated and vomiting. She has an abdominal mass and suspected small intestinal obstruction. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate? A. "The tube will help to drain the stomach contents and prevent further vomiting." B. "The tube will push past the area that is blocked and thus help to stop the vomiting." C. "The tube is just a standard procedure before many types of surgery to the abdomen." D. "The tube will let us measure your stomach contents so that we can plan what type of IV fluid replacement would be best."

A The NG tube is used to decompress the stomach by draining stomach contents and thereby prevent further vomiting. The NG tube will not push past the blocked area. Potential surgery is not currently indicated. The location of the obstruction will determine the type of fluid to use, not measure the amount of stomach contents

The nurse is teaching a client how to use a truss for a femoral hernia. Which statement by the client indicates the need for further teaching? a. "I will put on the truss before I go to bed each night." b. "I will put some powder under the truss to avoid skin irritation." c. "The truss will help my hernia because I can't have surgery." d. "If I have abdominal pain, I will let my health care provider know right away."

A The client is instructed to apply the truss before arising, not before going to bed at night. The other statements show accurate knowledge in using a truss.

The nurse is caring for a client who has acute viral gastroenteritis. Which dietary instruction does the nurse provide to the client? a. "Drink plenty of fluids to prevent dehydration." b. "You can have only clear liquids to drink." c. "Milk products will give you extra protein." d. "You can have sips of cola or tea to relieve nausea."

A The client should drink plenty of fluids to prevent dehydration. Clients are not necessarily restricted to clear liquids. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.

The nurse is caring for a client with an umbilical hernia who reports increased abdominal pain, nausea, and vomiting. The nurse notes high-pitched bowel sounds. Which conclusion does the nurse draw from these assessment findings? a. Bowel obstruction; client should be placed on NPO status. b. Perforation of the bowel; client needs emergency surgery. c. Adhesions in the hernia; client needs elective surgery. d. Hernia is dangerously enlarged; client needs a nasogastric (NG) tube.

A The client with a hernia presenting with abdominal pain, fever, tachycardia, nausea and vomiting, and hypoactive bowel sounds should be suspected of having developed strangulation. Strangulation poses a risk of intestinal obstruction. The client should be placed on NPO status, and the health care provider should be notified. The symptoms are not suggestive of enlargement of the hernia, adhesion formation, or bowel perforation.

When evaluating the patient's understanding about the care of the ileostomy, what statement by the patient indicates the patient needs more teaching? A. "I will be able to regulate when I have stools." B. "I will be able to wear the pouch until it leaks." C. "Dried fruit and popcorn must be chewed very well." D. "The drainage from my stoma can damage my skin."

A The ileostomy is in the ileum and drains liquid stool frequently, unlike the colostomy which has more formed stool the further distal the ostomy is in the colon. The ileostomy pouch is usually worn 4-7 days or until it leaks. It must be changed immediately if it leaks because the drainage is very irritating to the skin. To avoid obstruction, popcorn, dried fruit, coconut, mushrooms, olives, stringy vegetables, food with skin, and meats with casings must be chewed extremely well before swallowing because of the narrow diameter of the ileostomy lumen.

A client tells the nurse that her husband is repulsed by her colostomy and refuses to be intimate with her after surgery. Which is the nurse's best response? a. "Let's talk to the ostomy nurse to help you and your husband work through this." b. "You could try to wear longer lingerie that will better hide the ostomy appliance." c. "You should empty the pouch first so it will be less noticeable for your husband." d. "If you are not careful, you can hurt the stoma if you engage in sexual activity."

A The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the client's concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by becoming intimate with her husband.

The nurse is caring for a client with Crohn's disease and colonic strictures. Which assessment finding requires the nurse to consult the health care provider immediately? a. Distended abdomen b. Temperature of 100.0° F (37.8° C) c. Traces of blood in the stool d. Crampy lower abdominal pain

A The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the client's provider should be notified right away. Low-grade fever, bloody diarrhea, and crampy abdominal pain are common symptoms of Crohn's disease.

A client has an anorectal abscess. Which teaching topic does the nurse address as the priority? a. Perineal hygiene b. Comfort measures c. Nutrition therapy d. Antibiotic use

A The priority intervention for a client with an anorectal abscess focuses on maintaining meticulous perineal hygiene to prevent infection. Comfort measures are also important, but are not as high a priority. Nutrition management and antibiotic teaching may or may not be needed.

A client who has had a colostomy placed in the ascending colon expresses concern that the effluent collected in the colostomy pouch has remained liquid for 2 weeks after surgery. Which is the nurse's best response? a. "This is normal for your type of colostomy." b. "I will let the health care provider know, so that it can be assessed." c. "You should add extra fiber to your diet to stop the diarrhea." d. "Your stool will become firmer over the next few weeks."

A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. The provider may be notified, but this is not the best response from the nurse. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet or with the passage of time.

The nurse is performing a physical examination on a client. Which assessment finding leads the nurse to check the client's abdomen for the presence of an acquired umbilical hernia? a. Body mass index (BMI) of 41.9 b. Cholecystectomy last year c. History of irritable bowel syndrome d. Daily dose of lansoprazole (Prevacid) 30 mg orally

A This type of hernia is associated with obesity. The other assessment findings do not place the client at increased risk for an acquired umbilical hernia.

Two days following a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result of A. impaired peristalsis. B. irritation of the bowel. C. nasogastric suctioning. D. inflammation of the incision site.

A Until peristalsis returns to normal following anesthesia, the patient may experience slowed gastrointestinal motility leading to gas pains and abdominal distention. Irritation of the bowel, nasogastric suctioning, and inflammation of the surgical site do not cause gas pains or abdominal distention.

The nurse is caring for a group of patients. Which patient is at highest risk for pancreatic cancer? A 38-year-old Hispanic female who is obese and has hyperinsulinemia A 23-year-old who has cystic fibrosis-related pancreatic enzyme insufficiency A 72-year-old African American male who has smoked cigarettes for 50 years A 19-year-old who has a 5-year history of uncontrolled type 1 diabetes mellitus

A 72-year-old African American male who has smoked cigarettes for 50 years Risk factors for pancreatic cancer include chronic pancreatitis, diabetes mellitus, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine. African Americans have a higher incidence of pancreatic cancer than whites. The most firmly established environmental risk factor is cigarette smoking. Smokers are two or three times more likely to develop pancreatic cancer as compared with nonsmokers. The risk is related to duration and number of cigarettes smoked.

Michael, a 42 y.o. man is admitted to the med-surg floor with a diagnosis of acute pancreatitis. His BP is 136/76, pulse 96, Resps 22 and temp 101. His past history includes hyperlipidemia and alcohol abuse. The doctor prescribes an NG tube. Before inserting the tube, you explain the purpose to patient. Which of the following is a most accurate explanation? a "It empties the stomach of fluids and gas." b "It prevents spasms at the sphincter of Oddi." c "It prevents air from forming in the small intestine and large intestine." d "It removes bile from the gallbladder."

A An NG tube is inserted into the patients stomach to drain fluid and gas

The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the patient's diet? a Meats and beans. b Butter and gravies. c Potatoes and pastas. d Cakes and pastries.

A Meats and beans are high-protein foods. In liver failure, the liver is unable to metabolize protein adequately, causing protein by-products to build up in the body rather than be excreted.

Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease the excessive accumulation of serous fluid in her peritoneal cavity? a Restrict fluids b Encourage ambulation c Increase sodium in the diet d Give antacids as prescribed

A Restricting fluids decrease the amount of body fluid and the accumulation of fluid in the peritoneal space.

Stephen is a 62 y.o. patient that has had a liver biopsy. Which of the following groups of signs alert you to a possible pneumothorax? a Dyspnea and reduced or absent breath sounds over the right lung b Tachycardia, hypotension, and cool, clammy skin c Fever, rebound tenderness, and abdominal rigidity d Redness, warmth, and drainage at the biopsy site

A Signs and Symptoms of pneumothorax include dyspnea and decreased or absent breath sounds over the affected lung (right lung).

What information is correct about stomach cancer? a Stomach pain is often a late symptom. b Surgery is often a successful treatment. c Chemotherapy and radiation are often successful treatments. d The patient can survive for an extended time with TPN.

A Stomach pain is often a late sign of stomach cancer; outcomes are particularly poor when the cancer reaches that point. Surgery, chemotherapy, and radiation have minimal positive effects. TPN may enhance the growth of the cancer.

Glenda has cholelithiasis (gallstones). You expect her to complain of: a Pain in the right upper quadrant, radiating to the shoulder. b Pain in the right lower quadrant, with rebound tenderness. c Pain in the left upper quadrant, with shortness of breath. d Pain in the left lower quadrant, with mild cramping.

A The gallbladder is located in the RUQ and a frequent sign of gallstones is pain radiating to the shoulder.

The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which individual should the nurse refer for an immunoglobin (IG) injection? A caregiver who lives in the same household with the patient A friend who delivers meals to the patient and family each week A relative with a history of hepatitis A who visits the patient daily A child living in the home who received the hepatitis A vaccine 3 months ago

A caregiver who lives in the same household with the patient IG is recommended for persons who do not have anti-HAV antibodies and are exposed as a result of close contact with persons who have HAV or foodborne exposure. Persons who have received a dose of HAV vaccine more than 1 month previously or who have a history of HAV infection do not require IG.

A male client with a long history of ulcerative colitis (UC) 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

When providing discharge teaching for the patient after a laparoscopic cholecystectomy, what information should the nurse include? A lower-fat diet may be better tolerated for several weeks. Correct Do not return to work or normal activities for 3 weeks. Bile-colored drainage will probably drain from the incision. Keep the bandages on and the puncture site dry until it heals.

A lower-fat diet may be better tolerated for several weeks. Correct Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks following surgery. Normal activities can be gradually resumed as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery, and the patient can shower.

D

A nursing intervention that is most appropriate to decrease postoperative edema and pain following an inguinal herniorraphy is: A. applying a truss to the hernia site B. allowing the patient to stand to void C. supporting the incision during coughing D. applying a scrotal support with ice bag

C

A patient with metastatic colorectal cancer is scheduled for both chemotherapy and radiation. Patient teaching regarding these therapies for this patient would include an explanation that: A. chemotherapy can be used to cure colorectal cancer B. radiation is commonly used as adjuvant therapy following surgery C. both chemotherapy and radiation can be used as palliative treatments D. the patient should expect few if any side effects from the chemotherapeutic agents

The nurse is checking the residual content for a client who is receiving intermittent feedings. Which residual content, if obtained, would lead the nurse to delay the feeding? a) 120 mL b) 60 mL c) 30 mL d) 90 mL

A) 120 mL Feedings typically are delayed if the residual content measures more than 100 mL for intermittent feedings or 10% to 20% of the hourly amount of a continuous feeding. Thus a residual content of 120 mL would require the nurse to delay the feeding.

After assessing a client with peritonitis, the nurse most likely would document the client's bowel sounds as: a) Absent. b) High-pitched. c) Mild. d) Hyperactive.

A) Absent Since lack of bowel motility typically accompanies peritonitis, bowel sounds are absent. Therefore, the nurse will not observe mild, high-pitched, or hyperactive bowel sounds.

A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal? a) Albumin b) Chloride c) Creatinine d) Urobilinogen

A) Albumin Albumin is an abnormal finding in a routine urine specimen. Ascites present in liver failure contain albumin; therefore, if the bladder ruptured, ascites containing albumin would drain from the indwelling urinary catheter because the catheter is no longer contained in the bladder. Creatinine, urobilinogen, and chloride are normally found in urine.

A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal? a) Albumin b) Chloride c) Urobilinogen d) Creatinine

A) Albumin Albumin is an abnormal finding in a routine urine specimen. Ascites present in liver failure contain albumin; therefore, if the bladder ruptured, ascites containing albumin would drain from the indwelling urinary catheter because the catheter is no longer contained in the bladder. Creatinine, urobilinogen, and chloride are normally found in urine.

When caring for a client with an acute exacerbation of a peptic ulcer, the nurse finds the client doubled up in bed with severe pain to his right shoulder. The intial appropriate action by the nurse is to a) Assess the client's abdomen and vital signs. b) Irrigate the client's NG tube. c) Place the client in the high-Fowler's position. d) Notify the health care provider.

A) Assess the client's abdomen and vital signs Signs and symptoms of perforation includes sudden, severe upper abdominal pain (persisting and increasing in intensity); pain may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm. The nurse should assess the vital signs and abdomen prior to notifying the physician. Irrigation of the NG tube should not be performed because the additional fluid may be spilled into the peritoneal cavity, and the client should be placed in a position of comfort, usually on the side with the head slightly elevated.

The nurse is to obtain a stool specimen from a client who reported that he is taking iron supplements. The nurse would expect the stool to be which color? a) Black b) Red c) Dark brown d) Green

A) Black Ingestion of iron can cause the stool to turn black. Meat protein causes stool to appear dark brown. Ingestion of large amounts of spinach may turn stool green while ingestion of carrots and beets may cause stool to turn red.

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this client's stools to be: a) black and tarry. b) coffee-ground-like. c) bright red. d) clay-colored.

A) Black and tarry Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes on the blood. Vomitus associated with upper GI tract bleeding commonly is described as coffee-ground-like. Clay-colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract bleeding.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: a) cirrhosis. b) cholelithiasis. c) appendicitis. d) peptic ulcer disease.

A) Cirrhosis Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.

Which of the following is the primary symptom of achalasia? a) Difficulty swallowing b) Pulmonary symptoms c) Chest pain d) Heartburn

A) Difficulty swallowing The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The patient may also report chest pain and heartburn that may or may not be associated with eating. Secondary pulmonary complications may result from aspiration of gastric contents.

The client cannot tolerate oral feedings due to an intestinal obstruction and is NPO. A central line has been inserted, and the client is being started on parenteral nutrition (PN). The nurse performs the following actions while the client receives PN (select all that apply): a) Document intake and output. b) Use clean technique for all catheter dressing changes. c) Weigh the client every day. d) Cover insertion site with a transparent dressing that is changed daily. e) Check blood glucose level every 6 hours.

A) Document intake and output; C) Weigh the client every day; E) Check blood glucose level every 6 hours When a client is receiving PN through a central line, the nurse weighs the client daily, checks blood glucose level every 6 hours, and documents intake and output. These actions are to ensure the client is receiving optimal nutrition. The nurse also performs activities to prevent infection, such as covering the insertion site with a transparent dressing that is changed weekly and/or prn and using sterile technique during catheter site dressing changes.

After administering a dose of promethazine (Phenergan) to a patient with nausea and vomiting, the nurse explains that which of the following may be experienced as a common temporary adverse effect of the medication? A) Drowsiness B) Reduced hearing C) Sensation of falling D) Photosensitivity

A) Drowsiness Although being given to this patient as an antiemetic, promethazine also has sedative and amnesic properties. For this reason, the patient is likely to experience drowsiness as an adverse effect of the medication.

Which diagnostic test is used first to evaluate a client with upper GI bleeding? a) Hemoglobin levels and hematocrit (HCT) b) Endoscopy c) Arteriography d) Upper GI series

A) Hemoglobin levels and hematocrit Hemoglobin and HCT are typically performed first in clients with upper GI bleeding to evaluate the extent of blood loss. Endoscopy is then performed to directly visualize the upper GI tract and locate the source of bleeding. An upper GI series, or barium study, usually isn't the diagnostic method of choice, especially in a client with acute active bleeding who's vomiting and unstable. An upper GI series is also less accurate than endoscopy. Although an upper GI series might confirm the presence of a lesion, it wouldn't necessarily reveal whether the lesion is bleeding. Arteriography is an invasive study associated with life-threatening complications and wouldn't be used for an initial evaluation.

Diet therapy for patients diagnosed with IBS include which of the following? a) High-fiber diet b) Fluids with meals c) Caffeinated products d) Spicy foods

A) High fiber diet A high-fiber diet is prescribed to help control diarrhea and constipation. Foods that are possible irritants such as caffeine, spicy foods, lactose, beans, fried foods, corn, wheat, alcohol should be avoided. Fluids should not be taken with meals because this results in abdominal distention.

Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? a) Hypotension b) Bradycardia c) Polyuria d) Warm moist skin

A) Hypotension Signs of potential hypovolemia include cool, clammy skin, tachycardia, decreased blood pressure, and decreased urine output.

Two days following a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms occur as a result of which of the following? A) Impaired peristalsis B) Irritation of the bowel C) Nasogastric suctioning D) Anastomosis site inflammation

A) Impaired peristalsis Until peristalsis returns to normal following anesthesia, the patient may experience slowed gastrointestinal motility leading to gas pains and abdominal distention.

A nursing instructor tells the class that review of oral hygiene is an important component during assessment of the gastrointestinal system. One of the students questions this statement. Which of the following explanations from the nurse educator is most appropriate? a) "Injury to oral mucosa or tooth decay can lead to difficulty in chewing food." b) "Mouth sores are caused by bacteria that can thin the villi of the small intestine." c) "Decaying teeth secrete toxins that decrease the absorption of nutrients." d) "Bad breath will encourage ingestion of fatty foods to mask odor."

A) Injury to the oral mucosa or tooth decay can lead to difficulty in chewing food Poor oral hygiene can result in injury to the oral mucosa, lip, or palate; tooth decay; or loss of teeth. Such problems may lead to disruption in the digestive system. The ability to chew food or even swallow may be hindered.

After 20 seconds of auscultating for bowel sounds on a client recovering from abdominal surgery, the nurse hears nothing. Which of the following should the nurse do based on the assessment findings? a) Listen longer for the sounds. b) Call the physician to report absent bowel sounds. c) Document that the client is constipated. d) Return in 1 hour and listen again to confirm findings.

A) Listen longer for sounds Auscultation is used to determine the character, location, and frequency of bowel sounds. The frequency and character of sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minutes. Normal sounds are heard about every 5 to 20 seconds, whereas hypoactive sounds can be one or two sounds in 2 minutes. Postoperatively, it is common for sounds to be reduced; therefore, the nurse needs to listen at least 3 to 5 minutes to verify absent or no bowel sounds.

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? a) Loss of 2.2 lb (1 kg) in 24 hours b) Serum potassium level of 3.5 mEq/L c) Blood pH of 7.25 d) Serum sodium level of 135 mEq/L

A) Loss of 2.2 lb (1 kg) in 24 hours Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.

The nurse is caring for a 68-year-old patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which of the following types of bowel sounds that is consistent with the patient's clinical picture? A) Low pitched and rumbling above the area of obstruction B) High pitched and hypoactive below the area of obstruction C) Low pitched and hyperactive below the area of obstruction D) High pitched and hyperactive above the area of obstruction

A) Low pitched and rumbling above the area of obstruction Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high pitched, sometimes referred to as "tinkling" above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.

A patient with type 2 diabetes and cirrhosis asks the nurse if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on knowledge that A) Milk thistle may affect liver enzymes and thus alter drug metabolism. B) Milk thistle is generally safe in recommended doses for up to 10 years. C) There is unclear scientific evidence for the use of milk thistle in treating cirrhosis. D) Milk thistle may elevate the serum glucose levels and is thus contraindicated in diabetes.

A) Milk thistle may affect liver enzymes and thus alter drug metabolism There is good scientific evidence for the use of milk thistle as an antioxidant to protect the liver cells from toxic damage in the treatment of cirrhosis. It is noted to be safe for up to 6 years, not 10 years, and it may lower, not elevate, blood glucose levels. It does affect liver enzymes and thus could alter drug metabolism. Therefore patients will need to be monitored for drug interactions.

A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. It is best for the nurse to a) Notify the surgeon about the tube's removal. b) Reinsert the nasogastric tube to the stomach. c) Document the discontinuation of the nasogastric tube. d) Place the nasogastric tube to the level of the esophagus.

A) Notify the surgeon about the tube's removal If the nasogastric tube is removed accidently in a client who has undergone esophageal or gastric surgery, it is usually replaced by the physician. Care is taken to avoid trauma to the suture line. The nurse will not insert the tube to the esophagus or to the stomach in this situation. The nurse needs to do more than just document its removal. The nurse needs to notify the physician who will make a determination of leaving out or inserting a new nasogastric tube.

Which of the following is caused by improper catheter placement and inadvertent puncture of the pleura? a) Pneumothorax b) Sepsis c) Fluid overload d) Air embolism

A) Pneumothorax A pneumothorax is caused by improper catheter placement and inadvertent puncture of the pleura. Air embolism can occur from a missing cap on a port. Sepsis can be caused by the separation of dressings. Fluid overload is caused by fluids infusing too rapidly.

A nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer? a) Polyps b) Weight gain c) Hemorrhoids d) Duodenal ulcers

A) Polyps Colorectal polyps are common with colon cancer. Duodenal ulcers and hemorrhoids aren't preexisting conditions of colorectal cancer. Weight loss — not gain — is an indication of colorectal cancer.

The most common cause of esophageal varices includes which of the following? a) Portal hypertension b) Asterixis c) Jaundice d) Ascites

A) Portal hypertension Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also complains of unpleasant tastes and odors. Which of the following measures should be included in the client's plan of care? a) Provide frequent mouth care. b) Keep the feeding formula refrigerated. c) Ensure adequate hydration with additional water. d) Flush the tube with water before adding the feedings.

A) Provide frequent mouth care Frequent mouth care helps to relieve the discomfort from dryness and unpleasant odors and tastes. It can be done with the help of ice chips and analgesic throat lozenges, gargles, or sprays. Adequate hydration is essential. If urine output is less than less than 500 mL/day, formula and additional water can be given as ordered. Keeping the feeding formula refrigerated and unopened until it is ready for use and flushing the tube with water before adding feedings are measures to protect the client from infections.

A patient with a history of peptic ulcer disease has presented to the emergency department with complaints of severe abdominal pain and a rigid, boardlike abdomen, prompting the health care team to suspect a perforated ulcer. Which of the following actions should the nurse anticipate? A) Providing IV fluids and inserting a nasogastric tube B) Administering oral bicarbonate and testing the patient's gastric pH level C) Performing a fecal occult blood test and administering IV calcium gluconate D) Starting parenteral nutrition and placing the patient in a high-Fowler's position

A) Providing IV fluids and inserting a NG tube A perforated peptic ulcer requires IV replacement of fluid losses and continued gastric aspiration by NG tube. Nothing is given by mouth and gastric pH testing is not a priority. Calcium gluconate is not a medication directly relevant to the patient's suspected diagnosis and parenteral nutrition is not a priority in the short term.

A patient scheduled to undergo an abdominal ultrasonography is advised to do which of the following? a) Restrict eating of solid food for 6 to 8 hours before the test. b) Do not consume anything sweet for 24 hours before the test c) Do not undertake any strenuous exercise for 24 hours before the test d) Avoid exposure to sunlight for at least 6 to 8 hours before the test

A) Restrict eating of solid food for 6 to 8 hours before the test For a patient who is scheduled to undergo an abdominal ultrasonography, the patient should restrict herself from solid food for 6 to 8 hours to avoid having images of her test obscured with gas and intestinal contents. Ultrasonography records the reflection of sound waves. Strenuous exercises, the consumption of sweets, and exposure to sunlight do not affect the results of the test in any way.

The nurse is caring for a patient in the emergency department with complaints of acute abdominal pain, nausea, and vomiting. When the nurse palpates the patient's left lower abdominal quadrant, the patient complains of pain in the right lower quadrant. The nurse will document this as which of the following diagnostic signs of appendicitis? A) Rovsing sign B) Referred pain C) Chvostek's sign D) Rebound tenderness

A) Rovsing sign In patients with suspected appendicitis, Rovsing sign may be elicited by palpation of the left lower quadrant, causing pain to be felt in the right lower quadrant.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: a) subnormal serum glucose and elevated serum ammonia levels. b) subnormal clotting factors and platelet count. c) elevated liver enzymes and low serum protein level. d) elevated blood urea nitrogen and creatinine levels and hyperglycemia.

A) Subnormal serum glucose and elevated serum ammonia levels In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.

Blood shed in sufficient quantities into the upper GI tract, produces which color of stool? a) Tarry-black b) Milky white c) Green d) Bright red

A) Tarry-black Blood shed in sufficient quantities into the upper GI tract produces a tarry-black stool. Blood entering the lower portion of the GI tract or passing rapidly through it will appear bright or dark red. A milky white stool is indicative "of" a patient who received barium. A green stool is indicative of a patient who has eaten spinach.

A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge? a) The client is free from esophagitis and achalasia. b) The client reports diminished duodenal inflammation. c) The client has normal gastric structures. d) The client doesn't exhibit rectal tenesmus.

A) The client is free from esophagitis and achalasia. Dysphagia may be the reason why a client with esophagitis or achalasia seeks treatment. Therefore, when the client is free of esophagitis or achalasia, he is ready for discharge. Dysphagia isn't associated with rectal tenesmus, duodenal inflammation, or abnormal gastric structures.

A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention? a) The client lying in a lateral position, with the head of bed flat b) Foley catheter bag containing 500 ml of amber urine c) Serosanguineous drainage on the dressing d) A piggyback infusion of levofloxacin (Levaquin)

A) The client lying in a lateral position, with the head of bed flat A client who has had neck surgery is at risk for neck swelling. To prevent respiratory complications, the head of the bed should be at least at a 30-degree angle. This position gives the lungs room to expand and decreases swelling by promoting venous and lymphatic drainage. This position also minimizes the risk of aspiration. Serosanguineous drainage on the dressing, a Foley bag containing amber urine, and levofloxacin infusing aren't causes for concern.

Which outcome indicates effective client teaching to prevent constipation? a) The client reports engaging in a regular exercise regimen. b) The client limits water intake to three glasses per day. c) The client verbalizes consumption of low-fiber foods. d) The client maintains a sedentary lifestyle.

A) The client reports engaging in a regular exercise regimen. The client having a regular exercise program indicates effective teaching. A regular exercise regimen promotes peristalsis and contributes to regular bowel elimination patterns. A low-fiber diet, a sedentary lifestyle, and limited water intake would predispose the client to constipation.

The nurse is preparing to insert a nasogastric tube into a 68-year-old patient with an abdominal mass and suspected bowel obstruction. The patient asks the nurse why this procedure is necessary. Which of the following responses is most appropriate? A) "The tube will help to drain the stomach contents and prevent further vomiting." B) "The tube will push past the area that is blocked, and thus help to stop the vomiting." C) "The tube is just a standard procedure before many types of surgery to the abdomen." D) "The tube will let us measure your stomach contents, so that we can plan what type of IV fluid replacement would be best."

A) The tube will help drain the stomach contents and prevent further vomiting The nasogastric tube is used to decompress the stomach by draining stomach contents, and thereby prevent further vomiting.

A client with GERD develops espophagitis. Which diagnostic test would the nurse expect the physician to order to confirm the diagnosis? a) Upper endoscopy with biopsy b) Stool testing for occult blood c) 24-hour esophageal pH monitoring d) Barium swallow

A) Upper endoscopy with biopsy Upper endoscopy with biopsy confirms esophagitis. Barium-swallow would reveal inflammation or stricture formation from chronic esophagitis. Tests of stool may show positive findings of blood. Ambulatory 24-hour esophageal pH monitoring allows for observation of the frequency of reflux episodes and their associated symptoms.

The nurse inserts a nasoduodenal tube for feeding of the client. To check best for placement, the nurse a) Verifies location with an abdominal x-ray b) Aspirates contents and checks the color of the aspirate c) Auscultates when injecting air d) Adds 8 to 10 inches of the tube after inserting to the xiphoid process

A) Verifies location with an abdominal x-ray Initially, an x-ray should be used to confirm placement of the nasoduodenal tube. It is the most accurate method to verify tube placement. Adding 8 to 10 inches to the length of the tube after measuring from nose to earlobe to xiphoid process is not supported, because it does not indicate that the tube will be in the correct position. Intestinal aspirate is usually clear and yellow to bile-colored. Gastric aspirate is usually cloudy and green, tan, off-white, or brown. Food particles may be present. The traditional method of injecting air through the tube while auscultating the epigastric area with a stethoscope to detect air insufflation is also an unreliable indicator.

Initially, which diagnostic should be completed following placement of a NG tube? a) X-ray b) Measurement of tube length c) pH measurement of aspirate d) Visual assessment of aspirate

A) X-ray Instead of auscultation, a combination of three methods is recommended: measurement of tube length, visual assessment of aspirate, and pH measurement of aspirate.

The nurse is caring for a patient diagnosed with IBS (irritable bowel syndrome). What symptoms are the patient most likely to exhibit? Select all that apply: a. Constipation b. Diarrhea c. Bloating d. Generalized abdominal pain e. High pitched bowel sounds.

A, B, C, D

When caring for a patient with liver disease, you recognize the need to prevent bleeding caused by altered clotting factors and rupture of varices. Which nursing interventions are appropriate to achieve this outcome (select all that apply)? A. Use smallest gauge possible when giving injections or drawing blood. B. Teach patient to avoid straining at stool, vigorous nose blowing, and coughing. C. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. D. Apply gentle pressure for the shortest possible period after performing venipuncture. E. Instruct patient to avoid aspirin and nonsteroidal antiinflammatory drugs (NSAIDs).

A, B, C, E

A nurse is teaching a community group about food poisoning and gastroenteritis. Which statements by the nurse are accurate? (Select all that apply.) a. Rotavirus is more common among infants and younger children. b. Escherichia coli diarrhea is transmitted by contact with infected animals. c. Don't drink water when swimming to prevent E. coli infection. d. All clients with botulism require hospitalization. e. Parasitic diseases may not show up for 1 to 2 weeks after infection.

A, C, D, E

The client asks the nurse how to avoid becoming ill with Salmonella infection again. Which are appropriate responses from the nurse? (Select all that apply.) a. "Wash leafy vegetables carefully before eating or cooking them." b. "Do not ingest water from the garden hose or the pool." c. "Wash your hands before and after using the bathroom." d. "Be sure meat is cooked to the proper temperature." e. "Avoid eating eggs that are sunny side up or undercooked." f. "When eating outdoors, be sure to keep flies off your food."

A, C, D, E, F

A nurse is teaching a community group ways to prevent Escherichia coli infection. Which statements made by the nurse are accurate? (Select all that apply.) a. "Wash your hands after any contact with animals." b. "It is not necessary to buy a meat thermometer." c. "Stay away from people who are ill with diarrhea." d. "Use separate cutting boards for meat and vegetables." e. "Avoid swimming in backyard pools and using hot tubs."

A, D

The nurse is caring for a patient with a transverse colostomy. Which of the following should the nurse perform during ostomy care. Select all that apply: a. Inspect the Stoma b. Test the stool for Guiac c. Clean the surrounding skin with alcohol d. Trim the wafer to the approximate size of the stoma e. Apply skin prep to the skin before applying the ostomy appliance.

A, D, E

The nurse is helping a student prepare to insert a nasogastric tube for an adult client with a bowel obstruction. Which actions by the student indicate to the nurse that a review of the procedure is needed? (Select all that apply.) a. Gathering supplies, including an 8 Fr Levin tube, sterile gloves, tape, and water-soluble lubricant b. Performing hand hygiene and positioning the client in high Fowler's position, with pillows behind the head and shoulders c. Attaching a 60-mL irrigation syringe to the end of the nasogastric tube before inserting it into the nose d. Instructing the client to extend the neck against the pillow once the nasogastric tube has reached the oropharynx e. Checking for correct placement by checking the pH of the fluid aspirated from the tube f. Securing the nasogastric tube by taping it to the client's nose and pinning the end to the pillowcase g. Connecting the nasogastric tube to intermittent medium suction with an anti-reflux valve on the air vent

A, D, F

When caring for a patient with a biliary obstruction, the nurse will anticipate administering which of the following vitamin supplements (select all that apply)? A) Vitamin A B) Vitamin D C) Vitamin E D) Vitamin K E) Vitamin B

A,B,C,D Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat soluble and thus would need to be supplemented in a patient with biliary obstruction.

When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which of the following nursing interventions would be appropriate to achieve this outcome (select all that apply)? A) Use smallest gauge possible when giving injections or drawing blood. B) Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. C) Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. D) Apply gentle pressure for the shortest possible time period after performing venipuncture. E) Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.

A,B,C,E Using the smallest gauge for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding.

One of the most challenging nursing interventions to promote healing in the patient with viral hepatitis is a. providing adequate nutritional intake b. promoting strict bed rest during the icteric phase c. providing pain relief without using liver metabolized drugs. d. providing quiet diversional activities during periods of fatigue

A- Adequate nutrition is especially important in promoting regeneration of liver cells, but the anorexia of viral hepatitis is often severe, requiring creative and innovative nursing interventions. Strict bed rest is not usually required, and the patient usually has only minor discomfort from with hepatitis. Diversional activities may be required to promote psychologic rest but not during periods of fatigue

The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? A. "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." B. "I need to take good care of my belly and ankle skin where it is swollen." C. "A scrotal support may be more comfortable when I have scrotal edema." D. "I can use pillows to support my head to help me breathe when I am in bed."

A. "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider, as this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.

The nurse is doing pre-op teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements? A. "I will need to drain the pouch regularly with a catheter." B. "I will need to wear a drainage bag for the rest of my life." C. "The drainage from this type of ostomy will be formed." D. "I will be able to pass stool from my rectum eventually."

A. A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining to about 3 times a day or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucus drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool only from the rectum if an ileal-anal pouch or anastamosis were created. This type of operation is a two-stage procedure.

The client being seen in a physician's office has just been scheduled for a barium swallow the next day. The nurse writes down which of the following instructions for the client to follow before the test? A. Fast for 8 hours before the test B. Eat a regular supper and breakfast C. Continue to take all oral medications as scheduled. D. Monitor own bowel movement pattern for constipation

A. A barium swallow is an x-ray study that uses a substance called barium for contrast to highlight abnormalities in the GI tract. The client should fast for 8 to 12 hours before the test, depending on the physician instructions. Most oral medications also are withheld before the test. After the procedure the nurse must monitor for constipation, which can occur as a result of the presence of barium in the GI tract.

The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which individual should the nurse refer for an immunoglobin (IG) injection? B. A friend who delivers meals to the patient and family each week C. A relative with a history of hepatitis A who visits the patient daily D. A child living in the home who received the hepatitis A vaccine 3 months ago

A. A caregiver who lives in the same household with the patient IG is recommended for persons who do not have anti-HAV antibodies and are exposed as a result of close contact with persons who have HAV or foodborne exposure. Persons who have received a dose of HAV vaccine more than 1 month previously or who have a history of HAV infection do not require IG.

Which of the following complications is thought to be the most common cause of appendicitis? A. A fecalith B. Bowel kinking C. Internal bowel occlusion D. Abdominal bowel swelling

A. A fecalith is a fecal calculus, or stone, that occludes the lumen of the appendix and is the most common cause of appendicitis. Bowel wall swelling, kinking of the appendix, and external occlusion, not internal occlusion, of the bowel by adhesions can also be causes of appendicitis.

Which of the following diets is most commonly associated with colon cancer? A. Low-fiber, high fat B. Low-fat, high-fiber C. Low-protein, high-carbohydrate D. Low carbohydrate, high protein

A. A low-fiber, high-fat diet reduced motility and increases the chance of constipation. The metabolic end products of this type of diet are carcinogenic. A low-fat, high-fiber diet is recommended to prevent colon cancer.

When providing discharge teaching for the patient after a laparoscopic cholecystectomy, what information should the nurse include? A. A lower-fat diet may be better tolerated for several weeks. B. Do not return to work or normal activities for 3 weeks. C. Bile-colored drainage will probably drain from the incision. D. Keep the bandages on and the puncture site dry until it heals.

A. A lower-fat diet may be better tolerated for several weeks. Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks following surgery. Normal activities can be gradually resumed as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery, and the patient can shower.

You explain to the patient undergoing ostomy surgery that the procedure that maintains the most normal functioning of the bowel is A. A sigmoid colostomy B. A transverse colostomy C. A descending colostomy D. An ascending colostomy

A. A sigmoid colostomy The more distal the ostomy, the more the intestinal contents resemble feces that are eliminated from an intact colon and rectum. Output from a sigmoid colostomy resembles normally formed stool, and some patients are able to regulate emptying time so they do not need to wear a collection bag.

You're caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic encephalopathy in her? a Asterixis b Chvostek's sign c Trousseau's sign d Hepatojugular reflex

A. Asterixis is an early neurologic sign of hepatic encephalopathy elicited by asking the patient to hold her arms stretched out. Asterixis is present if the hands rapidly extend and flex.

The patient is admitted to the hospital with a severe exacerbation of ulcerative colitis. What finding is most important for you to act on? A. Blood urea nitrogen (BUN): 50 mg/dL B. Hemoglobin (Hb): 12 g/dL C. White blood cells (WBC): 11,000/μL D. Sodium (Na+): 148 mEq/L

A. Blood urea nitrogen (BUN): 50 mg/dL Patients with severe ulcerative colitis frequently have bloody diarrhea. Dehydration is present as evidenced by the high BUN. This must be treated first before the mild anemia and mild inflammation are addressed.

A client has just had surgery for colon cancer. Which of the following disorders might the client develop? A. Peritonitis B. Diverticulosis C. Partial bowel obstruction D. Complete bowel obstruction

A. Bowel spillage could occur during surgery, resulting in peritonitis. Complete or partial bowel obstruction may occur before bowel resection. Diverticulosis doesn't result from surgery or colon cancer.

Which contributing etiologic factor would a nurse expect to find in a patient with acute pancreatitis? A. Cholelithiasis B. Smoking C. Crohn's disease D. Taking an angiotensin-converting enzyme (ACE) inhibitor

A. Cholelithiasis and alcohol intake

During assessment of a patient with obstructive jaundice, what do you expect to find? A. Clay-colored stools B. Dark urine and stools C. Pyrexia and severe pruritus D. Elevated level of urinary urobilinogen

A. Clay-colored stools

Which of the following symptoms indicated diverticulosis? A. No symptoms exist B. Change in bowel habits C. Anorexia with low-grade fever D. Episodic, dull, or steady midabdominal pain

A. Diverticulosis is an asymptomatic condition. The other choices are signs and symptoms of diverticulitis.

What is a classic diagnostic finding in a patient with appendicitis? A. Elevated white blood cell (WBC) count B. Elevated level of lipase C. Left lower quadrant tenderness D. Positive Kernig's sign

A. Elevated white blood cell (WBC) count The WBC count is mildly to moderately elevated in about 90% of cases. The classic location for appendicitis is McBurney's point in the right lower quadrant.

Which of the following areas is the most common site of fistulas in client's with Crohn's disease? A. Anorectal B. Ileum C. Rectovaginal D. Transverse colon

A. Fistulas occur in all these areas, but the anorectal area is most common because of the relative thinness of the intestinal wall in this area.

A female client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurse's best response? a. "You may have eaten contaminated restaurant food." b. "You could have gotten it by using I.V. drugs." c. "You must have received an infected blood transfusion." d. "You probably got it by engaging in unprotected sex."

A. Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming food contaminated by infected food handlers. The virus isn't transmitted by the I.V. route, blood transfusions, or unprotected sex. Hepatitis B can be transmitted by I.V. drug use or blood transfusion. Hepatitis C can be transmitted by unprotected sex.

Two days after a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. You plan care for the patient based on the knowledge that the symptoms occur as a result of A. Impaired peristalsis B. Irritation of the bowel C. Nasogastric suctioning D. Anastomosis site inflammation

A. Impaired peristalsis Until peristalsis returns to normal after anesthesia, the patient may experience slowed gastrointestinal motility leading to gas pains and abdominal distention.

A patient is suspected of having a large intestine obstruction. What is the best indication that an obstruction is present? A. Lack of flatus B. Nausea C. Temperature of 100.4° F (38° C) D. Thirst

A. Lack of flatus Inability to pass gas or constipation is a common manifestation of a large intestinal obstruction.

Which of the following types of diets is implicated in the development of diverticulosis? A. Low-fiber diet B. High-fiber diet C. High-protein diet D. Low-carbohydrate diet

A. Low-fiber diets have been implicated in the development of diverticula because these diets decrease the bulk in the stool and predispose the person to the development of constipation. A high-fiber diet is recommended to help prevent diverticulosis. A high-protein or low-carbohydrate diet has no effect on the development of diverticulosis.

A patient with type 2 diabetes and cirrhosis asks the nurse if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge? A. Milk thistle may affect liver enzymes and thus alter drug metabolism. B. Milk thistle is generally safe in recommended doses for up to 10 years. C. There is unclear scientific evidence for the use of milk thistle in treating cirrhosis. D. Milk thistle may elevate the serum glucose levels and is thus contraindicated in diabetes.

A. Milk thistle may affect liver enzymes and thus alter drug metabolism. There is good scientific evidence that there is no real benefit from using milk thistle to protect the liver cells from toxic damage in the treatment of cirrhosis. Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore patients will need to be monitored for drug interactions. It is noted to be safe for up to 6 years, not 10 years, and it may lower, not elevate, blood glucose levels.

The elderly patient was informed that outpouches were found in the descending colon during the screening colonoscopy. The patient asks you what this finding means. What is the best explanation? A. Most people get these outpouchings as they age. B. These findings respond well to treatment with sulfa antibiotics. C. It is a precursor to colon cancer, and routine screening is essential. D. They contribute to malabsorption of cobalamin (vitamin B12) and fat.

A. Most people get these outpouchings as they age. It is believed that 65% of people have the saccular dilations or outpouchings of the mucosa by the time they are 85 years old. It is believed to be from high intraluminal pressure on weakened areas of the bowel wall from inadequate dietary fiber. It is typically asymptomatic and not a concern unless inflamed or diverticulitis develops.

Which of the following aspects is the priority focus of nursing management for a client with peritonitis? A. Fluid and electrolyte balance B. Gastric irrigation C. Pain management D. Psychosocial issues

A. Peritonitis can advance to shock and circulatory failure, so fluid and electrolyte balance is the priority focus of nursing management. Gastric irrigation may be needed periodically to ensure patency of the nasogastric tube. Although pain management is important for comfort and psychosocial care will address concerns such as anxiety, focusing on fluid and electrolyte imbalance will maintain hemodynamic stability.

The patient has esophageal varices and a Sengstaken-Blakemore tube is inserted. What is your priority action? A. Place scissors at the bedside. B. Aspirate gastric secretions and test for pH. C. Irrigate with copious amounts of ice water solution. D. Order a chest x-ray to confirm placement.

A. Place scissors at the bedside. Rationale Nursing care includes monitoring for complications and occlusion of the airway by the balloon. If the gastric balloon breaks, the esophageal balloon will slip upward, obstructing the airway. If this happens, the tube must be cut, and you need to keep scissors at the bedside. Aspirating gastric secretions and testing for pH are actions related to confirming placement of a nasogastric tube. Ice water irrigations may be ordered, but bleeding complications usually are controlled with medications, sclerotherapy, and other treatments. Placement is not routinely confirmed with radiographs. Reference: 1084

The patient with advanced cirrhosis has esophageal varices and coffee-ground emesis. What action is most important for you to perform? A. Prepare for endoscopic sclerotherapy. B. Insert a nasogastric tube. C. Assess the stool for occult blood. D. Administer oxygen by non-rebreather mask.

A. Prepare for endoscopic sclerotherapy.

The patient with Crohn's disease has had multiple intestinal resections. Which symptom indicates that short bowel syndrome has developed? A. Steatorrhea B. Constipation C. Hypercholesteremia D. Hypercalcemia

A. Steatorrhea The predominant manifestation is diarrhea or steatorrhea. Diarrhea, not constipation, is a concern because there is decreased intestinal surface to absorb fluid and nutrients. Decreased absorption of bile salts is the issue; increased cholesterol is not related to short bowel syndrome.

The client with a new colostomy is concerned about the odor from the stool in the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor? A. Yogurt B. Broccoli C. Cucumbers D. Eggs

A. The client should be taught to include deodorizing foods in the diet, such a beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas forming food as well. Broccoli, cucumbers, and eggs are gas forming foods.

Fistulas are most common with which of the following bowel disorders? A. Crohn's disease B. Diverticulitis C. Diverticulosis D. Ulcerative colitis

A. The lesions of Crohn's disease are transmural; that is, they involve all thickness of the bowel. These lesions may perforate the bowel wall, forming fistulas with adjacent structures. Fistulas don't develop in diverticulitis or diverticulosis. The ulcers that occur in the submucosal and mucosal layers of the intestine in ulcerative colitis usually don't progress to fistula formation as in Crohn's disease.

The nurse instructs the ileostomy client to do which of the following as a part of essential care of the stoma? A. Cleanse the peristomal skin meticulously B. Take in high-fiber foods such as nuts C. Massage the area below the stoma D. Limit fluid intake to prevent diarrhea.

A. The peristomal skin must receive meticulous cleansing because the ileostomy drainage has more enzymes and is more caustic to the skin than colostomy drainage. Foods such as nuts and those with seeds will pass through the ileostomy. The client should be taught that these foods will remain undigested. The area below the ileostomy may be massaged if needed if the ileostomy becomes blocked by high fiber foods. Fluid intake should be maintained to at least six to eight glasses of water per day to prevent dehydration.

The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons (select all that apply)? A. There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. B. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. C. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. D. Osmoreceptors in the hypothalamus stimulate thirst, which causes the stimulation to take in fluids orally. E. Overactivity of the enlarged spleen results in increased removal of blood cells from the circulation, which decreases the vascular pressure.

A. There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. B. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. C. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. The ascites related to cirrhosis are caused by decreased colloid oncotic pressure from the lack of albumin from liver inability to synthesize it and the portal hypertension that shifts the protein from the blood vessels to the peritoneal cavity, and hyperaldosteronism which increases sodium and fluid retention. The intake of fluids orally and the removal of blood cells by the spleen do not directly contribute to ascites

When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome (select all that apply)? A. Use smallest gauge needle possible when giving injections or drawing blood. B. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. C. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. D. Apply gentle pressure for the shortest possible time period after performing venipuncture. E. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.

A. Use smallest gauge needle possible when giving injections or drawing blood. B. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. C. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. E. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present. Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding

When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements (select all that apply)? A. Vitamin A B. Vitamin D C. Vitamin E D. Vitamin K E. Vitamin B

A. Vitamin A B. Vitamin D C. Vitamin E D. Vitamin K Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat-soluble and thus would need to be supplemented in a patient with biliary obstruction.

A male client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: a. yellow sclerae. b. light amber urine. c. circumoral pallor. d. black, tarry stools.

A. Yellow sclerae may be the first sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

You are developing a careplan on Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the following do you include? a Administering a lactulose enema as ordered. b Encouraging a protein-rich diet. c Administering sedatives, as necessary. d Encouraging ambulation at least four times a day.

A. You may administer the laxative lactulose to reduce ammonia levels in the colon.

Identify the rationales for the following interventions in treating the cirrhotic patient with hepatic encephalopathy a. Lactulose (Cephulac) b. Neomycin c. Eliminating blood from the GI tract

A. reduction of ammonia formation by decreasing absorption of ammonia from bowel B. reduction of ammonia formation by reducing bacterial flora that produce ammonia C. Reduction of ammonia formation by removing red blood cells as a source of protein

A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge? a. "Do you have a one- or two-story home?" b. "Can you check your own pulse rate?" c. "Do you have any alcohol in your home?" d. "Can you prepare your own meals?"

ANS: A A client recovering from chronic pancreatitis should be limited to one floor until strength and activity increase. The client will need a bathroom on the same floor for frequent defecation. Assessing pulse rate and preparation of meals is not specific to chronic pancreatitis. Although the client should be encouraged to stop drinking alcoholic beverages, asking about alcohol availability is not adequate to assess this client's safety.

51. Which menu choice by the patient with diverticulosis is best for preventing diverticulitis? a. Navy bean soup and vegetable salad b. Whole grain pasta with tomato sauce c. Baked potato with low-fat sour cream d. Roast beef sandwich on whole wheat bread

ANS: A A diet high in fiber and low in fats and red meat is recommended to prevent diverticulitis. Although all of the choices have some fiber, the bean soup and salad will be the highest in fiber and the lowest in fat.

26. The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to a. administer IV fluids. b. give stool softeners and enemas. c. order a diet high in fiber and fluids. d. prepare the patient for colonoscopy.

ANS: A A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have enemas or a colonoscopy because of the risk for perforation and peritonitis.

25. A 34-year-old female patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _____ cups. a. 2 b. 3 c. 4 d. 5

ANS: A After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL daily. One cup is about 240 mL.

5. A patient complains of gas pains and abdominal distention two days after a small bowel resection. Which nursing action is best to take? a. Encourage the patient to ambulate. b. Instill a mineral oil retention enema. c. Administer the ordered IV morphine sulfate. d. Offer the ordered promethazine (Phenergan) suppository.

ANS: A Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine (Phenergan) is used as an antiemetic rather than to decrease gas pains or distention.

8. Which nursing action will be included in the plan of care for a 27-year-old male patient with bowel irregularity and a new diagnosis of irritable bowel syndrome (IBS)? a. Encourage the patient to express concerns and ask questions about IBS. b. Suggest that the patient increase the intake of milk and other dairy products. c. Educate the patient about the use of alosetron (Lotronex) to reduce symptoms. d. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: A Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects, and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS.

A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to urgently contact the health care provider? a. Drainage from a fistula b. Absent bowel sounds c. Pain at the incision site d. Nasogastric (NG) tube drainage

ANS: A Complications of a Whipple procedure include secretions that drain from a fistula and peritonitis. Absent bowel sounds, pain at the incision site, and NG tube drainage are normal postoperative findings.

A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client? a. "Have you been experiencing any constipation?" b. "Are you eating a diet high in fiber and fluids?" c. "Do you have a history of high blood pressure?" d. "What vitamins and supplements are you taking?"

ANS: A Ischemic colitis is a life-threatening complication of alosetron. The nurse should assess the client for constipation. The other questions do not identify complications related to alosetron.

15. A 51-year-old male patient has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months. The nurse will plan to teach about a. medication use. b. fluid restriction. c. enteral nutrition. d. activity restrictions.

ANS: A Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings.

A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 18 to 14 breaths/min d. A decrease in the client's weight by 6 kg

ANS: A Rapid removal of ascetic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the client's weight to drop as fluid is removed. Six kilograms is less than 3 pounds and is expected.

A nurse cares for a client with end-stage pancreatic cancer. The client asks, "Why is this happening to me?" How should the nurse respond? a. "I don't know. I wish I had an answer for you, but I don't." b. "It's important to keep a positive attitude for your family right now." c. "Scientists have not determined why cancer develops in certain people." d. "I think that this is a trial so you can become a better person because of it."

ANS: A The client is not asking the nurse to actually explain why the cancer has occurred. The client may be expressing his or her feelings of confusion, frustration, distress, and grief related to this diagnosis. Reminding the client to keep a positive attitude for his or her family does not address the client's emotions or current concerns. The nurse should validate that there is no easy or straightforward answer as to why the client has cancer. Telling a client that cancer is a trial is untrue and may diminish the client-nurse relationship.

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

ANS: A The client who has undergone a laparoscopic cholecystectomy may report free air pain due to retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide. Cold compresses and drinking a warm beverage would not be helpful. Coughing and deep breathing are important postoperative activities, but they are not related to discomfort from carbon dioxide.

A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, "I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone!" Which action should the nurse take? a. Instruct the client to sit in as upright a position as possible. b. Add humidity to the oxygen and encourage the client to wear it. c. Document the client's refusal, and call the health care provider. d. Contact the provider to request an extra dose of the client's diuretic.

ANS: A The client with hepatopulmonary syndrome is often dyspneic. Because the oxygen saturation is not significantly low, the nurse should first allow the client to sit upright to see if that helps. If the client remains dyspneic, or if the oxygen saturation drops further, the nurse should investigate adding humidity to the oxygen and seeing whether the client will tolerate that. The other two options may be beneficial, but they are not the best choices. If the client is comfortable, his or her agitation will decrease; this will improve respiratory status.

A nurse cares for a client who has a new colostomy. Which action should the nurse take? a. Empty the pouch frequently to remove excess gas collection. b. Change the ostomy pouch and wafer every morning. c. Allow the pouch to completely fill with stool prior to emptying it. d. Use surgical tape to secure the pouch and prevent leakage.

ANS: A The nurse should empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy wafers with paste should be used to secure and seal the ostomy appliance; surgical tape should not be used.

A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, "I do not want to take this medication because it causes diarrhea." How should the nurse respond? a. "Diarrhea is expected; that's how your body gets rid of ammonia." b. "You may take Kaopectate liquid daily for loose stools." c. "Do not take any more of the medication until your stools firm up." d. "We will need to send a stool specimen to the laboratory."

ANS: A The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The client must understand that this is an expected and therapeutic effect for him or her to remain compliant. The nurse should not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.

A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus). Which statement should the nurse include in this client's discharge education? a. "Use a pill organizer to ensure you take this medication as prescribed." b. "Transient muscle aching is a common side effect of this medication." c. "Follow up with your provider in 1 week to test your blood for toxicity." d. "Take your radial pulse for 1 minute prior to taking this medication."

ANS: A Treatment of hepatitis C with ribavirin takes up to 48 weeks, making compliance a serious issue. The nurse should work with the client on a strategy to remain compliant for this length of time. Muscle aching is not a common side effect. The client will be on this medication for many weeks and does not need a blood toxicity examination. There is no need for the client to assess his or her radial pulse prior to taking the medication.

A nurse assesses a client who is recovering from an open Whipple procedure. Which action should the nurse perform first? a. Assess the client's endotracheal tube with 40% FiO2. b. Insert an indwelling Foley catheter to gravity drainage. c. Place the client's nasogastric tube to low intermittent suction. d. Start lactated Ringer's solution through an intravenous catheter.

ANS: A Using the ABCs, airway and oxygenation status should always be assessed first, so checking the endotracheal tube is the first action. Next, the nurse should start the IV line (circulation). After that, the Foley catheter can be inserted and the nasogastric tube can be set.

A nurse cares for a client who presents with tachycardia and prostration related to biliary colic. Which actions should the nurse take? (Select all that apply.) a. Contact the provider immediately. b. Lower the head of the bed. c. Decrease intravenous fluids. d. Ask the client to bear down. e. Administer prescribed opioids.

ANS: A, B Clients who are experiencing biliary colic may present with tachycardia, pallor, diaphoresis, prostration, or other signs of shock. The nurse should stay with the client, lower the client's head, and contact the provider or Rapid Response Team for immediate assistance. Treatment for shock usually includes intravenous fluids; therefore, decreasing fluids would be an incorrect intervention. The client's tachycardia is a result of shock, not pain. Performing the vagal maneuver or administering opioids could knock out the client's compensation mechanism.

A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this client's assessment? (Select all that apply.) a. "Which food types cause an exacerbation of symptoms?" b. "Where is your pain and what does it feel like?" c. "Have you lost a significant amount of weight lately?" d. "Are your stools soft, watery, and black in color?" e. "Do you experience nausea associated with defecation?"

ANS: A, B, E The nurse should ask the client about factors that may cause exacerbations of symptoms, including food, stress, and anxiety. The nurse should also assess the location, intensity, and quality of the client's pain, and nausea associated with defecation or meals. Clients who have IBS do not usually lose weight and stools are not black in color.

A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this laboratory result? (Select all that apply.) a. "How frequently do you drink alcohol?" b. "Have you ever had sex with a man?" c. "Do you have a family history of cancer?" d. "Have you ever worked as a plumber?" e. "Were you previously incarcerated?"

ANS: A, B, E When assessing a client with suspected cirrhosis, the nurse should ask about alcohol consumption, including amount and frequency; sexual history and orientation (specifically men having sex with men); illicit drug use; history of tattoos; and history of military service, incarceration, or work as a firefighter, police officer, or health care provider. A family history of cancer and work as a plumber do not put the client at risk for cirrhosis.

A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Oxygen therapy b. Prone position c. Feet elevated on pillows d. Daily weights e. Physical therapy

ANS: A, C, D Care for a client who has hepatopulmonary syndrome should include oxygen therapy, the head of bed elevated at least 30 degrees or as high as the client wants to improve breathing, elevated feet to decrease dependent edema, and daily weights. There is no need to place the client in a prone position, on the client's stomach. Although physical therapy may be helpful to a client who has been hospitalized for several days, physical therapy is not an intervention specifically for hepatopulmonary syndrome.

A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.) a. "Apply lotion to the client's dry skin areas." b. "Use a basin with warm water to bathe the client." c. "For the client's oral care, use a soft toothbrush." d. "Provide clippers so the client can trim the fingernails." e. "Bathe with antibacterial and water-based soaps."

ANS: A, C, D Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush should be used to prevent gum bleeding, and the client's nails should be trimmed short to prevent the client from scratching himself or herself. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap.

An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.) a. Policies related to consistent use of Standard Precautions b. Hepatitis vaccination mandate for workers in high-risk areas c. Implementation of a needleless system for intravenous therapy d. Number of sharps used in client care reduced where possible e. Postexposure prophylaxis provided in a timely manner

ANS: A, C, D, E Nurses should always use Standard Precautions for client care, and policies should reflect this. Needleless systems and reduction of sharps can help prevent hepatitis. Postexposure prophylaxis should be provided immediately. All health care workers should receive the hepatitis vaccinations that are available.

1. Which information will the nurse include when teaching a patient how to avoid chronic constipation (select all that apply)? a. Many over-the-counter (OTC) medications can cause constipation. b. Stimulant and saline laxatives can be used regularly. c. Bulk-forming laxatives are an excellent source of fiber. d. Walking or cycling frequently will help bowel motility. e. A good time for a bowel movement may be after breakfast.

ANS: A, C, D, E Stimulant and saline laxatives should be used infrequently. Use of bulk-forming laxatives, regular early morning timing of defecation, regular exercise, and avoiding many OTC medications will help the patient avoid constipation.

A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) a. Registered dietitian b. Nursing assistant c. Clinical pharmacist d. Certified herbalist e. Health care provider

ANS: A, C, E Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or parenteral nutrition. The nurse should collaborate with the registered dietitian, clinical pharmacist, and health care provider to plan and implement the more appropriate nutritional interventions. The nursing assistant and certified herbalist would not assist with this clinical decision.

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

ANS: A, C, E The client's head should be flexed forward once the NG tube has reached the oropharynx. The NG tube should be secured to the client's gown, not to the pillowcase, because it could become dislodged easily. All the other actions are appropriate.

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

ANS: A, D, F Obesity, pregnancy, and diabetes are all risk factors for the development of cholelithiasis. A diet low in saturated fats and moderate alcohol intake may decrease the risk. Although metabolic syndrome is a precursor to diabetes, it is not a risk factor for cholelithiasis. The client should be informed of the connection.

A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic in appearance, and the family expresses distress that the client is receiving little dietary protein. How should the nurse respond? a. "A low-protein diet will help the liver rest and will restore liver function." b. "Less protein in the diet will help prevent confusion associated with liver failure." c. "Increasing dietary protein will help the client gain weight and muscle mass." d. "Low dietary protein is needed to prevent fluid from leaking into the abdomen."

ANS: B A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the client's dietary protein will cause complications of liver failure and should not be suggested. Increased intravascular protein will help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein.

A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the client daily.

ANS: B A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.

A nose obtains a clients's health history at a community health clinic. Which statement alerts the nurse to prove health teaching to this client? a. "I drink two glasses of red wine each week." b. "I take a lot of Tylenol for my arthritis pain." c. "I have a cousin who died of liver cancer." d. "I got a hepatitis vaccine before traveling."

ANS: B Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about this limitation and should explore other drug options with the client to manage his or her arthritis pain. Two glasses of wine each week, a cousin with liver cancer, and the hepatitis vaccine do not place the client at risk for a liver disorder, and therefore do not require any health teaching.

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

ANS: B After cholecystectomy, clients need a nutritious diet without a lot of excess fat; otherwise a special diet is not recommended for most clients. Good fluid intake is healthy for all people but is not related to the surgery. Drinking fluids between meals helps with dumping syndrome, which is not seen with this procedure. Restriction of sweets is not required.

A nurse cares for a client with hepatitis C. The client's brother states, "I do not want to contract this infection, so I will not go into his hospital room." How should the nurse respond? a. "If you wear a gown and gloves, you will not get this virus." b. "Viral hepatitis is not spread through casual contact." c. "This virus is only transmitted through a fecal specimen." d. "I can give you an update on your brother's status from here."

ANS: B Although family members may be afraid that they will contract hepatitis C, the nurse should educate the client's family about how the virus is spread. Viral hepatitis, or hepatitis C, is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing, blood and organ transplantation, accidental needle sticks, unsanitary tattoo equipment, and sharing of intranasal cocaine paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. The nurse would be violating privacy laws by sharing the client's status with the brother.

9. A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to a. administer IV metoclopramide (Reglan). b. discontinue the patient's oral food intake. c. administer cobalamin (vitamin B12) injections. d. teach the patient about total colectomy surgery.

ANS: B An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate.

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

ANS: B Assessment findings indicate that the client may have an over-full bladder. In the immediate postoperative period, the client may experience difficulty voiding due to urinary retention. The nurse should assess when the client last voided. The client's vital signs may be checked after the nurse determines the client's last void. Asking about flatus and auscultating bowel sounds are not related to a hemorrhoidectomy.

18. The nurse preparing for the annual physical exam of a 50-year-old man will plan to teach the patient about a. endoscopy. b. colonoscopy. c. computerized tomography screening. d. carcinoembryonic antigen (CEA) testing.

ANS: B At age 50, individuals with an average risk for colorectal cancer (CRC) should begin screening for CRC. Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical exam at age 50.

10. Which nursing action will the nurse include in the plan of care for a 35-year-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict oral fluid intake. b. Monitor stools for blood. c. Ambulate four times daily. d. Increase dietary fiber intake.

ANS: B Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Because dietary fiber may increase gastrointestinal (GI) motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.

35. A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a. Insert a urinary catheter to drainage. b. Infuse metronidazole (Flagyl) 500 mg IV. c. Send the patient for a computerized tomography scan. d. Place a nasogastric (NG) tube to intermittent low suction.

ANS: B Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated.

41. Which information obtained by the nurse interviewing a 30-year-old male patient is most important to communicate to the health care provider? a. The patient has a history of constipation. b. The patient has noticed blood in the stools. c. The patient had an appendectomy at age 27. d. The patient smokes a pack/day of cigarettes.

ANS: B Blood in the stools is a possible clinical manifestation of colorectal cancer and requires further assessment by the health care provider. The other patient information will also be communicated to the health care provider, but does not indicate an urgent need for further testing or intervention.

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk

ANS: B Clients with IBS are advised to eat a high-fiber diet (30 to 40 g/day), with 8 to 10 cups of liquid daily. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants.

14. After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all these changes. I don't want to look at the stoma." What is the best action by the nurse? a. Reassure the patient that ileostomy care will become easier. b. Ask the patient about the concerns with stoma management. c. Develop a detailed written list of ostomy care tasks for the patient. d. Postpone any teaching until the patient adjusts to the ileostomy.

ANS: B Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgment of the patient's feelings and concerns is important rather than offering false reassurance. Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy care plan will not improve the patient's ability to manage the ostomy. Although detailed ostomy teaching may be postponed, the nurse should offer teaching about some aspects of living with an ostomy.

33. A 54-year-old critically ill patient with sepsis is frequently incontinent of watery stools. What action by the nurse will prevent complications associated with ongoing incontinence? a. Apply incontinence briefs. b. Use a fecal management system c. Insert a rectal tube with a drainage bag. d. Assist the patient to a commode frequently.

ANS: B Fecal management systems are designed to contain loose stools and can be in place for as long as 4 weeks without causing damage to the rectum or anal sphincters. Although incontinence briefs may be helpful, unless they are changed frequently, they are likely to increase the risk for skin breakdown. Rectal tubes are avoided because of possible damage to the anal sphincter and ulceration of the rectal mucosa. A critically ill patient will not be able to tolerate getting up frequently to use the commode or bathroom.

A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I am experiencing right flank pain and have a temperature of 101° F." How should the nurse respond? a. "The anti-rejection drugs you are taking make you susceptible to infection." b. "You should go to the hospital immediately to have your new liver checked out." c. "You should take an additional dose of cyclosporine today." d. "Take acetaminophen (Tylenol) every 4 hours until you feel better."

ANS: B Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention. Anti-rejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse should not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.

16. A 24-year-old woman with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? a. Bacteria in the perianal area can enter the urethra. b. Fistulas can form between the bowel and bladder. c. Drink adequate fluids to maintain normal hydration. d. Empty the bladder before and after sexual intercourse.

ANS: B Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. Teaching for UTI prevention in general includes good hygiene, adequate fluid intake, and voiding before and after intercourse.

A nurse cares for a client who is scheduled for a paracentesis. Which intervention should the nurse delegate to an unlicensed assistive personnel (UAP)? a. Have the client sign the informed consent form. b. Assist the client to void before the procedure. c. Help the client lie flat in bed on the right side. d. Get the client into a chair after the procedure.

ANS: B For safety, the client should void just before a paracentesis. The nurse or the provider should have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the side of the bed and leaning over the bedside table. The client will be on bedrest after the procedure.

23. Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? a. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Use care when eating high-fiber foods to avoid obstruction of the ileum. c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d. Change the pouch every day to prevent leakage of contents onto the skin.

ANS: B High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible.

An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first? a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Obtain the client's complete health history.

ANS: B On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present, because this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or obtaining a complete health history is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity.

52. After change-of-shift report, which patient should the nurse assess first? a. 40-year-old male with celiac disease who has frequent frothy diarrhea b. 30-year-old female with a femoral hernia who has abdominal pain and vomiting c. 30-year-old male with ulcerative colitis who has severe perianal skin breakdown d. 40-year-old female with a colostomy bag that is pulling away from the adhesive wafer

ANS: B Pain and vomiting with a femoral hernia suggest possible strangulation, which will necessitate emergency surgery. The other patients have less urgent problems.

50. A new 19-year-old male patient has familial adenomatous polyposis (FAP). Which action will the nurse in the gastrointestinal clinic include in the plan of care? a. Obtain blood samples for DNA analysis. b. Schedule the patient for yearly colonoscopy. c. Provide preoperative teaching about total colectomy. d. Discuss lifestyle modifications to decrease cancer risk.

ANS: B Patients with FAP should have annual colonoscopy starting at age 16 and usually have total colectomy by age 25 to avoid developing colorectal cancer. DNA analysis is used to make the diagnosis, but is not needed now for this patient. Lifestyle modifications will not decrease cancer risk for this patient.

55. Which prescribed intervention for a 61-year-old female patient with chronic short bowel syndrome will the nurse question? a. Ferrous sulfate (Feosol) 325 mg daily b. Senna (Senokot) 1 tablet every day c. Psyllium (Metamucil) 2.1 grams 3 times daily d. Diphenoxylate with atropine (Lomotil) prn loose stools

ANS: B Patients with short bowel syndrome have diarrhea because of decreased nutrient and fluid absorption and would not need stimulant laxatives. Iron supplements are used to prevent iron-deficiency anemia, bulk-forming laxatives help make stools less watery, and opioid antidiarrheal drugs are helpful in slowing intestinal transit time.

6. A 58-year-old man with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? a. Auscultate the bowel sounds. b. Prepare the patient for surgery. c. Check the patient's oral temperature. d. Obtain information about the accident.

ANS: B Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery.

11. Which patient statement indicates that the nurse's teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective? a. "The medication will be tapered if I need surgery." b. "I will need to use a sunscreen when I am outdoors." c. "I will need to avoid contact with people who are sick." d. "The medication will prevent infections that cause the diarrhea."

ANS: B Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine does not reduce immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed.

A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this client's plan of care to reduce discomfort? a. Administer morphine sulfate intravenously every 4 hours as needed. b. Maintain nothing by mouth (NPO) and administer intravenous fluids. c. Provide small, frequent feedings with no concentrated sweets. d. Place the client in semi-Fowler's position with the head of bed elevated.

ANS: B The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.

A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, "I need to have a bowel movement." Which action should the nurse take? a. Obtain a bedside commode for the client to use. b. Stay with the client while providing privacy. c. Make sure the call light is in reach to signal completion. d. Gather supplies to collect a stool sample for the laboratory.

ANS: B The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure the call light is within reach is an important nursing action too, but it does not take priority over client safety. Obtaining a bedside commode and taking a stool sample are not needed in this situation.

36. A 25-year-old male patient calls the clinic complaining of diarrhea for 24 hours. Which action should the nurse take first? a. Inform the patient that laboratory testing of blood and stools will be necessary. b. Ask the patient to describe the character of the stools and any associated symptoms. c. Suggest that the patient drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte. d. Advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility.

ANS: B The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment.

An emergency room nurse assesses a client after a motor vehicle crash. The nurse notices a "steering wheel mark" across the client's chest. Which action should the nurse take? a. Ask the client where in the car he or she was sitting during the crash. b. Assess the client by gently palpating the abdomen for tenderness. c. Notify the laboratory to draw blood for blood type and crossmatch. d. Place the client on the stretcher in reverse Trendelenburg position.

ANS: B The liver is often injured by a steering wheel in a motor vehicle crash. Because the client's chest was marked by the steering wheel, the nurse should perform an abdominal assessment. Assessing the client's position in the crash is not needed because of the steering wheel imprint. The client may or may not need a blood transfusion. The client does not need to be in reverse Trendelenburg position.

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

ANS: B The nurse should encourage the client to use the PCA pump prior to napping and upon awakening. Administering additional intravenous morphine while the client sleeps places the client at risk for respiratory depression. The nurse should also evaluate dosages received compared with dosages requested and contact the provider if the dose or frequency is not adequate. Only the client should push the pain button on a PCA pump.

2. A 71-year-old male patient tells the nurse that growing old causes constipation so he has been using a suppository for constipation every morning. Which action should the nurse take first? a. Encourage the patient to increase oral fluid intake. b. Assess the patient about risk factors for constipation. c. Suggest that the patient increase intake of high-fiber foods. d. Teach the patient that a daily bowel movement is unnecessary.

ANS: B The nurse's initial action should be further assessment of the patient for risk factors for constipation and for his usual bowel pattern. The other actions may be appropriate but will be based on the assessment.

After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "Some medications have been known to cause hepatitis A." b. "I may have been exposed when we ate shrimp last weekend." c. "I was infected with hepatitis A through a recent blood transfusion." d. "My infection with Epstein-Barr virus can co-infect me with hepatitis A."

ANS: B The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications, blood transfusions, or Epstein-Barr virus. Toxic and drug-induced hepatitis is caused from exposure to hepatotoxins, but this is not a form of hepatitis A. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection that is not associated with hepatitis A.

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? (Select all that apply.) a. "Do not allow the client to eat between meals." b. "Make sure the client receives a protein shake." c. "Do not allow caffeine-containing beverages." d. "Make sure the foods are bland with little spice." e. "Do not allow high-carbohydrate food items."

ANS: B, C, D During the healing phase of pancreatitis, the client should be provided small, frequent, moderate- to high-carbohydrate, high-protein, low-fat meals. Protein shakes can be provided to supplement the diet. Foods and beverages should not contain caffeine and should be bland.

A nurse cares for a client with pancreatic cancer who is prescribed implanted radioactive iodine seeds. Which actions should the nurse take when caring for this client? (Select all that apply.) a. Dispose of dirty linen in a red "biohazard" bag. b. Place the client in a private room. c. Wear a lead apron when providing client care. d. Bundle care to minimize exposure to the client. e. Initiate Transmission-Based Precautions.

ANS: B, C, D The client should be placed in a private room and dirty linens kept in the client's room until the radiation source is removed. The nurse should wear a lead apron while providing care, ensuring that the apron always faces the client. The nurse should also bundle care to minimize exposure to the client. Transmission-Based Precautions will not protect the nurse from the implanted radioactive iodine seeds.

A nurse assesses a client who is recovering from a Whipple procedure. Which clinical manifestations alert the nurse to a complication from this procedure? (Select all that apply.) a. Clay-colored stools b. Substernal chest pain c. Shortness of breath d. Lack of bowel sounds or flatus e. Urine output of 20 mL/6 hr

ANS: B, C, D, E Myocardial infarction (chest pain), pulmonary embolism (shortness of breath), adynamic ileus (lack of bowel sounds or flatus), and renal failure (urine output of 20 mL/6 hr) are just some of the complications for which the nurse must assess the client after the Whipple procedure. Clay-colored stools are associated with cholecystitis and are not a complication of a Whipple procedure.

An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? (Select all that apply.) a. Hypertension b. Tachycardia c. Flushed skin d. Confusion e. Shallow respirations

ANS: B, D Symptoms of hemorrhage and hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, diaphoresis, cool and clammy skin, and confusion

A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Take a 20-minute walk at least 5 days each week." b. "Attend local Alcoholics Anonymous (AA) meetings weekly." c. "Choose whole grains rather than foods with simple sugars." d. "Use cooking spray when you cook rather than margarine or butter." e. "Stay away from milk and dairy products that contain lactose." f. "We can talk to your doctor about a prescription for nicotine patches."

ANS: B, D, F The client should be advised to stay sober, and AA is a great resource. The client requires a low-fat diet, and cooking spray is low in fat compared with butter or margarine. If the client smokes, he or she must stop because nicotine can precipitate an exacerbation. A nicotine patch may help the client quit smoking. The client must rest until his or her strength returns. The client requires high carbohydrates and calories for healing; complex carbohydrates are not preferred over simple ones. Dairy products do not cause a problem.

19. The nurse is providing preoperative teaching for a 61-year-old man scheduled for an abdominal-perineal resection. Which information will the nurse include? a. Another surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir. b. The patient will begin sitting in a chair at the bedside on the first postoperative day. c. The patient will drink polyethylene glycol lavage solution (GoLYTELY) preoperatively. d. IV antibiotics will be started at least 24 hours before surgery to reduce the bowel bacteria.

ANS: C A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for infection. A permanent colostomy is created with this surgery. Sitting is contraindicated after an abdominal-perineal resection. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal bacteria.

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

ANS: C A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the client's concerns prior to contacting the provider.

1. Which action will the nurse include in the plan of care for a 42-year-old patient who is being admitted with Clostridium difficile? a. Educate the patient about proper food storage. b. Order a diet with no dairy products for the patient. c. Place the patient in a private room on contact isolation. d. Teach the patient about why antibiotics will not be used.

ANS: C Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile.

21. A 71-year-old patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery? a. Teach about a low-residue diet. b. Monitor output from the stoma. c. Assess the perineal drainage and incision. d. Encourage acceptance of the colostomy stoma.

ANS: C Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.

A nurse prepares to assess the emotional state of a client with end-stage pancreatic cancer. Which action should the nurse take first? a. Bring the client to a quiet room for privacy. b. Pull up a chair and sit next to the client's bed. c. Determine whether the client feels like talking about his or her feelings. d. Review the health care provider's notes about the prognosis for the client.

ANS: C Before conducting an assessment about the client's feelings, the nurse should determine whether he or she is willing and able to talk about them. If the client is open to the conversation and his or her room is not appropriate, an alternative meeting space may be located. The nurse should be present for the client during this time, and pulling up a chair and sitting with the client indicates that presence. Because the nurse is assessing the client's response to a terminal diagnosis, it is not necessary to have detailed information about the projected prognosis; the nurse knows that the client is facing an end-of-life illness.

29. A 62-year-old patient has had a hemorrhoidectomy at an outpatient surgical center. Which instructions will the nurse include in discharge teaching? a. Maintain a low-residue diet until the surgical area is healed. b. Use ice packs on the perianal area to relieve pain and swelling. c. Take prescribed pain medications before a bowel movement is expected. d. Delay having a bowel movement for several days until healing has occurred.

ANS: C Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. A high-residue diet will increase stool bulk and prevent constipation. Delay of bowel movements is likely to lead to constipation. Warm sitz baths rather than ice packs are used to relieve pain and keep the surgical area clean.

A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this client's plan of care? a. "You may experience nausea and vomiting for the first few weeks." b. "Carbonated beverages can help decrease acid reflux from anastomosis sites." c. "Take a stool softener to promote softer stools for ease of defecation." d. "You may return to your normal workout schedule, including weight lifting."

ANS: C Clients recovering from a colon resection should take a stool softener as prescribed to keep stools a soft consistency for ease of passage. Nausea and vomiting are symptoms of intestinal obstruction and perforation and should be reported to the provider immediately. The client should be advised to avoid gas-producing foods and carbonated beverages, and avoid lifting heavy objects or straining on defecation.

A nurse cares for a client who has chronic cirrhosis from substance abuse. The client states, "All of my family hates me." How should the nurse respond? a. "You should make peace with your family." b. "This is not unusual. My family hates me too." c. "I will help you identify a support system." d. "You must attend Alcoholics Anonymous."

ANS: C Clients who have chronic cirrhosis may have alienated relatives over the years because of substance abuse. The nurse should assist the client to identify a friend, neighbor, or person in his or her recovery group for support. The nurse should not minimize the client's concerns by brushing off the client's comment. Attending AA may be appropriate, but this response doesn't address the client's concern. Making peace with the client's family may not be possible. This statement is not client-centered.

13. Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? a. Scrambled eggs b. White toast and jam c. Oatmeal with cream d. Pancakes with syrup

ANS: C During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.

A nurse cares for a client with acute pancreatitis. The client states, "I am hungry." How should the nurse reply? a. "Is your stomach rumbling or do you have bowel sounds?" b. "I need to check your gag reflex before you can eat." c. "Have you passed any flatus or moved your bowels?" d. "You will not be able to eat until the pain subsides."

ANS: C Paralytic ileus is a common complication of acute pancreatitis. The client should not eat until this has resolved. Bowel sounds and decreased pain are not reliable indicators of peristalsis. Instead, the nurse should assess for passage of flatus or bowel movement.

38. Four hours after a bowel resection, a 74-year-old male patient with a nasogastric tube to suction complains of nausea and abdominal distention. The first action by the nurse should be to a. auscultate for hypotonic bowel sounds. b. notify the patient's health care provider. c. reposition the tube and check for placement. d. remove the tube and replace it with a new one.

ANS: C Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider unless other interventions do not resolve the problem. Information about the presence or absence of bowel sounds will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient, so that would only be done if the tube was completely occluded.

After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "The capsules can be opened and the powder sprinkled on applesauce if needed." b. "I will wipe my lips carefully after I drink the enzyme preparation." c. "The best time to take the enzymes is immediately after I have a meal or a snack." d. "I will not mix the enzyme powder with food or liquids that contain protein."

ANS: C The enzymes should be taken immediately before eating meals or snacks. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. Protein items will be dissolved by the enzymes if they are mixed together.

47. A 76-year-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first? a. Administer bulk-forming laxatives. b. Assist the patient to sit on the toilet. c. Manually remove the impacted stool. d. Increase the patient's oral fluid intake.

ANS: C The initial action with a fecal impaction is manual disimpaction. The other actions will be used to prevent future constipation and impactions.

49. A 72-year-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider? a. Patient has not voided for the last 4 hours. b. Skin is dry with poor turgor on all extremities. c. Crackles are heard halfway up the posterior chest. d. Patient has had 5 loose stools over the last 6 hours.

ANS: C The presence of crackles in an older patient receiving IV fluids at a high rate suggests volume overload and a need to reduce the rate of the IV infusion. The other data will also be reported, but are consistent with the patient's age and diagnosis and do not require a change in the prescribed treatment.

A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action should the nurse take? a. Ask if the client is experiencing pain in the right shoulder. b. Perform a rectal examination and assess for polyps. c. Contact the provider and recommend computed tomography. d. Administer a laxative to increase bowel movement activity.

ANS: C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. The nurse should contact the provider with these results and recommend a computed tomography scan for further diagnostic testing. This assessment finding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The registered nurse is not qualified to complete a rectal examination for polyps, and laxatives would not help this client.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of carcinoma of the liver? a. A 22-year-old with a history of blunt liver trauma b. A 48-year-old with a history of diabetes mellitus c. A 66-year-old who has a history of cirrhosis d. An 82-year-old who has chronic malnutrition

ANS: C The risk of contracting a primary carcinoma of the liver is higher in clients with cirrhosis from any cause. Blunt liver trauma, diabetes mellitus, and chronic malnutrition do not increase a person's risk for developing liver cancer.

42. Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Auscultation for bowel sounds b. Nasogastric (NG) tube irrigation c. Applying petroleum jelly to the lips d. Assessment of the nares for irritation

ANS: C UAP education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN.

12. A 22-year-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? a. The patient uses incontinence briefs to contain loose stools. b. The patient asks for antidiarrheal medication after each stool. c. The patient uses witch hazel compresses to decrease irritation. d. The patient cleans the perianal area with soap after each stool.

ANS: C Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with plain water after each stool.

3. A 64-year-old woman who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response? a. Absorption of fat-soluble vitamins may be reduced by fiber-containing laxatives. b. Dietary sources of fiber should be eliminated to prevent excessive gas formation. c. Use of this type of laxative to prevent constipation does not cause adverse effects. d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.

ANS: D A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should gradually increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives.

17. A 73-year-old patient with diverticulosis has a large bowel obstruction. The nurse will monitor for a. referred back pain. b. metabolic alkalosis. c. projectile vomiting. d. abdominal distention.

ANS: D Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction.

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

ANS: D Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, low-fat milk, grilled cheese, cream, and cream of potato soup all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.

31. The nurse will plan to teach a patient with Crohn's disease who has megaloblastic anemia about the need for a. oral ferrous sulfate tablets. b. regular blood transfusions. c. iron dextran (Imferon) infusions. d. cobalamin (B12) spray or injections.

ANS: D Crohn's disease frequently affects the ileum, where absorption of cobalamin occurs. Cobalamin must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions.

A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect? a. Nausea and vomiting b. Frontal headache c. Vertigo and syncope d. Mid-sternal chest pain

ANS: D Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. Nausea and vomiting, headache, and vertigo and syncope are not side effects of vasopressin.

34. Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome? a. "Have you been passing a lot of gas?" b. "What foods affect your bowel patterns?" c. "Do you have any abdominal distention?" d. "How long have you had abdominal pain?"

ANS: D One criterion for the diagnosis of irritable bowel syndrome (IBS) is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are also associated with IBS, but are not diagnostic criteria.

A nurse assesses clients on the medical-surgical unit. Which client should the nurse identify as at high risk for pancreatic cancer? a. A 26-year-old with a body mass index of 21 b. A 33-year-old who frequently eats sushi c. A 48-year-old who often drinks wine d. A 66-year-old who smokes cigarettes

ANS: D Risk factors for pancreatic cancer include obesity, older age, high intake of red meat, and cigarette smoking. Sushi and wine intake are not risk factors for pancreatic cancer.

44. Which patient should the nurse assess first after receiving change-of-shift report? a. 60-year-old patient whose new ileostomy has drained 800 mL over the previous 8 hours b. 50-year-old patient with familial adenomatous polyposis who has occult blood in the stool c. 40-year-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours d. 30-year-old patient who has abdominal distention and an apical heart rate of 136 beats/minute

ANS: D The patient's abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should also be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses.

43. After several days of antibiotic therapy, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first? a. Notify the health care provider. b. Obtain a stool specimen for analysis. c. Teach the patient about handwashing. d. Place the patient on contact precautions.

ANS: D The patient's history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions are also appropriate but can be accomplished after contact precautions are implemented.

37. A 45-year-old patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102° F (38.3° C), pulse 120, respirations 32, and blood pressure (BP) 82/54. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac (Toradol) 15 mg. b. Draw blood for a complete blood count (CBC). c. Obtain a computed tomography (CT) scan of the abdomen. d. Infuse 1 liter of lactated Ringer's solution over 30 minutes.

ANS: D The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.

22. A 47-year-old female patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should a. place ice packs around the stoma. b. notify the surgeon about the stoma. c. monitor the stoma every 30 minutes. d. document stoma assessment findings.

ANS: D The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed.

A client is scheduled for discharge after surgery for inflammatory bowel disease (IBD). The client's spouse will be assisting home health services with the client's care. What is most important for the home health nurse to assess in the client and the spouse with regard to the client's home care?

Ability of the couple to perform incision care and dressing changes

The physican has determine the client with Hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D

Answer 1: Hepatitis A is the correct answer because it is transmitted by the oral-fecal route, via contaminated food or food handlers. B, C, and D are transmitted most commonly via infected body fluids

"A nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which of the following laboratory results would the nurse expect to note if the client does have appendicitis? 1. Leukopenia with a shift to the right 2. Leukocytosis with a shift to the right 3.Leukocytosis with a shift to the left 4. Leukopenia with a shift to the left"

Answer 2 - no rationale

"The female nurse sticks herself with a dirty needle. Which action should the nurse implement first? 1.Notify the infection control nurse. 2.Cleanse the area with soap and water. 3.Request post-exposure prophylaxis. 4.Check the hepatitis status of the client.

Answer 2. The nurse should first clean the needle stick with soap and water to help remove any virus that is on the skin

The RN is providing discharge information to a client with hep B. The RN instructs the client to prevent transmission via: a. airborne pathogens 2. blood and body secretions 3. skin contact 4. fecal and oral routes

Answer 2: Hep b is transmitted via blood and body secretions. The RN instructs the client to prevent transmission through correct use of latex condoms, and by not sharing personal care items that may have blood on them. Diseases such as pneumonia are spread by airborne pathogens, hep A is spread by fecal and oral routes. Hep B is not transmitted by skin contact.

"A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications?" " 1. Deficient fluid volume. 2. Intestinal obstruction. 3. Bowel ischemia. 4. Peritonitis.

Answer 4 Complications of acute appendicitis are perforation, peritonitis, and abscess development. Signs of the development of peritonitis include abdominal pain and distention, tachycardia, tachypnea, nausea, vomiting, and fever. Because peritonitis can cause hypovolemic shock, hypotension can develop. Deficient fluid volume would not cause a fever. Intestinal obstruction would cause abdominal distention, diminished or absent bowel sounds, and abdominal paIn. Bowel ischemia has signs and symptoms similar to those found with intestinal obstruction.

"Which statement by the client diagnosed with hepatitis warrants immediate intervention by the clinic nurse? "1) ""I will not drink any type of beer or mixed drink."" 2)""I will get adequate rest so I don't get exhausted."" 3) ""I had a big hearty breakfast this morning."" 4) ""I took some cough syrup for this nasty head cold.""

Answer 4: "Rationale: 1) The client should avoid all alcohol to prevent further liver damage and promote healing. 2) Rest is needed for healing of the liver and to promote optimum immune function. 3) Clients with hepatitis need increased caloric intake so this is a good statement. 4)The client needs to understand some types of cough syrup have alcohol and all alcohol must be avoided to prevent further injury to the liver; therefore, this statement requires intervention"

"A female client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurse's best response? "a. "You may have eaten contaminated restaurant food." b. "You could have gotten it by using I.V. drugs." c. "You must have received an infected blood transfusion." d. "You probably got it by engaging in unprotected sex.""

Answer A Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming food contaminated by infected food handlers. The virus isn't transmitted by the I.V. route, blood transfusions, or unprotected sex. Hepatitis B can be transmitted by I.V. drug use or blood transfusion. Hepatitis C can be transmitted by unprotected sex."

"The nurse is caring for a patient in the emergency department with complaints of acute abdominal pain, nausea, and vomiting. When the nurse palpates the patient's left lower abdominal quadrant, the patient complains of pain in the right lower quadrant. The nurse will document this as which of the following diagnostic signs of appendicitis? "a. Rovsing sign b. referred pain c. Chvostek's sign d. rebound tenderness correct answer: A"

Answer A In patients with suspected appendicitis, Rovsing sign may be elicited by palpation of the left lower quadrant, causing pain to be felt in the right lower quadrant.

A female client being seen in a physician's office has just been scheduled for a barium swallow the next day. The nurse writes down which instruction for the client to follow before the test? a. Fast for 8 hours before the test b. Eat a regular supper and breakfast c. Continue to take all oral medications as scheduled d. Monitor own bowel movement pattern for constipation

Answer A. A barium swallow is an x-ray study that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal tract. The client should fast for 8 to 12 hours before the test, depending on physician instructions. Most oral medications also are withheld before the test. After the procedure, the nurse must monitor for constipation, which can occur as a result of the presence of barium in the gastrointestinal tract.

Dr. Smith has determined that the client with hepatitis has contracted the infection form contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? a. Hepatitis A b. Hepatitis B c. Hepatitis C d. Hepatitis D

Answer A. Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.

Nurse Ryan is assessing for correct placement of a nosogartric tube. The nurse aspirates the stomach contents and check the contents for pH. The nurse verifies correct tube placement if which pH value is noted? a. 3.5 b. 7.0 c. 7.35 d. 7.5

Answer A. If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric aspirates have acidic pH values and should be 3.5 or lower. Option B indicates a slightly acidic pH. Option C indicates a neutral pH. Option D indicates an alkaline pH.

Nurse Juvy is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intension to increase the intake of: a. Pork b. Milk c. Chicken d. Broccoli

Answer A. The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Milk contains vitamins A, D, and B2. Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid

The nurse is teaching a female client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do? a. Increase fluid intake b. Place heat on the abdomen c. Perform the irrigation in the evening d. Reduce the amount of irrigation solution

Answer A. To enhance effectiveness of the irrigation and fecal returns, the client is instructed to increase fluid intake and to take other measures to prevent constipation. Options B, C and D will not enhance the effectiveness of this procedure.

Nurse Oliver checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is appropriate action for the nurse to take? a. Hold the feeding b. Reinstill the amount and continue with administering the feeding c. Elevate the client's head at least 45 degrees and administer the feeding d. Discard the residual amount and proceed with administering the feeding

Answer A. Unless specifically indicated, residual amounts more than 100 mL require holding the feeding. Therefore options B, C, and D are incorrect. Additionally, the feeding is not discarded unless its contents are abnormal in color or characteristics.

"Dr. Smith has determined that the client with hepatitis has contracted the infection form contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? "a. Hep A. b. Hep. B. c. Hep. C. d. Hep D

Answer A: Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.

"A patient with hepatitis B is being discharged in 2 days. In the discharge teching plan the nurse should include instructions to: a. Avoid alcohol for the first 3 weeks b. Use a condom during sexual intercourse c. Have family members get an injection of immunoglobin d. Follow a low-protein, moderate-carbohydrate, moderate-fat diet

Answer B Hepatitis B virus may be transmitted by mucosal exposure to infectious blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Hepatitis B is a sexually transmitted disease that is acquired through unprotected sex with an infected person. Condom use should be taught to patients to prevent transmission of hepatitis B.

A client is admitted to the hospital with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? "a. Select foods high in fat b. Increase intake of fluids, including juices. c. Eat a good supper when anorexia is not as severe. d. Eat less often, preferably only three large meals daily."

Answer B : Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet because fat may be tolerated poorly because of decreased bile production. Small frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morining, so it is easier to eat a good breakfast. An adequated fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.

To prevent the spread of hepatitis A virus (HAV) infection the nurse is especially careful when: "A. Disposing of food trays B. Emptying the bed pan C. Taking an oral temperature D. Changing IV tubing"

Answer B, Rationale: HAV is transmitted primarily person-to-person by the fecal-oral route. Food can be a method of transmission but needs to be fecally contaminated. Since the transmission of hepatitis A is fecal-oral and not saliva or blood like hepatitis B, taking a temperature and changing IV tubing would not spread hepatitis A.

"When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? a. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. b. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. c. The appendix may develop gangrene and rupture, especially in a middle-aged client. d. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage."

Answer B. A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Geriatric, not middle-aged, clients are especially susceptible to appendix rupture.

When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?"a. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. b. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. c. The appendix may develop gangrene and rupture, especially in a middle-aged client. d. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage."

Answer B. A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Geriatric, not middle-aged, clients are especially susceptible to appendix rupture.

The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention? A.Suggest that the client take warm showers. B.Add baby oil to the client's bath water. C.Apply powder to the client's skin. D.Suggest a hot-water rinse after bathing.

Answer B. Applying baby oil could help soothe the itchy skin. Answer A, C, and D would increase dryness and worsen the itching.

The nurse is caring for a male client postoperatively following creation of a colostomy. Which nursing diagnosis should the nurse include in the plan of care? a. Sexual dysfunction b. Body image, disturbed c. Fear related to poor prognosis d. Nutrition: more than body requirements, imbalanced

Answer B. Body image, disturbed relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). No data in the question support options A and C. Nutrition: less than body requirements, imbalanced is the more likely nursing diagnosis.

The nurse is instructing the male client who has an inguinal hernia repair how to reduce postoperative swelling following the procedure. What should the nurse tell the client? a. Limit oral fluid b. Elevate the scrotum c. Apply heat to the abdomen d. Remain in a low-fiber diet

Answer B. Following inguinal hernia repair, the client should be instructed to elevate the scrotum and apply ice packs while in bed to decrease pain and swelling. The nurse also should instruct the client to apply a scrotal support when out of bed. Heat will increase swelling. Limiting oral fluids and a low-fiber diet can cause constipation.

The nurse is performing a colostomy irrigation on a male client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action? a. Notify the physician b. Stop the irrigation temporarily c. Increase the height of the irrigation d. Medicate for pain and resume the irrigation

Answer B. If cramping occurs during a colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too much pressure. The physician does not need to be notified. Increasing the height of the irrigation will cause further discomfort. Medicating the client for pain is not the appropriate action in this situation.

A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis? a. Elevated hemoglobin level b. Elevated serum bilirubin level c. Elevated blood urea nitrogen level d. Decreased erythrocycle sedimentation rate

Answer B. Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated erythrocyte sedimentation rates, and leukopenia. An elevated blood urea nitrogen level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

During evaluation of a patient at an outpatient clinic, the nurse determines that administration of hepatitis B vaccine has been effective when a specimen of the patient's blood reveals: a. HBsAg. b. anti-HBs c. anti-HBc IgM. d. anti-HBc IgG"

Answer B: The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV

A male client with a peptic ulcer is scheduled for a vagotomy and the client asks the nurse about the purpose of this procedure. Which response by the nurse best describes the purpose of a vagotomy? a. Halts stress reactions b. Heals the gastric mucosa c. Reduces the stimulus to acid secretions d. Decreases food absorption in the stomach

Answer C. A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion. Options A, B, and D are incorrect descriptions of a vagotomy.

The nurse is providing discharge instructions to a male client following gastrectomy and instructs the client to take which measure to assist in preventing dumping syndrome? a. Ambulate following a meal b. Eat high carbohydrate foods c. Limit the fluid taken with meal d. Sit in a high-Fowler's position during meals

Answer C. Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a Billroth II procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low-Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed.

The nurse is reviewing the medication record of a female client with acute gastritis. Which medication, if noted on the client's record, would the nurse question? a. Digoxin (Lanoxin) b. Furosemide (Lasix) c. Indomethacin (Indocin) d. Propranolol hydrochloride (Inderal)

Answer C. Indomethacin (Indocin) is a nonsteroidal anti-inflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Furosemide (Lasix) is a loop diuretic. Digoxin is a cardiac medication. Propranolol (Inderal) is a β-adrenergic blocker. Furosemide, digoxin, and propranolol are not contraindicated in clients with gastric disorders.

The nurse is reviewing the physician's orders written for a male client admitted to the hospital with acute pancreatitis. Which physician order should the nurse question if noted on the client's chart? a. NPO status b. Nasogastric tube inserted c. Morphine sulfate for pain d. An anticholinergic medication

Answer C. Meperidine (Demerol) rather than morphine sulfate is the medication of choice to treat pain because morphine sulfate can cause spasms in the sphincter of Oddi. Options A, B, and D are appropriate interventions for the client with acute pancreatitis.

The nurse is caring for a hospitalized female client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician? a. Hypotension b. Bloody diarrhea c. Rebound tenderness d. A hemoglobin level of 12 mg/dL

Answer C. Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the physician.

The nurse is performing an abdominal assessment and inspects the skin of the abdomen. The nurse performs which assessment technique next? a. Palpates the abdomen for size b. Palpates the liver at the right rib margin c. Listens to bowel sounds in all for quadrants d. Percusses the right lower abdominal quadrant

Answer C. The appropriate sequence for abdominal examination is inspection, auscultation, percussion, and palpation. Auscultation is performed after inspection to ensure that the motility of the bowel and bowel sounds are not altered by percussion or palpation. Therefore, after inspecting the skin on the abdomen, the nurse should listen for bowel sounds.

A nurse is inserting a nasogastric tube in an adult male client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the appropriate nursing action? a. Quickly insert the tube b. Notify the physician immediately c. Remove the tube and reinsert when the respiratory distress subsides d. Pull back on the tube and wait until the respiratory distress subsides

Answer D. During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. Options B and C are unnecessary. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.

The nurse is assessing a male client 24 hours following a cholecystectomy. The nurse noted that the T tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is appropriate? a. Clamp the T tube b. Irrigate the T tube c. Notify the physician d. Document the findings

Answer D. Following cholecystectomy, drainage from the T tube is initially bloody and then turns to a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output.

The nurse is monitoring a female client with a diagnosis of peptic ulcer. Which assessment findings would most likely indicate perforation of the ulcer? a. Bradycardia b. Numbness in the legs c. Nausea and vomiting d. A rigid, board-like abdomen

Answer D. Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and board-like. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.

Polyethylene glycol-electrlyte solution (GoLYTELY) is prescribed for the female client scheduled for a colonoscopy. The client begins to experience diarrhea following administration of the solution. What action by the nurse is appropriate? a. Start an IV infusion b. Administer an enema c. Cancel the diagnostic test d. Explain that diarrhea is expected

Answer D. The solution GoLYTELY is a bowel evacuant used to prepare a client for a colonoscopy by cleansing the bowel. The solution is expected to cause a mild diarrhea and will clear the bowel in 4 to 5 hours. Options A, B, and C are inappropriate actions.

A nurse is preparing to care for a female client with esophageal varices who has just has a Sengstaken-Blakemore tube inserted. The nurse gathers supplies, knowing that which of the following items must be kept at the bedside at all times? a. An obturator b. Kelly clamp c. An irrigation set d. A pair of scissors

Answer D. When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client's bedside at all times. The client needs to be observed for sudden respiratory distress, which occurs if the gastric balloon ruptures and the entire tube moves upward. If this occurs, the nurse immediately cuts all balloon lumens and removes the tube. An obturator and a Kelly clamp are kept at the bedside of a client with a tracheostomy. An irrigation set may be kept at the bedside, but it is not the priority item.

A nurse is caring for a child who had a laproscopic appendectomy. What interventions should the nurse document on the child's clinical record? Select all that apply. 1) Intake and Output 2) Measurement of Pain 3) Tolerance to low-residue diet 4) Frequency of dressing changes 5) Auscultation of bowel sounds

Answer: 1, 2, 5 1) Assessment and documentation of fluid balance are critical aspects of all postoperative care. 2) Laparoscopic surgery involves insufflating the abdominal cavity with air, which is painful until it is absorbed. The amount of pain should be measured and documented with either a 1-10 scale or the Wong's FACES for younger children. 3) A special diet is not indicated after this surgery. 4) After a laparoscopic appendectomy there is little drainage and no dressings. 5) Auscultating for bowel sounds and documenting their presennce or absence evaluate the child's adaptation to the intestinal trauma caused by the surgery.

The nurse is assessing an adolescent who is admitted to the hospital with appendicitis. The nurse should report which of the following to the HCP? "1) change in pain rating of 7 to 8 on a 10 point scale. 2) sudden relief of sharp pain, shifting to diffuse pain. 3)shallow breathing with normal vital signs. 4) decrease of pain rating from 8 to 6 when parents visit.

Answer: 2 Rationale: The nurse notifies the HCP if the client has sudden relief of sharp pain and on presence of more diffuse pain. this change in the pain indicates the appendix has ruprured. The diffuse pain is typically accompanied by rigid guarding of the abdomen, progressive abdominal distension, tachycardia, pallor, chills, and irritability. The slight increase pain can be expected; the decrease in pain when parents visit may be attributed to being distracted from the pain. shallow breathing is likely due to the pain and is insignificant when other vital signs are normal

When providing preoperative care for a client ready to undergo a ileostomy, the nurse knows which of the following need to occur (Select All that Apply): A) Give a low fiber, low fat diet B) Discontinue corticosteroid use C) Fluid replacement via IV D) Patient education about stoma E) Regular meals provided, 3 times a day

Answer: A, C, and D. A low fiber, low fat diet (AKA low residue diet) is given to the client in small, frequent feedings. Corticosteroid use is continued to prevent steroid-induced adrenal insufficiency. Fluid replacement is critical during this time period. Small, frequent meals are provided (more than three times a day

Which of the following complications is thought to be the most common cause of appendicitis? a. A fecalith b. Internal bowel occlusion c. Bowel kinking d. Abdominal wall swelling"

Answer: A. A fecalith Rationale: A fecalith is a hard piece of stool which is stone like that commonly obstructs the lumen. Due to obstruction, inflammation and bacterial invasion can occur. Tumors or foreign bodies may also cause obstruction."

Your patient has a severe small bowel obstruction and is headed to surgery. Their vitals are BP-140/90 T 97.7 R-18, HR-98, SPO2 - 95%. What is the nurses priority? A) Start IV fluid as ordered B) Apply O2 prn as ordered C) Put in NG tube and start suction D) Obtaining consent

Answer: A. IV fluids is necessary to replace depleted water and electrolytes. Although oxygen is important, there is no indication that it is needed right now. NG is not necessary for surgery. The surgeon is responsible for obtaining consent

The nurse is getting ready to change an ostomy appliance. Which of the following is NOT done during this procedure? A) Wash the skin with normal saline B) Make sure the skin is dry before applying the appliance C) Place the sizing guide directly on the skin around the stoma, leaving as little skin as possible around the stoma uncovered D) Before applying to irritated skin, lightly dust with nystatin powder

Answer: A. The skin should be washed with mild soap and water, not normal saline. The skin should be dry before its applied. The sizing guide should be used to make the fit as close as possible. If the skin is irritated, nystatin (Mycostatin) powder may be applied after spraying with Kenalog spray

"During an admission assessment, the nurse notes a client with hepatitis exhibits all of the following signs or symptoms. Which one is not related to hepatitis? "A. Anorexia B. Bloody stools C. Dark urine D. Yellow sclera"

Answer: B "RATIONALE (A) Anorexia is an expected assessment finding with hepatitis. (B) Rectal bleeding is not related to hepatitis. Further assessment 358 Clinical Specialties: Content Reviews and Testsis needed to identify the cause. (C) Dark urine is an expected assessment finding with hepatitis and is a result of increased serum bilirubin being excreted by the kidneys. (D) Yellow sclera is a sign of jaundice and is an expected assessment finding with hepatitis. Jaundice is caused by increased serum bilirubin"

"To prevent the spread of hepatitis A virus (HAV) infection the nurse is especially careful when "A. Disposing of food trays B. Emptying bed pan C. Taking an oral temperature D. Changing IV tubing"

Answer: B Rationale: HAV is transmitted primarily person-to-person by the fecal-oral route. Food can be a method of transmission but needs to be fecally contaminated. Since the transmission of hepatitis A is fecal-oral and not saliva or blood like hepatitis B, taking a temperature and changing IV tubing would not spread hepatitis A.

When asking your patient with colorectal cancer medical history, the nurse identifies which statement as a risk factor for this cancer? A) Being between the ages of 40 and 65 B) Lack of fiber C) Type O blood D) Overuse of asthma medications

Answer: B. The lack of fiber in the diet is a risk factor for colorectal cancer because it slows the passage of food through the intestines, prolonging the possible exposure to carcinogens. Other potential risk factors include carcinogens in diet, lack of exercise, family history of polyps, and having IBD

Which of the following people are at greatest risk for developing colon cancer? A) A 55 year old bank accountant who has a family history of appendicitis B) A 83 year old male who drinks one alcoholic beverage a day C) A postmenopausal woman who has a family history of colon cancer D) A 35 year old male who is morbidly obese and smokes

Answer: C. Family history provides the highest risk of developing the disease along with having polyps or IBD. History of appendicitis is not linked to colon cancer. One alcoholic beverage a day is considered within moderate limits. Although smoking can be a risk factor for colon cancer, D is quite young and is at less risk than C

Obstruction is a common complication of which of the following diseases: A) Diverticular disease B) Ulcerative Collitis C) Peritonitis D) Appendicitis

Answer: C. Inflammation process may cause intestinal obstruction, primarily from the development of intestinal adhesions. None of the others have this listed as a main adverse effect

A client with complaints of right lower quadrant pain is admitted to the emergency department. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the physician immediately? "a) Hematocrit 42% b) Serum potassium 4.2 mEq/L c) Serum sodium 135 mEq/L d) White blood cell (WBC) count 22.8/mm3.

Answer: D "D) White blood cell (WBC) count 22.8/mm3 The nurse should report the elevated WBC count. This finding, which is a sign of infection, indicates that the client's appendix might have ruptured. Hematocrit of 42%, serum potassium of 4.2 mEq/L, and serum sodium of 135 mEq/L are within normal limits. Alterations in these levels don't indicate appendicitis."

Bobby, a 13 year old is being seen in the emergency room for possible appendicitis. An important nursing action to perform when preparing Bobby for an appendectomy is to:""a) administer saline enemas to cleanse the bowels b) apply heat to reduce pain c) measure abdominal girth d) continuously monitor pain

Answer: D Rationale: Pain is closely monitored in appendicitis. In most cases, pain medication is not given until prior to surgery or until the diagnosis is confirmed to be able to closely monitor the progression of the disease. A sudden change in the character of pain may indicate rupture or bowel perforation. Administering an enema or applying heat may cause perforation and abdominal girth may not change with appendicitis.

All of the following are forms of mechanical bowel obstruction, EXCPT: A) Tumor B) Intussusception C) Hernia D) Impaction

Answer: D. Impaction is considered a functional blockage. Other forms of mechanical blockage include: adhesions, volvulus, stenosis, strictures, and abscesses

Your patient is experiencing dull abdominal pain and melena, and states that he "feels constantly fatigued for some reason". He also tells you that his bowel patterns have been odd over the past few months, and sometimes he has constipation or diarrhea. In his medical record, you see an elevated CEA level. Which of the following diseases do you suspect this patient has. A) Chron's disease B) Irritable Bowel Syndrome C) PUD D) Collorectal Cancer

Answer: D. Signs and symptoms of colorectal cancer include fatigue, changes in bowel patterns (first), and blood in stools (second). Symptoms of right sided cancer include dull abdominal pain and melena. Also, the elevated CEA levels help confirm this suspicion

"The school nurse is discussing ways to prevent an outbreak of hepatitis A with a groupof high school teachers. Which action is the most important intervention that theschool nurse must explain to the school teachers? 1. Do not allow students to eat or drink after each other 2. Drink bottled water as much as possible. 3. Encourage protected sexual activity. 4. Throughly wash hands.

Answer= 4 1. Eating after each other should be discouraged but it is not the most important intervention. 2. only bottle water should be consumed in Third World countries, but that precaution is not necessary in American high schools. 3. Hepatitis B and C, not hepatitis A, are transmitted by sexual acvitity. 4. Hepatitis A is transmitted via the fecal-oral route. Good hand washing helps to prevent its spread.

The nurse is caring for several patients. Which patient is most likely to need a guaiac test? a. Patient reports dark amber colored urine b. Patient reports black stool. c. Patient vomits small amounts of bile. d. Patient complains of right upper quadrant pain.

B

The patient has an Salem sump placed for gastric decompression. The nurse notes there has been no drainage for the past 4 hours. What should the nurse do first? a. Assess for abdominal distension b. Assess the patency of the tube. c. Assess the output from the last shift. d. Assess the bowel sounds.

B

A nurse is caring for a client hospitalized with botulism. The nurse obtains the following vital signs: temperature—99.8° F (37.6° C), pulse—100, respiratory rate—10 and shallow, and blood pressure—100/62 mm Hg. What action by the nurse is most appropriate? a. Allow the client rest periods without interruption. b. Stay with the client while another nurse calls the physician. c. Check the client's IV rate and document all findings. d. Help the client order appropriate food items from the menu.

B A client with botulism is at risk for respiratory failure. This client's respiratory rate is slow and shallow, which could indicate impending respiratory distress or failure. The nurse should remain with the client while another nurse notifies the provider. Nothing is allowed by mouth until all respiratory function and swallowing are normal. The nurse should monitor and document the IV infusion per protocol, but this does not take priority. Allowing the client to rest and ordering food items are not appropriate actions.

A 61-year-old patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times? A. 7:00 AM, 10:00 AM, and 1:00 PM B. 8:00 AM, 12:00 PM, and 4:00 PM C. 9:00 AM and 3:00 PM D. 9:00 AM, 12:00 PM, and 3:00 PM

B A nasogastric tube should be checked for patency routinely at 4-hour intervals. Thus if the tube were inserted at 4:00 AM, it would be due to be checked at 8:00 AM, 12:00 PM, and 4:00 PM.

The nurse is performing a physical assessment for a client who underwent a hemorrhoidectomy the previous day. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which is the nurse's priority action? a. Assess the client's vital signs. b. Determine the last time the client voided. c. Insert a rectal tube to facilitate passage of flatus. d. Document the findings in the client's chart.

B Assessment findings indicate that the client may have an overfull bladder. In the immediate postoperative period, the client may experience difficulty voiding owing to urinary retention. A rectal tube should not be inserted for a client who had a hemorrhoidectomy the previous day. The client's vital signs may be checked after the nurse determines the client's last void. The nurse should document all findings and actions in the client's medical record.

What information would have the highest priority to be included in preoperative teaching for a 68-year-old patient scheduled for a colectomy? A. How to care for the wound B. How to deep breathe and cough C. The location and care of drains after surgery D. Which medications will be used during surgery

B Because anesthesia, an abdominal incision, and pain can impair the patient's respiratory status in the postoperative period, it is of high priority to teach the patient to cough and deep breathe. Otherwise, the patient could develop atelectasis and pneumonia, which would delay early recovery from surgery and hospital discharge. Care for the wound and location and care of the drains will be briefly discussed preoperatively, but done again with higher priority after surgery. Knowing which drugs will be used during surgery may not be meaningful to the patient and should be reviewed with the patient by the anesthesiologist.

A patient who is given a bisacodyl (Dulcolax) suppository asks the nurse how long it will take to work. The nurse replies that the patient will probably need to use the bedpan or commode within which time frame after administration? A. 2-5 minutes B. 15-60 minutes C. 2-4 hours D. 6-8 hours

B Bisacodyl suppositories usually are effective within 15 to 60 minutes of administration, so the nurse should plan accordingly to assist the patient to use the bedpan or commode.

The nurse is caring for a client who is having approximately 20 foul-smelling stools each day. Laboratory Gram stain testing indicates the presence of white blood cells (WBCs) and red blood cells (RBCs) in the stool. Which organism does the nurse expect to see in the culture report? a. Helicobacter pylori b. Campylobacter jejuni c. Clostridium botulinum d. Norwalk virus

B Campylobacter gastroenteritis causes foul-smelling diarrhea with up to 20 to 30 stools per day for 7 days. Both RBCs and WBCs are present in a Gram stain of the stools. Infection with Clostridium causes not diarrhea, but constipation, paralysis, and respiratory failure. H. pylori is a common cause of gastric ulcers, not gastroenteritis. Norwalk virus produces milder illness with diarrhea and vomiting.

A client has irritable bowel syndrome. Which menu selections by this client indicate good understanding of dietary teaching? a. Tuna salad on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed green beans, glass of apple juice c. Grilled cheese sandwich, small ripe banana, cup of hot tea with lemon d. Grilled steak, green beans, dinner roll with butter, cup of coffee with cream

B Clients with irritable bowel syndrome are advised to eat a high-fiber diet (30 to 40 grams a day), with 8 to 10 cups of liquid daily. This selection has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants.

The nurse is caring for an older client with Salmonella food poisoning. Which is the priority action of the nurse? a. Monitor vital signs. b. Maintain IV fluids. c. Provide perineal care. d. Initiate Isolation Precautions.

B Dehydration can occur quickly in older clients with Salmonella food poisoning caused by diarrhea, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions, but are of lower priority than fluid replacement. Contact Isolation is not regularly instituted for Salmonella infection. Standard Precautions are usually sufficient.

The nurse is caring for a client who had ileostomy surgery 10 days ago. The client verbalizes concerns that the effluent has not become formed and is still liquid green. Which is the nurse's best response? a. "I will call your health care provider right away because the stool should be semi-solid by now." b. "Your stools will firm up in a few weeks as your body gets used to the ileostomy." c. "You should eat a high-fiber diet to help make the stool bulkier and more solid." d. "You can add buttermilk or yogurt to your diet and avoid carbonated soft drinks."

B Effluent from an ileostomy will become less liquid (but not solid) over time as the body adapts to loss of the large bowel. This process takes time and the client should be reassured of this. Clients with a new ileostomy should avoid high-fiber diets for the first few weeks because blockage of the bowel may occur. Buttermilk, yogurt, and carbonated drinks will not affect this process.

A client underwent the first stage of a restorative proctocolectomy with ileo-anal anastomosis (RPC-IPAA). What topic is a high priority for the nurse to teach? a. Perineal care b. Ostomy care c. Nutrition therapy d. Relaxation techniques

B In the first stage of the RPC-IPAA procedure, the temporary ileostomy is created. Because the effluent is caustic, severe skin irritation can occur. The client needs good instruction on ostomy care and comfort measures. Perineal care is not needed because stool drains through the ostomy. Nutrition therapy and relaxation techniques are not as high a priority as preventing skin damage.

A middle-aged male client has irritable bowel syndrome that has not responded well to diet changes and bulk-forming laxatives. He asks the nurse about the new drug lubiprostone (Amitiza). What information does the nurse provide him? a. "This drug is investigational right now for irritable bowel syndrome." b. "Unfortunately, this drug is approved only for use in women." c. "Lubiprostone works well only in a small fraction of irritable bowel cases." d. "Let's talk to your health care provider about getting you a trial prescription."

B Lubiprostone (Amitiza) is approved only for use in women. The other statements are not accurate.

The nurse should administer an as-needed dose of magnesium hydroxide (MOM) after noting what information while reviewing a patient's medical record? A. Abdominal pain and bloating B. No bowel movement for 3 days C. A decrease in appetite by 50% over 24 hours D. Muscle tremors and other signs of hypomagnesemia

B MOM is an osmotic laxative that produces a soft, semisolid stool usually within 15 minutes to 3 hours. This medication would benefit the patient who has not had a bowel movement for 3 days. MOM would not be given for abdominal pain and bloating, decreased appetite, or signs of hypomagnesemia.

The nurse is caring for a client with colon cancer and a new colostomy. The client wishes to talk with someone who had a similar experience. Which is the nurse's best response? a. "Most people who have had a colostomy are reluctant to talk about it." b. "I will make a referral to the United Ostomy Associations of America." c. "You can get all the information you need from the enterostomal therapist." d. "I do not think that we have any other clients with colostomies on the unit right now."

B Nurses need to become familiar with community-based resources to assist clients better. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. Many people are willing to share their ostomy experience in the hope of helping others. The nurse should not brush aside the client's request by saying that no colostomy clients are present on the unit at the time.

A colectomy is scheduled for a 38-year-old woman with ulcerative colitis. The nurse should plan to include what prescribed measure in the preoperative preparation of this patient? A. Instruction on irrigating a colostomy B. Administration of a cleansing enema C. A high-fiber diet the day before surgery D. Administration of IV antibiotics for bowel preparation

B Preoperative preparation for bowel surgery typically includes bowel cleansing with antibiotics, such as oral neomycin and cleansing enemas, including Fleet enemas. Instructions to irrigate the colostomy will be done postoperatively. Oral antibiotics are given preoperatively, and an IV antibiotic may be used in the OR. A clear liquid diet will be used the day before surgery with the bowel cleansing.

7. A 23-year-old woman is being evaluated in the emergency department for acute lower abdominal pain and vomiting. During the nursing history, the most helpful question by the nurse to obtain information regarding the patient's condition is a. "What type of foods do you usually eat?" b. "Can you tell me about your pain?" c. "What is your usual elimination pattern?" d. "Is it possible that you are pregnant?"

B Rationale: A complete description of the pain provides clues about the cause of the problem. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most. Cognitive Level: Application Text Reference: p. 1044 Nursing Process: Assessment NCLEX: Physiological Integrity

22. The nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements for a patient who is hospitalized with an acute exacerbation of Crohn's disease, based on the finding of a. complaints of fatigue and weakness. b. hemoglobin of 10 g/dl (120 g/L). c. weight loss of 2 pounds (0.9 kg) in 2 days. d. a 1500-calorie intake over the last day.

B Rationale: A hemoglobin count of 10 g/dl indicates that the patient's iron and possibly protein intake are low. Fatigue and weakness may be due to the acute inflammatory response and to lack of rest because of frequent stools. A 2-pound weight loss over 2 days is not unusual in patients who are well nourished. A 1500-calorie diet may be sufficient to meet patient needs, depending on the patient's size. Cognitive Level: Application Text Reference: pp. 1053, 1059 Nursing Process: Diagnosis NCLEX: Physiological Integrity

5. Psyllium (Metamucil) is prescribed for a patient with chronic constipation. In teaching the patient about the use of the drug, the nurse stresses that a. the use of this type of laxative is safe and adverse effects are very minimal. b. large amounts of fluid should be taken to prevent impaction or bowel obstruction. c. dietary sources of fiber should be eliminated to prevent excessive gas formation. d. fat-soluble vitamins must be taken because the drug blocks absorption of these vitamins.

B Rationale: A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives. Cognitive Level: Comprehension Text Reference: pp. 1042, 1044 Nursing Process: Implementation NCLEX: Physiological Integrity

21. A total proctocolectomy with a permanent ileostomy is performed for a patient with ulcerative colitis. The patient is very upset and tells the nurse, "I can not bear to even look at the stoma. I do not think I can manage all these changes." The nurse's best approach to the patient's remarks is to a. reassure the patient that care for the ileostomy will become easier. b. ask the patient if a member of an ostomy support group may visit. c. develop a detailed written plan for ostomy care for the patient. d. wait to intervene until the patient adjusts to the body image change.

B Rationale: A visitor from an ostomy support group who has had similar experiences may be helpful to the patient. In the response beginning, "reassure the patient," the nurse does not acknowledge the patient's feelings. The response beginning "develop a detailed written plan" also fails to acknowledge the patient's emotional response to the ostomy. The nurse should act to assist the patient with body image changes, not just wait for the patient to adjust as in the remaining response. Cognitive Level: Application Text Reference: p. 1075 Nursing Process: Implementation NCLEX: Psychosocial Integrity

39. A 42-year-old patient recently developed abdominal distention, weight loss, steatorrhea, and flatulence. A diagnosis of adult celiac disease is made, and treatment is initiated. The nurse determines that teaching about the treatment of the disease has been effective when the patient says, a. "I must take folic acid for the rest of my life." b. "I will avoid dietary wheat, rye, barley, and oats." c. "I will be sure to take all of the ordered antibiotics." d. "I should eat only very low-fat or fat-free foods."

B Rationale: Avoidance of gluten-containing foods is the only treatment for celiac disease. Folic acid deficiency may occur, but once the inflammatory process is resolved, the patient will not need to take folic acid. Antibiotics are not helpful in the treatment of the inflammatory process. Avoidance of dietary fat is not necessary. Cognitive Level: Application Text Reference: p. 1081 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

16. While obtaining a nursing history from a patient with IBD, the nurse recognizes that the patient most likely has ulcerative colitis rather than Crohn's disease when the patient reports experiencing a. weight loss. b. bloody stools. c. abdominal pain and cramping. d. disease onset at age 20.

B Rationale: Because ulcerative colitis affects the colon, blood in the stools is more common with this form of IBD. Weight loss, abdominal pain and cramping, and onset at age 20 are consistent with both Crohn's disease and ulcerative colitis. Cognitive Level: Comprehension Text Reference: p. 1051 Nursing Process: Assessment NCLEX: Physiological Integrity

43. A patient with Crohn's disease has a megaloblastic anemia. The nurse will anticipate teaching the patient about the ongoing need for a. oral ferrous sulfate tablets. b. cobalamin (B12) injections. c. iron dextran (Imferon) injections. d. regular blood transfusions.

B Rationale: Crohn's disease frequently affects the ileum, where absorption of vitamin B12 occurs and the B12 must be administered regularly by the IM route to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions. Cognitive Level: Application Text Reference: pp. 1052-1053, 1056-1057 Nursing Process: Planning NCLEX: Physiological Integrity

25. A patient with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, foul-smelling urine. The nurse will teach the patient a. to clean the perianal carefully after any stools. b. about fistula formation between the bowel and bladder. c. to empty the bladder before and after sexual intercourse. d. about the effects of corticosteroid use on immune function.

B Rationale: Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. There is no information indicating that the patient's risk for UTI is caused by poor cleaning or not voiding before and after intercourse. Steroid use may increase the risk for infection, but the characteristics of the patient's urine indicate that a fistula has occurred. Cognitive Level: Application Text Reference: p. 1052 Nursing Process: Implementation NCLEX: Physiological Integrity

17. Sulfasalazine (Azulfidine) is prescribed for a patient who has been diagnosed with ulcerative colitis. The nurse recognizes that teaching about this drug has been effective when the patient says, a. "The medication will prevent infections that cause the diarrhea." b. "The medication suppresses the inflammation in my large intestine." c. "I will need lab tests to be sure that I can still fight infections." d. "I will take the sulfasalazine as an enema or suppository."

B Rationale: Sulfasalazine suppresses the inflammatory process that causes the symptoms of ulcerative colitis. It is not used to treat infections. Laboratory tests for immune suppression are needed for the immunosuppressant medications used for ulcerative colitis. Sulfasalazine is an oral medication, although the active portion of the medication (5-ASA) may be given rectally. Cognitive Level: Application Text Reference: p. 1054 Nursing Process: Evaluation NCLEX: Physiological Integrity

12. A patient is admitted to the emergency department for evaluation of right lower-quadrant abdominal pain with nausea and vomiting. The patient has a white blood cell count (WBC) of 14,000/l with a shift to the left. Which of these actions is appropriate for the nurse to take? a. Encouraging the patient to take sips of clear liquids b. Applying an ice pack to the right lower quadrant c. Checking for rebound tenderness every 30 minutes d. Teaching the patient how to cough and deep breathe

B Rationale: The patient's clinical manifestations are consistent appendicitis, and application of an ice pack will decrease inflammation at the area. The patient should be NPO in case immediate surgery is needed. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain and the patient is not likely to retain information at this point. Cognitive Level: Application Text Reference: p. 1049 Nursing Process: Implementation NCLEX: Physiological Integrity

The nurse has taught self-care measures to a client with an anal fissure. Which action by the client requires the nurse to do additional teaching? a. Taking warm sitz baths several times daily b. Administering daily enemas to prevent constipation c. Using bulk-producing agents to aid elimination d. Self-administering anti-inflammatory suppositories

B The client should not use enemas to promote elimination, but rather should rely on bulk-producing agents such as psyllium hydrophilic mucilloid (Metamucil). The other actions are appropriate.

The nurse is providing preoperative teaching for a client who will undergo herniorrhaphy surgery. Which instruction does the nurse give to the client? a. "Eat a low-residue diet for the first week after surgery." b. "Change the dressing every day until the staples are removed." c. "Take acetaminophen (Tylenol) 1000 mg every 4 hours for pain." d. "Cough and deep breathe every 2 hours for the first week after surgery."

B The dressing should be changed every day until the staples are removed, so the client can check the incision for signs of infection. Constipation is common following hernia surgery, so clients should include adequate amounts of fiber in the diet. The maximum daily dosage of Tylenol is 4000 mg. Taking 1000 mg of Tylenol every 4 hours means that intake is 6000 mg/day, which could cause toxicity and liver damage. The client should change positions and take deep breaths to facilitate lung expansion but should avoid coughing, which can place stress on the incision line.

The nurse has completed the teaching session for a client with a new colostomy. Which feedback statement by the nurse is the most appropriate? a. "I realize that you had a tough time today, but it will get easier with practice." b. "You cleaned the stoma well. Now you need to practice putting on the appliance." c. "You seem to understand what I taught you today. What else can I help you with?" d. "You seem uncomfortable. Do you want your daughter to care for your ostomy?"

B The nurse should provide both approval and room for improvement in feedback after a teaching session. Feedback should be objective and constructive, and not evaluative. Reassuring the client that things will improve does not offer anything concrete for the client to work on, nor does it let him or her know what was done well. The nurse should not make the client convey learning needs because the client may not know what else he or she needs to understand. The client needs to become the expert in self-management of the ostomy, and the nurse should not offer to teach the daughter instead of the client.

The nurse conducts a physical assessment for a client with severe right lower quadrant (RLQ) abdominal pain. The nurse notes that the abdomen is rigid and the client's temperature is 101.1° F (38.4° C). Which laboratory value does the nurse bring to the attention of the health care provider as a priority? a. A "left shift" in the white blood cell count b. White blood cell count, 22,000/mm3 c. Serum sodium, 149 mEq/L d. Serum creatinine, 0.7 mg/dL

B This client may have appendicitis based on RLQ pain. A white blood cell count of 22,000/mm3 is severely elevated and could indicate a perforated appendix, as could the fever. The nurse should bring these findings to the provider's attention as soon as possible. A left shift would be expected in uncomplicated appendicitis. The sodium reading is only slightly high; this could be due to hemoconcentration from vomiting or from decreased intake. The creatinine level is normal.

The nurse is caring for a client with perineal excoriation caused by diarrhea from acute gastroenteritis. Which client statement indicates that additional teaching about perineal care is needed? a. "I will rinse my rectal area with warm water after each stool and then apply zinc oxide ointment." b. "I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel." c. "I will take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry." d. "I will clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment."

B Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not an effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry.

George has a T tube in place after gallbladder surgery. Before discharge, what information or instructions should be given regarding the T tube drainage? a "If there is any drainage, notify the surgeon immediately." b "The drainage will decrease daily until the bile duct heals." c "First, the drainage is dark green; then it becomes dark yellow." d "If the drainage stops, milk the tube toward the puncture wound."

B As healing occurs from the bile duct, bile drains from the tube; the amount of bile should decrease. Teach the patient to expect dark green drainage and to notify the doctor if drainage stops.

Ralph has a history of alcohol abuse and has acute pancreatitis. Which lab value is most likely to be elevated? a Calcium b Glucose c Magnesium d Potassium

B Glucose level increases and diabetes mellitus may result d/t the pancreatic damage to the islets of langerhans.

"To prevent the spread of hepatitis A virus (HAV) infection the nurse is especially careful when A. Disposing of food trays B. Emptying bed pans C. Taking an oral temperature D. Changing IV

B is the correct answer. HAV is transmitted primarily person-to-person by the fecal-oral route. Food can be a method of transmission but needs to be fecally contaminated. Since the transmission of hepatitis A is fecal-oral and not saliva or blood like hepatitis B, taking a temperature and changing IV tubing would not spread hepatitis A.

The results of a patient's recent endoscopy indicate the presence of peptic ulcer disease (PUD). Which of the following teaching points should the nurse provide to the patient in light of his new diagnosis? A) "You'll need to drink at least two to three glasses of milk daily." B) "It would likely be beneficial for you to eliminate drinking alcohol." C) "Many people find that a minced or pureed diet eases their symptoms of PUD." D) "Your medications should allow you to maintain your present diet while minimizing symptoms."

B) "It would likely be beneficial for you to eliminate drinking alcohol" Although there is no specific recommended dietary modification for PUD, most patients find it necessary to make some sort of dietary modifications to minimize symptoms. Milk may exacerbate PUD and alcohol is best avoided because it can delay healing.

A patient who is administering a bisacodyl (Dulcolax) suppository asks the nurse how long it will take to work. The nurse replies that the patient will probably need to use the bedpan or commode within which of the following time frames after administration? A) 2-5 Minutes B) 15-60 Minutes C) 2-4 Hours D) 6-8 Hours

B) 15-60 minutes Bisacodyl suppositories usually are effective within 15 to 60 minutes of administration, so the nurse should plan accordingly to assist the patient to use the bedpan or commode.

A 61-year-old patient with suspected bowel obstruction has had a nasogastric tube inserted at 4:00 am. The nurse shares in the morning report that the day shift staff should check the tube for patency at which of the following times? A) 7:00 am, 10:00 am, and 1:00 pm B) 8:00 am and 12:00 pm C) 9:00 am and 3:00 pm D) 9:00 am, 12:00 pm, and 3:00 pm

B) 8:00 am and 12:00 pm A nasogastric tube should be checked for patency routinely at 4-hour intervals. Thus if the tube were inserted at 4:00 am, it would be due to be checked at 8:00 am and 12:00 pm.

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? a) Anxiety related to unknown outcome of hospitalization b) Acute pain related to biliary spasms c) Imbalanced nutrition: Less than body requirements related to biliary inflammation d) Deficient knowledge related to prevention of disease recurrence

B) Acute pain related to biliary spams The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client? a) Providing mouth care b) Administering morphine I.V. as ordered c) Placing the client in a semi-Fowler's position d) Maintaining nothing-by-mouth (NPO) status

B) Administering morphine IV as ordered The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

A colectomy is scheduled for a 68-year-old woman with an abdominal mass, possible bowel obstruction, and a history of rectal polyps. The nurse should plan to include which of the following prescribed measures in the preoperative preparation of this patient? A) Instruction on irrigating a colostomy B) Administration of a cleansing enema C) A high-fiber diet the day before surgery D) Administration of IV antibiotics for bowel preparation

B) Administration of a cleansing enema Preoperative preparation for bowel surgery typically includes bowel cleansing with antibiotics, such as oral neomycin and cleansing enemas, including Fleet enemas.

A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to a) Change the nasal tape every 2 to 3 days. b) Auscultate lung sounds every 4 hours. c) Inspect the nose daily for skin irritation. d) Apply water-based lubricant to the nares daily.

B) Auscultate lung sounds every 4 hours Pulmonary complications may occur as a result of nasogastric intubation. It is a high priority according to Maslow's hierarchy of needs and takes a higher priority over assessing the nose, changing nasal tape, or applying a water-based lubricant.

A client with a peptic ulcer is about to begin a therapeutic regimen that includes a bland diet, antacids, and famotidine (Pepcid). Before the client is discharged, the nurse should provide which instruction? a) "Eat three balanced meals every day." b) "Avoid aspirin and products that contain aspirin." c) "Stop taking the drugs when your symptoms subside." d) "Increase your intake of fluids containing caffeine."

B) Avoid aspirin and products that contain aspirin The nurse should instruct the client to avoid aspirin because it's a gastric irritant and should not be taken by clients with peptic ulcer to prevent further erosion of the stomach lining. The client should eat small, frequent meals rather than three large ones. Antacids and ranitidine prevent acid accumulation in the stomach; they should be taken even after symptoms subside. Caffeine should be avoided because it increases acid production in the stomach.

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? a) "Lie down after meals to promote digestion." b) "Avoid coffee and alcoholic beverages." c) "Limit fluid intake with meals." d) "Take antacids with meals."

B) Avoid coffee and alcoholic beverages To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren't gastric irritants.

A patient scheduled to undergo an abdominal ultrasonography is advised to do which of the following? a) Do not undertake any strenuous exercise for 24 hours before the test b) Restrict eating of solid food for 6 to 8 hours before the test. c) Avoid exposure to sunlight for at least 6 to 8 hours before the test d) Do not consume anything sweet for 24 hours before the test

B) Avoid eating of solid food for 6 to 8 hours before the test. For a patient who is scheduled to undergo an abdominal ultrasonography, the patient should restrict herself from solid food for 6 to 8 hours to avoid having images of her test obscured with gas and intestinal contents. Ultrasonography records the reflection of sound waves. Strenuous exercises, the consumption of sweets, and exposure to sunlight do not affect the results of the test in any way.

The nurse is assessing a client with a bleeding gastric ulcer. When examining the client's stool, which of the following characteristics would the nurse be most likely to find? a) Green color and texture b) Black and tarry appearance c) Clay-like quality d) Bright red blood in stool

B) Black and tarry appearance Black and tarry stools (melena) are a sign of bleeding in the upper gastrointestinal (GI) tract. As the blood moves through the GI system, digestive enzymes turn red blood to black. Bright red blood in the stool is a sign of lower GI bleeding. Green color and texture is a distractor for this question. Clay-like stools are a characteristic of biliary disorders

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding? a) The ostomy bag should be adjusted. b) Blood supply to the stoma has been interrupted. c) An intestinal obstruction has occurred. d) This is a normal finding 1 day after surgery.

B) Blood supply to the stoma has been interrupted. An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion. The nurse should interpret this finding as an indication that the stoma's blood supply is interuppted, which may lead to tissue damage or necrosis. A dusky stoma isn't a normal finding 1 day after surgery. Adjusting the ostomy bag wouldn't affect stoma color, which depends on blood supply to the area. An intestinal obstruction also wouldn't change stoma color.

Which of the follow statements provide accurate information regarding cancer of the colon and rectum? a) There is no hereditary component to colon cancer. b) Cancer of the colon and rectum is the second most common type of internal cancer in the United States. c) Rectal cancer affects more than twice as many people as colon cancer. d) The incidence of colon and rectal cancer decreases with age.

B) Cancer of the colon and rectum is the second most common type of internal cancer in the US Cancer of the colon and rectum is the second most common type of internal cancer in the United States. Colon cancer affects more than twice as many people as does rectal cancer (94,700 for colon, 34,700 for rectum). The incidence increases with age (the incidence is highest in people older than 85). Colon cancer occurrence is higher in people with a family history of colon cancer.

A client is scheduled for several diagnostic tests to evaluate her gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when she identifies which test as not requiring the use of a contrast medium? a) Computer tomography b) Colonoscopy c) Small bowel series d) Upper GI series

B) Colonoscopy A colonoscopy is a direct visual examination of the entire large intestine. It does not involve the use of a contrast agent. Contrast medium may be used with a small bowel series, computed tomography, and upper GI series.

A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to: a) restrict fluid intake to 1 qt (1,000 ml)/day. b) drink liquids only between meals. c) don't drink liquids 2 hours before meals. d) drink liquids only with meals.

B) Drink liquids only between meals. A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in the prevention of rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals.

The nurse is caring for a patient treated with intravenous fluid therapy for severe vomiting. As the patient recovers and begins to tolerate oral intake, the nurse understands that which of the following food choices would be most appropriate? A) Ice tea B) Dry toast C) Warm broth D) Plain hamburger

B) Dry toast Dry toast or crackers may alleviate the feeling of nausea and prevent further vomiting. Extremely hot or cold liquids and fatty foods are generally not well tolerated.

A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test? a) Serve dairy products. b) Encourage plenty of fluids. c) Serve the client his usual diet. d) Order a high-fiber diet.

B) Encourage plenty of fluids The nurse should encourage plenty of fluids because adequate fluid intake is necessary to avoid dehydration that may be caused by the bowel preparation and to prevent fecal impaction after the procedure. The client may be placed on a low-residue diet 1 to 2 days before the procedure to reduce the contents in the GI tract. Fiber intake is limited in a low-residue diet. Because dairy products leave a residue, they aren't allowed the evening before the test. Clear liquids only are allowed the evening before the test.

Which of the following medications requires the nurse to contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Buccal or sublingual tablets b) Enteric-coated tablets c) Soft gelatin capsules filled with liquid d) Simple compressed tablets

B) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change in the form of medication is necessary for patients with tube feedings. Simple compressed tablets may be crushed and dissolved in water for patients receiving oral medications by feeding tube. Buccal or sublingual tablets are absorbed by mucous membranes and may be given as intended to the patient undergoing tube feedings. The nurse may make an opening in the capsule and squeeze out contents for administration by feeding tube.

A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is appropriate? a) Maintaining wrinkles in the faceplate so it doesn't irritate the skin b) Gently washing the area surrounding the stoma using a facecloth and mild soap c) Scrubbing fecal material from the skin surrounding the stoma d) Cutting the faceplate opening no more than 2? larger than the stoma

B) Gently washing the area surrounding the stoma using a facecloth and mild soap For a client with an ostomy, maintaining skin integrity is a priority. The nurse should gently wash the area surrounding the stoma using a facecloth and mild soap. Scrubbing the area around the stoma can damage the skin and cause bleeding. The faceplate opening should be no more than 1/8? to 1/6? larger than the stoma. This size protects the skin from exposure to irritating fecal material. The nurse can create an adequate seal and prevent leakage of fecal material from under the faceplate by applying a thin layer of skin barrier and smoothing out wrinkles in the faceplate. Eliminating wrinkles in the faceplate also protects the skin surrounding the stoma from pressure.

The patient who is admitted with a diagnosis of diverticulitis and a history of irritable bowel disease and gastroesophageal reflux disease (GERD) has received a dose of Mylanta 30 ml PO. The nurse would evaluate its effectiveness by questioning the patient as to whether which of the following symptoms has been resolved? A) Diarrhea B) Heartburn C) Constipation D) Lower abdominal pain

B) Heartburn Mylanta is an antacid that contains both aluminum and magnesium. It is indicated for the relief of GI discomfort, such as with heartburn associated with GERD.

The nurse is planning care for a 68-year-old patient with an abdominal mass and suspected bowel obstruction. Which of the following factors in the patient's history increases the patient's risk for colorectal cancer? A) Osteoarthritis B) History of rectal polyps C) History of lactose intolerance D) Use of herbs as dietary supplements

B) History of rectal polyps A history of rectal polyps places this patient at risk for colorectal cancer. This tissue can degenerate over time and become malignant. The other factors identified do not pose additional risk to the patient.

The nurse is preparing to interview a client with cirrhosis. Based on an understanding of this disorder, which question would be most important to include? a) "What type of over-the-counter pain reliever do you use?" b) "How often do you drink alcohol?" c) "Have you had an infection recently?" d) "Does your work expose you to chemicals?"

B) How often do you drink alcohol? The most common type of cirrhosis results from chronic alcohol intake and is frequently associated with poor nutrition. Although it can follow chronic poisoning with chemicals or ingestion of hepatotoxic drugs such as acetaminophen, asking about alcohol intake would be most important. Asking about an infection or exposure to hepatotoxins or industrial chemicals would be important if the client had postnecrotic cirrhosis.

Which of the following would be the highest priority information to include in preoperative teaching for a 68-year-old patient scheduled for a colectomy? A) How to care for the wound B) How to deep breathe and cough C) The location and care of drains after surgery D) What medications will be used during surgery

B) How to deep breathe and cough Because anesthesia, an abdominal incision, and pain can impair the patient's respiratory status in the postoperative period, it is of high priority to teach the patient to cough and deep breathe. Otherwise, the patient could develop atelectasis and pneumonia, which would delay early recovery from surgery and hospital discharge.

An elderly patient diagnosed with diarrhea is taking digoxin (Lanoxin). Which of the following electrolyte imbalances should the nurse be alert to? a) Hyponatremia b) Hypokalemia c) Hypernatremia d) Hyperkalemia

B) Hypokalemia The older person taking digitalis must be aware of how quickly dehydration and hypokalemia can occur with diarrhea. The nurse teaches the patient to recognize the symptoms of hypokalemia because low levels of potassium intensify the action of digitalis, leading to digitalis toxicity.

Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? a) Bradycardia b) Hypotension c) Polyuria d) Warm moist skin

B) Hypotension Signs of potential hypovolemia include cool, clammy skin, tachycardia, decreased blood pressure, and decreased urine output.

A client who is recovering from anesthesia following oral surgery for lip cancer is experiencing difficulty breathing deeply and coughing up secretions. Which of the following measures will help ease the client's discomfort? a) Positioning the client flat on the abdomen or side. b) Keeping the head of the bed elevated. c) Turning the client's head to the side. d) Providing a tracheostomy tray near the bed.

B) Keeping the head of the bed elevated It is essential to position the client with the head of the bed elevated because it is easier for the client to breathe deeply and cough up secretions after recovering from the anesthetic. Positioning the client flat either on the abdomen or side with the head turned to the side will facilitate drainage from the mouth. A tracheostomy tray is kept by the bed for respiratory distress or airway obstruction. When mouth irrigation is carried out, the nurse should turn the client's head to the side to allow the solution to run in gently and flow out.

A 74-year-old client is on the hospital unit where you practice nursing. She will be undergoing rhinoplasty and you are completing her admission assessment and paperwork. She reports medications she uses on a daily basis, which you record for her chart. Which of her daily medications will result in constipation? a) Acetaminophen b) Laxative c) NSAIDs d) Multivitamin without iron

B) Laxative Constipation may also result from chronic use of laxatives ("cathartic colon") because such use can cause a loss of normal colonic motility and intestinal tone. Laxatives also dull the gastrocolic reflex.

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct? a) "Maintain a high-sodium, high-calorie diet." b) "Maintain a high-carbohydrate, low-fat diet." c) "Maintain a high-fat, high-carbohydrate diet." d) "Maintain a high-fat diet and drink at least 3 L of fluid a day."

B) Maintain a high carbohydrate, low fat diet A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake isn't necessary because chronic pancreatitis isn't associated with hyponatremia or fluid loss.

If a client has abdominal surgery and a portion of the small intestine is removed, the client is at risk for which of the following? a) Gastric ulcers b) Malabsorption syndrome c) Constipation d) Cirrhosis

B) Malabsorption syndrome Absorption is the primary function of the small intestine. Vitamins and minerals are absorbed essentially unchanged. Nutrients are absorbed at specific locations in the small intestine.

A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission? a) Skim milk b) Nothing by mouth c) Regular diet d) Clear liquids

B) NPO Shock and bleeding must be controlled before oral intake, so the client should receive nothing by mouth. When the bleeding is controlled, the diet is gradually increased, starting with ice chips and then clear liquids. Skim milk shouldn't be given because it increases gastric acid production, which could prolong bleeding. A clear liquid diet is the first diet offered after bleeding and shock are controlled.

The nurse should administer a prn dose of magnesium hydroxide (MOM) after noting which of the following while reviewing a patient's medical record? A) Abdominal pain and bloating B) No bowel movement for 3 days C) A decrease in appetite by 50% over 24 hours D) Muscle tremors and other signs of hypomagnesemia

B) No bowel movement for 3 days MOM is an osmotic laxative that produces a soft, semisolid stool usually within 15 minutes to 3 hours. This medication would benefit the patient who has not had a bowel movement for 3 days.

A client with a disorder of the oral cavity cannot tolerate tooth brushing or flossing. Which of the following strategies can the nurse employ to assist this client? a) Regularly wipe the outside of the client's mouth to prevent germs from entering. b) Provide the client with an irrigating solution of baking soda and warm water. c) Recommend that the client drink a small glass of alcohol at the end of the day to kill germs. d) Urge the client to regularly rinse the mouth with tap water.

B) Provide the client with an irrigating solution of baking soda and warm water If a client cannot tolerate brushing or flossing, an irrigating solution of 1 tsp of baking soda to 8 oz of warm water, half strength hydrogen peroxide, or normal saline solution is recommended.

When a central venous catheter dressing becomes moist or loose, what should a nurse do first? a) Notify the physician. b) Remove the dressing, clean the site, and apply a new dressing. c) Remove the catheter, check for catheter integrity, and send the tip for culture. d) Draw a circle around the moist spot and note the date and time.

B) Remove dressing, clean the site, and apply a new dressing. A nurse maintaining a central venous catheter should change the dressing every 72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the nurse should use sterile technique to clean around the site in accordance with facility policy. After the cleaning solution has dried, the nurse should cover the site with a transparent semipermeable dressing. A nurse who notes drainage on a wound dressing should draw a circle around the moist spot and note the date and time. She should notify the physician if she observes any catheter-related complications. Only a nurse with the appropriate qualifications may remove a central venous catheter, and a moist or loose dressing isn't a reason to remove the catheter.

A nurse is providing postprocedure instructions for a client who had an esophagogastroduodenoscopy. The nurse should perform which action? a) Tell the client to call back in the morning so she can give him instructions over the phone. b) Review the instructions with the person accompanying the client home. c) Tell the client there aren't specific instructions for after the procedure. d) Give instructions to the client immediately before discharge.

B) Review the instructions with the person accompanying the client home A client who undergoes esophagogastroduodenoscopy receives sedation during the procedure, and his memory becomes impaired. Clients tend not to remember instructions provided after the procedure. The nurse's best course of action is to give the instructions to the person who is accompanying the client home. It isn't appropriate for the nurse to tell the client to call back in the morning for instructions. The client needs to be aware at discharge of potential complications and signs and symptoms to report to the physician.

A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? a) Left upper quadrant b) Right lower quadrant c) Left lower quadrant d) Right upper quadrant

B) Right lower quadrant The pain of acute appendicitis localizes in the right lower quadrant (RLQ) at McBurney's point, an area midway between the umbilicus and the right iliac crest. Often, the pain is worse when manual pressure near the region is suddenly released, a condition called rebound tenderness.

Patients with chronic liver dysfunction have problems with insufficient vitamin intake. Which of the following may occur as a result of vitamin C deficiency? a) Beriberi b) Scurvy c) Night blindness d) Hypoprothrombinemia

B) Scurvy Scurvy may result from a vitamin C deficiency. Night blindness, hypoprothrombinemia, and beriberi do not result from a vitamin C deficiency.

Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. The nurse also expects to find: a) tenderness and pain in the right upper abdominal quadrant. b) severe abdominal pain with direct palpation or rebound tenderness. c) jaundice and vomiting. d) rectal bleeding and a change in bowel habits.

B) Severe abdominal pain with direct palpation or rebound tenderness Peritonitis decreases intestinal motility and causes intestinal distention. A classic sign of peritonitis is a sudden, diffuse, severe abdominal pain that intensifies in the area of the underlying causative disorder (such as appendicitis, diverticulitis, ulcerative colitis, or a strangulated obstruction). The client may also have rebound tenderness. Tenderness and pain in the right upper abdominal quadrant suggest cholecystitis. Jaundice and vomiting are signs of cirrhosis of the liver. Rectal bleeding or a change in bowel habits may indicate colorectal cancer.

Which of the following medications would the nurse expect the physician to order for a client with cirrhosis who develops portal hypertension? a) Kanamycin (Kantrex) b) Spironolactone (Aldactone) c) Cyclosporine (Sandimmune) d) Lactulose (Cephulac)

B) Spironlactone (Aldactone) For portal hypertension, a diuretic usually an aldosterone antagonist such as spironolactone (Aldactone) is ordered. Kanamycin (Kantrex) would be used to treat hepatic encephalopathy to destroy intestinal microorganisms and decrease ammonia production. Lactulose would be used to reduce serum ammonia concentration in a client with hepatic encephalopathy. Cyclosporine (Sandimmune) would be used to prevent graft rejection after a transplant.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: a) elevated blood urea nitrogen and creatinine levels and hyperglycemia. b) subnormal serum glucose and elevated serum ammonia levels. c) subnormal clotting factors and platelet count. d) elevated liver enzymes and low serum protein level.

B) Subnormal serum glucose and elevated serum ammonia levels In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.

The nurse is preparing to examine the abdomen of a client complaining of a change in his bowel pattern. The nurse would place the client in which position? a) Lithotomy b) Supine with knees flexed c) Knee-chest d) Left Sim's lateral

B) Supine with knees flexed When examining the abdomen, the client lies supine with his knees flexed. This position assists in relaxing the abdominal muscles. The lithotomy position commonly is used for a female pelvic examination and to examine the rectum. The knee-chest position can be used for a variety of examinations, most commonly the anus and rectum. The left Sim's lateral position may be used to assess the rectum or vagina and to administer an enema.

A client receives a local anesthetic to suppress the gag reflex for a diagnostic procedure of the upper GI tract. Which of the following nursing interventions is advised for this patient? a) The client should be monitored for any breathing related disorder or discomforts b) The client should not be given any food and fluids until the gag reflex returns c) The client should be monitored for cramping or abdominal distention d) The client's fluid output should be measured for at least 24 hours after the procedure

B) The client should not be given any food and fluids until the gag reflex returns. For a client receiving a local anesthetic that suppresses the gag reflex, the nurse is advised to withhold food and fluids until the reflex returns.

Which patient teaching component is important for the nurse to communicate regarding pain management prior to or during diagnostic testing for a disorder of the GI system? a) The patient should not expel gas and test fluids from the bowel when he or she experiences the urge during the procedure. b) The patient should inform the test personnel if he or she experiences pressure or cramping during the instillation of test fluids. c) The patient should take a sedative before the procedure to avoid the possibility of experiencing any discomfort. d) The patient should lie down in a supine position for at least 3 hours before the test to reduce any discomfort during the test.

B) The patient should inform the test personnel if he or she experiences pressure or cramping during instillation of test fluids To ensure that a patient who is to undergo a diagnostic test for a disorder of the gastrointestinal system experiences no or minimal discomfort during the test, the patient should be instructed to inform the test personnel if he or she experiences pressure or cramping during the instillation of test fluids. The test personnel can slow the instillation or take other measures to relieve discomfort. The patient should also be advised to expel gas and test fluids from the bowel when he or she experiences the urge. Ignoring the urge to expel the bowel contents increases pain and discomfort. The patient should be advised not to take any sedative or analgesic before the test, unless prescribed. Lying down in a supine position is not known to have any consequence on the level of discomfort experienced by a patient during a diagnostic test for a GI disorder.

Paul Cavanagh, a 63-year-old retired teacher, had oral cancer and had extensive surgery to excise the malignancy. While is surgery was deemed successful, it was quite disfiguring and incapacitating. What is essential to Mr. Cavanagh and his family? a) Knowing that everything will work out just fine b) Time to mourn, accept, and adjust to the loss c) Not giving in to anger d) Having a courageous attitude

B) Time to mourn, accept, and adjust to the loss The first time family members or clients see the effects of surgery, the experience usually is traumatic. The nurse needs to promote effective coping and therapeutic grieving at this time. Responses may range from crying or extreme sadness and avoiding contact with others to refusing to talk about the surgery or changes in appearance. Allowing the client time to mourn, accept, and adjust to losses is essential.

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client? a) Vitamin K b) Vitamin A c) Riboflavin d) Thiamine

B) Vitamin A Problems common to clients with severe chronic liver dysfunction result from inadequate intake of sufficient vitamins. Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency can lead to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Vitamin K deficiency can cause hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses.

A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The physician has ordered a visualization of the small intestine via a capsule endoscopy. Which of the following will the nurse include in the client education about this procedure? a) "An x-ray machine will use a capsule ray to follow your intestinal tract." b) "You will need to swallow a capsule." c) "The physician will use a scope called a capsule to view your intestine." d) "A capsule will be inserted into your rectum."

B) You will need to swallow a capsule A capsule endoscopy allows for noninvasive visualization of the small intestinal mucosa. The technique consists of the client swallowing a capsule that is embedded with a wireless miniature camera, which is propelled through the intestine by peristalsis. The capsule passes from the rectum in 1 to 2 days.

The nurse is providing discharge teaching for a client who has undergone colon resection surgery with a colostomy. Which statements by the client indicate that the instruction was understood? (Select all that apply.) a. "I will change the ostomy appliance daily and as needed." b. "I will use warm water and a soft washcloth to clean around the stoma." c. "I will start bicycling and swimming again once my incision has healed." d. "I will notify the doctor right away if any bleeding from the stoma occurs." e. "I will check the stoma regularly to make sure that it stays a deep red color." f. "I will avoid dairy products to reduce gas and odor in the pouch." g. "I will cut the flange so it fits snugly around the stoma to avoid skin breakdown."

B, C, G

When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant? Select all that apply. A. Assessing the client's bowel sounds B. Providing skin care following bowel movements C. Evaluating the client's response to antidiarrheal medications D. Maintaining intake and output records E. Obtaining the client's weight.

B, D, E and 5. The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client's weight. Assessing the client's bowel sounds and evaluating the client's response to medication are registered nurse activities that cannot be delegated.

Laboratory test results that the nurse would expect to find in a patient with cirrhosis include a. serum albumin 7.0 g/dL b. bilirubin total 3.2 mg/dL c. serum cholesterok 260 mg/dL d. aspartate aminotransferase (AST) 6.0 U/L

B- Serum bilirubin, both direct and indirect, would be expected to be increased in cirrhosis. Serum albumin and cholesterol are decreased, and liver enzymes, such as AST and ALT, are elevated

A patient with advanced cirrhosis has a nursing diagnosis of imbalanced nutrition: less than body requirements r/t anorexia and inadequate food intake. An appropriate midday snack for the patient would be a. peanut butter and salt free crackers b. a fresh tomato sandwich with salt free butter c. popcorn with salt free butter and herbal seasoning d. canned chicken noodle soup with low protein bread

B- The patient with advanced, complicated cirrhosis requires a high calore, high carbohydrate diet with moderate to low fat. Patients with cirrhosis are at risk for edema and ascites and their sodium intake should be limited. The tomato sandwich with salt free butter best meets these requirements. Rough foods, such as popcorn, may irritate the esophagus and stomach and lead to bleeding. Peanut butter is high in sodium and fat, and canned chicken noodle soup is very high in sodium

The nurse identifies a need for further teaching when the patient with hepatitis B states, a. I should avoid alcohol completely for as long as a year b. I must avoid all physical contact with my family until the jaundice is gone c. I should use a condom to prevent spread of the disease to my sexual partners d. I will need to rest several times a day, gradually increasing my activity as I tolerate it.

B- The patient with hep B is infectious for 4 to 6 months, and precautions to prevent transmission through percutaneous and sexual contact should be maintained until tests for HBsAg are negative. Close contact does not have to be avoided, but close contacts of the patient should be vaccinated. Alcohol should not be used for at least a year, and rest with increasing activity during convalescence is recommended

To prevent the spread of hepatitis A infections the nurse is especially careful when: A) Disposing of food trays B) Disposing of bed pan C) taking an oral temp D) Changing IV tubing

B. Rationale: HAV is transmitted primarily person-to-person by the fecal-oral route. Food can be a method of transmission but needs to be fecally contaminated. Since the transmission of hepatitis A is fecal-oral and not saliva or blood like hepatitis B, taking a temperature and changing IV tubing would not spread hepatitis A."

Which of the following tests should be administered to a client suspected of having diverticulosis? A. Abdominal ultrasound B. Barium enema C. Barium swallow D. Gastroscopy

B. A barium enema will cause diverticula to fill with barium and be easily seen on x-ray. An abdominal US can tell more about structures, such as the gallbladder, liver, and spleen, than the intestine. A barium swallow and gastroscopy view upper GI structures.

When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? a. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. b. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. c. The appendix may develop gangrene and rupture, especially in a middle-aged client. d. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage.

B. A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Geriatric, not middle-aged, clients are especially susceptible to appendix rupture.

The nurse evaluates the client's stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician? A. The stoma is slightly edematous B. The stoma is dark red to purple C. The stoma oozes a small amount of blood D. The stoma does not expel stool

B. A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing of blood are normal in the early post-op period. The colostomy would typically not begin functioning until 2-4 days after surgery.

Which of the following symptoms would a client in the early stages of peritonitis exhibit? A. Abdominal distention B. Abdominal pain and rigidity C. Hyperactive bowel sounds D. Right upper quadrant pain

B. Abdominal pain causing rigidity of the abdominal muscles is characteristic of peritonitis. Abdominal distention may occur as a late sign but not early on. Bowel sounds may be normal or decreased but not increased. Right upper quadrant pain is chatacteristic of cholecystitis or hepatitis.

When evaluating a male client for complications of acute pancreatitis, the nurse would observe for: a. increased intracranial pressure. b. decreased urine output. c. bradycardia. d. hypertension.

B. Acute pancreatitis can cause decreased urine output, which results from the renal failure that sometimes accompanies this condition. Intracranial pressure neither increases nor decreases in a client with pancreatitis. Tachycardia, not bradycardia, usually is associated with pulmonary or hypovolemic complications of pancreatitis. Hypotension can be caused by a hypovolemic complication, but hypertension usually isn't related to acute pancreatitis.

The patient is admitted to the hospital for acute pancreatitis. Which nursing action is a priority? A. Provide clear liquid diet. B. Administer IV fluids. C. Teach the patient to avoid alcohol. D. Teach the patient to watch for steatorrhea.

B. Administer IV fluids. Rationale Hypovolemia is a potential major systemic complication. Patients initially are NPO, and fluid replacement is essential. Care for problems takes priority over teaching about future needs, although this discharge teaching eventually must be provided. Reference: 1090, 1092

Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which of the following points do you include? a. "You'll need to lie on your stomach during the test." b. "You'll need to lie on your right side after the test." c. "During the biopsy you'll be asked to exhale deeply and hold it." d. "The biopsy is performed under general anesthesia.

B. After a liver biopsy, the patient is placed on the right side to compress the liver and to reduce the risk of bleeding or bile leakage.

Care for the postoperative client after gastric resection should focus on which of the following problems? A. Body image B. Nutritional needs C. Skin care D. Spiritual needs

B. After gastric resection, a client may require total parenteral nutrition or jejunostomy tube feedings to maintain adequate nutritional status.

Which is correct information about the treatment of Crohn's disease? A. Surgery is the preferred treatment. B. Aminosalicylates are frequently used first. C. Corticosteroids are given for long-term therapy. D. High-fiber foods are encouraged to add bulk to diarrheal stool.

B. Aminosalicylates are frequently used first. Aminosalicylates (5-ASAs) are used first because they are less toxic, although there is a movement to using biologic and targeted therapy as first-line therapy. Drugs with 5-ASA suppress the proinflammatory cytokines and inflammatory mediators.

A nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen is distended and the bowel sounds are diminished. Which of the following is the most appropriate nursing intervention? A. Administer dilaudid B. Notify the physician C. Call and ask the operating room team to perform the surgery as soon as possible D. Reposition the client and apply a heating pad on a warm setting to the client's abdomen.

B. Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.

A client with gastric cancer can expect to have surgery for resection. Which of the following should be the nursing management priority for the preoperative client with gastric cancer? A. Discharge planning B. Correction of nutritional deficits C. Prevention of DVT D. Instruction regarding radiation treatment

B. Client's with gastric cancer commonly have nutritional deficits and may be cachectic. Discharge planning before surgery is important, but correcting the nutrition deficit is a higher priority. At present, radiation therapy hasn't been proven effective for gastric cancer, and teaching about it preoperatively wouldn't be appropriate. Prevention of DVT also isn't a high priority to surgery, though it assumes greater importance after surgery.

The patient with Crohn's disease has an ileostomy, with the terminal ileum removed. Absorption of what nutrient is a key concern? A. Carbohydrate B. Cobalamin C. Gluten D. Lactose

B. Cobalamin Patients who had the terminal ileum removed have reduced absorption of cobalamin (vitamin B12). Instrinsic factor is secreted in the stomach but absorbed in the small intestine.

The immunosuppressant azathioprine (Imuran) is given to maintain remission after corticosteroid induction therapy for an exacerbation of ulcerative colitis. What monitoring is required? A. Carcinogenic embryonic antigen (CEA) B. Complete blood cell count (CBC) C. Prostate-specific antigen (PSA) D. Potassium

B. Complete blood cell count (CBC) Regular CBC monitoring is required because the drug can suppress the bone marrow and lead to inflammation of the pancreas or gallbladder. CEA is used to monitor for recurrence of colorectal cancer. PSA is used to monitor for prostate cancer.

The nurse is reviewing the record of a client with Crohn's disease. Which of the following stool characteristics would the nurse expect to note documented on the client's record? A. Chronic constipation B. Diarrhea C. Constipation alternating with diarrhea D. Stool constantly oozing from the rectum

B. Crohn's disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration and severity. The other option are not associated with diarrhea.

Which goal of the client's care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis? A. Promoting self-care and independence B. Managing diarrhea C. Maintaining adequate nutrition D. Promoting rest and comfort

B. Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and decreasing the frequency of stools is the first goal of treatment. The other goals are ongoing and will be best achieved by halting the exacerbation. The client may receive antidiarrheal medications, antispasmodic agents, bulk hydrophilic agents, or anti-inflammatory drugs.

Which of the following definitions best describes diverticulosis? A. An inflamed outpouching of the intestine B. A noninflamed outpouching of the intestine C. The partial impairment of the forward flow of intestinal contents D. An abnormal protrusion of an organ through the structure that usually holds it.

B. Diverticulosis involves a noninflamed outpouching of the intestine. Diverticulitis involves an inflamed outpouching. The partial impairment of forward flow of the intestine is an obstruction; abnormal protrusion of an organ is a hernia.

An enema is prescribed for a client with suspected appendicitis. Which of the following actions should the nurse take? A. Prepare 750 ml of irrigating solution warmed to 100*F B. Question the physician about the order C. Provide privacy and explain the procedure to the client D. Assist the client to left lateral Sim's position

B. Enemas are contraindicated in an acute abdominal condition of unknown origin as well as after recent colon or rectal surgery or myocardial infarction. The other answers are correct only when enema administration is appropriate.

A male client with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse position the client for this test initially? a. Lying on the right side with legs straight b. Lying on the left side with knees bent c. Prone with the torso elevated d. Bent over with hands touching the floor

B. For a colonoscopy, the nurse initially should position the client on the left side with knees bent. Placing the client on the right side with legs straight, prone with the torso elevated, or bent over with hands touching the floor wouldn't allow proper visualization of the large intestine.

What is a key etiologic factor in primary biliary cirrhosis? A. Alcohol consumption B. Genetics and chemical exposure C. Smoking D. Autoimmune and drug use

B. Genetics and chemical exposure

The patient with cirrhosis is having a bedside paracentesis for relief of respiratory symptoms related to the patient's ascites. You are assisting the primary health care provider. Which action should you take? A. Explain the risks and benefits of the procedure to the patient. B. Have the patient void. C. Place the patient in a fetal position. D. Keep the patient flat for 8 hours after the procedure.

B. Have the patient void. Rationale Immediately before a paracentesis, the patient should void to prevent puncture of the bladder. Explaining the risks and benefits of an invasive procedure is the responsibility of the health care provider who is doing the procedure. The patient is placed in a sitting or high Fowler position; a fe`tal position is used for a lumbar puncture. It is not necessary to keep the patient flat after the procedure. The patient is monitored for hypovolemia and electrolyte imbalances, and the dressing is checked for bleeding and leakage. Reference: 1083

Which condition is most likely to have a nursing diagnosis of fluid volume deficit? a. Appendicitis b. Pancreatitis c. Cholecystitis d. Gastric ulcer

B. Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis. The other conditions are less likely to exhibit fluid volume deficit.

Which of the following symptoms is associated with ulcerative colitis? A. Dumping syndrome B. Rectal bleeding C. Soft stools D. Fistulas

B. In ulcerative colitis, rectal bleeding is the predominant symptom. Soft stools are more commonly associated with Crohn's disease, in which malabsorption is more of a problem. Dumping syndrome occurs after gastric surgeries. Fistulas are associated with Crohn's disease.

The patient had chronic hepatitis B that resulted in liver failure. The patient underwent liver transplantation. What is the correct information to teach the patient? A. The patient will have immunity for hepatitis B for the rest of his life. B. Intravenous immune globulin will be used to prevent reinfection. C. The patient is at higher risk for liver cancer. D. The patient must avoid raw seafood for the rest of his life.

B. Intravenous immune globulin will be used to prevent reinfection.

A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis? a. Elevated hemoglobin level b. Elevated serum bilirubin level c. Elevated blood urea nitrogen level d. Decreased erythrocycle sedimentation rate"

B. Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated erythrocyte sedimentation rates, and leukopenia. An elevated blood urea nitrogen level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

What is the main treatment for a patient with acute diverticulitis? A. Colon resection and ostomy B. Nasogastric tube and intravenous (IV) fluids C. Long-term course of oral corticosteroids D. Mechanical soft diet

B. Nasogastric tube and intravenous (IV) fluids In acute diverticulitis, the goal of treatment is to allow the colon to rest and inflammation to subside. Bowel rest can be accomplished with the use of a nasogastric tube and IV fluids.

The patient with advanced cirrhosis asks you why his abdomen is so swollen. What knowledge is your response based on? A. A lack of clotting factors promotes the collection of blood in the abdominal cavity. B. Portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. C. Decreased peristalsis in the gastrointestinal tract contributes to gas formation and distention of the bowel. D. Bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid.

B. Portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. Rationale Ascites is the accumulation of serous fluid in the peritoneal or abdominal cavity and a common manifestation of cirrhosis. With portal hypertension, proteins shift from the blood vessels through the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, they leak through the liver capsule into the peritoneal cavity. The osmotic pressure of the proteins pulls additional fluid into the peritoneal cavity. A second mechanism of ascites formation is hypoalbuminemia resulting from the inability of the liver to synthesize albumin. The hypoalbuminemia results in decreased colloidal oncotic pressure. A third mechanism is hyperaldosteronism, which occurs when aldosterone is not metabolized by damaged hepatocytes. The increased level of aldosterone causes increased sodium reabsorption by the renal tubules. This retention of sodium, as well as an increase in antidiuretic hormone, causes additional water retention. Reference: 1075, 1077

How does the drug sulfasalazine (Azulfidine) work in the treatment of IBD? A. Destroys bacteria B. Suppresses inflammatory mediators C. Slows gastric motility D. Promotes electrolyte exchange across intestinal membrane

B. Suppresses inflammatory mediators Sulfasalazine contains sulfapyridine and 5-aminosalicylic acid (5-ASA). Although the exact action is unknown, it works by suppressing inflammatory mediators. IBD is an autoimmune inflammatory disease; no specific infectious agent has been identified, although antimicrobials (Flagyl, Cipro) occasionally are used.

After a right hemicolectomy for treatment of colon cancer, a 57-year old client is reluctant to turn while on bed rest. Which action by the nurse would be appropriate? A. Asking a co-worker to help turn the client B. Explaining to the client why turning is important. C. Allowing the client to turn when he's ready to do so D. Telling the client that the physician's order states he must turn every 2 hours

B. The appropriate action is to explain the importance of turning to avoid postoperative complications. Asking a coworker to help turn the client would infringe on his rights. Allowing him to turn when he's ready would increase his risk for postoperative complications. Telling him he must turn because of the physician's orders would put him on the defensive and exclude him from participating in care decision.

Which of the following symptoms is a client with colon cancer most likely to exhibit? A. A change in appetite B. A change in bowel habits C. An increase in body weight D. An increase in body temperature

B. The most common complaint of the client with colon cancer is a change in bowel habits. The client may have anorexia, secondary abdominal distention, or weight loss. Fever isn't associated with colon cancer.

The client with a colostomy has an order for irrigation of the colostomy. The nurse used which solution for irrigation? A. Distilled water B. Tap water C. Sterile water D. Lactated Ringer's

B. Warm tap water or saline solution is used to irrigate a colostomy. If the tap water is not suitable for drinking, then bottled water should be used.

A patient with Hepatitis B is being discharged in 2 days. In the discharge teaching plan the nurse should include instructions to : A.) avoid alcohol for the first 3 weeks B.) use a condom during sexual intercourse C.) have family members get an injection of immunoglobulin D.) follow a low-protein, moderate carbohydrate, moderate fat diet.

B.) use a condom during sexual intercourse Rationale: Hepatitis B virus may be transmitted by mucosal exposure to infectious blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Hepatitis B is a sexually transmitted disease that is acquired through unprotected sex with an infected person. Condom use should be taught to patients to prevent transmission of hepatitis B.

A nurse is teaching a client 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 Mushrooms Onions Peas

The nurse is caring for a patient with stomatitis. Which nursing intervention is appropriate? a. Check the gastric residual before the feeding. b. Assess a typical 24 hour eating pattern. c. Offer frequent mouth care. d. Assess BMI

C

The student nurse is participating in colorectal cancer-screening program. Which patient has the fewest risk factors for colon cancer? a Janice, a 45 y.o. with a 25-year history of ulcerative colitis b George, a 50 y.o. whose father died of colon cancer c Herman, a 60 y.o. who follows a low-fat, high-fiber diet d Sissy, a 72 y.o. with a history of breast cancer

C

You are performing an abdominal assessment. The patient begins to vomit. What is your priority action? a. Assess the emesis for blood, bile or fecal material. b. Offer the patient mouth care. c. Assist the patient to a sitting or sidelying position. d. Administer a PRN anti-emetic.

C

A nurse is working in the emergency room and receives a client with suspected botulism. Which action is a priority for the nurse to initiate? a) administer vaccine for botulism b) initiate isolation c) induce vomiting d) administer antibiotics

C - botulism is food poisoning. Vomiting rids the body toxins.

The nurse is assigned to a 40-year old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of: a) 45 units/L b) 100 units/L c) 300 units/L d) 500 units/L

C - the normal serum amylase level is 25 to 151 unit/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Option A and B are within normal limits. Option D is an extremely elevated level seen in acute pancreatitis.

An adult client was diagnosed with acute pancreatitis 9 days ago. The nurse interprets that the client is recovering from this episode if the serum lipase level decreases to which of the following values, which is just below the upper limit of normal? a) 20 unit/L b) 80 unit/L c) 135 unit/L d) 350 unit/L

C - the normal serum lipase level is 10 to 140 units/L. The client who is recovering from acute pancreatitis usually has elevated lipase levels for about 10 days after the onset of symptoms. This makes lipase a valuable test in monitoring the client's pancreatic function because serum amylase levels usually return to normal 3 days after the onset of symptoms. Option C is the only option that contains a value just below the upper limit of normal.

A client who has had fecal occult blood testing tells the nurse that the test was negative for colon cancer and wishes to cancel a colonoscopy scheduled for the next day. Which is the nurse's best response? a. "I will call and cancel the test for tomorrow." b. "You need two negative fecal occult blood tests." c. "This does not rule out the possibility of colon cancer." d. "You should wait at least a week to have the colonoscopy."

C A negative result does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed, so the entire colon can be visualized and a tissue sample taken for biopsy. The client need not wait a week before the colonoscopy. Two negative fecal occult blood tests do not rule out the presence of colorectal cancer (CRC).

The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the highest priority? a. Skin integrity b. Blood pressure c. Heart rate and rhythm d. Abdominal percussion

C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Abdominal percussion is an important part of physical assessment but has lower priority for this client than heart rate and rhythm.

The nurse is caring for a client who just had colon resection surgery with a new colostomy. Which teaching objective does the nurse include in the client's plan of care? a. Understanding colostomy care and lifestyle implications b. Learning how to change the appliance independently c. Demonstrating the correct way to change the appliance by discharge d. Not being afraid to handle the ostomy appliance tomorrow

C Client learning goals must be measurable and objective with a time frame, so the nurse can determine whether they have been met. When the goal is to have the client demonstrate a particular skill, the nurse can easily determine whether the goal was met. The specific time frame of "by discharge" is easily measurable also. The other goals are all subjective and cannot be measured objectively. The first two options do not have time frames. "Tomorrow" is a vague time frame.

The nurse is preparing a client with diverticulitis for discharge from the hospital. Which statement by the client indicates that additional teaching is needed? a. "I will ride my bike or take a long walk at least three times a week." b. "I will try to include at least 25 g of fiber in my diet every day." c. "I will take a senna laxative at bedtime to avoid becoming constipated." d. "I will use my legs rather than my back muscles when I lift heavy objects."

C Laxatives are not recommended for clients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining.

The nurse is caring for an older client with gastroenteritis. Which order does the nurse consult with the health care provider about? a. IV 0.45% NS at 50 mL/hr b. Clear liquids as tolerated c. Diphenoxylate hydrochloride/atropine sulfate (Lomotil) orally, after each loose stool d. Acetaminophen (Tylenol), 325-650 mg orally every 4 hr PRN pain

C Lomotil can cause drowsiness and can increase the older client's risk for falls. The nurse should consult with the provider to see if this medication is really necessary and, if an antidiarrheal medication is warranted, what other options might be available. The other orders are appropriate, although the nurse would have to monitor the client's total 24-hour Tylenol dosage to ensure that the client did not receive more than 4000 mg/24 hr.

38. The nurse identifies a nursing diagnosis of acute pain related to edema and surgical incision for a patient who has had a herniorrhaphy performed for an incarcerated inguinal hernia. An appropriate nursing intervention for this problem is to a. administer stool softeners as ordered. b. provide warm sitz baths several times a day. c. apply a scrotal support with application of ice. d. apply moist heat to the abdomen.

C Rationale: Because swelling is likely to affect the scrotum, a scrotal support and ice are used to reduce edema. Stool softeners will not decrease pain or swelling. Sitz baths or moist heat application will not reduce swelling or edema in the scrotal area. Cognitive Level: Application Text Reference: p. 1078 Nursing Process: Implementation NCLEX: Physiological Integrity

32. A patient returns from surgery following an abdominal-perineal resection with a sigmoid colostomy and abdominal and perineal incisions. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The perineal incision is partially closed and has two drains attached to Jackson-Pratt suction. On the first postoperative day, the nurse gives the highest priority to a. teaching about a low-residue diet. b. monitoring drainage from the stoma. c. assessing the perineal drainage and incision. d. encouraging acceptance of the colostomy site.

C Rationale: Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period. Cognitive Level: Application Text Reference: p. 1068 Nursing Process: Planning NCLEX: Physiological Integrity

31. Before undergoing a colon resection for cancer of the colon, a patient has an elevated carcinoembryonic antigen (CEA) test. The nurse explains that the test is used to a. identify the extent of cancer spread or metastasis. b. confirm the diagnosis of colon cancer. c. monitor the tumor status after surgery. d. determine the need for postoperative chemotherapy.

C Rationale: CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on other factors than CEA. Cognitive Level: Comprehension Text Reference: p. 1066 Nursing Process: Implementation NCLEX: Physiological Integrity

23. A 26-year-old patient is diagnosed with Crohn's disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months. The nurse will plan to teach the patient about a. activity restrictions. b. fluid restriction. c. oral corticosteroids. d. enteral feedings.

C Rationale: Corticosteroids are used to achieve remission in IBD, and systemic corticosteroids will be used in Crohn's disease to affect the small intestine. Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings. Cognitive Level: Application Text Reference: p. 1054 Nursing Process: Planning NCLEX: Physiological Integrity

34. A patient has a newly formed ileostomy for treatment of ulcerative colitis. In teaching the patient about the care of the ileostomy, the nurse informs the patient about the need to a. restrict fluid intake to prevent constant liquid drainage from the stoma. b. change the pouch every day to prevent leakage of contents onto the skin. c. use care when eating high-fiber foods to avoid obstruction of the ileum. d. irrigate the ileostomy daily to avoid having to wear a drainage appliance.

C Rationale: High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible. Cognitive Level: Application Text Reference: p. 1073 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

45. The RN and nursing assistant (NA) are caring for a patient with a paralytic ileus. Which of these nursing activities is appropriate for the nurse to delegate to the NA? a. Irrigation of the NG tube with saline b. Retaping the NG tube c. Applying petroleum jelly to the lips d. Auscultation for bowel sounds

C Rationale: NA education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN. Cognitive Level: Comprehension Text Reference: p. 1062 Nursing Process: Implementation NCLEX: Physiological Integrity

9. Following an exploratory laparotomy and bowel resection, a patient has an NG tube to suction but complains of nausea and stomach distention. The nurse irrigates the tube PRN as ordered, but the irrigating fluid does not return. The first action by the nurse should be to a. notify the patient's health care provider. b. auscultate for bowel sounds. c. reposition the tube and check for placement. d. remove the tube and replace it with a new one.

C Rationale: Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider. Information about the presence of absence of bowel tones will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient. Cognitive Level: Application Text Reference: p. 1045 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment

46. When performing an admission assessment for a patient with abdominal pain, the nurse palpates the left lower quadrant and the patient complains of right lower quadrant pain. The nurse will document this as a. McBurney's point. b. rebound pain. c. Rovsing's sign. d. Cullen's sign.

C Rationale: Rovsing's sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. McBurney's point, rebound pain, and Cullen's sign are used to describe other aspects of the abdominal assessment. Cognitive Level: Application Text Reference: pp. 1047-1049 Nursing Process: Assessment NCLEX: Physiological Integrity

13. The nurse identifies the collaborative problem of potential complication: hypovolemic shock related to loss of circulatory volume for a patient with bacterial peritonitis resulting from a ruptured appendix. The nurse recognizes that the major loss of circulating fluid volume occurs as a result of a. prolonged nasogastric (NG) suctioning. b. increased production of stress hormones. c. extracellular fluid shift into the peritoneal cavity. d. loss of purulent drainage into the peritoneal cavity.

C Rationale: The inflammatory process causes the shift of fluids into the peritoneal space. Patients with NG suctioning receive IV fluids to compensate for fluid loss. Stress hormone production causes retention of fluids. Purulent drainage is not usually a significant source of fluid loss. Cognitive Level: Application Text Reference: p. 1049 Nursing Process: Diagnosis NCLEX: Physiological Integrity

4. A 67-year-old patient tells the nurse, "I have problems with constipation now that I am older, so I use a suppository every morning." The most appropriate nursing action at this time is to a. encourage the patient to drink at least 3000 ml of fluid a day. b. inform the patient that a daily bowel movement is not necessary. c. perform a focused nursing assessment to identify risk factors for constipation. d. suggest that the patient increase dietary intake of foods that are high in fiber.

C Rationale: The nurse's initial action should be further assessment of the patient for risk factors for constipation and for usual bowel pattern. The other actions may be appropriate but will be based on the assessment. Cognitive Level: Application Text Reference: pp. 1042-1043 Nursing Process: Implementation NCLEX: Physiological Integrity

42. After being treated for a respiratory tract infection with a 10-day course of antibiotics, a 69-year-old patient calls the clinic and tells the nurse about developing frequent, watery diarrhea. The nurse anticipates that the patient will need to a. prepare for colonoscopy by taking laxatives. b. have blood drawn for blood cultures. c. bring a stool specimen in to be tested for C. difficile. d. schedule a barium enema to check for inflammation.

C Rationale: The patient's age and history of antibiotic use suggest a C. difficile infection. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema. Cognitive Level: Application Text Reference: pp. 1036-1037 Nursing Process: Planning NCLEX: Physiological Integrity

19. Surgery is recommended by the health care provider for a patient with severe ulcerative colitis. The patient asks the nurse for clarification about the various procedures and the associated advantages and disadvantages. In responding to the patient's concerns, the nurse explains that a. surgery for ulcerative colitis involves the formation of a temporary ileostomy to divert fecal contents until the large bowel heals. b. in a total proctocolectomy with a continent ileostomy, a pouch is created that holds bowel contents and is emptied once a day with the use of a catheter. c. a total colectomy and ileal reservoir provide the most normal elimination function, but this surgery consists of two procedures, requiring a temporary ileostomy for 8 to 12 weeks. d. any proposed surgery for treatment of ulcerative colitis should be given serious consideration because the disease often recurs in previously unaffected parts of the bowel.

C Rationale: The total colectomy and ileal reservoir enable the patient to pass stool rectally but require two procedures 8 to 12 weeks apart. Although a temporary ileostomy may be needed, the large bowel is removed rather than being allowed to heal. The pouch formed during total proctocolectomy with continent ileostomy is drained more often than once daily. Surgical treatment for ulcerative colitis is curative because the colon is removed. Cognitive Level: Application Text Reference: p. 1055 Nursing Process: Implementation NCLEX: Physiological Integrity

18. The nurse identifies a nursing diagnosis of impaired skin integrity related to having 15 to 20 daily episodes of diarrhea for a patient with ulcerative colitis. The nurse recognizes that teaching regarding perianal care has been effective when the patient a. takes a sitz bath for 40 minutes following each stool. b. asks for antidiarrheal medication after each diarrhea stool. c. uses witch hazel compresses to provide relief from anal irritation. d. cleans the perianal area with soap and water after each stool.

C Rationale: Witch hazel compresses are suggested to reduce anal irritation and discomfort. Sitz baths may be helpful but should be limited to 15 or 20 minutes. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with water after each stool. Cognitive Level: Application Text Reference: p. 1059 Nursing Process: Evaluation NCLEX: Physiological Integrity

A client is brought to the emergency department with an abrupt onset of vomiting, abdominal cramping, and diarrhea 2 hours after eating food at a picnic. Which infectious microorganism does the nurse suspect as the probable cause? a. Salmonella b. Giardia lamblia c. Staphylococcus aureus d. Clostridium botulinum

C Staphylococcus can be found in meat and dairy products and can be transmitted to people. Food poisoning occurs, especially if foods are left unrefrigerated over a period of time. Symptoms of Staphylococcus food poisoning include sudden onset of vomiting, abdominal cramping, and diarrhea within 2 to 4 hours. The client's symptoms are not consistent with infection by the other microorganisms.

The nurse is preparing to begin teaching the client about how to care for a new ileostomy. Which consideration is the highest priority for the nurse when planning teaching for this client? a. Informing the client about what to expect with basic ostomy care b. Starting the teaching after the client has received pain medication c. Starting the teaching when the client is ready to look at the stoma d. Making sure that all needed supplies are ready at the client's bedside

C The nurse should wait until the client is ready to look at the ostomy and stoma before initiating teaching about ostomy care. The nurse should monitor clues from the client and encourage him or her to start taking an active role in management. Effective learning will occur only when the learner is ready. The other considerations are of lower priority for the client and nurse.

The nurse is caring for a teenage girl with a new ileostomy. She tells the nurse tearfully that she cannot go to the prom with an ostomy. Which is the nurse's best response? a. "You should get your prom dress one size larger to hide the ostomy appliance." b. "You should avoid broccoli and carbonated drinks so that the pouch won't fill with air under your dress." c. "Let's talk to the enterostomal therapist (ET) about options for ostomy supplies and dress styles so that you can look beautiful for the prom." d. "You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable."

C The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible.

The nurse is performing a physical assessment of a client with a new diagnosis of colorectal cancer. The nurse notes the presence of visible peristaltic waves and, on auscultation, hears high-pitched bowel sounds. Which conclusion does the nurse draw from these findings? a. The tumor has metastasized to the liver and biliary tract. b. The tumor has caused an intussusception of the intestine. c. The growing tumor has caused a partial bowel obstruction. d. The client has developed toxic megacolon from the growing tumor.

C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. Assessment findings do not indicate metastasis to the liver, intussusception of the intestine, or toxic megacolon.

Following bowel resection, a patient has a nasogastric (NG) tube to suction, but complains of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority action by the nurse? A. Notify the physician. B. Auscultate for bowel sounds. C. Reposition the tube and check for placement. D. Remove the tube and replace it with a new one.

C The tube may be resting against the stomach wall. The first action by the nurse (since this is intestinal surgery and not gastric surgery) is to reposition the tube and check it again for placement. The physician does not need to be notified unless the tube function cannot be restored by the nurse. The patient does not have bowel sounds, which is why the NG tube is in place. The NG tube would not be removed and replaced unless it was no longer in the stomach or the obstruction of the tube could not be relieved.

A 53 y.o. patient has undergone a partial gastrectomy for adenocarcinoma of the stomach. An NG tube is in place and is connected to low continuous suction. During the immediate postoperative period, you expect the gastric secretions to be which color? a Brown. b Clear. c Red. d Yellow.

C Coffee-ground emesis occurs when there is upper GI bleeding that has undergone gastric digestion. For blood to appear as coffee-ground emesis, it would have to be digested for approximately 2 hours.

A 24-year-old athlete is admitted to the trauma unit following a motor-vehicle collision. The client is comatose and has developed ascites as a result of the accident. You are explaining the client's condition to his parents. In your education, what do you indicate is the primary function of the small intestine? a) Digest proteins b) Digest fats c) Absorb nutrients d) Absorb water

C) Absorb nutrients The primary function of the small intestine is to absorb nutrients from the chyme.

A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To which of the following diagnoses does the nurse attribute these findings? A) Malnutrition B) Osteomyelitis C) Alcohol abuse D) Diabetes mellitus

C) Alcohol Abuse The patient with alcohol abuse could develop pancreatitis as a complication, which would increase the serum amylase (normal 30-122 U/L) and serum lipase (normal 31-186 U/L) levels as shown.

A longitudinal tear or ulceration in the lining of the anal canal is termed a (an) a) anorectal abscess. b) anal fistula. c) anal fissure. d) hemorrhoid.

C) Anal fissure Fissures are usually caused by the trauma of passing a large, firm stool or from persistent tightening of the anal canal secondary to stress or anxiety (leading to constipation). An anorectal abscess is an infection in the pararectal spaces. An anal fistula is a tiny, tubular, fibrous tract that extends into the anal canal from an opening located beside the anus. A hemorrhoid is a dilated portion of vein in the anal canal.

A longitudinal tear or ulceration in the lining of the anal canal is termed a (an) a) hemorrhoid. b) anorectal abscess. c) anal fissure. d) anal fistula.

C) Anal fissure Fissures are usually caused by the trauma of passing a large, firm stool or from persistent tightening of the anal canal secondary to stress or anxiety (leading to constipation). An anorectal abscess is an infection in the pararectal spaces. An anal fistula is a tiny, tubular, fibrous tract that extends into the anal canal from an opening located beside the anus. A hemorrhoid is a dilated portion of vein in the anal canal.

The nurse is preparing to measure the client's abdominal girth as part of the physical examination. At which location would the nurse most likely measure? a) At the lower border of the liver b) In the right upper quadrant c) At the umbilicus d) Just below the last rib

C) At the umbilicus Measurement of abdominal girth is done at the widest point, which is usually the umbilicus. The right upper quadrant, lower border of the liver, or just below the last rib would be inappropriate sites for abdominal girth measurement.

A client is prescribed tetracycline to treat peptic ulcer disease. Which of the following instructions would the nurse give the client? a) "Take the medication with milk." b) "Do not drive when taking this medication." c) "Be sure to wear sunscreen while taking this medicine." d) "Expect a metallic taste when taking this medicine, which is normal."

C) Be sure to wear sunscreen while taking this medicine Tetracycline may cause a photosensitivity reaction in clients. The nurse should caution the client to use sunscreen when taking this drug. Dairy products can reduce the effectiveness of tetracycline, so the nurse should not advise him or her to take the medication with milk. A metallic taste accompanies administration of metronidazole (Flagyl). Administration of tetracycline does not necessitate driving restrictions.

A nurse is caring for a client who had gastric bypass surgery 2 days ago. Which assessment finding requires immediate intervention? a) The client states he has been passing gas. b) The client states he is nauseated. c) The client's right lower leg is red and swollen. d) The client complains of pain at the surgical site.

C) Client's right lower leg is red and swollen A red, swollen extremity is a possible sign of a thromboembolism, a common complication after gastric surgery because of the fact that the clients are obese and tend to ambulate less than other surgical clients. The nurse should inform the physician of the finding. Pain at the surgical site should be investigated, but the red, swollen leg is a higher priority. It isn't unusual for a client to be nauseated after gastric bypass surgery. The nurse should follow up with the finding, but only after she has notified the physician about the possible thromboembolism. Passing gas is normal and a sign that the client's intestinal system is beginning to mobilize.

A client is scheduled for an esophagogastroduodenoscopy (EGD) to detect lesions in the gastrointestinal tract. The nurse would observe for which of the following while assessing the client during the procedure? a) Signs of perforation b) Gag reflex c) Client's tolerance for pain and discomfort d) Client's ability to retain the barium

C) Client's tolerance for pain and discomfort The nurse has to assess the client's tolerance for pain and discomfort during the procedure. The nurse should assess the signs of perforation and the gag reflex after the procedure of EGD and not during the procedure. Assessing the client's level for retaining barium is important for a diagnostic test that involves the use of barium. EGD does not involve the use of barium.

A client is scheduled for several diagnostic tests to evaluate her gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when she identifies which test as not requiring the use of a contrast medium? a) Computer tomography b) Small bowel series c) Colonoscopy d) Upper GI series

C) Colonoscopy A colonoscopy is a direct visual examination of the entire large intestine. It does not involve the use of a contrast agent. Contrast medium may be used with a small bowel series, computed tomography, and upper GI series.

A client with a gastrojejunostomy is beginning to take solid food. Which finding would lead the nurse to suspect that the client is experiencing dumping syndrome? a) Slowed heart beat b) Hyperglycemia c) Diarrhea d) Dry skin

C) Diarrhea Clients with a gastrojejunostomy are at risk for developing the dumping syndrome when they begin to take solid food. This syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramps, and diarrhea, which result from the rapid emptying (dumping) of large amounts of hypertonic chyme (a liquid mass of partly digested food) into the jejunum. This concentrated solution in the gut draws fluid from the circulating blood into the intestine, causing hypovolemia. The drop in blood pressure can produce syncope. As the syndrome progresses, the sudden appearance of carbohydrates in the jejunum stimulates the pancreas to secrete excessive amounts of insulin, which in turn causes hypoglycemia.

A client is scheduled for magnetic resonance imaging (MRI). During the client teaching, the nurse will discuss which of the following? a) "The examination will take only 15 minutes." b) "You must be NPO for the day before the examination." c) "Do you experience any claustrophobia?" d) "You must remove all jewelry but can wear your wedding ring."

C) Do you experience any claustrophobia? MRI is a noninvasive technique that uses magnetic fields and radio waves to produce images of the area being studied. Clients must be NPO for 6 to 8 hours before the study and remove all jewelry and other metals. The examination takes 60 to 90 minutes and can induce feelings of claustrophobia, because the scanner is close fitting.

A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find? a) Decreased white blood cell count b) Decreased liver enzyme levels c) Elevated urine amylase levels d) Increased serum calcium levels

C) Elevated urine amylase levels Elevated serum and urine amylase, lipase, and liver enzyme levels accompany significant pancreatitis. If the common bile duct is obstructed, the bilirubin level is above normal. Blood glucose levels and white blood cell counts can be elevated. Serum electrolyte levels (calcium, potassium, and magnesium) are low.

The nurse determines that a patient has experienced the beneficial effects of medication therapy with famotidine (Pepcid) when which of the following symptoms is relieved? A) Nausea B) Belching C) Epigastric pain D) Difficulty swallowing

C) Epigastric Pain Famotidine is an H2-receptor antagonist that inhibits parietal cell output of HCl acid and minimizes damage to gastric mucosa related to hyperacidity, thus relieving epigastric pain.

Which of the following would be the least important assessment in a patient diagnosed with ascites? a) Measurement of abdominal girth b) Palpation of abdomen for a fluid shift c) Foul-smelling breath d) Weight

C) Foul smelling breath Foul-smelling breath would not be considered an important assessment for this patient. Measurement of abdominal girth, weight, and palpation of the abdomen for a fluid shift are all important assessment parameters for the patient diagnosed with ascites.

Which of the following surgical procedures for obesity utilizes a prosthetic device to restrict oral intake? a) Vertical-banded gastroplasty b) Roux-en-Y gastric bypass c) Gastric banding d) Biliopancreatic diversion with duodenal switch

C) Gastric banding In gastric banding, a prosthetic device is used to restrict oral intake by creating a small pouch of 10 to 15 milliliters that empties through the narrow outlet into the remainder of the stomach. Roux-en-Y gastric bypass uses a horizontal row of staples across the fundus of the stomach to create a pouch with a capacity of 20 to 30 mL. Vertical-banded gastroplasty involves placement of a vertical row of staples along the lesser curvature of the stomach, creating a new, small gastric pouch. Biliopancreatic diversion with duodenal switch combines gastric restriction with intestinal malabsorption.

The nurse is caring for a man who has experienced a spinal cord injury. Throughout his recovery, the client expects to gain control of his bowels. The nurse's best response to this client would be which of the following? a) "Over time, the nerve fibers will regrow new tracts, and you can have bowel movements again." b) "Wearing an undergarment will become more comfortable over time." c) "Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact." d) "It is not going to happen. Your nerve cells are too damaged."

C) Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact The act of defecation is a spinal reflex involving the parasympathetic nerve fibers. Normally, the external anal sphincter is maintained in a state of tonic contraction. With a spinal cord injury, the client no longer has this nervous system control and is often incontinent.

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? a) Hepatitis B is transmitted primarily by the oral-fecal route. b) Hepatitis A is frequently spread by sexual contact. c) Hepatitis C increases a person's risk for liver cancer. d) Infection with hepatitis G is similar to hepatitis A.

C) Hep C increases a person's risk for liver cancer Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.

Which of the following is a protrusion of the intestine through a weakened area in the abdominal wall? a) Tumor b) Adhesion c) Hernia d) Volvulus

C) Hernia A hernia is a protrusion of intestine through a weakened area in the abdominal muscle or wall. A tumor that extends into the intestinal lumen, or a tumor outside the intestine causes pressure on the wall of the intestine. Volvulus occurs when the bowel twists and turns on itself. An adhesion occurs when loops of intestine become adherent to areas that heal slowly or scar after abdominal surgery.

When reviewing the history of a client with pancreatic cancer, the nurse would identify which of the following as a possible risk factor? a) Ingestion of caffeinated coffee b) Ingestion of a low-fat diet c) History of pancreatitis d) One-time exposure to petrochemicals

C) History of pancreatitis Pancreatitis is associated with the development of pancreatic cancer. Other factors that correlate with pancreatic cancer include diabetes mellitus, a high-fat diet, and chronic exposure to carcinogenic substances (i.e., petrochemicals). Although data are inconclusive, a relationship may exist between cigarette smoking and high coffee consumption (especially decaffeinated coffee) and the development of pancreatic carcinoma.

A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment? a) "I'll lie down immediately after a meal." b) "I'll eat three large meals every day without any food restrictions." c) "I'll eat frequent, small, bland meals that are high in fiber." d) "I'll gradually increase the amount of heavy lifting I do."

C) I'll eat frequent, small, bland meals that are high in fiber In hiatal hernia, the upper portion of the stomach protrudes into the chest when intra-abdominal pressure increases. To minimize intra-abdominal pressure and decrease gastric reflux, the client should eat frequent, small, bland meals that can pass easily through the esophagus. Meals should be high in fiber to prevent constipation and minimize straining on defecation (which may increase intra-abdominal pressure from the Valsalva maneuver). Eating three large meals daily would increase intra-abdominal pressure, possibly worsening the hiatal hernia. The client should avoid spicy foods, alcohol, and tobacco because they increase gastric acidity and promote gastric reflux. To minimize intra-abdominal pressure, the client shouldn't recline after meals, lift heavy objects, or bend.

Crohn's disease is a condition of malabsorption caused by which of the following pathophysiological processes? a) Gastric resection b) Infectious disease c) Inflammation of all layers of intestinal mucosa d) Disaccharidase deficiency

C) Inflammation of all layers of intestinal mucosa Crohn's disease is also known as regional enteritis and can occur anywhere along the GI tract, but most commonly at the distal ileum and in the colon. Infectious disease causes problems such as small bowel bacterial overgrowth leading to malabsorption. Disaccharidase deficiency leads to lactose intolerance. Postoperative malabsorption occurs after gastric or intestinal resection.

The client is receiving a 25% dextrose solution of parenteral nutrition. The infusion machine is beeping, and the nurse determines the intravenous (IV) bag is empty. The nurse finds there is no available bag to administer. It is most important for the nurse to a) Request a new bag from the pharmacy department. b) Flush the line with 10 mL of sterile saline. c) Infuse a solution containing 10% dextrose and water. d) Catch up with the next bag when it arrives.

C) Infuse a solution containing 10% dextrose and water If the parenteral nutrition solution runs out, a solution of 10% dextrose and water is infused to prevent hypoglycemia. The nurse would then order the next parenteral nutrition bag from the pharmacy. Flushing a peripherally inserted catheter is usually prescribed every 8 hours or per hospital established protocols. It is not the most important activity at this moment. The infusion rate should not be increased to compensate for fluids that were not infused, because hyperglycemia and hyperosmolar diuresis could occur.

When assisting with the plan of care for a client receiving tube feedings, which of the following would the nurse include to reduce the client's risk for aspiration? a) Administering 15 to 30 mL of water every 4 hours. b) Aspirating for residual contents every 4 to 8 hours. c) Keeping the client in a semi-Fowler's position at all times. d) Giving the feedings at room temperature.

C) Keeping the client in a semi Fowler's position at all times With continuous tube feedings, the nurse needs to keep the client in a semi-Fowler's position at all times to reduce regurgitation and the risk for aspiration. Aspirating for residual contents helps to ensure adequate nutrition and prevent overfeeding. Administering 15 to 30 mL of water every 4 hours helps to maintain tube patency. Giving the feedings at room temperature reduces the risk for diarrhea.

While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure? a) Spleen b) Appendix c) Liver d) Sigmoid colon

C) Liver The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of the colon, portions of the ascending and transverse colon, and a portion of the right kidney. The sigmoid colon is located in the left lower quadrant; the appendix, in the right lower quadrant; and the spleen, in the left upper quadrant.

When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are a) absent. b) hypoactive. c) normal. d) sluggish.

C) Normal Normal bowel sounds are heard every 5 to 20 seconds. Hypoactive bowel sound is the description given to auscultation of one to two bowel sounds in 2 minutes. Sluggish is not a term a nurse would use to accurately describe bowel sounds. The nurse records that bowel sounds are absent when no sound is heard in 3 to 5 minutes.

The nurse asks a client to point to where she feels pain. The client asks why this is important. The nurse's best response would be which of the following? a) "This determines the pain medication to be ordered." b) "If the doctor massages over the exact painful area, the pain will disappear." c) "Often the area of pain is referred from another area." d) "The area may determine the severity of the pain."

C) Often the area of pain is referred from another area Pain can be a major symptom of disease. The location and distribution of pain can be referred from a different area. If a client points to an area of pain and has other symptoms associated with a certain disease, this is valuable information for treatment.

Which of the following represents the medication classification of a proton (gastric acid) pump inhibitor? a) Famotidine (Pepcid) b) Metronidazole (Flagyl) c) Omeprazole (Prilosec) d) Sucralfate (Carafate)

C) Omeprazole Omeprazole decreases gastric acid by slowing the hydrogen-potassium adenosine triphosphatase pump on the surface of the parietal cells. Sucralfate is a cytoprotective drug. Famotidine is a histamine-2 receptor antagonist. Metronidazole is an antibiotic, specifically an amebicide.

The nurse recognizes that the patient diagnosed with a duodenal ulcer will likely experience a) weight loss. b) vomiting. c) pain 2 to 3 hours after a meal. d) hemorrhage.

C) Pain 2 to 3 hours after a meal The patient with a gastric ulcer often awakens between 1 to 2 with pain, and ingestion of food brings relief. Vomiting is uncommon in the patient with duodenal ulcer. Hemorrhage is less likely in the patient with duodenal ulcer than the patient with gastric ulcer. The patient with a duodenal ulcer may experience weight gain.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure? a) Encouraging frequent visits from family and friends b) Administering frequent oral feedings c) Positioning the client on the side with the knees flexed d) Administering an analgesic once per shift, as ordered, to prevent drug addiction

C) Postitioning the client on the side with the knees flexed The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.

A client presents with complaints of blood in her stools. Upon inspection, the nurse notes streaks of bright red blood visible on the outer surface of formed stool. Which of the following will the nurse further investigate with this client? a) Ingestion of cherry soda b) Ingestion of cocoa c) Presence or history of hemorrhoids d) Recent barium studies

C) Presence or history of hemorrhoids Stool is normally light to dark brown. Blood in the stool can present in various ways and must be investigated. Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool or blood is noted on toilet tissue.

The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also complains of unpleasant tastes and odors. Which of the following measures should be included in the client's plan of care? a) Ensure adequate hydration with additional water. b) Keep the feeding formula refrigerated. c) Provide frequent mouth care. d) Flush the tube with water before adding the feedings.

C) Provide frequent mouth care Frequent mouth care helps to relieve the discomfort from dryness and unpleasant odors and tastes. It can be done with the help of ice chips and analgesic throat lozenges, gargles, or sprays. Adequate hydration is essential. If urine output is less than less than 500 mL/day, formula and additional water can be given as ordered. Keeping the feeding formula refrigerated and unopened until it is ready for use and flushing the tube with water before adding feedings are measures to protect the client from infections.

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? a) Ascites and orthopnea b) Gynecomastia and testicular atrophy c) Purpura and petechiae d) Dyspnea and fatigue

C) Purpura and petechiae A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

A group of students are studying for an examination on the gastrointestinal (GI) system and are reviewing the structures of the esophagus and stomach. The students demonstrate understanding of the material when they identify which of the following as the opening between the stomach and duodenum? a) Hypoharyngeal sphincter b) Cardiac sphincter c) Pyloric sphincter d) Ileocecal valve

C) Pyloric Sphincter The pyloric sphincter is the opening between the stomach and duodenum. The cardiac sphincter is the opening between the esophagus and the stomach. The hypopharyngeal sphincter or upper esophageal sphincter prevents food or fluids from re-entering the pharynx. The ileocecal valve is located at the distal end of the small intestine and regulates flow of intestinal contents into the large intestine.

Following administration of a dose of metoclopramide (Reglan) to the patient, the nurse determines that the medication has been effective when which of the following is noted? A) Decreased blood pressure B) Absence of muscle tremors C) Relief of nausea and vomiting D) No further episodes of diarrhea

C) Relief of nausea and vomiting Metoclopramide is classified as a prokinetic and antiemetic medication. If it is effective, the patient's nausea and vomiting should resolve.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client? a) Maintaining adequate nutritional status b) Preventing fluid volume overload c) Relieving abdominal pain d) Teaching about the disease and its treatment

C) Relieving abdominal pain The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Therefore, relieving abdominal pain is the nurse's primary goal. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse can't help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

The nurse is assessing a client for constipation. Which of the following is the first review that the nurse should conduct in order to identify the cause of constipation? Choose the correct option. a) Review the client's current medications b) Review the client's alcohol consumption c) Review the client's usual pattern of elimination d) Review the client's activity levels

C) Review the client's usual pattern of elimination Constipation has many possible reasons; assessing the client's usual pattern of elimination is the first step in identifying the cause.

A nurse is teaching a client with malabsorption syndrome about the disorder and its treatment. The client asks which part of the GI tract absorbs food. The nurse tells the client that products of digestion are absorbed mainly in the: a) rectum. b) stomach. c) small intestine. d) large intestine.

C) Small intestine The small intestine absorbs products of digestion, completes food digestion, and secretes hormones that help control the secretion of bile, pancreatic juice, and intestinal secretions. The stomach stores, mixes, and liquefies the food bolus into chyme and controls food passage into the duodenum; it doesn't absorb products of digestion. Although the large intestine completes the absorption of water, chloride, and sodium, it plays no part in absorbing food. The rectum is the portion of the large intestine that forms and expels feces from the body; its functions don't include absorption.

After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? a) Large intestine b) Ileum c) Stomach d) Liver

C) Stomach The upper gastrointestinal (GI) tract begins at the mouth and ends at the jejunum. Therefore, the stomach would be a component of the upper GI tract. The lower GI tract begins at the ileum and ends at the anus. The liver is considered an accessory structure.

A client has noticed increased incidence of constipation since he broke his ankle and cannot complete his daily three-mile walk. As his home care nurse, you complete your assessment and discuss the potential causes. During your client education session, what do you explain as the mechanical cause of his constipation? a) No known cause b) Ingesting excessive fiber c) Stool remaining in the large intestine too long. d) Drinking excessive water

C) Stool remaining in the large intestine too long Whenever stool remains stationary in the large intestine, moisture continues to be absorbed from the residue. Consequently, retention of stool, for any number of reasons, causes stool to become dry and hard.

A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient? a) Instruct the patient to keep a record of food intake b) Instruct the patient to avoid prune or apple juice c) Suggest fluid intake of at least 2 L per day d) Assist the patient regarding the correct diet or to minimize food intake

C) Suggest fluid intake of at least 2 L per day For constipation the nurse should suggest a fluid intake of at least 2L per day. The nurse should also offer prune or apple juice because they promote elimination. The nurse should encourage the patient to eat regular meals. Dieting or fasting can decrease stool volume and slow elimination. The nurse should instruct the patient to keep a record of food intake in case of diarrhea because this helps identify specific foods that irritate the GI tract.

A client with hepatitis who has not responded to medical treatment is scheduled for a liver transplant. Which of the following most likely would be ordered? a) Chenodiol b) Ursodiol c) Tacrolimus d) Interferon alfa-2b, recombinant

C) Tacrolimus In preparation for a liver transplant, a client receives immunosuppressants to reduce the risk for organ rejection. Tacrolimus or cyclosporine are two immunosuppresants that may be used. Chenodiol and ursodiol are agents used to dissolve gall stones. Recombinant interferon alfa-2b is used to treat chronic hepatitis B, C, and D to force the virus into remission.

An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make? a) Administer a tap-water enema weekly. b) Take a mild laxative such as magnesium citrate when necessary. c) Take a stool softener such as docusate sodium (Colace) daily. d) Administer a phospho-soda (Fleet) enema when necessary.

C) Take a stool softener such as docusate sodium (Colace) daily Stool softeners taken daily promote absorption of liquid into the stool, creating a softer mass. They may be taken on a daily basis without developing a dependence. Dependence is an adverse effect of daily laxative use. Enemas used daily or on a frequent basis can also lead to dependence of the bowel on an external source of stimulation.

A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care? a) Prepare the client for a gastrostomy tube placement. b) Administer morphine (Duramorph PF) routinely, as ordered. c) Test all stools for occult blood. d) Administer topical ointment to the rectal area to decrease bleeding.

C) Test all stools for occult blood Blood in the stools is one of the warning signs of colorectal cancer. The nurse should plan on checking all stools for both frank and occult blood. The blood in the stool is coming from the colon or rectum; administering an ointment wouldn't help decrease the bleeding. Preparing a client for a gastrostomy tube isn't appropriate when diagnosing colorectal cancer. Colorectal cancer is usually painless; administering opioid pain medication isn't needed.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation? a) The client didn't take his morning dose of lactulose (Cephulac). b) The client is relaxed and not in pain. c) The client's hepatic function is decreasing. d) The client is avoiding the nurse.

C) The client's hepatic function is decreasing The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings don't indicate that the client is relaxed or avoiding the nurse.

Which of the following is the best method for determining nasogastric tube placement? a) Placement of external end of tube under water b) Testing of pH of gastric aspirate c) X-ray d) Observation of gastric aspirate

C) X-ray Radiologic identification of tube placement in the stomach is the most reliable method. Gastric fluid may be grassy green, brown, clear, or odorless while an aspirate from the lungs may be off-white or tan. Hence, checking aspirate is not the best method of determining nasogastric tube placement in the stomach. Gastric pH values are typically lower or more acidic than that of the intestinal or respiratory tract, but not always. Placement of external end of tube under water and watching for air bubbles is not a reliable method for determining nasogastric tube placement in the stomach.

an 18 yr old is admitted with an acute onset of right lower quadrant pain. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis A) urinary retention B) gastric hyperacidity C) rebound tenderness D) increased lower bowel motility

C) rebound tenderness is a classic subjective sign of appendicitis

Which clinical manifestations of inflammatory bowel disease are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply)? A. Restricted to rectum B. Strictures are common. C. Bloody, diarrhea stools D. Cramping abdominal pain E. Lesions penetrate intestine.

C, D Clinical manifestations of UC and Crohn's disease include bloody diarrhea, cramping abdominal pain, and nutritional disorders. Intestinal lesions associated with UC are usually restricted to the rectum before moving into the colon. Lesions that penetrate the intestine or cause strictures are characteristic of Crohn's disease

In discussing long term management with the patient with alcoholic cirrhosis, the nurse advises the patient that a. a daily exercise regimen is important to increase the blood flow through the liver b. cirrhosis can be reversed if the patient follows a regimen of proper rest and nutrition c. abstinence from alcohol is the most important factor in improvement of the patient's condition d. the only over the counter analgesic that should be used for minor aches and pains is acetaminophen

C- Abstinence from alcohol is very important in alcoholic cirrhosis and may result in improvement if started when liver damage is reduced by rest and nutrition, most changes in the liver cannot be reversed. Exercise does not promote portal circulation, and very moderate exercise is recommended. Acetaminophen should not be used by the patient with liver disease because it is potentially hepatotoxic.

During the treatment of the patient with bleeding esophageal varices, it is most important that the nurse a. prepare the patient for immediate portal shunting surgery b. perform guaiac testing on all stools to detect occult blood c. maintain the patient's airway and prevent aspiration of blood d. monitor for the cardiac effects of IV vasopressin and nitroglycerin

C- Bleeding esophageal varices are a medical emergency. During an episode of bleeding, management of the airway and prevention of aspiration of blood are critical factors. Occult blood as well as fresh blood from the GI tract would be expected and is not tested. Vasopressin causes vasoconstriction, decreased HR, and decreased coronary blood flow; nitroglycerin is given with the vasopressin to counter these side effects. Portal shunting surgery is performed for esophageal varices but not during an acute hemorrhage

When caring for a patient with autoimmune hepatitis, the nurse recognizes that, unlike viral hepatitis, the patient a. does not manifest hepatomegaly or jaundice b. experiences less liver inflammation and damage c. is treated with corticosteroids or other immunosuppressant agents d. is usually an older adult who has used a wide variety of prescription and over the counter drugs

C- Immunosuppressive agents are indicated i hepatitis associated with immune disorders to decrease liver damage caused by autoantibodies. Autoimmune hepatitis is similar to viral hepatitis in presenting signs and symptoms and may become chronic and lead to cirrhosis.

The nurse provides discharge instructions for a 64-year-old woman with ascites and peripheral edema related to cirrhosis. Which statement, if made by the patient, indicates teaching was effective? A. "It is safe to take acetaminophen up to four times a day for pain." B. "Lactulose (Cephulac) should be taken every day to prevent constipation." C. "Herbs and other spices should be used to season my foods instead of salt." D. "I will eat foods high in potassium while taking spironolactone (Aldactone)."

C. "Herbs and other spices should be used to season my foods instead of salt." A low-sodium diet is indicated for the patient with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices. Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided as these medications may be toxic to the liver. The patient should avoid potentially hepatotoxic over-the-counter drugs (e.g., acetaminophen) because the diseased liver is unable to metabolize these drugs. Spironolactone is a potassium-sparing diuretic. Lactulose results in the acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.

The nurse instructs a 50-year-old woman about cholestyramine to reduce pruritis caused by gallbladder disease. Which statement by the patient to the nurse indicates she understands the instructions? A. "This medication will help me digest fats and fat-soluble vitamins." B. "I will apply the medicated lotion sparingly to the areas where I itch." C. "The medication is a powder and needs to be mixed with milk or juice." D. "I should take this medication on an empty stomach at the same time each day."

C. "The medication is a powder and needs to be mixed with milk or juice." For treatment of pruritus, cholestyramine may provide relief. This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Cholestyramine is in powder form and should be mixed with milk or juice before oral administration.

The nurse is caring for a group of patients. Which patient is at highest risk for pancreatic cancer? A. A 38-year-old Hispanic female who is obese and has hyperinsulinemia B. A 23-year-old who has cystic fibrosis-related pancreatic enzyme insufficiency Incorrect C. A 72-year-old African American male who has smoked cigarettes for 50 years D. A 19-year-old who has a 5-year history of uncontrolled type 1 diabetes mellitus

C. A 72-year-old African American male who has smoked cigarettes for 50 years Risk factors for pancreatic cancer include chronic pancreatitis, diabetes mellitus, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine. African Americans have a higher incidence of pancreatic cancer than whites. The most firmly established environmental risk factor is cigarette smoking. Smokers are two or three times more likely to develop pancreatic cancer as compared with nonsmokers. The risk is related to duration and number of cigarettes smoked.

In a client with diarrhea, which outcome indicates that fluid resuscitation is successful? A. The client passes formed stools at regular intervals B. The client reports a decrease in stool frequency and liquidity C. The client exhibits firm skin turgor D. The client no longer experiences perianal burning.

C. A client with diarrhea has a nursing diagnosis of Deficient fluid volume related to excessive fluid loss in the stool. Expected outcomes include firm skin turgor, moist mucous membranes, and urine output of at least 30 ml/hr. The client also has a nursing diagnosis of diarrhea, with expected outcomes of passage of formed stools at regular intervals and a decrease in stool frequency and liquidity. The client is at risk for impaired skin integrity related to irritation from diarrhea; expected outcomes for this diagnosis include absence of erythema in perianal skin and mucous membranes and absence of perianal tenderness or burning.

Which of the following treatments is used for rectal cancer but not for colon cancer? A. Chemotherapy B. Colonoscopy C. Radiation D. Surgical resection

C. A client with rectal cancer can expect to have radiation therapy in addition to chemotherapy and surgical resection of the tumor. A colonoscopy is performed to diagnose the disease. Radiation therapy isn't usually indicated in colon cancer.

In a client with Crohn's disease, which of the following symptoms should not be a direct result from antibiotic therapy? A. Decrease in bleeding B. Decrease in temperature C. Decrease in body weight D. Decrease in the number of stools

C. A decrease in body weight may occur during therapy due to inadequate dietary intake, but isn't related to antibiotic therapy. Effective antibiotic therapy will be noted by a decrease in temperature, number of stools, and bleeding.

A patient with cholelithiasis needs to have the gallbladder removed. Which patient assessment is a contraindication for a cholecystectomy? A. Low-grade fever of 100° F and dehydration B. Abscess in the right upper quadrant of the abdomen C. Activated partial thromboplastin time (aPTT) of 54 seconds D. Multiple obstructions in the cystic and common bile duct

C. Activated partial thromboplastin time (aPTT) of 54 seconds An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given to eliminate the dehydration; the abscess can be assessed, and the obstructions in the cystic and common bile duct would be relieved with the cholecystectomy.

A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To which diagnosis do you attribute these findings? A. Malnutrition B. Osteomyelitis C. Alcohol abuse D. Diabetes mellitus

C. Alcohol abuse

Medical management of the client with diverticulitis should include which of the following treatments? A. Reduced fluid intake B. Increased fiber in diet C. Administration of antibiotics D. Exercises to increase intra-abdominal pressur

C. Antibiotics are used to reduce the inflammation. The client isn't typically isn't allowed anything orally until the acute episode subsides. Parenteral fluids are given until the client feels better; then it's recommended that the client drink eight 8-ounce glasses of water per day and gradually increase fiber in the diet to improve intestinal motility. During the acute phase, activities that increase intra-abdominal pressure should be avoided to decrease pain and the chance of intestinal obstruction.

What should you do to prevent infection in a patient who undergone liver transplantation? A. Place the patient in droplet isolation. B. Place the patient in a negative-pressure room. C. Avoid fresh flowers in a vase. D. Restrict visitors.

C. Avoid fresh flowers in a vase.

The nurse is preparing a discharge teaching plan for the client who had an umbilical hernia repair. Which of the following would the nurse include in the plan? A. Restricting pain medication B. Maintaining bedrest C. Avoiding coughing D. Irrigating the drain

C. Bedrest is not required following this surgical procedure. The client should take analgesics as needed and as prescribed to control pain. A drain is not used in this surgical procedure, although the client may be instructed in simple dressing changes. Coughing is avoided to prevent disruption of the tissue integrity, which can occur because of the location of this surgical procedure.

A patient with metastatic colorectal cancer is scheduled for chemotherapy and radiation therapy. Patient teaching regarding these therapies should include which explanation? A. Chemotherapy can be used to cure colorectal cancer. B. Irradiation is routinely used as adjuvant therapy after surgery. C. Both chemotherapy and irradiation can be used as palliative treatments. D. The patient should expect few or no side effects from chemotherapeutic agents.

C. Both chemotherapy and irradiation can be used as palliative treatments. Chemotherapy can be used to shrink the tumor before surgery, as an adjuvant therapy after colon resection, and as palliative therapy for nonresectable colorectal cancer. Radiation therapy may be used postoperatively as an adjuvant to surgery and chemotherapy or as a palliative measure for patients with metastatic cancer.

The nurse is monitoring a client for the early signs of dumping syndrome. Which symptom indicates this occurrence? A. Abdominal cramping and pain B. Bradycardia and indigestion C. Sweating and pallor D. Double vision and chest pain

C. Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

A client's ulcerative colitis symptoms have been present for longer than 1 week. The nurse recognizes that the client should be assessed carefully for signs of which of the following complications? A. Heart failure B. DVT C. Hypokalemia D. Hypocalcemia

C. Excessive diarrhea causes significant depletion of the body's stores of sodium and potassium as well as fluid. The client should be closely monitored for hypokalemia and hyponatremia. Ulcerative colitis does not place the client at risk for heart failure, DVT, or hypocalcemia.

Five days after undergoing surgery, a client develops a small-bowel obstruction. A Miller-Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority? A. Imbalanced nutrition: Less than body requirements B. Acute pain C. Deficient fluid volume D. Excess fluid volume

C. Fluid shifts to the site of the bowel obstruction, causing a fluid deficit in the intravascular spaces. If the obstruction isn't resolved immediately, the client may experience an imbalanced nutritional status (less than body requirements); however, deficient fluid volume takes priority. The client may also experience pain, but that nursing diagnosis is also of lower priority than deficient fluid volume.

The nurse has given instructions to the client with an ileostomy about foods to eat to thicken the stool. The nurse determines that the client needs further instructions if the client stated to eat which of the following foods to make the stools less watery? A. Pasta B. Boiled rice C. Bran D. Low-fat cheese

C. Foods that help thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese. Bran is high in dietary fiber and thus will increase output of watery stool by increasing propulsion through the bowel. Ileostomy output is liquid. Addition or elimination of various foods can help thicken or loosen this liquid drainage.

The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer? A. Serum α-fetoprotein level B. Ventilation/perfusion scan C. Hepatic structure ultrasound D. Abdominal girth measurement

C. Hepatic structure ultrasound Correct Hepatic structure ultrasound, CT, and MRI are used to screen and diagnose liver cancer. Serum α-fetoprotein level may be elevated with liver cancer or other liver problems. Ventilation/perfusion scans do not diagnose liver cancer. Abdominal girth measurement would not differentiate between cirrhosis and liver cancer.

The nurse is performing a colostomy irrigation on a client. During the irrigation, a client begins to complain of abdominal cramps. Which of the following is the most appropriate nursing action? A. Notify the physician B. Increase the height of the irrigation C. Stop the irrigation temporarily. D. Medicate with dilaudid and resume the irrigation

C. If cramping occurs during a colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too much pressure. Increasing the height of the irrigation will cause further discomfort. The physician does not need to be notified. Medicating the client for pain is not the most appropriate action (damn).

The patient has nonresectable colorectal cancer. The primary provider has recommended chemotherapy. What is the best explanation of this treatment? A. It gives the patient a sense of hope that something is being done. B. It shrinks the tumor before surgery. C. It provides palliative treatment. D. It prevents metastasis to the liver.

C. It provides palliative treatment. Palliative treatment is done for nonresectable colorectal cancer to shrink the tumor and prevent obstruction.

What should you teach the patient with cirrhosis about nutritional therapy? A. Calorie restriction for weight loss B. Protein restriction C. Low-sodium diet D. High-calcium diet

C. Low-sodium diet Rationale The patient with ascites and edema is on a low-sodium diet. Adequate calories (3000 calories/day) are required. Although there may be some protein restriction for patients immediately after a severe flare of symptoms, it is rarely justified for the long term. Malnutrition is a more serious clinical problem than hepatic encephalopathy. Calcium is not a key concern for patients with cirrhosis. Reference: 1080

Which of the following interventions should be included in the medical management of Crohn's disease? A. Increasing oral intake of fiber B. Administering laxatives C. Using long-term steroid therapy D. Increasing physical activity

C. Management of Crohn's disease may include long-term steroid therapy to reduce the inflammation associated with the deeper layers of the bowel wall. Other management focuses on bowel rest (not increasing oral intake) and reducing diarrhea with medications (not giving laxatives). The pain associated with Crohn's disease may require bed rest, not an increase in physical activity.

Britney, a 20 y.o. student is admitted with acute pancreatitis. Which laboratory findings do you expect to be abnormal for this patient? a Serum creatinine and BUN b Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) c Serum amylase and lipase d Cardiac enzymes

C. Pancreatitis involves activation of pancreatic enzymes, such as amylase and lipase. These levels are elevated in a patient with acute pancreatitis.

Which assessment is most important for a nurse to do for a patient with acute pancreatitis? A. Level of pain B. Blood pressure C. Pulse oximetry D. Temperature

C. Pulse oximetry Rationale Main systemic complications of acute pancreatitis are pulmonary (pleural effusion, atelectasis, and pneumonia), likely due to the passage of exudates containing pancreatic enzymes. Nurses should regularly assess respiratory function. Pain is important to treat, but oxygenation is a priority. Mild fever may be present from the inflammation, but oxygenation is apriority. Reference: 1090, 1092

A client with ulcerative colitis has an order to begin salicylate medication to reduce inflammation. The nurse instructs the client to take the medication: A. 30 minutes before meals B. On an empty stomach C. After meals D. On arising

C. Salicylate compounds act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and to increase fluid intake throughout the day. This medication needs to be taken after meals to reduce GI irritation.

A client has surgery for a perforated appendix with localized peritonis. In which position should the nurse place the client? A) Sims position B) trendelenburg C) semi-fowlers D)dorsal recumbant

C. Semi-fowlers aids in drainage and prevents spread of infection throughout the abodominal cavity.

The patient with cirrhosis asks why he is taking Colace. What is the best explanation? A. Constipation increases the ammonia absorption. B. Colace enhances the retention of potassium. C. Straining can cause bleeding from varices. D. Colace promotes the instrinsic factor utilization.

C. Straining can cause bleeding from varices. Rationale Varices are distended, torturous vessels caused by portal hypertension, and they can be hemorrhoidal, esophageal, or gastric in location. Colace is used to prevent straining at stool, which may cause bleeding of hemorrhoidal varices. Reference: 1083

The patient presents to the emergency department reporting nausea, vomiting, and right upper quadrant pain. What part of the patient's history is most important to further investigate? A. Consumes one or two beers every weekend B. Recently traveled to Canada C. Takes 10 extra-strength Tylenol daily D. Never immunized against hepatitis A

C. Takes 10 extra-strength Tylenol daily

A 30-year old client experiences weight loss, abdominal distention, crampy abdominal pain, and intermittent diarrhea after birth of her 2nd child. Diagnostic tests reveal gluten-induced enteropathy. Which foods must she eliminate from her diet permanently? A. Milk and dairy products B. Protein-containing foods C. Cereal grains (except rice and corn) D. Carbohydrates

C. To manage gluten-induced enteropathy, the client must eliminate gluten, which means avoiding all cereal grains except for rice and corn. In initial disease management, clients eat a high calorie, high-protein diet with mineral and vitamin supplements to help normalize nutritional status.

The patient has elevated levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. What question is most important to ask the patient? A. Do you have intolerance to high fat foods? B. Do you have a history of pancreatitis? C. What medications are you taking? D. Do you smoke?

C. What medications are you taking?

In planning care for the patient with Crohn's disease, you recognize that a major difference between ulcerative colitis and Crohn's disease is that Crohn's disease A. frequently results in toxic megacolon. B. causes fewer nutritional deficiencies than does ulcerative colitis. C. often recurs after surgery, whereas ulcerative colitis is curable with a colectomy. D. is manifested by rectal bleeding and anemia more frequently than is ulcerative colitis.

C. often recurs after surgery, whereas ulcerative colitis is curable with a colectomy. Because there is a high recurrence rate after surgical treatment of Crohn's disease, medications are the preferred treatment.

The nurse is monitoring a client diagnosed with appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begns to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the appropriate nursing intervention? "1. Notify the Physician 2. Administer the prescribed pain medication 3. Call and ask the operating room team to perform the surgery as soon as possible 4. Reposition the client and apply a heating pad on warm setting to the client's abdomen

CORRECT ANSWER: 1" "1. Based on the assessment information the nurse should suspect peritonitis, a complication that is associated with appendicitis, and notify the physician. 2. Administering pain medication is not an appropriate intervention 3. Scheduling surgical time is not within the scope of practice of an RN. 4. Heat should never be applied to the abdomen of a patient suspected of having peritonitis because of the risk of rupture."

The patient with suspected pancreatic cancer is having many diagnostic studies done. Which one can be used to establish the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment? Spiral CT scan A PET/CT scan Incorrect Abdominal ultrasound Cancer-associated antigen 19-9

Cancer-associated antigen 19-9 Correct The cancer-associated antigen 19-9 (CA 19-9) is the tumor marker used for the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment. Although a spiral CT scan may be the initial study done and provides information on metastasis and vascular involvement, this test and the PET/CT scan or abdominal ultrasound do not provide additional information.

A client has vague symptoms that indicate an acute inflammatory bowel disorder (IBD). Which symptom is most indicative of Crohn's disease (CD)?

Chronic diarrhea, abdominal pain, and fever

Which is a correct statement differentiating Crohn's disease (CD) from ulcerative colitis (UC)?

Clients with UC may experience hemorrhage

A nurse is teaching a client about dietary methods to help manage exacerbations ("flare-ups") of diverticulitis. What does the nurse advise the client?

Consume a low fiber diet while your diverticulitis is active. When it resoles, consume a high fiber diet

The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What should the nurse expect to do for this patient? Prevent all oral intake. Control abdominal pain. Provide enteral feedings. Avoid dietary cholesterol.

Control abdominal pain. Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated. NPO status may be needed if the patient will have surgery but will not be used for all patients with cholelithiasis. Enteral feedings should not be needed, and avoiding dietary cholesterol is not used to treat cholelithiasis.

Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? 1.Hepatitis A. 2.Hepatitis B.3.Hepatitis C.4.Hepatitis D

Correct 1 "1.The hepatitis A virus is in the stool of infected people up to two (2) weeks beforesymptoms develop. 2.Hepatitis B virus is spread through contact with infected blood and body fluids.3.Hepatitis C virus is transmitted throughinfected blood and body fluids.4.Hepatitis D virus only causes infection inpeople who are also infected with hepatitis Bor C"

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the appropriate nursing intervention? Saunders Comprehensive Review for the NCLEX-RN Examination 5th ed. 1. Notify the physician 2. Administer the prescribed pain medication 3. Call and ask the operating room team to perform the surgery as soon as possible 4. Reposition the client and apply a heating pad on warm setting to the clien't abdomen

Correct 1 Based on the signs and symptoms presented in the question, the nurse shoudl suspect peritonitis and notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client wiht suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.

"The physician has determined that the client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D"

Correct 1 Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers.

"A client is admitted with right lower quadrant pain, anorexia, nausea, low-grade fever, and an elevated white blood cell count. Which complication is most likely the cause? "1. A fecalith 2. Bowel kinking 3. Internal bowel occlusion 4. Abdominal wall swelling"

Correct 1 The client is experiencing appendicitis. A fecalith is a fecal calculus, or stone, that occludes the lumen of the appendix and is the most common cause of appendicitis. Bowel wall swelling, kinking of the appendix, and external occlusion, not internal occlusion, of the bowel by adhesions can also be causes of appendicitis.

Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? "1. Hepatitis A. 2. Hepatitis B. 3. Hepatitis C. 4. Hepatitis D."

Correct 1 "1.The hepatitis A virus is in the stool of infected people up to two (2) weeks before symptoms develop. 2. Hepatitis B virus is spread through contact with infected blood and body fluids. 3.Hepatitis C virus is transmitted through infected blood and body fluids. 4.Hepatitis D virus only causes infection in people who are also infected with hepatitis B or C.

"What type of precautions should the nurse implement to protect from being exposed to any of the hepatitis viruses? "1. Airborne precautions 2. Standard precautions 3. Droplet precautions 4. Exposure precautions"

Correct 2 2. Standard precautions apply to blood, all body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood

The client with sever abdominal pain is being evaluated for appendicitis. What is the most common cause of appendicistis? http://nursing.slcc.edu/nclexrn3500/ 1. Rupture of the appendix 2.Obstruction of the appendix 3 A high-fat diet 4. A duodenal ulcer

Correct 2 Appendicitis most commonly results from obstruction of the appendix, which may lead to rupture. A high-fat diet or duodenal ulcer doesn't cause appendicitis; however, a client may require dietary restrictions after an appendectomy

"The client is admitted to the hospital with viral hepatitis, complaining of ""no appetite"" and ""losing my taste for food."" What instruction should the nurse give the client to provide adequate nutrition? "1. Select foods high in fat 2. Increase intake of fluids, including juices 3. Eat a good supper when anorexia is not as severe 4. Eat less often, preferbly only three large meals daily"

Correct 2: Rationale: Although no specific diet is required to treat viral hepatitis, it is recommended tht clients consume a low-fat diet because fat may be poorly tolerated because of decreased bile production. Small frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.

which statement made by the client who is postoperative abdominal surgery indicates the discharge teaching has been effective? 1. "i will take my temp each week and report any elevation." 2. "i will not need any pain meds when i go home." 3. i will take all of my antibiotics until they are gone." 4. i will not take a shower until my three month check up.

Correct 3 1. the client should check the temp twice a day. 2. it is not realistic to expect the client to experience no pain after surgery. 3 (CORRECT): this statement about taking all the antibiotics ordered indicates the teaching is effective. 4. clients may shower after surgery, but not taking a tub bath for three months after surgery is too long a time.

A 40-year-old woman has been diagnosed with hepatitis A and asks the nurse if other members of her family are at risk for ""catching"" the disease. The nurse's response should be based on the understanding that hepatitis A is transmitted primarily:" "1. during sexual intercourse 2. by contact with infected body secretions. 3. through fecal contamination of food or water. 4. through kissing that involves contact with mucous membranes."

Correct 3: "Hepatitis A is primarily transmitted through ingestion of organisms on fecally contaminated hands, food, or water. Care should be taken in the handling of food and water as well as contaminated items such as bed linens, bedpans, and toilets. Hand hygiene and personal protective equipment such as gloves are important to prevent the spread of infection for hospital personnel. In the home, hand hygiene and good personal hygiene are important to decrease transmission.

A client complains of severe pain in the right lower quadrant of the abdomen. To assist with pain relief, the nurse should take which of the following actions? "1. Encourage the client to change positions frequently in bed 2. Massage the right lower quadrant fo the abdomen 3. Apply warmth to the abdomen with a heating pad 4. Use comfort measures and pillows to position the client"

Correct 4 "1. ""Encourage the client..."" - unnecesary movement will increase pain and should be avoided 2. ""Massage the lower..."" - if appendicitis is suspected, massorge or palpation should never be performed as thes actions may cause the appendix to rupture 3. ""Apply warmth..."" - if pain is casused by appendicitis, increased circulation from the heat may cause appendix to rupture 4. ""Use comfort measures..."" - CORRECT: non-pharmacological methods of pain relief"

"A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications?... "1. Deficient fluid volume. 2. Intestinal obstruction. 3. Bowel ischemia. 4. Peritonitis

Correct 4 "Complications of acute appendicitis are perforation, peritonitis, and abscess development. Signs of the development of peritonitis include abdominal pain and distention, tachycardia, tachypnea, nausea, vomiting, and fever. Because peritonitis can cause hypovolemic shock, hypotension can develop. Deficient fluid volume would not cause a fever. Intestinal obstruction would cause abdominal distention, diminished or absent bowel sounds, and abdominal pain. Bowel ischemia has signs and symptoms similar to those found with intestinal obstruction."

The nurse instructs a client diagnosed with hepatitis A about untoward signs and symptoms related to hepatitis that may develop. The one that should be reported to the practitioner is: 1)Fatigue 2)Anorexia 3)Yellow urine 4)Clay-covered stools

Correct 4 1)It is unnecessary to call the practitioner because this symptom is characteristic of hepatitis from the onset of clinical manifestations. 2)It is unnecessary to call the practitioner because this symptom is characteristic of hepatitis from the onset of clinical manifestations. 3) This is the expected color of urine. 4) Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines.

"A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care? 1. Remove the dressing and leave the incision open to air. 2. Remove the drain if wound drainage is minimal. 3. Gently irrigate the drain to remove exudate. 4. Clean the area around the drain moving away from the drain.

Correct 4 The nurse should gently clean the area around the drain by moving in a circular motion away from the drain. Doing so prevents the introduction of microorganisms to the wound and drain site. The incision cannot be left open to air as long as the drain is intact. The nurse should note the amount and character of wound drainage, but the surgeon will determine when the drain should be removed. Surgical wound drains are not irrigated.

"The school nurse is discussing ways to prevent an outbreak of hepatitis A with a groupof high school teachers. Which action is the most important intervention that theschool nurse must explain to the school teachers? "1.Do not allow students to eat or drink after each other. 2.Drink bottled water as much as possible. 3.Encourage protected sexual activity. 4.Thoroughly wash hands.

Correct 4: "Hepatitis A is transmitted via the fecal-oralroute. Good hand washing helps to prevent its spread. HINT - good hand washing is the most impor-tant action in preventing transmission of any of the hepatitis viruses. Often, the test taker will not select the answer option that seemstoo easy—but remember, do not overlook the"

Which of the following would confirm a diagnosis of appendicitis? "a. The pain is localized at a position halfway between the umbilicus and the right iliac crest. b. Mr. Liu describes the pain as occurring 2 hours after eating c. The pain subsides after eating d. The pain is in the left lower quadrant"

Correct A "Pain over McBurney's point, the point halfway between the umbilicus and the iliac crest, is diagnosis for appendicitis. Options b and c are common with ulcers; option d may suggest ulcerative"

Dr. Smith has determined that the client with hepatitis has contracted the infection form contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? a. Hepatitis A b. Hepatitis B c. Hepatitis C d. Hepatitis D"

Correct A Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.

A client is admitted with ongoing symptoms of the flu. There are not other obvious signs of illness. This client should be tested for hepatitis because... "A. She could have anicteric hepatitis, which means no jaundice B. She has an allergy to shellfish C. She has a blood pressure of 90/50 D. She was living with a roommate who had similar symptoms"

Correct A Rationale: A. Only about 25% percent of people with aute hepatitis develop jaundice. Patients with anicteric hepatitis may have severely compromised her liver function that is overlooked due to lack of jaundice.

"A patient with hepatitis A is in the acute phase. The nurse plans care for the patient based on the knowledge that "a. pruritus is a common problem with jaundice in this phase. b. the patient is most likely to transmit the disease during this phase. c. gastrointestinal symptoms are not as severe in hepatitis A as they are in hepatitis B. d. extrahepatic manifestations of glomerulonephritis and polyarteritis are common in this phase.

Correct A Rationale: The acute phase of jaundice may be icteric (i.e., symptomatic, including jaundice) or anicteric. Jaundice results when bilirubin diffuses into the tissues. Pruritus sometimes accompanies jaundice. Pruritus is the result of an accumulation of bile salts beneath the skin.

A client is admitted with ongoing symptoms of the flu. There are no other obvious signs of illness. This client should be tested for hepatitis because: "a) She could have anicteric hepatitis, which means no jaundice. b) She has a blood pressure of 90/50. c) She was living with a roommate who had similar symptoms. d) She has an allergy to shellfish."

Correct A: (Correct Answer=A) Only about 25 percent of people with acute hepatitis develop jaundice. Patients with anicteric hepatitis may have severely compromised liver function that is overlooked due to lack of jaundice.

Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? 1.Hepatitis A.2.Hepatitis B.3.Hepatitis C.4.Hepatitis D.

Correct Answer 1: The hepatitis A virus is in the stool of infected people up to two (2) weeks beforesymptoms develop.

The physician has determined that the client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? 1. Hep-A 2. Hep-B. 3. Hep-C. 4 Hep-D

Correct Answer 1: Hep-A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hep-B, -C or -D are most commonly transmitted via infected blood or body fluids.

"A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which of the following? "1. Malaise 2. Dark stools 3. Weight gain 4. Left upper quadrant discomfort"

Correct Answer 1: Rationale: Hepatitis causes GI symptoms such as anorexia, nausea, right upper quadrant discomfort and weight loss. Fatigue and malaise are common. Stools will be light or clay colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.

A college student is required to be inculated for hepatitis before starting college. The nurse recognizes that he will be inoculated for: 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D

Correct Answer 2 Hepatitis B is considered a significant sexually transmitted disease and is seen in all age groups. A vaccine is available for this type of hepatitis.

"Question: A 40-year-old woman has been diagnosed with hepatitis A and asks the nurse if other members of her family are at risk for ""catching"" the disease. The nurse's response should be based on the understanding that hepatitis A is transmitted primarily1. During sexual intercourse; 2. By contact with infected body secretions; 3. Through fecal contamination of food or water 4. Through kissing that involves contact with mucous membranes.

Correct Answer 3 Anwer: (3). Rationale: Hepatitis A is primarily transmitted through ingestion of organisms on fecally contaminated hands, food, or water. Care should be taken in the handling of food and water as well as contaminated items such as bed linens, bedpans, and toilets. Hand hygiene and personal protective equipment such as gloves are important to prevent the spread of infection for hospital personnel. In the home, hand hygiene and good personal hygiene are important to decrease transmission. Sexual intercourse (1), contact with infected body secretions (2), and contact through mucous membranes (4) all present higher risk for hepatitis B and C.

A client is suspected of having hepatitis. Which diagnoistic test result will assist in confirming this diagonis ? A.Elevate hemoglobin level B. Elevated serum bilirubin level C. Elevated blood urea nitrogen level D. Decreasd erythrocycte sedimentation rate

Correct Answer B Laboratory indicator of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels.Thinking about the organ that is involved in hepatitis should assist in directing to choose option B liver function test.

What type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? A. Airborne Precautions. B. Standard Precautions. C. Droplet Precautions. D. Exposure Precautions.

Correct Answer B: Standard precautions apply to blood, all body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood. Airborne Precautions are only for airborne droplet nuclei or dust particles, Droplet precaution involves large particle droplets in the mucus membranes, and Exposure precaution is not a designated isolation category.

"A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, the nurse would expect serologic testing to reveal" "a. hepatitis B surface antigen (HBsAg). b. anti-hepatitis B core immunoglobulin M (anti-HBc IgM). c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG). D. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)."

Correct Answer D "Rationale: Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen or antibodies for hepatitis B. Anti-HAV IgG would indicate past infection and lifelong immunity."

A sexually active 20-year-old client has developed viral hepatitis. Which of the following statements, if made by the client, would indicate a need for futher teaching? 1. "A condom should be used for sexual intercourse." 2. "I can never drink alcohol again." 3. "I won't go back to work right away." 4. "My close friends should get the vaccine."

Correct Answer: 2. "I can never drink alcohol again." Rationale: To prevent transmission of hepatitis, a condom is advised during sexual intercourse and vaccination of the partner. Alcohol should be avoided because it is detoxified in the liver and may interfere with recover. Rest is especially important until laboratory studies show that liver function has returned to normal. The client's activity is increased gradually

The school nurse is discussing ways to prevent an outbreak of hepatitis A with a groupof high school teachers. Which action is the most important intervention that theschool nurse must explain to the school teachers? 1. Do not allow students to eat or drink after each other. 2.Drink bottled water as much as possible. 3.Encourage protected sexual activity. 4.Thoroughly wash hands.

Correct Answer: 4. Throroughly was hands" "1.Eating after each other should be discouraged,but it is not the most important intervention. 2.Only bottled water should be consumed in Third World countries, but that precaution isnot necessary in American high schools. 3.Hepatitis B and C, not hepatitis A, are trans-mitted by sexual activity. 4.Hepatitis A is transmitted via the fecal-oralroute. Good hand washing helps to prevent its spread. TEST-TAKING HINTS: The test taker must realize that good hand washing is the most important action in preventing transmission of any of the hepatitis viruses. Often, the test taker will not select the answer option that seems"

"When evaluating a male client for complications of acute pancreatitis, the nurse would observe for: "a. increased intracranial pressure. b. decreased urine output. c. bradycardia. d. hypertension."

Correct Answer: B Rationale: Acute pancreatitis can cause decreased urine output, which results from the renal failure that sometimes accompanies this condition. Intracranial pressure neither increases nor decreases in a client with pancreatitis. Tachycardia, not bradycardia, usually is associated with pulmonary or hypovolemic complications of pancreatitis. Hypotension can be caused by a hypovolemic complication, but hypertension usually isn't related to acute pancreatitis."

A patient withhepatitis B is being discharged in 2 days. In the discharge teaching plan the nurse should include instructions to "a) Avoid alcohol for the first 3 weeks b) use a condom during sexual intercourse c) have family members get an injection of immunoglobulin d) follow a low-protein, moderate-carbohydrate, moderate fat diet"

Correct B "Correct Answer: B Rationale: Hepatitis B virus may be transmitted by mucosal exposure to infectious blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Hepatitis B is a sexually transmitted disease that is acquired through unprotected sex with an infected person. Condom use should be taught to patients to prevent transmission of hepatitis B."

"When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? "a. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. b. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. c. The appendix may develop gangrene and rupture, especially in a middle-aged client. d. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage."

Correct B A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Geriatric, not middle-aged, clients are especially susceptible to appendix rupture."

When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? "a. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. b. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. c. The appendix may develop gangrene and rupture, especially in a middle-aged client. d. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage."

Correct B A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Geriatric, not middle-aged, clients are especially susceptible to appendix rupture.

A patient is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis? a. Elevated hemoglobin level, b. Elevated serum bilirubin level, c. Elevated blood urea nitrogen level, d. Decreased erythrocyte sedimentation rate

Correct B Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin leveles, elevated erythrocyte sedimentatation rates, and leukopenia. An elevated blood urea nitrogen level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

"The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which of the following responses by the nurse is most appropriate?" "A. "The hepatitis vaccine will provide immunity from this exposure and future exposures." B. "I am afraid there is nothing you can do since the patient was infectious before admission." C. "You will need to be tested first to make sure you don't have the virus before we can treat you." D. "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure.""

Correct C "Immunoglobulin provides temporary (1-2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis."

"A client with acute hepatitis is prescribed lactulose. The nurse knows this medication will: "a. Mobilize iron stores from the liver. b. Prevent hypoglycemia c. Remove bilirubin from the blood d. Prevent the absorption of ammonia from the bowel.

Correct D Lactulose helps prevent the absorption of ammonia from the bowel because it will cause frequent bowel movements, which facilitates the removal of ammonia from the intestines.

"During the assessment of a patient with acute abdominal pain, the nurse should: a. perform deep palpation before auscultation b. obtain blood pressure and pulse rate to determine hypervolemic changes c. auscultate bowel sounds because hyperactive bowel sounds suggest paralytic ileus d. measure body temperature because an elevated temperature may indicate an inflammatory or infectious process.

Correct D Rationale: for the patient complaining of acute abdominal pain, nurse should take vital signs immediately. Increased pulse and decreasing blood pressure are indicative of hypovolemia. An elevated temperature suggests an inflammatory infectious process. Intake and output measurements provide essential information about the adequate of vascular volume. Inspect abdomen first and then auscultate bowel sounds. Palpation is performed next and should be gentle.

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which of the following responses by the nurse is most appropriate? "A:"The hepatitis vaccine will provide immunity from this exposure and future exposures." B:"I am afraid there is nothing you can do since the patient was infectious before admission." C:"You will need to be tested first to make sure you don't have the virus before we can treat you." D: "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure.""

Correct D: Immunoglobulin provides temporary (1-2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.

A colleges student is required to be inoculated for hepatits before beginning college. The nurse relaizes this client will be inocualted to prevent the development of: 1. Hepatitis C 2. Hepatitis E 3. hepatitis B 4. Hepatitis D

Correct answer Hepatitis B Hepatitis B is considered a significant sexually transmitted disease and is seen in all age groups. A vaccine is available for this type of hepatitis.

"A nurse is assessing a clinic patient with a diagnosis of hepatitis A. Which of the following is the most likely route of transmission? "A. Sexual contact with an infected partner. B. Contaminated food. C. Blood transfusion. D. Illegal drug use.

Correct answer: B" Hepatitis A is the only type that is transmitted by the fecal-oral route through contaminated food. Hepatitis B, C, and D are transmitted through infected bodily fluids.

"A client is admitted with ongoing symptoms of the flu. There are no other obvious signs of illness. This client should be tested for hepatitis because: "a) She has an allergy to shellfish. b) She could have anicteric hepatitis, which means no jaundice. c) She was living with a roommate who had similar symptoms. d)She has a blood pressure of 90/50.

Correct answer: B" Only about 25 percent of people with acute hepatitis develop jaundice. Patients with anicteric hepatitis may have severely compromised liver function that is overlooked due to lack of jaundice.

The nurse would increase the comfort of the patient with appendicitis by: a. Having the patient lie prone b. Flexing the patient's right knee c. Sitting the patient upright in a chair d. Turning the patient onto his or her left side

Correct answer: B" The patient with appendicitis usually prefers to lie still, often with the right leg flexed to decrease pain.

When preparing a patient for a capsule endoscopy study, what should the nurse do? a. Ensure the patient understands the required bowel preparation. b. Have the patient return to the procedure room for removal of the capsule. c. Teach the patient to maintain a clear liquid diet throughout the procedure. d. Explain to the patient that conscious sedation will be used during placement of the capsule.

Correct answer: a Rationale: A capsule endoscopy study involves the patient performing a bowel prep to cleanse the bowel before swallowing the capsule. The patient will be on a clear liquid diet for 1 to 2 days before the procedure and will remain NPO for 4 to 6 hours after swallowing the capsule. The capsule is disposable and will pass naturally with the bowel movement, although the monitoring device will need to be removed.

What problem should the nurse assess the patient for if the patient was on prolonged antibiotic therapy? a. Coagulation problems b. Elevated serum ammonia levels c. Impaired absorption of amino acids d. Increased mucus and bicarbonate secretion

Correct answer: a Rationale: Bacteria int he colon (1) synthesize vitamin K, which is needed for the production of prothrombin by the liver and (2) deaminate undigested or non absorbed proteins, producing ammonia, which is converted to urea by the liver. A reduction in normal flora bacteria by antibiotic therapy can lead to decreased vitamin K, resulting in decreased prothrombin and coagulation problems. Bowel bacteria do not influence protein absorption or the secretion of mucus.

A patient is jaundiced and her stools are clay colored (gray). This is most likely related to a. decreased bile flow into the intestine. b. increase production of urobilinogen. c. increased production of cholecystokinin. d. increased bile and bilirubin in the blood.

Correct answer: a Rationale: Bile is produced by the hepatocytes and is stored and concentrated in the gallbladder. When bile is released from the common bile duct, it enters the duodenum. In the intestines, bilirubin is reduced to stercobilinogen and urobilinogen by bacterial action. Stercobilinogen accounts for the brown color of stool. Stools may be clay-colored if bile is not released from the common bile duct into the duodenum. Jaundice may result if the bilirubin level in the blood is elevated.

A patient had a stomach resection for stomach cancer. The nurse should teach the patient about the loss of the hormone that stimulates gastric acid secretion and motility and maintains lower esophageal sphincter tone. Which hormone will be decreased with a gastric resection? a. Gastrin b. Secretin c. Cholecystokinin d. Gastric inhibitory peptide

Correct answer: a Rationale: Gastrin is the hormone activated in the stomach (and duodenal mucosa) by stomach distention that stimulates gastric acid secretion and motility and maintains lower esophageal sphincter tone. Secretin inhibits gastric motility and acid secretion and stimulates pancreatic bicarbonate secretion. Cholecystokinin allows increased flow of bile into the duodenum and release of pancreatic digestive enzymes. Gastric inhibitory peptide inhibits gastric acid secretion and motility.

A patient with hepatitis A is in the acute phase. The nurse plans care for the patient based on the knowledge that a. pruritus is a common problem with jaundice in this phase. b. the patient is most likely to transmit the disease during this phase. c. gastrointestinal symptoms are not as severe in hepatitis A as they are in hepatitis B. d. extrahepatic manifestations of glomerulonephritis and polyarteritis are common in this phase. (Lewis 1042)

Correct answer: a Rationale: The acute phase of jaundice may be icteric or anicteric. Jaundice results when bilirubin diffuses into the tissues. Pruritus sometimes accompanies jaundice. Pruritus is the result of an accumulation of bile salts beneath the skin.

Checking for the return of the gag reflex and monitoring for LUQ pain, nausea and vomiting are necessary nursing actions after which diagnostic procedure? a. ERCP b. Colonoscopy c. Barium swallow d. Esophagogastroduodenoscopy (EGD)

Correct answer: a Rationale: The left upper quadrant (LUQ) pain and nausea and vomiting could occur from perforation. The return of gag reflex is essential to prevent aspiration after an ERCP. The gag reflex is also assessed with an EGD. These are not relevant assessments for the colonoscopy and barium swallow.

A 90-year-old healthy man is suffering from dysphagia. The nurse explains what age-related change of the GI tract is the most likely cause of his difficulty? a. Xerostomia b. Esophageal cancer c. Decreased taste buds d. Thinner abdominal wall

Correct answer: a Rationale: Xerostomia, decreased volume of saliva, leads to dry oral mucosa and dysphagia. Esophageal cancer is not an age-related change. Decreased taste buds and a thinner abdominal wall do not contribute to difficulty swallowing.

The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that a. a lack of clotting factors promotes the collection of blood in the abdominal cavity. b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. c. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel. d. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid. (Lewis 1042)

Correct answer: b Rationale: Ascites is the accumulation of serous fluid in the peritoneal or abdominal cavity and is a common manifestation of cirrhosis. With portal hypertension, proteins shift from the blood vessels through the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, those substances leak through the liver capsule into the peritoneal cavity. Osmotic pressure of the proteins pulls additional fluid into the peritoneal cavity. A second mechanism of ascites formation is hypoalbuminemia, which results from the inability of the liver to synthesize albumin. Hypoalbuminemia results in decreased colloidal oncotic pressure. A third mechanism is hyperaldosteronism, which occurs when aldosterone is not metabolized by damaged hepatocytes. The increased level of aldosterone causes increases in sodium reabsorption by the renal tubules. Sodium retention and an increase in antidiuretic hormone levels cause additional water retention.

A patient has an elevated blood level of indirect (unconjugated) bilirubin. One cause of this finding is that a. the gallbladder is unable to contract to release stored bile. b. bilirubin is not being conjugated and excreted into the bile by the liver. c. the Kupffer cells in the liver are unable to remove bilirubin from the blood. d. there is an obstruction in the biliary tract preventing flow of bile into the small intestine.

Correct answer: b Rationale: Bilirubin is a pigment derived from the breakdown of hemoglobin and is insoluble in water. Bilirubin is bound to albumin for transport to the liver and is referred to as unconjugated. An indirect bilirubin determination is a measurement of unconjugated bilirubin, and the level may be elevated in hepatocellular and hemolytic conditions.

A patient with acute hepatitis B is being discharged in 2 days. In the discharge teaching plan the nurse should include instructions to a. avoid alcohol for the first 3 weeks. b. use a condom during sexual intercourse. c. have family members get an injection of immunoglobulin. d. follow a low-protein, moderate-carbohydrate, moderate-fat diet. (Lewis 1042)

Correct answer: b Rationale: Hepatitis B virus may be transmitted by mucosal exposure to infected blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Hepatitis B is a sexually transmitted disease that is acquired through unprotected sex with an infected person. Condom use should be taught to patients to prevent transmission of hepatitis B.

A patient has been told that she has elevated liver enzymes caused by nonalcoholic fatty liver disease (NAFLD). The nursing teaching plan should include a. having genetic testing done. b. recommending a heart-healthy diet. c. the necessity to reduce weight rapidly. d. avoiding alcohol until liver enzymes return to normal. (Lewis 1042)

Correct answer: b Rationale: Nonalcoholic fatty liver disease (NAFLD) can progress to liver cirrhosis. There is no definitive treatment, and therapy is directed at reduction of risk factors, which include treatment of diabetes, reduction in body weight, and elimination of harmful medications. For patients who are overweight, weight reduction is important. Weight loss improves insulin sensitivity and reduces liver enzyme levels. No specific dietary therapy is recommended. However, a heart-healthy diet as recommended by the American Heart Association is appropriate.

During an examination of the abdomen the nurse should a. position the patient in the supine position with the head of the bed flat and knees straight. b. listen in the epigastrium and all four quadrants for 2 minutes for bowel sounds. c. use the following order of techniques: inspection, palpation, percussion, auscultation. d. describe bowel sounds as absent if no sound is heard in the lower right quadrant after 2 minutes.

Correct answer: b Rationale: The nurse should listen in the epigastrium and all four quadrants for bowel sounds for at least 2 minutes. The patient should be in the supine position and should slightly flex the knees; the head of the bed should be raised slightly. During examination of the abdomen, the nurse auscultates before performing percussion and palpation because the latter procedures may alter the bowel sounds. Bowel sounds cannot be described as absent until no sound is heard for 5 minutes in each quadrant.

What is a normal finding on physical examination of the abdomen? a. Auscultation of bruits b. Observation of visible pulsations c. Percussion of liver dullness in the left midclavicular line d. Palpation of the spleen 1 to 2 cm below the left costal margin

Correct answer: b Rationale: The pulsation of the aorta in the epigastric area is a normal finding. Bruits indicate that blood flow is abnormal, the liver is percussed in the right midclavicular line, and a normal spleen cannot be palpated.

The patient tells the nurse she had a history of abdominal pain, so she had a surgery to make an opening into the common bile duct to remove stones. The nurse knows that this surgery is called a a. colectomy b. cholecystectomy c. choledocholithotomy d. choledochojejunostomy

Correct answer: c Rationale: A choledocholithotomy is an opening into the common bile duct for the removal of stones. A colectomy is the removal of the colon. The cholecystectomy is the removal of the gallbladder. The choledochojejunostomy is an opening between the common bile duct and the jejunum.

What is a normal finding during physical assessment of the mouth? a. A red, slick appearance of the tongue b. Uvular deviation to the side on saying "Ahh" c. A thin, white coating of the dorsum of the tongue d. Scattered red, smooth areas on the dorsum of the tongue

Correct answer: c Rationale: A thin white coating of the dorsum (top) of the tongue is normal. A red, slick appearance is characteristic of cobalamin deficiency and scattered red, smooth areas on the tongue are known as geographic tongue. The uvula should remain in the midline while the patient is saying "Ahh"

The health care team is assessing a male patient for acute pancreatitis after he presented to the emergency department with severe abdominal pain. Which laboratory value is the best diagnostic indicator of acute pancreatitis? a. Gastric pH b. Blood glucose c. Serum amylase d. Serum potassium

Correct answer: c Rationale: Elevated serum amylase levels indicate early pancreatic dysfunction and are used to diagnose acute pancreatitis. Serum lipase levels stay elevated longer than serum amylase in acute pancreatitis. Blood glucose, gastric pH, and potassium levels are not direct indicators of acute pancreatic dysfunction.

When caring for the patient with heart failure, the nurse knows that which gastrointestinal process is most dependent on cardiac output and may affect the patient's nutritional status? a. Ingestion b. Digestion c. Absorption d. Elimination

Correct answer: c Rationale: Substances that interface with the absorptive surfaces of the GI tract (primarily in the small intestine) diffuse across the intestinal membranes into intestinal capillaries and are then carried to other parts of the body for use in energy production. The cardiac output provides the blood flow for this absorption of nutrients to occur.

How will an obstruction at the ampulla of Vater affect the digestion of all nutrients? a. Bile is responsible for emulsification of all nutrients and vitamins. b. Intestinal digestive enzymes are released through the ampulla of Vater. c. Both bile and pancreatic enzymes enter the duodenum at the ampulla of Vater. d. Gastric contents can ply pass to the duodenum when the ampulla of Vater is open.

Correct answer: c Rationale: The ampulla of Vater is the site where the pancreatic duct and common bile duct enter the duodenum and the opening and closing of the ampulla is controlled by the sphincter of Oddi. Because bile from the common bile duct is needed for emulsification of fat to promote digestion and pancreatic enzymes from the pancreas are needed for digestion of all nutrients, a blockage at this point would affect the digestion of all nutrients. Gastric contents pass into the duodenum through the pylorus or pyloric valve.

The nurse is assessing a 50-year-old woman admitted with a possible bowel obstruction. Which assessment finding would be expected in this patient? a. Tympany to abdominal percussion b. Aortic pulsation visible in epigastric region c. High-pitched sounds on abdominal auscultation d. Liver border palpable 1 cm below the right costal margin

Correct answer: c Rationale: The bowel sounds are more high pitched (rushes and tinkling) when the intestines are under tension, as in intestinal obstruction. Bowel sounds may also be diminished or absent with an intestinal obstruction. Normal findings include aortic pulsations on inspection and tympany with percussion, and the liver may be palpable 1 to 2 cm along the right costal margin.

A patient receives atropine, an anticholinergic drug, in preparation for surgery. The nurse expects this drug to affect the GI tract by doing what? a. Increasing gastric emptying b. Relaxing pyloric and ileocecal sphincters c. Decreasing secretions and peristaltic action d. Stimulation the nervous system of the GI tract

Correct answer: c Rationale: The parasympathetic nervous system stimulates activity of the gastrointestinal (GI) tract, increasing motility and secretions and relaxing sphincters to promote movement of contents. A drug that blocks this activity decreases secretions and peristalsis, slows gastric emptying, and contracts sphincters. The enteric nervous system of the GI tract is modulated by sympathetic and parasympathetic influence.

Priority Decision: When caring for a patient who has had most of the stomach surgically removed, what is important for the nurse to teach the patient? a. Extra iron will need to be taken to prevent anemia. b. Avoid foods with lactose to prevent bloating and diarrhea. c. Lifelong supplementation of cobalamin (vitamin B12) will be needed. d. Because of the absence of digestive enzymes, protein malnutrition is likely.

Correct answer: c Rationale: The stomach secretes intrinsic factor, necessary for cobalamin (vitamin B12) absorption in the intestine. When part or all of the stomach is removed, cobalamin must be supplemented for life. The other options will not be a problem.

Which nursing actions are indicated for a liver biopsy (select all that apply)? a. Observe for white stools b. Monitor for rectal bleeding c. Monitor for internal bleeding d. Position to right side after test e. Ensure bowel preparation was done f. Check coagulation status before test

Correct answer: c, d, f Rationale: Because the liver is a vascular organ, vital signs are monitored to assess for internal bleeding. Prevention of bleeding is the reason for positioning on the right side for at least 2 hours and for splinting the puncture site. Again, because of the vasculature of the liver, coagulation status is checked before the biopsy is done. White stools occur with upper gastrointestinal (UGI) or barium swallow tests. No smoking is to be done after midnight before the study with an UGI. The bowel must be cleared before a lower GI or barium enema, a virtual colonoscopy, or a colonoscopy. Rectal bleeding may occur with a sigmoidoscopy or colonoscopy. A perforation may occur with an esophagogastroduodenoscopy (EGD), ERCP, or peritoneoscopy.

The nurse is performing a focused abdominal assessment of a patient who has been recently admitted. In order to palpate the patient's liver, where should the nurse palpate the patient's abdomen? a. Left lower quadrant b. Left upper quadrant c. Right lower quadrant d. Right upper quadrant

Correct answer: d Rationale: Although the left lobe of the liver is located in the left upper quadrant of the abdomen, the bulk of the liver is located in the right upper quadrant.

The nurse is reviewing the home medication list for a 44-year-old man admitted with suspected hepatic failure. Which medication could cause hepatotoxicity? a. Nitroglycerin b. Digoxin (Lanoxin) c. Ciprofloxacin (Cipro) d. Acetaminophen (Tylenol)

Correct answer: d Rationale: Many chemicals and drugs are potentially hepatotoxic (see Table 39-6) and result in significant patient harm unless monitored closely. For example, chronic high doses of acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) may be hepatotoxic.

A patient is admitted to the hospital with a diagnosis of diarrhea with dehydration. The nurse recognizes that increased peristalsis resulting in diarrhea can be related to a. sympathetic inhibition. b. mixing and propulsion. c. sympathetic stimulation. d. parasympathetic stimulation.

Correct answer: d Rationale: Peristalsis is increased by parasympathetic stimulation.

What is a clinical manifestation of age-related changes in the GI system that the nurse may find in an older patient? a. Gastric hyperacidity b. Intolerance to fatty foods c. Yellowish tinge to the skin d. Reflux of gastric contents into the esophagus

Correct answer: d Rationale: There is decreased tone of the lower esophageal sphincter with again and regurgitation of gastric contents back into the esophagus occurs, causing heartburn and belching. There is a decrease in hydrochloric acid secretion with aging. Jaundice and intolerance to fatty foods are symptoms of liver or gallbladder disease and are not normal age-related findings.

A 68-year-old patient is in the office for a physical. She notes that she no longer has regular bowel movements. Which suggestion by the nurse would be most helpful to the patient? a. Take an additional laxative to stimulate defecation. b. Eat less acidic foods to enable the gastrointestinal system to increase peristalsis. c. Eat less food at each meal to prevent feces from backing up related to slowed peristalsis. d. Attempt defecation after breakfast because gastrocolic reflexes increase colon peristalsis at that time.

Correct answer: d Rationale: When food inters the stomach and duodenum, the gastrocolic and duodenocolic reflexes are initiated and are more active after the first daily meal. Additional laxatives or laxative abuse contribute to constipation in older adults. Decreasing food intake is not recommended, as many older adults have a decreased appetite. Fibre and fluids should be increased.

The ED nurse has inspected, auscultated, and palpated the abdomen with no obvious abnormalities, except pain. When the nurse palpates the abdomen for rebound tenderness, there is severe pain. The nurse should know that this could indicate what problem? a. Hepatic cirrhosis b. Hypersplenomegaly c. Gall bladder distention d. Peritoneal inflammation

Correct answer: d Rationale: When palpating for rebound tenderness, the problem area of the abdomen will produce pain and severe muscle spasm when there is peritoneal inflammation. Hepatic cirrhosis, hypersplenomegaly, and gall bladder distention do not manifest with rebound tenderness.

"The client with hepatitis asks the nurse ""I went to an herbalist, who recommended I take milk thistle. What do you think about the herb?"" Which statement is the nurse's best response? "1. ""You are concerned about taking an herb"" 2. ""The herb has been used to treat liver disease"" 3. ""I would not take anything that is not prescribed"" 4. ""Why would you want to take any herbs?""

Correct: 2 "1. This is a therapeutic response and the nurse should provide factual information 2. Milk thistle has an active ingredient, silymarin, which has been used to treat liver disease for more than 2,000 yrs. It is a powerful oxidant and promotes liver cell growth. 3. The nurse should not discourage complementary therapies. 4. This is a judgmental statement, and the nurse should encourage the client to ask questions."

The home care nurse is visiting a client with a diagnosis of hepatitis of unknown etiology. The nurse knows that teaching has been successful if the patient makes which on of the following statements? "1. ""I am so sad that I am not able to hold my baby."" 2."" I will eat after my family eats."" 3. ""I will make sure that my children don't eat or drink after me."" 4. ""I'm glad that I don't have to get help taking care of my children."""

Correct: 3 "1. not spread by casual contact 2. can eat together, but not share utensils 3. to prevent transmission - do not share eating utensils or drinking glasses, wash hands before eating and after using toilet 4. alternate rest/activity to promote hepatic healing, mother of young children will need help"

The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should: "1. Contact the surgeon to request an order for a narcotic for the pain. 2. Maintain the client in a recumbent position. 3. Place the client on nothing-by-mouth (NPO) status. 4. Apply heat to the abdomen in the area of the pain."

Correct: 3 The nurse should place the client on NPO status in anticipation of surgery. The nurse can initiate pain relief strategies, such as relaxation techniques, but the surgeon will likely not order narcotic medication prior to surgery. The nurse can place the client in a position that is most comfortable for the client. Heat is contraindicated because it may lead to perforation of the appendix

The home care nurse is visiting a client during an icteric phase of hepatitis of unknown etiology. The nurse would be MOST concerned if the client made which of the following comments? "1. ""I must not share eating utensils with my family."" 2. ""I must use my own bath towel."" 3. ""I'm glad that my husband and I can continue to have intimate relations."" 4. ""I must eat small, frequent feedings."""

Correct: 3 3. ""I'm glad my husband..."" - CORRECT: avoid sexual contact until serologic indicators return to normal

"The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should: "1. Contact the surgeon to request an order for a narcotic for the pain. 2. Maintain the client in a recumbent position. 3. Place the client on nothing-by-mouth (NPO) status. 4. Apply heat to the abdomen in the area of the pain."

Correct: 3 - no rationale

A client is hospitalized with hepatitis A. Which of the client's regular medications is contraindicated due to the current illness? http://www.rnpedia.com/home/exams/nclex-exam/nclex-rn-practice-questions-6 "1. Prilosec (omeprazole) 2. Synthroid (levothyroxine) 3. Premarin (conjugated estrogens) 4. Lipitor (atorvastatin)

Correct: 4 Lipid-lowering agents are contraindicated in the client with active liver disease. Answers A, B, and C are incorrect because they are not contraindicated in the client with active liver disease.

"A client has an appendectomy and develops peritonitis. The nurse should asses the client for an elevated temperature and which additional clinical indication commonly associated with peritonitis? "1. hyperactivity 2. extreme hunger 3. urinary retention 4. local muscular rigidity

Correct: 4 muscular rigidity over the affected area is a classic sign of peritonitis

"A patient with hepatitis A is in the acute phase. The nurse plans care for the patient based on the knowledge that: "A. pruritus is a common problem with jaundice in this phase. B. the patient is most likley to transmit the disease during this phase. C. gastrointestinal symptoms are not as severe in hepatitis A as they are in hepatitis B. D. extrahepatic manifestations of glomerulonephritis and polyarteritis are common in this phase."

Correct: A The acute phase of jaundice may be icteric (i.e., symptomatic, including jaundice) or anicteric. Jaundice results when bilirubin diffuses into the tissues. Pruritus sometimes accompanies jaundice. Pruritus is the result of an accumulation of bile salts beneath the skin.

A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis? a. Elevated hemoglobin level B.. Elevated serum bilirubin level c. Elevated blood urea nitrogen leveld. Decreased erythrocycle sedimentation rate

Correct: B Answer B. Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated erythrocyte sedimentation rates, and leukopenia. An elevated blood urea nitrogen level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis

"A patient with hepatitis B is being discharged in 2 days. In the discharge teaching plan the nurse should include instructions to: "A. Avoid alcohol for the first 3 weeks B.use condoms during sexual intercourse C. have family members get an injection of immunoglobulin D. follow low protein, moderate carb, moderate fat diet"

Correct: B B. is the correct answer as it is important to instruct the patient they this disease can be spread through sexual contact

"A patient with hepatitis B is being discharged in 2 days. In the discharge teaching plan the nurse should include instructions to... a. avoid alcohol for the first 3 weeks b. use a condom during sexual intercourse c. have family members get an injection of imunoglobulin d. follow a low-protein, moderate-carbohydrate, moderate-fat diet."

Correct: B Rationale: Hepatitis B virus may be transmitted by mucosal exposure to infectious blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Hepatitis B is a sexually transmitted disease that is acquired through unprotected sex with an infected person. Condom use should be taught to patients to prevent transmission of hepatitis B.

"When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? "a. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. b. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. c. The appendix may develop gangrene and rupture, especially in a middle-aged client. d. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage."

Correct: B - no rationale

A client has an appendectomy. This is an example of what kind of surgery? a. Diagnostic b. palliative c. ablative d. constructive

Correct: C Appendectomy is an example of ablative surgery. Diagnostic confirms or establishes a diagnosis, palliative relieves or reduces pain, and constructive restores function or appearance.

Which client requires immediate nursing intervention? "The client who: a) complains of epigastric pain after eating. b) complains of anorexia and periumbilical pain. c) presents with ribbonlike stools. d) presents with a rigid, boardlike abdomen.

Correct: D A rigid, boardlike abdomen is a sign of peritonitis, a possibly life-threatening condition. Epigastric pain occurring 90 minutes to 3 hours after eating indicates a duodenal ulcer. Anorexia and periumbilical pain are characteristic of appendicitis. Risk of rupture is minimal within the first 24 hours, but increases significantly after 48 hours. A client with a large-bowel obstruction may have ribbonlike stools.

A female client with hepatitis C develops liver failure and GI hemorrhage. The blood products that would most likely bring about hemostasis in the client are: a. whole blood and albumin. b. platelets and packed red blood cells. c. fresh frozen plasma and whole blood. D.cryoprecipitate and fresh frozen plasma.

Correct: D Answer D. The liver is vital in the synthesis of clotting factors, so when it's diseased or dysfunctional, as in hepatitis C, bleeding occurs. Treatment consists of administering blood products that aid clotting. These include fresh frozen plasma containing fibrinogen and cryoprecipitate, which have most of the clotting factors. Although administering whole blood, albumin, and packed cells will contribute to hemostasis, those products aren't specifically used to treat hemostasis. Platelets are helpful, but the best answer is cryoprecipitate and fresh frozen plasma.

Hyperactive bowel sounds in one quadrant and absent bowel sounds in other quadrants plus nausea and vomiting may indicate: a. Pancreatitis b. Cholesystitis c. Peptic ulcer d. Intestinal obstruction

D

A client with a mechanical bowel obstruction reports that abdominal pain, which was previously intermittent and colicky, is now more constant. Which is the priority action of the nurse? a. Measure the abdominal girth. b. Place the client in a knee-chest position. c. Medicate the client with an opioid analgesic. d. Assess for bowel sounds and rebound tenderness.

D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse need not measure abdominal girth. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse should not medicate the client until the physician has been notified of the change in his or her condition.

The nurse is teaching a client how to care for a new ileostomy. Which client statement indicates that additional teaching is needed? a. "I will consult the pharmacist before filling any new prescriptions." b. "I will empty the ostomy pouch when it is half-filled with stool or gas." c. "I will wash my hands with antibacterial soap before and after ostomy care." d. "I will call my health care provider if I have not had ostomy drainage for 3 hours."

D A client with an ileostomy should call the provider if no drainage has come from the ostomy in 6 to 12 hours. The other statements indicate good understanding of self-management.

When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend? A. White bread, cheese, and green beans B. Fresh tomatoes, pears, and corn flakes C. Oranges, baked potatoes, and raw carrots D. Dried beans, All Bran (100%) cereal, and raspberries

D A high fiber diet is recommended for diverticular disease. Dried beans, All Bran (100%) cereal, and raspberries all have higher amounts of fiber than white bread, cheese, green beans, fresh tomatoes, pears, corn flakes, oranges, baked potatoes, and raw carrots.

A client is brought to the emergency department after being shot in the abdomen and is hemorrhaging heavily. Which action by the nurse is the priority? a. Draw blood for type and crossmatch. b. Start two large IVs for fluid resuscitation. c. Obtain vital signs and assess skin perfusion. d. Assess and maintain a patent airway.

D All options are important nursing actions in the care of a trauma client. However, airway always comes first. The client must have a patent airway, or other interventions will not be helpful.

The nurse is caring for a client who is taking mesalamine (5-aminosalicylic acid) (Asacol, Rowasa) for ulcerative colitis. The client has trouble swallowing the pill. Which action by the nurse is most appropriate? a. Crush the pill carefully and administer it to the client in applesauce or pudding. b. Empty the contents of the capsule into applesauce or pudding for administration. c. Contact the client's health care provider to request an order for Asacol suspension. d. Contact the client's health care provider to request an order for Rowasa enemas instead.

D Asacol is enteric coated and should not be crushed, chewed, or broken. If the client is unable to swallow the Asacol pill, Rowasa enemas may be administered instead, with a provider's order. Asacol is not available as a suspension or elixir.

The nurse is preparing to administer a dose of bisacodyl (Dulcolax). In explaining the medication to the patient, the nurse would explain that it acts in what way? A. Increases bulk in the stool B. Lubricates the intestinal tract to soften feces C. Increases fluid retention in the intestinal tract D. Increases peristalsis by stimulating nerves in the colon wall

D Bisacodyl is a stimulant laxative that aids in producing a bowel movement by irritating the colon wall and stimulating enteric nerves. It is available in oral and suppository forms. Fiber and bulk forming drugs increase bulk in the stool; water and stool softeners soften feces, and saline and osmotic solutions cause fluid retention in the intestinal tract.

The nurse is screening clients at a community health fair. Which client is at highest risk for development of colorectal cancer? a. Young adult who drinks eight cups of coffee every day b. Middle-aged client with a history of irritable bowel syndrome c. Older client with a BMI of 19.2 who works 65 hours per week d. Older client who travels extensively and eats fast food frequently

D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Irritable bowel syndrome, a heavy workload, and coffee intake do not increase the risk for colon cancer. A BMI of 19.2 is within normal limits.

What should the nurse instruct the patient to do to best enhance the effectiveness of a daily dose of docusate sodium (Colace)? A. Take a dose of mineral oil at the same time. B. Add extra salt to food on at least one meal tray. C. Ensure dietary intake of 10 g of fiber each day. D. Take each dose with a full glass of water or other liquid.

D Docusate lowers the surface tension of stool, permitting water and fats to penetrate and soften the stool for easier passage. The patient should take the dose with a full glass of water and should increase overall fluid intake, if able, to enhance effectiveness of the medication. Dietary fiber intake should be a minimum of 20 g daily to prevent constipation. Mineral oil and extra salt are not recommended.

The nurse is caring for a 68-year-old patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass, and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? A. Low-pitched and rumbling above the area of obstruction B. High-pitched and hypoactive below the area of obstruction C. Low-pitched and hyperactive below the area of obstruction D. High-pitched and hyperactive above the area of obstruction

D Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high-pitched, sometimes referred to as "tinkling" above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.

The nurse is caring for a postoperative patient with a colostomy. The nurse is preparing to administer a dose of famotidine (Pepcid) when the patient asks why the medication was ordered since the patient does not have a history of heartburn or gastroesophageal reflux disease (GERD). What response by the nurse would be the most appropriate? A. "This will prevent air from accumulating in the stomach, causing gas pains." B. "This will prevent the heartburn that occurs as a side effect of general anesthesia." C. "The stress of surgery is likely to cause stomach bleeding if you do not receive it." D. "This will reduce the amount of HCl in the stomach until the nasogastric tube is removed and you can eat a regular diet again

D Famotidine is an H2-receptor antagonist that inhibits gastric HCl secretion and thus minimizes damage to gastric mucosa while the patient is not eating a regular diet after surgery. Famotidine does not prevent air from accumulating in the stomach or stop the stomach from bleeding. Heartburn is not a side effect of general anesthesia.

The nurse would question the use of which cathartic agent in a patient with renal insufficiency? A. Bisacodyl (Dulcolax) B. Lubiprostone (Amitiza) C. Cascara sagrada (Senekot) D. Magnesium hydroxide (Milk of Magnesia)

D Milk of Magnesia may cause hypermagnesemia in patients with renal insufficiency. The nurse should question this order with the health care provider. Bisacodyl, lubiprostone, and cascara sagrada are safe to use in patients with renal insufficiency as long as the patient is not currently dehydrated.

30. During preoperative preparation for a patient scheduled for an abdominal-perineal resection, the nurse will a. give IV antibiotics starting 24 hours before surgery to reduce the number of bowel bacteria. b. teach the patient that activities such as sitting at the bedside will be started the first postoperative day. c. instruct the patient that another surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir. d. administer enemas and laxatives to ensure that the bowel is empty before the surgery.

D Rationale: A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for infection. Oral antibiotics are given to reduce colonic and rectal bacteria. Sitting is contraindicated after an abdominal-perineal resection. A permanent colostomy is created with this surgery. Cognitive Level: Application Text Reference: p. 1066 Nursing Process: Implementation NCLEX: Physiological Integrity

27. A patient has a large bowel obstruction that occurred as a result of a fecal impaction. During nursing assessment of the patient, a finding by the nurse that is consistent with a large bowel obstruction includes a. metabolic alkalosis. b. referred pain to the back. c. bile colored vomiting. d. abdominal distension.

D Rationale: Abdominal distension is seen in lower intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Referred back pain is not a common clinical manifestation of intestinal obstruction. Bile-colored vomit is associated with higher intestinal obstruction. Cognitive Level: Comprehension Text Reference: pp. 1061-1062 Nursing Process: Assessment NCLEX: Physiological Integrity

3. A patient who is hospitalized with a diagnosis of Giardia lamblia infection frequently has uncontrollable explosive diarrhea. The patient closes the eyes and will not talk to the nurse when the linens are changed and skin care is performed. To help maintain the patient's self-esteem, the nurse should a. use incontinence briefs for the patient so that the cleaning is less cumbersome and embarrassing. b. request an order for an antidiarrheal drug from the health care provider to help control the diarrhea episodes. c. ensure the patient that the lack of control is temporary and will resolve after about a week of treatment. d. acknowledge the behavior as reflective of a difficult situation and provide privacy during hygiene.

D Rationale: Acknowledging the difficulty of the situation and providing privacy will decrease the patient's embarrassment about the incontinence. Incontinence briefs are usually perceived as humiliating for patients. Use of antidiarrheal medications prolongs the exposure to the Giardia by slowing GI motility. Giardia may take several months to resolve. Cognitive Level: Application Text Reference: pp. 1039-1040 Nursing Process: Implementation NCLEX: Psychosocial Integrity

14. A patient diagnosed with irritable bowel syndrome (IBS) tells the nurse, "My friends tell me this problem is all in my head." In caring for the patient, the nurse should a. discuss the new medications that are available to treat the condition. b. inform the patient that IBS has a specific, identifiable cause. c. explain that modifications to increase dietary fiber can control the symptoms. d. encourage the patient to express feelings and ask questions about IBS.

D Rationale: Because psychologic and emotional factors can impact on the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Although new medications are available, discussion of these medications does not address the patient's concerns with what friends think or say. There is no specific cause for IBS. Modifications in fiber intake may help some patients but might also increase bloating and gas pain. In addition, discussion of fiber does not address the patient's feelings. Cognitive Level: Application Text Reference: pp. 1057-1058 Nursing Process: Implementation NCLEX: Psychosocial Integrity

26. A patient is hospitalized with severe vomiting and colicky abdominal pain that is somewhat relieved with the vomiting. The health care provider orders an IV infusion of lactated Ringer's solution and placement of an NG tube. An appropriate collaborative problem for the nurse to identify for the patient at this time is a. potential complication: volvulus. b. potential complication: thromboembolism. c. potential complication: renal insufficiency. d. potential complication: metabolic alkalosis.

D Rationale: Metabolic alkalosis is a complication of NG suction resulting from loss of HCl from the stomach. Volvulus and thromboembolism are not associated with NG placement. The patient is hydrated with IV fluids to avoid renal insufficiency or failure. Cognitive Level: Application Text Reference: pp. 1061-1062 Nursing Process: Diagnosis NCLEX: Physiological Integrity

29. While obtaining a nursing history from a 55-year-old patient scheduled for a colonoscopy, the nurse will be most concerned about a. lifelong constipation. b. nausea and vomiting. c. history of an appendectomy. d. recent blood in the stools.

D Rationale: Rectal bleeding is associated with colorectal cancer. Recent changes in bowel patterns are a clinical manifestation of colorectal cancer, but lifelong constipation is not an indication. Nausea and vomiting are not common clinical manifestations of problems with the distal GI tract. An appendectomy is not a risk factor for cancer of the colon. Cognitive Level: Application Text Reference: pp. 1064-1065 Nursing Process: Assessment NCLEX: Physiological Integrity

10. A patient is brought to the emergency department following an automobile accident in which blunt trauma to the abdomen occurred. The patient is splinting the abdomen and complaining of pain, and bowel sounds are decreased. Peritoneal lavage returns brown drainage. Based on the results of the lavage, the nurse plans for a. preparation for a paracentesis. b. administration of pain medications. c. continued monitoring of the patient's condition. d. immediate preparation of the patient for surgery.

D Rationale: Return of brown drainage suggests perforation of the bowel and the need for immediate surgery. Paracentesis is not a treatment for abdominal trauma and may spread infection. Administration of pain medication and/or continued monitoring may be indicated for a negative finding with peritoneal lavage. Cognitive Level: Application Text Reference: p. 1048 Nursing Process: Planning NCLEX: Physiological Integrity

20. After teaching a patient with IBD about recommended dietary modifications, the nurse identifies a need for further instruction when the patient chooses from the menu a. spaghetti with tomato sauce. b. poached eggs and crisp bacon. c. boiled shrimp and white rice. d. ham hocks and beans.

D Rationale: The patient is taught to avoid high-fiber foods such as beans. In addition, high-fat foods such as ham may trigger diarrhea in some patients. The other choices are appropriate for a patient with IBD. Cognitive Level: Application Text Reference: pp. 1057-1058 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

44. After a patient with IBD has had dietary teaching, which food choice by the patient indicates that the teaching has been successful? a. Oatmeal with cream, whole wheat toast, and a banana b. Corn tortilla taco with chicken, lettuce, tomato, and cheese c. Roast beef, mashed potatoes, and a tossed green salad d. Chicken sandwich with mayonnaise on white bread

D Rationale: This choice is consistent with the appropriate high-protein, low-residue diet. Oatmeal, whole wheat toast, green salad, corn tacos, lettuce, and tomato are all high-fiber choices and likely to worsen symptoms. Cognitive Level: Application Text Reference: pp. 1056-1057, 1059 Nursing Process: Evaluation NCLEX: Physiological Integrity

The nurse is caring for a client who has food poisoning that may be the result of Clostridium botulinum infection. Which is the priority nursing assessment for this client? a. Heart rate and rhythm b. Bowel sounds and heart tones c. Fluid balance and urine output d. Oxygen saturation and respiratory rate

D Severe infection with Clostridium botulinum can lead to respiratory failure, so assessments of oxygen saturation and respiratory rate are of high priority for clients with suspected Clostridium botulinum infection. The other assessments may be completed after the respiratory system has been assessed.

The nurse is teaching self-care measures for a client who has hemorrhoids. Which nursing intervention does the nurse include in the plan of care for the client? a. Instruct the client to use dibucaine (Nupercainal) ointment whenever needed. b. Teach the client to choose low-fiber foods to make bowels move more easily. c. Tell the client to take his or her time on the toilet when needing to defecate. d. Encourage the client to dab with moist wipes instead of wiping with toilet paper.

D The client should be instructed to use wet wipes and dab the anal area after defecating to avoid further irritation. Dibucaine can be used only for short periods of time because long-term use can mask worsening symptoms. Clients with hemorrhoids require high-fiber foods. The client should not be encouraged to strain at stool or to spend long periods of time on the toilet, because this increases pressure in the rectal area, which can make hemorrhoids worse.

The nurse is caring for a client with Crohn's disease who has developed a fistula. Which nursing intervention is the highest priority? a. Monitor the client's hematocrit and hemoglobin. b. Position the client to allow gravity drainage of the fistula. c. Check and record blood glucose levels every 6 hours. d. Encourage the client to consume a diet high in protein and calories.

D The client with Crohn's disease is already at risk for malabsorption and malnutrition. Malnutrition impairs healing of the fistula and immune responses. Therefore, maintaining adequate nutrition is a priority for this client. The client will require 3000 calories per day to promote healing of the fistula. Monitoring the client's blood sugar and hemoglobin levels is important, but less so than encouraging nutritional intake. The client need not be positioned to facilitate gravity drainage of the fistula, because fistulas often are found in the abdominal cavity.

The nurse is caring for a client who has suffered abdominal trauma in a motor vehicle crash. Which laboratory finding indicates that the client's liver was injured? a. Serum lipase, 49 U/L b. Serum amylase, 68 IU/L c. Serum creatinine, 0.8 mg/dL d. Serum transaminase, 129 IU/L

D The level of serum transaminase, a liver enzyme, is elevated with liver trauma. The other laboratory values are within normal limits and are not specific for the liver.

The nurse asks a 68-year-old patient scheduled for colectomy to sign the operative permit as directed in the physician's preoperative orders. The patient states that the physician has not really explained very well what is involved in the surgical procedure. What is the most appropriate action by the nurse? A. Ask family members whether they have discussed the surgical procedure with the physician. B. Have the patient sign the form and state the physician will visit to explain the procedure before surgery. C. Explain the planned surgical procedure as well as possible and have the patient sign the consent form. D. Delay the patient's signature on the consent and notify the physician about the conversation with the patient

D The patient should not be asked to sign a consent form unless the procedure has been explained to the satisfaction of the patient. The nurse should notify the physician, who has the responsibility for obtaining consent.

The nurse helps a client with diverticular disease choose appropriate dinner options. Which menu selections are most appropriate? a. Roasted chicken, rice pilaf, cup of coffee with cream b. Spaghetti with meat sauce, fresh fruit cup, hot tea with lemon c. Chicken Caesar salad, cup of bean soup, glass of low-fat milk d. Baked fish with steamed asparagus, dinner roll with butter, glass of apple juice

D Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup of bean soup) should be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet.

After an abdominal resection for colon cancer, Madeline returns to her room with a Jackson-Pratt drain in place. The purpose of the drain is to: a Irrigate the incision with a saline solution. b Prevent bacterial infection of the incision. c Measure the amount of fluid lost after surgery. d Prevent accumulation of drainage in the wound.

D A Jackson-Pratt drain promotes wound healing by allowing fluid to escape from the wound

Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment is effective? a There is no skin breakdown. b Her appetite improves. c She loses more than 10 lbs. d Stools are less fatty and decreased in frequency.

D Pancrelipase provides the exocrine pancreatic enzyme necessary for proper protein, fat, and carb digestion. With increased fat digestion and absorption, stools become less frequent and normal in appearance.

Which of the following is an outcome of histamine 2 (H2)-receptor antagonists blocking the action of histamine in the stomach? a) Blood phosphate levels are elevated. b) Symptoms of gastroesophageal reflux are relieved. c) Acid indigestion is relieved. d) Acid secretion is reduced.

D) Acid secretion is reduced H2-receptor antagonists decrease the amount of hydrochloric acid that the stomach produces by blocking the action of histamine on histamine receptors of potential cells in the stomach.

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? a) Imbalanced nutrition: Less than body requirements related to biliary inflammation b) Anxiety related to unknown outcome of hospitalization c) Deficient knowledge related to prevention of disease recurrence d) Acute pain related to biliary spasms

D) Acute pain related to biliary spasms The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.

A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention: a) alcohol abuse and a history of acute renal failure. b) a history of hemorrhoids and smoking. c) a sedentary lifestyle and smoking. d) alcohol abuse and smoking.

D) Alcochol abuse and smoking The nurse should mention that risk factors for peptic (gastric and duodenal) ulcers include alcohol abuse, smoking, and stress. A sedentary lifestyle and a history of hemorrhoids aren't risk factors for peptic ulcers. Chronic renal failure, not acute renal failure, is associated with duodenal ulcers.

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which of the following responses by the nurse is most appropriate? A) "The hepatitis vaccine will provide immunity from this exposure and future exposures." B) "I am afraid there is nothing you can do since the patient was infectious before admission." C) "You will need to be tested first to make sure you don't have the virus before we can treat you." D) "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure."

D) An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure Immunoglobulin provides temporary (1-2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.

Which of the following would a nurse expect to assess in a client with peritonitis? a) Decreased pulse rate b) Deep slow respirations c) Hyperactive bowel sounds d) Board-like abdomen

D) Board-like abdomen The client with peritonitis would typically exhibit a rigid, board-like abdomen, with absent bowel sounds, elevated pulse rate, and rapid, shallow respirations.

The nurse is preparing to administer a scheduled dose of docusate sodium (Colace) when the patient complains of an episode of loose stool and does not want to take the medication. Which of the following is the appropriate action by the nurse? A) Write an incident report about this untoward event. B) Attempt to have the family convince the patient to take the ordered dose. C) Withhold the medication at this time and try to administer it later in the day. D) Chart the dose as not given on the medical record and explain in the nursing progress notes.

D) Chart the dose as not given on the medical record and explain in the nursing progress notes. Whenever a patient refuses medication, the dose should be charted as not given. An explanation of the reason should then be documented in the nursing progress notes. In this instance, the refusal indicates good judgment by the patient.

What kind of feeding should be administered to a client who is at the risk of diarrhea due to hypertonic feeding solutions? a) Bolus feeding b) Intermittent feeding c) Cyclic feeding d) Continuous feedings

D) Continuous feedings. Continuous feedings should be administered to a client who is at the risk of diarrhea due to hypertonic feeding solutions.

To ensure patency of central venous line ports, diluted heparin flushes are used in which of the following situations? a) Before drawing blood b) With continuous infusions c) When the line is discontinued d) Daily when not in use

D) Daily when not in use Daily instillation of dilute heparin flush when a port is not in use will maintain the port. Continuous infusion maintains the patency of each port. Heparin flushes are used after each intermittent infusion. Heparin flushes are used after blood drawing in order to prevent clotting of blood within the port. Heparin flush of ports is not necessary if a line is to be discontinued.

The most common symptom of esophageal disease is a) nausea. b) odynophagia. c) vomiting. d) dysphagia.

D) Dysphagia This symptom may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain on swallowing. Nausea is the most common symptom of gastrointestinal problems in general. Vomiting is a nonspecific symptom that may have a variety of causes. Odynophagia refers specifically to acute pain on swallowing.

The client is experiencing swallowing difficulties and is now scheduled to receive a gastric feeding. She has the following oral medications prescribed: furosemide (Lasix), digoxin, enteric coated aspirin (Ecotrin), and vitamin E. The nurse withholds a) furosemide b) digoxin c) vitamin E d) enteric coated aspirin

D) Enteric coated aspirin Simple compressed tablets (furosemide, digoxin) may be crushed and dissolved in water. Soft gelatin capsules filled with liquid (vitamin E) may be opened, and the contents squeezed out. Enteric coated tablets (enteric coated aspirin) are not to be crushed and a change in the form of the medications is required.

What are medium-length nasoenteric tubes are used for? a) Aspiration b) Emptying c) Decompression d) Feeding

D) Feeding Placement of the tube must be verified prior to any feeding. A gastric sump and nasoenteric tube are used for gastrointestinal decompression. Nasoenteric tubes are used for feeding. Gastric sump tubes are used to decompress the stomach and keep it empty.

A client has a gastrointestinal tube that enters the stomach through a surgically created opening in the abdominal wall. The nurse documents this as which of the following? a) Jejunostomy tube b) Nasogastric tube c) Orogastric tube d) Gastrostomy tube

D) Gastrostomy tube A gastrostomy tube enters the stomach through a surgically created opening into the abdominal wall. A jejunostomy tube enters jejunum or small intestine through a surgically created opening into the abdominal wall. A nasogastric tube passes through the nose into the stomach via the esophagus. An orogastric tube passes through the mouth into the stomach.

A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is appropriate? a) Maintaining wrinkles in the faceplate so it doesn't irritate the skin b) Scrubbing fecal material from the skin surrounding the stoma c) Cutting the faceplate opening no more than 2? larger than the stoma d) Gently washing the area surrounding the stoma using a facecloth and mild soap

D) Gently washing the area surrounding the stoma using a facecloth and mild soap For a client with an ostomy, maintaining skin integrity is a priority. The nurse should gently wash the area surrounding the stoma using a facecloth and mild soap. Scrubbing the area around the stoma can damage the skin and cause bleeding. The faceplate opening should be no more than 1/8? to 1/6? larger than the stoma. This size protects the skin from exposure to irritating fecal material. The nurse can create an adequate seal and prevent leakage of fecal material from under the faceplate by applying a thin layer of skin barrier and smoothing out wrinkles in the faceplate. Eliminating wrinkles in the faceplate also protects the skin surrounding the stoma from pressure.

Which of the following is the major carbohydrate that tissue cells use as fuel? a) Proteins b) Fats c) Chyme d) Glucose

D) Glucose Glucose is the major carbohydrate that tissue cells use as fuel. Proteins are a source of energy after they are broken down into amino acids and peptides. Chyme stays in the small intestine for 3 to 6 hours, allowing for continued breakdown and absorption of nutrients. Ingested fats become monoglycerides and fatty acids by the process of emulsification.

When reviewing the history of a client with pancreatic cancer, the nurse would identify which of the following as a possible risk factor? a) Ingestion of a low-fat diet b) One-time exposure to petrochemicals c) Ingestion of caffeinated coffee d) History of pancreatitis

D) History of pancreatitis Pancreatitis is associated with the development of pancreatic cancer. Other factors that correlate with pancreatic cancer include diabetes mellitus, a high-fat diet, and chronic exposure to carcinogenic substances (i.e., petrochemicals). Although data are inconclusive, a relationship may exist between cigarette smoking and high coffee consumption (especially decaffeinated coffee) and the development of pancreatic carcinoma.

A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test? a) "I'll drink full liquids the day before the test." b) "There is no need for special preparation before the test." c) "I'll take a laxative to clear my bowels before the test." d) "I'll avoid eating or drinking anything 6 to 8 hours before the test."

D) I'll avoid eating or drinking anything 6 to 8 hours before the test The client demonstrates understanding of a barium swallow when he states that he must refrain from eating or drinking for 6 to 8 hours before the test. No other preparation is needed. Before a lower GI series, the client should eat a low-residue or clear liquid diet for 2 days and take a potent laxative and an oral liquid preparation.

Which of the following is a parasympathetic response in the GI tract? a) Blood vessel constriction b) Decreased gastric secretion c) Decreased motility d) Increased peristalsis

D) Increased peristalsis Increased peristalsis is a parasympathetic response in the GI tract. Decreased gastric secretion, blood vessel constriction, and decreased motility are sympathetic responses in the GI tract.

The nurse is preparing to administer a dose of bisacodyl (Dulcolax). In explaining the medication to the patient, the nurse would state that it acts in which of the following ways? A) Increases bulk in the stool B) Lubricates the intestinal tract to soften feces C) Increases fluid retention in the intestinal tract D) Increases peristalsis by stimulating nerves in the colon wall

D) Increases peristalsis by stimulating nerves in the colon wall Bisacodyl is a stimulant laxative that aids in producing a bowel movement by irritating the colon wall and stimulating enteric nerves. It is available in oral and suppository forms.

When planning care for a patient with cirrhosis, the nurse will give highest priority to which of the following nursing diagnoses? A) Imbalanced nutrition: less than body requirements B) Impaired skin integrity related to edema, ascites, and pruritus C) Excess fluid volume related to portal hypertension and hyperaldosteronism D) Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

D) Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.

Crohn's disease is a condition of malabsorption caused by which of the following pathophysiological processes? a) Infectious disease b) Gastric resection c) Disaccharidase deficiency d) Inflammation of all layers of intestinal mucosa

D) Inflammation of all layers of intestinal mucosa Crohn's disease is also known as regional enteritis and can occur anywhere along the GI tract, but most commonly at the distal ileum and in the colon. Infectious disease causes problems such as small bowel bacterial overgrowth leading to malabsorption. Disaccharidase deficiency leads to lactose intolerance. Postoperative malabsorption occurs after gastric or intestinal resection.

Which of the following terms describes a gastric secretion that combines with vitamin B12 so that it can be absorbed? a) Amylase b) Trypsin c) Pepsin d) Intrinsic factor

D) Intrinsic factor Intrinsic factor, secreted by the gastric mucosa, combines with dietary vitamin B12 so that the vitamin can be absorbed in the ileum. In the absence of intrinsic factor, vitamin B12 cannot be absorbed and pernicious anemia results. Amylase is an enzyme that aids in the digestion of starch. Pepsin, an important enzyme for protein digestion, is the end product of the conversion of pepsinogen from the chief cells. Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein.

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption? a) Hydrochloric acid b) Histamine c) Liver enzyme d) Intrinsic factor

D) Intrinsic factor Vitamin B12 absorption depends on intrinsic factor, which is secreted by parietal cells in the stomach. The vitamin binds with intrinsic factor and is absorbed in the ileum. Hydrochloric acid, histamine, and liver enzymes don't influence vitamin B12 absorption.

A nurse is preparing a client for a protcosigmoidoscopy. Identify the quadrant on which this diagnostic test will focus. A) RUQ B) RLQ C) LUQ D) LLQ

D) LLQ The sigmoid colon is in the left lower quadrant. Proctosigmoidoscopy is examination of the rectum and sigmoid colon using a rigid endoscope inserted anally about 10 inches.

A physician has ordered a liver biopsy for a client whose condition is deteriorating. Which of the following places the client at high risk due to her altered liver function during the biopsy? a) Low hemoglobin b) Decreased prothrombin time c) Low sodium level d) Low platelet count

D) Low platelet count Certain blood tests provide information about liver function. Prolonged prothrombin time (PT) and low platelet count place the client at high risk for hemorrhage. The client may receive intravenous (IV) administration of vitamin K or infusions of platelets before liver biopsy to reduce the risk of bleeding.

Regarding oral cancer, the nurse provides health teaching to inform the patient that a) most oral cancers are painful at the outset. b) blood testing is used to diagnose oral cancer. c) a typical lesion is soft and craterlike. d) many oral cancers produce no symptoms in the early stages.

D) Many oral cancers produce no symptoms in the early stages The most frequent symptom of oral cancer is a painless sore that does not heal. The patient may complain of tenderness, and difficulty with chewing, swallowing, or speaking as the cancer progresses. Biopsy is used to diagnose oral cancer. A typical lesion in oral cancer is a painless hardened ulcer with raised edges.

The nurse would question the use of which of the following cathartic agents in a patient with renal insufficiency? A) Bisacodyl B) Lubiprostone C) Cascara sagrada D) Milk of magnesia

D) Milk of Magnesia Milk of magnesia may cause hypermagnesemia in patients with renal insufficiency. The nurse should question this order with the health care provider before administration.

A nurse is caring for a client who is undergoing a diagnostic workup for a suspected GI problem. The client reports gnawing epigastric pain following meals and heartburn. The nurse suspects the client has: a) diverticulitis. b) peptic ulcer disease. c) appendicitis. d) ulcerative colitis.

D) Peptic Ulcer Disease Peptic ulcer disease is characterized by dull, gnawing pain in the midepigastrium or the back that worsens with eating. Ulcerative colitis is characterized by exacerbations and remissions of severe bloody diarrhea. Appendicitis is characterized by epigastric or umbilical pain along with nausea, vomiting, and low-grade fever. Pain caused by diverticulitis is in the left lower quadrant and has a moderate onset. It's accompanied by nausea, vomiting, fever, and chills.

Which client requires immediate nursing intervention? The client who: a) complains of epigastric pain after eating. b) complains of anorexia and periumbilical pain. c) presents with ribbonlike stools. d) presents with a rigid, boardlike abdomen.

D) Presents with a rigid, boardlike abdomen A rigid, boardlike abdomen is a sign of peritonitis, a possibly life-threatening condition. Epigastric pain occurring 90 minutes to 3 hours after eating indicates a duodenal ulcer. Anorexia and periumbilical pain are characteristic of appendicitis. Risk of rupture is minimal within the first 24 hours, but increases significantly after 48 hours. A client with a large-bowel obstruction may have ribbonlike stools.

A patient reports having dry mouth and asks for some liquid to drink. The nurse reasons that this symptom can most likely be attributed to a common adverse effect of which of the following medications? A) Digoxin (Lanoxin) B) Cefotetan (Cefotan) C) Famotidine (Pepcid) D) Promethazine (Phenergan)

D) Promethazine (Phenergan) A common adverse effect of promethazine, an antihistamine antiemetic agent, is dry mouth; another is blurred vision.

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? a) Withhold oral feedings for the client. b) Instruct the client to avoid coughing. c) Monitor pulse oximetry every hour. d) Reposition the client every 2 hours.

D) Reposition the client every 2 hours Repositioning the client every 2 hours minimizes the risk of atelectasis in a client who is being treated for pancreatitis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring the pulse oximetry helps show changes in respiratory status and promote early intervention, but it would do little to minimize the risk of atelectasis. Withholding oral feedings limits the reflux of bile and duodenal contents into the pancreatic duct.

When collecting an admission history, the nurse identifies that the client prefers fish and crustaceans over other sources of protein. When planning discharge teaching for this client the nurse should include the fact that the cooked food most likely to remain contaminated by the virus that causes Hep A is A) canned tuna B) broiled shrimp C) baked haddock D) steamed lobster

D) Steamed lobster. The temperature during steaming is never high enough or sustained long enough to kill organisms

After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? a) Large intestine b) Ileum c) Liver d) Stomach

D) Stomach The upper gastrointestinal (GI) tract begins at the mouth and ends at the jejunum. Therefore, the stomach would be a component of the upper GI tract. The lower GI tract begins at the ileum and ends at the anus. The liver is considered an accessory structure.

After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? a) Ileum b) Liver c) Large intestine d) Stomach

D) Stomach The upper gastrointestinal (GI) tract begins at the mouth and ends at the jejunum. Therefore, the stomach would be a component of the upper GI tract. The lower GI tract begins at the ileum and ends at the anus. The liver is considered an accessory structure.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: a) elevated liver enzymes and low serum protein level. b) subnormal clotting factors and platelet count. c) elevated blood urea nitrogen and creatinine levels and hyperglycemia. d) subnormal serum glucose and elevated serum ammonia levels.

D) Subnormal serum glucose and elevated serum ammonia levels. In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.

Why should total parental nutrition (TPN) be used cautiously in clients with pancreatitis? a) Such clients can digest high-fat foods. b) Such clients are at risk for hepatic encephalopathy. c) Such clients are at risk for gallbladder contraction. d) Such clients cannot tolerate high-glucose concentration.

D) Such clients cannot tolerate high glucose concentration Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.

An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make? a) Take a mild laxative such as magnesium citrate when necessary. b) Administer a tap-water enema weekly. c) Administer a phospho-soda (Fleet) enema when necessary. d) Take a stool softener such as docusate sodium (Colace) daily.

D) Take a stool softener such as docuaste sodium (Colace) daily. Stool softeners taken daily promote absorption of liquid into the stool, creating a softer mass. They may be taken on a daily basis without developing a dependence. Dependence is an adverse effect of daily laxative use. Enemas used daily or on a frequent basis can also lead to dependence of the bowel on an external source of stimulation.

A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge? a) Hold his breath b) Bear down as if having a bowel movement c) Pant like a dog d) Take long, slow breaths

D) Take long, slow breaths During passage of the bougies used to dilate the esophagus, the client should take long, slow breaths to minimize the vomiting urge. Having the client hold the breath, bear down as if having a bowel movement, or pant like a dog is neither required nor helpful.

Blood shed in sufficient quantities into the upper GI tract, produces which color of stool? a) Bright red b) Milky white c) Green d) Tarry-black

D) Tarry-black Blood shed in sufficient quantities into the upper GI tract produces a tarry-black stool. Blood entering the lower portion of the GI tract or passing rapidly through it will appear bright or dark red. A milky white stool is indicative "of" a patient who received barium. A green stool is indicative of a patient who has eaten spinach.

A client with diabetes begins to have digestive problems and is told by the physician that they are a complication of the diabetes. Which of the following explanations from the nurse is most accurate? a) Insulin has an adverse effect of constipation. b) The nerve fibers of the intestinal lining are experiencing neuropathy. c) Elevated glucose levels cause bacteria overgrowth in the large intestine. d) The pancreas secretes digestive enzymes.

D) The pancreas secretes digestive enzymes While the pancreas has the well-known function of secreting insulin, it also secretes digestive enzymes. These enzymes include trypsin, amylase, and lipase. If the secretion of these enzymes are affected by a diseased pancreas as foundi with diabetes, the digestive functioning may be impaired.

The most significant complication related to continuous tube feedings is a) an interruption in fat metabolism and lipoprotein synthesis. b) a disturbance in the sequence of intestinal and hepatic metabolism. c) the interruption of GI integrity, d) the potential for aspiration,

D) The potential for aspiration Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the patient receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis.

The nurse is caring for a postoperative patient with a colostomy. The nurse is preparing to administer a dose of famotidine (Pepcid) when the patient asks why the medication was ordered since the patient does not have a history of heartburn or gastroesophageal reflux disease (GERD). Which of the following would be the most appropriate response by the nurse? A) "This will prevent air from accumulating in the stomach, causing gas pains." B) "This will prevent the heartburn that occurs as a side effect of general anesthesia." C) "The stress of surgery is likely to cause stomach bleeding if you do not receive it." D) "This will reduce the amount of HCl in the stomach until the nasogastric tube is removed, and you can eat a regular diet again."

D) This will reduce the amount of HCl in the stomach until the nasogastric tube is removed, and you can eat a regular diet again Famotidine is an H2-receptor antagonist that inhibits gastric HCl secretion and thus minimizes damage to gastric mucosa while the patient is not eating a regular diet after surgery.

Why are antacids administered regularly, rather than as needed, in peptic ulcer disease? a) To increase pepsin activity b) To maintain a regular bowel pattern c) To promote client compliance d) To keep gastric pH at 3.0 to 3.5

D) To keep gastric pH at 3.0 to 3.5 To maintain a gastric pH of 3.0 to 3.5 throughout each 24-hour period, regular (not as needed) doses of an antacid are needed to treat peptic ulcer disease. Frequent administration of an antacid tends to decrease client compliance rather than promote it. Antacids don't regulate bowel patterns, and they decrease pepsin activity.

Which of the following symptoms characterizes regional enteritis? a) Severe diarrhea b) Diffuse involvement c) Exacerbations and remissions d) Transmural thickening

D) Transmural thickening Transmural thickening is an early pathologic change of Crohn's disease. Later pathology results in deep, penetrating granulomas. Regional enteritis is characterized by regional discontinuous lesions. Severe diarrhea is characteristic of ulcerative colitis while diarrhea in regional enteritis is less severe. Regional enteritis is characterized by a prolonged and variable course while ulcerative colitis is characterized by exacerbations and remissions.

A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. The nurse suspects: a) Peritonitis b) A normal reaction to surgery c) Dehiscence of the surgical wound d) Vasomotor symptoms associated with dumping syndrome

D) Vasomotor symptoms associated with dumping syndrome Early manifestations of dumping syndrome occur 15 to 30 minutes after eating. Signs and symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, diarrhea, nausea, and the desire to lie down. Dehiscence of the surgical wound is characterized by pain and a pulling or popping feeling at the surgical site. Peritonitis presents with a rigid, boardlike abdomen, tenderness, and fever. The client's signs and symptoms aren't a normal reaction to surgery.

A client with complaints of right lower quadrant pain is admitted to the emergency department. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the physician immediately? a) Hematocrit 42% b) Serum potassium 4.2 mEq/L c) Serum sodium 135 mEq/L d) White blood cell (WBC) count 22.8/mm3

D) White blood cell (WBC) count 22.8/mm3 The nurse should report the elevated WBC count. This finding, which is a sign of infection, indicates that the client's appendix might have ruptured. Hematocrit of 42%, serum potassium of 4.2 mEq/L, and serum sodium of 135 mEq/L are within normal limits. Alterations in these levels don't indicate appendicitis.

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: a) black, tarry stools. b) circumoral pallor. c) light amber urine. d) yellow sclerae.

D) Yellow sclerae Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

Fulminant viral hepatitis as a complication of viral hepatitis is highest in those individuals with a. hepatitis A b. Hepatitis C c. hepatitis B accompanied with hepatitis C d. hepatitis B accompanied with hepatitis D

D- Although fulminant hepatitis can occur with hepatitis A and hepatitis C, it is more common in hepatitis B, especially in Hep B infection accompanied by infection with Hep D virus

A patient with cirrhosis that is refractory to other treatments for esophageal varices undergoes a peritoneovenous shunt. As a result of this procedure, the nurse would expect the patient to experience a. an improved survival rate b. decreased serum ammonia levels c. improved metabolism of nutrients d. improved hemodynamic function and renal perfusion

D- By shunting fluid sequestered in the peritoneum into the venous system, pressur eon esophageal veins is decreased, and more volume is returned to the circulation, improving CO and renal perfusion. However, because ammonia is diverted past the liver, hepatic encephalopathy continues. These procedures do not prolong life or promote liver function.

The nurse recognizes early signs of hepatic encephalopathy in the patient who a. manifests asterixis b. becomes unconscious c. has increasing oliguria d. is irritable and lethargic

D- Early signs of this neurologic condition include euphoria, depression, apathy, irritability, confusion, agitation, drowsiness, and lethargy. Loss of consciousness is usually preceded by asterixis, disorientation, hyperventilation, hypothermia, and alterations in reflexes. Increasing oliguria is a sign of hepatorenal syndrome.

The family members of a patient with hepatitis A ask if there is anything that will prevent them from developing the disease. The best response by the nurse is a. "no immunization is available for hepatitis A, nor are you likely to get the disease" b. "only individuals who have had sexual contact with the patient should receive immunization" c. "all family members should receive the hepatitis A vaccine to prevent or modify the infection" d. "those who have had household or close contact with the patient should receive immune globulin"

D- Individuals who have been exposed to hepatitis A through household contact or foodborne outbreaks should be given immune globulin within 1 to 2 weeks of exposure to prevent or modify the illness. Hep A vaccine is used to provide pre-exposure immunity to the virus and is indicated for individuals at high risk for hep A exposure. Although hep A can be spread by sexual contact, the risk is higher for transmission with the oral-fecal route.

The systemic effects of viral hepatitis are caused primarily by a. cholestasis b. impaired portal circulation c. toxins produced by the infected liver d. activation of the complement system by antigen-antibody complexes

D- The systemic manifestations of rash, angioedema, arthritis, fever, and malaise in viral hepatitis are caused by the activation o the complement system by circulating immune complexes. Liver manifestations include jaundice from hepatic cell damage and cholestasis as well as anorexia perhaps caused by toxins produced by the damaged liver. Impaired portal circulation usually does not occur in uncomplicated viral hepatitis but would be a liver manifestation

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which response by the nurse is most appropriate? A. "The hepatitis vaccine will provide immunity from this exposure and future exposures." B. "I am afraid there is nothing you can do since the patient was infectious before admission." C. "You will need to be tested first to make sure you don't have the virus before we can treat you." D. "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure."

D. "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure." Immunoglobulin provides temporary (1-2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.

When teaching the patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement? A. "I will use care when kissing my wife to prevent giving it to her." B. "I will need to take adofevir (Hepsera) to prevent chronic HCV." C. "Now that I have had HCV, I will have immunity and not get it again." D. "I will need to be checked for chronic HCV and other liver problems."

D. "I will need to be checked for chronic HCV and other liver problems." The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adofevir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.

If a client had irritable bowel syndrome, which of the following diagnostic tests would determine if the diagnosis is Crohn's disease or ulcerative colitis? A. Abdominal computed tomography (CT) scan B. Abdominal x-ray C. Barium swallow D. Colonoscopy with biopsy

D. A colonoscopy with biopsy can be performed to determine the state of the colon's mucosal layers, presence of ulcerations, and level of cytologic development. An abdominal x-ray or CT scan wouldn't provide the cytologic information necessary to diagnose which disease it is. A barium swallow doesn't involve the intestine.

Which of the following laboratory results would be expected in a client with peritonitis? A. Partial thromboplastin time above 100 seconds B. Hemoglobin level below 10 mg/dL C. Potassium level above 5.5 mEq/L D. White blood cell count above 15,000

D. Because of infection, the client's WBC count will be elevated. A hemoglobin level below 10 mg/dl may occur from hemorrhage. A PT time longer than 100 seconds may suggest disseminated intravascular coagulation, a serious complication of septic shock. A potassium level above 5.5 mEq/L may indicate renal failure.

Crohn's disease can be described as a chronic relapsing disease. Which of the following areas in the GI system may be involved with this disease? A. The entire length of the large colon B. Only the sigmoid area C. The entire large colon through the layers of mucosa and submucosa D. The small intestine and colon; affecting the entire thickness of the bowel

D. Crohn's disease can involve any segment of the small intestine, the colon, or both, affecting the entire thickness of the bowel. Answers 1 and 3 describe ulcerative colitis, answer 2 is too specific and therefore, not likely.

The health care provider orders lactulose for a patient with hepatic encephalopathy. How will you assess effectiveness of this medication? A. Relief of constipation B. Relief of abdominal pain C. Decreased liver enzymes D. Decreased ammonia levels

D. Decreased ammonia levels

The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what? A. Relief of constipation B. Relief of abdominal pain C. Decreased liver enzymes D. Decreased ammonia levels

D. Decreased ammonia levels. Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy

When teaching an elderly client how to prevent constipation, which of the following instructions should the nurse include? A. "Drink 6 glasses of fluid each day." B. "Avoid grain products and nuts." C. "Add at least 4 grams of brain to your cereal each morning." D. "Be sure to get regular exercise."

D. Exercise helps prevent constipation. Fluids and dietary fiber promote normal bowel function. The client should drink eight to ten glasses of fluid each day. Although adding bran to cereal helps prevent constipation by increasing dietary fiber, the client should start with a small amount and gradually increase the amount as tolerated to a maximum of 2 grams a day.

A client presents to the emergency room, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts him at risk for which of the following? A. Metabolic acidosis with hyperkalemia B. Metabolic acidosis with hypokalemia C. Metabolic alkalosis with hyperkalemia D. Metabolic alkalosis with hypokalemia

D. Gastric acid contains large amounts of potassium, chloride, and hydrogen ions. Excessive loss of these substances, such as from vomiting, can lead to metabolic alkalosis and hypokalemia.

You are caring for a 68-year-old patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass and a bowel obstruction is suspected. You are auscultating the abdomen listening for which types of bowel sounds that are consistent with the patient's clinical picture? A. Low pitched and rumbling above the area of obstruction B. High pitched and hypoactive below the area of obstruction C. Low pitched and hyperactive below the area of obstruction D. High pitched and hyperactive above the area of obstruction

D. High pitched and hyperactive above the area of obstruction Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high pitched, sometimes referred to as "tinkling" above the level of the obstruction. This occurs because peristaltic action increases to push past the area of obstruction.

A patient who has hepatitis B surface antigen (HBsAg) in the serum is being discharged with pain medication after knee surgery. Which medication order should the nurse question because it is most likely to cause hepatic complications? A. Tramadol (Ultram) B. Hydromorphone (Dilaudid) C. Oxycodone with aspirin (Percodan) D. Hydrocodone with acetaminophen (Vicodin)

D. Hydrocodone with acetaminophen (Vicodin) The analgesic with acetaminophen should be questioned because this patient is a chronic carrier of hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage.

When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? A. Impaired skin integrity related to edema, ascites, and pruritus B. Imbalanced nutrition: less than body requirements related to anorexia C. Excess fluid volume related to portal hypertension and hyperaldosteronism D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.

During preparation for bowel surgery, a male client receives an antibiotic to reduce intestinal bacteria. Antibiotic therapy may interfere with synthesis of which vitamin and may lead to hypoprothrombinemia? a. vitamin A b. vitamin D c. vitamin E d. vitamin K

D. Intestinal bacteria synthesize such nutritional substances as vitamin K, thiamine, riboflavin, vitamin B12, folic acid, biotin, and nicotinic acid. Therefore, antibiotic therapy may interfere with synthesis of these substances, including vitamin K. Intestinal bacteria don't synthesize vitamins A, D, or E.

The nurse is reviewing the physician's orders written for a client admitted with acute pancreatitis. Which physician order would the nurse question if noted on the client's chart? A. NPO status B. Insert a nasogastric tube C. An anticholinergic medication D. Morphine for pain

D. Meperidine (Demerol) rather than morphine is the medication of choice because morphine can cause spasm in the sphincter of Oddi.

Which of the following substances is most likely to cause gastritis? A. Milk B. Bicarbonate of soda, or baking soda C. Enteric coated aspirin D. Nonsteriodal anti-imflammatory drugs

D. NSAIDS are a common cause of gastritis because they inhibit prostaglandin synthesis. Milk, once thought to help gastritis, has little effect on the stomach mucosa. Bicarbonate of soda, or baking soda, may be used to neutralize stomach acid, but it should be used cautiously because it may lead to metabolic acidosis. ASA with enteric coating shouldn't contribute significantly to gastritis because the coating limits the aspirin's effect on the gastric mucosa.

For a patient with Crohn's disease which assessment finding is most important for you to follow-up? A. Bloody diarrheal stool: 4 times/day B. Abdominal cramping C. Temperature: 100.4° F (38° C) D. Positive rebound tenderness

D. Positive rebound tenderness Positive rebound tenderness is a classic sign of peritonitis and requires emergency follow-up. The other options are expected signs or symptoms with ulcerative colitis, which has intermittent exacerbations.

The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician? A. Bloody diarrhea B. Hypotension C. A hemoglobin of 12 mg/dL D. Rebound tenderness

D. Rebound tenderness may indicate peritonitis. Blood diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the physician.

What frequent complication should you monitor for in a patient with fulminant liver failure? A. Crohn's disease B. Sepsis C. Pancreatitis D. Renal failure

D. Renal failure

In patients at high risk for liver cancer, screening consists of computed tomography (CT), magnetic resonance imaging (MRI), or ultrasound imaging of the liver with what laboratory value? A. Lipase B. Bilirubin C. White blood cells (WBCs) D. Serum α-fetoprotein (AFP)

D. Serum α-fetoprotein (AFP)

Which of the following symptoms may be exhibited by a client with Crohn's disease? A. Bloody diarrhea B. Narrow stools C. N/V D. Steatorrhea

D. Steatorrhea from malaborption can occur with Crohn's disease. N/V, and bloody diarrhea are symptoms of ulcerative colitis. Narrow stools are associated with diverticular disease.

Which of the following diagnostic tests should be performed annually over age 50 to screen for colon cancer? A. Abdominal CT scan B. Abdominal x-ray C. Colonoscopy D. Fecal occult blood test

D. Surface blood vessels of polyps and cancers are fragile and often bleed with the passage of stools. Abdominal x-ray and CT scan can help establish tumor size and metastasis. A colonoscopy can help locate a tumor as well as polyps, which can be removed before they become malignant.

The client who has undergone creation of a colostomy has a nursing diagnosis of Disturbed body image. The nurse would evaluate that the client is making the most significant progress toward identified goals if the client: A. Watches the nurse empty the colostomy bag B. Looks at the ostomy site C. Reads the ostomy product literature D. Practices cutting the ostomy appliance

D. The client is expected to have a body image disturbance after colostomy. The client progresses through normal grieving stages to adjust to this change. The client demonstrates the greatest deal of acceptance when the client participates in the actual colostomy care. Each of the incorrect options represents an interest in colostomy care but is a passive activity. The correct option shows the client is participating in self-care.

Which of the following therapies is not included in the medical management of a client with peritonitis? A. Broad-spectrum antibiotics B. Electrolyte replacement C. I.V. fluids D. Regular diet

D. The client with peritonitis usually isn't allowed anything orally until the source of peritonitis is confirmed and treated. The client also requires broad-spectrum antibiotics to combat the infection. I.V. fluids are given to maintain hydration and hemodynamic stability and to replace electrolytes.

Which of the following nursing interventions should be implemented to manage a client with appendicitis? A. Assessing for pain B. Encouraging oral intake of clear fluids C. Providing discharge teaching D. Assessing for symptoms of peritonitis

D. The focus of care is to assess for peritonitis, or inflammation of the peritoneal cavity. Peritonitis is most commonly caused by appendix rupture and invasion of bacteria, which could be lethal. The client with appendicitis will have pain that should be controlled with analgesia. The nurse should discourage oral intake in preparation of surgery. Discharge teaching is important; however, in the acute phase, management should focus on minimizing preoperative complications and recognizing when such may be occurring.

During the assessment of a client's mouth, the nurse notes the absence of saliva. The client is also complaining of pain near the area of the ear. The client has been NPO for several days because of the insertion of a NG tube. Based on these findings, the nurse suspects that the client is developing which of the following mouth conditions? A. Stomatitis B. Oral candidiasis C. Parotitis D. Gingivitis

D. The lack of saliva, pain near the area of the ear, and the prolonged NPO status of the client should lead the nurse to suspect the development of parotitis, or inflammation of the parotid gland. Parotitis usually develops in cases of dehydration combined with poor oral hygiene or when clients have been NPO for an extended period. Preventative measures include the use of sugarless hard candy or gum to stimulate saliva production, adequate hydration, and frequent mouth care. Stomatitis (inflammation of the mouth) produces excessive salivation and a sore mouth.

A female client with hepatitis C develops liver failure and GI hemorrhage. The blood products that would most likely bring about hemostasis in the client are: a. whole blood and albumin. b. platelets and packed red blood cells. c. fresh frozen plasma and whole blood. d. cryoprecipitate and fresh frozen plasma.

D. The liver is vital in the synthesis of clotting factors, so when it's diseased or dysfunctional, as in hepatitis C, bleeding occurs. Treatment consists of administering blood products that aid clotting. These include fresh frozen plasma containing fibrinogen and cryoprecipitate, which have most of the clotting factors. Although administering whole blood, albumin, and packed cells will contribute to hemostasis, those products aren't specifically used to treat hemostasis. Platelets are helpful, but the best answer is cryoprecipitate and fresh frozen plasma.

Which of the following terms best describes the pain associated with appendicitis? A. Aching B. Fleeting C. Intermittent D. Steady

D. The pain begins in the epigastrium or periumbilical region, then shifts to the right lower quadrant and becomes steady. The pain may be moderate to severe.

Which of the following associated disorders may a client with ulcerative colitis exhibit? A. Gallstones B. Hydronephrosis C. Nephrolithiasis D. Toxic megacolon

D. Toxic megacolon is extreme dilation of a segment of the diseased colon caused by paralysis of the colon, resulting in complete obstruction. This disorder is associated with both Crohn's disease and ulcerative colitis. The other disorders are more commonly associated with Crohn's disease.

Which of the following mechanisms can facilitate the development of diverticulosis into diverticulitis? A. Treating constipation with chronic laxative use, leading to dependence on laxatives B. Chronic constipation causing an obstruction, reducing forward flow of intestinal contents C. Herniation of the intestinal mucosa, rupturing the wall of the intestine D. Undigested food blocking the diverticulum, predisposing the area to bacteria invasion.

D. Undigested food can block the diverticulum, decreasing blood supply to the area and predisposing the area to invasion of bacteria. Chronic laxative use is a common problem in elderly clients, but it doesn't cause diverticulitis. Chronic constipation can cause an obstruction—not diverticulitis. Herniation of the intestinal mucosa causes an intestinal perforation.

The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what? Relief of constipation Relief of abdominal pain Decreased liver enzymes Decreased ammonia levels

Decreased ammonia levels Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy.

A nurse is assisting with a percutaneous liver biopsy. Place the steps involved in care in the correct sequence from first to last. Ensure that the biopsy equipment is assembled and in order. Help the client assume a supine position. Make sure that the specimen container is labeled and delivered to the laboratory. While the physician inserts the needle, instruct the client to take a deep breath and hold it to keep the liver as near to the abdominal wall as possible. Place a rolled towel beneath the client's right lower ribs.

Ensure that the biopsy equipment is assembled and in order. Help the client assume a supine position. Place a rolled towel beneath the client's right lower ribs. While the physician inserts the needle, instruct the client to take a deep breath and hold it to keep the liver as near to the abdominal wall as possible. Make sure that the specimen container is labeled and delivered to the laboratory. When assisting with a percutaneous liver biopsy, the nurse ensures that the biopsy equipment is assembled and in order. He or she helps the client assume a supine position with a rolled towel beneath the right lower ribs. Before the physician inserts the needle, the nurse instructs the client to take a deep breath and hold it to keep the liver as near to the abdominal wall as possible. After specimen cells are obtained, they are placed in a preservative. The nurse makes sure that the specimen container is labeled and delivered to the laboratory.

A client with a history of osteoarthritis has a 10-inch incision following a colon resection. The incision has become infected, and the wound requires extensive irrigation and packing. What aspect of the client's care does the nurse make certain to discuss with the health care provider before the client's discharge?

Having a home health consultation for wound care

The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer? Serum α-fetoprotein level Ventilation/perfusion scan Hepatic structure ultrasound Abdominal girth measurement

Hepatic structure ultrasound Hepatic structure ultrasound, CT, and MRI are used to screen and diagnose liver cancer. Serum α-fetoprotein level may be elevated with liver cancer or other liver problems. Ventilation/perfusion scans do not diagnose liver cancer. Abdominal girth measurement would not differentiate between cirrhosis and liver cancer.

A nurse is caring for a client who is to be discharged after a bowel resection and the creation of a colostomy. Which client statement demonstrates that additional instruction from the nurse is needed?

I can drive my car in about two weeks. The client should avoid driving for 4-6 weeks

An obese client is discharged 10 days after being hospitalized for peritonitis, which resulted in an exploratory laparotomy. Which assessment finding by the client's home health nurse requires immediate action?

I feel like the incision is splitting open

A home health nurse is teaching a client about the care of a new colostomy. Which client statement demonstrates correct understanding of the instructions?

I need to check for leakage underneath my colostomy

A Certified Wound, Ostomy, Continence Nurse (CWOCN) is teaching a client with colorectal cancer how to care for a newly created colostomy. Which client statement reflects correct understanding of the necessary self-management skills?

I will make certain that I always have an extra bag available

A nurse is teaching a client who has undergone a hemorrhoidectomy about a follow-up plan of care. Which client statement demonstrates correct understanding of the nurse's instructions?

I will need to eat a diet high in fiber

A client suspected of having irritable bowel syndrome (IBS) is scheduled for a hydrogen breath test. What does the nurse tell the client about this test?

If you have IBS, hydrogen levels will be increased in your breath samples

A client has developed gastroenteritis while traveling outside the country. What is the likely cause of the client's symptoms?

Ingestion of parasites in water

A client with ulcerative colitis (UC) has stage 1 of a restorative proctocolectomy with ileoanal anastomosis (RPC-IPAA) procedure performed. The client 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

The nurse is caring for a 55-year-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect the patient to exhibit? Hematochezia Left upper abdominal pain Ascites and peripheral edema Temperature over 102o F (38.9o C)

Left upper abdominal pain Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations of acute pancreatitis include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration).

"The client diagnosed with appendicitis has undergone an appendectomy. At two hours postoperative, the nurse takes the vital signs and notes T 102.6 F, P 132, R 26, and BP 92/46. Which interventions should the nurse implement? List in order of priority. 1. Increase the IV rate. 2. Notify the health care provider. 3. Elevate the foot of the bed. 4. Check the abdominal dressing. 5. Determine if the IV antibiotics have been administered.

Order of priority: 1, 3, 4, 5, 2." "1. The nurse should increase the IV rate to maintain the circulatory system function until further orders can be obtained. 3. The foot of the bed should be elevated to help treat shock, the symptoms of which include elevated pulse and decreased BP. Those signs and an elevated temperature indicate an infection may be present and the client could be developing septicemia. 4. The dressing should be assessed to determine if bleeding is occurring. 5. The nurse should administer any IV antibiotics ordered after addressing hypovolemia. The nurse will need this information when reporting to the HCP. 2. The HCP should be notified when the nurse has the needed information."

A client demonstrates the manifestations of appendicitis with a suspected complication of peritonitis. What is the priority nursing intervention?

Preparing the client for emergency surgery

A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm his diagnosis? a) Recent weight loss and temperature elevation b) Presence of easy bruising and bradycardia c) Adventitious breath sounds and hypertension d) Presence of blood in the client's stool and recent hypertension

Recent weight loss and temperature elevation Assessment findings associated with pancreatitis include recent weight loss and temperature elevation. Inflammation of the pancreas causes a response that elevates temperature and leads to abdominal pain that typically occurs with eating. Nausea and vomiting may occur as a result of pancreatic tissue damage that's caused by the activation of pancreatic enzymes. The client may experience weight loss because of the lost desire to eat. Blood in stools and recent hypertension aren't associated with pancreatitis; fatty diarrhea and hypotension are usually present. Presence of easy bruising and bradycardia aren't found with pancreatitis; the client typically experiences tachycardia, not bradycardia. Adventitious breath sounds and hypertension aren't associated with pancreatitis.

A nurse is caring for a client who returns to the unit after having an exploratory abdominal laparotomy. How does the nurse position this client after the client is situated in bed?

Semi-fowlers

A client asks a nurse, "Can you tell me some foods to include in my diet so that I can reduce my chances of getting colorectal cancer?" Which dietary selection does the nurse suggest?

Steamed broccoli with turkey

A

The appropriate collaborative therapy for the patient with acute diarrhea caused by a viral infection is to: A. increased fluid intake B. administer an antibiotic C. administer antimotility drugs D. quarantine the patient to prevent spread of the virus

The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? Has completed a college education Has been able to stop smoking cigarettes Has well-controlled type 1 diabetes mellitus The chest x-ray showed another lung cancer lesion.

The chest x-ray showed another lung cancer lesion. Correct Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug and/or alcohol abuse, and the inability to comprehend or comply with the rigorous post-transplant course.

A male client's sister was recently diagnosed with colorectal cancer (CRC), and his brother died of CRC 5 years ago. He asks the nurse whether he will inherit the disease too. How does the nurse respond?

The only way to know whether you have a predisposition to CRC is by genetic testing

True or False? The nurse encourages that patient with chronic constipation to attempt defecation after the first meal of the day because gastrocolic and duodenocolic reflexes increase colon peristalsis at that time.

True

True or False? The secretion of hydrochloric acid and pepsinogen is stimulated by the sight, smell, and taste of food.

True

When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome (select all that apply)? Use smallest gauge needle possible when giving injections or drawing blood. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. Apply gentle pressure for the shortest possible time period after performing venipuncture. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.

Use smallest gauge needle possible when giving injections or drawing blood. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present. Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding.

When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements (select all that apply)? Vitamin A Vitamin D Vitamin E Vitamin K Vitamin B

Vitamin A Correct Vitamin D Correct Vitamin E Correct Vitamin K Correct Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat-soluble and thus would need to be supplemented in a patient with biliary obstruction.

D

Which of the following should a patient be taught after a hemorrhoidectomy? A. take mineral oil prior to bedtime B eat a low fiber diet to rest the colon C. administer oil retention enema to empty the colon D. use prescribed pain medication before a bowel movement

A client who had surgery for inflammatory bowel disease (IBD) is being discharged. The case manager will arrange for home health care follow-up. The client 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?

Written and oral instructions regarding symptoms to report to the health care provider

In planning care for a patient with metastatic liver cancer, the nurse should include interventions that a. focus primarily on symptomatic and comfort measures. b. reassure the patient that chemotherapy offers a good prognosis. c. promote the patient's confidence that surgical excision of the tumor will be successful. d. provide information necessary for the patient to make decisions regarding liver transplantation. (Lewis 1042)

a Rationale: Nursing intervention for a patient with liver cancer focuses on keeping the patient as comfortable as possible. The prognosis for patients with liver cancer is poor. The cancer grows rapidly, and death may occur within 4 to 7 months as a result of hepatic encephalopathy or massive blood loss from gastrointestinal (GI) bleeding.

A client is admitted to rule out acute pancreatitis. Which of the following laboratory tests will provide the most accurate information to support this medical diagnosis? a Serum lipase b Serum sodium c Serum amylase d Serum potassium

a The most commonly measured pancreatic enzymes are serum amylase and lipase. Measuring lipase levels provides a longer period for trending values than that provided by serum amylase levels.

The nurse performs a detailed assessment of the abdomen of a patient with a possible bowel obstruction, knowing that manifestations of a obstruction in the large intestine are (select all that apply): a. persistent abdominal pain b. marked abdominal distention c. diarrhea that is loose or liquid d. colicky, severe, intermittent pain e. profuse committing that relieves abdominal pain

a & b Rationale: With lower intestinal obstructions, abdominal distention is markedly increased and pain is persistent. Onset of a large intestine obstruction is gradual, vomiting is rare, and there is usually absolute constipation, not diarrhea.

Nursing management of the patient with acute pancreatitis includes (select all that apply) a. checking for signs of hypocalcemia. b. providing a diet low in carbohydrates. c. giving insulin based on a sliding scale. d. observing stools for signs of steatorrhea. e. monitoring for infection, particularly respiratory tract infection. (Lewis 1042)

a, e Rationale: During the acute phase, it is important to monitor vital signs. Hemodynamic stability may be compromised by hypotension, fever, and tachypnea. Intravenous fluids are ordered, and the response to therapy is monitored. Fluid and electrolyte balances are closely monitored. Frequent vomiting, along with gastric suction, may result in decreased levels of chloride, sodium, and potassium. Because hypocalcemia can occur in acute pancreatitis, the nurse should observe for symptoms of tetany, such as jerking, irritability, and muscular twitching. Numbness or tingling around the lips and in the fingers is an early indicator of hypocalcemia. The patient should be assessed for Chvostek's sign or Trousseau's sign. A patient with acute pancreatitis should be observed for fever and other manifestations of infection. Respiratory infections are common because the retroperitoneal fluid raises the diaphragm, which causes the patient to take shallow, guarded abdominal breaths.

When evaluating the patient's understanding about the care of the ileostomy, what statement by the patient indicates the patient needs more teaching? a. "I will be able to regulate when I have stools." b. "I will be able to wear the pouch until it leaks." c. "Dried fruit and popcorn must be chewed very well." d. "The drainage from my stoma can damage my skin."

a. "I will be able to regulate when I have stools." The ileostomy is in the ileum and drains liquid stool frequently, unlike the colostomy which has more formed stool the further distal the ostomy is in the colon. The ileostomy pouch is usually worn 4-7 days or until it leaks. It must be changed immediately if it leaks because the drainage is very irritating to the skin. To avoid obstruction, popcorn, dried fruit, coconut, mushrooms, olives, stringy vegetables, food with skin, and meats with casings must be chewed extremely well before swallowing because of the narrow diameter of the ileostomy lumen.

A stroke patient who primarily uses a wheelchair for mobility has diarrhea with fecal incontinence. What should the nurse assess first? a. Fecal impaction b. Perineal hygiene c. Dietary fiber intake d. Antidiarrheal agent use

a. Fecal impaction Patients with limited mobility are at risk for fecal impactions due to constipation that may lead to liquid stool leaking around the hardened impacted feces, so assessing for fecal impaction is the priority. Perineal hygiene can be assessed at the same time. Assessing the dietary fiber and fluid intake and antidiarrheal agent use will be assessed and considered next.

The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation? a. Maintain a high intake of fluid and fiber in the diet. b. Reduce intake of medications causing constipation. c. Eat several small meals per day to maintain bowel motility. d. Sit upright during meals to increase bowel motility by gravity.

a. Maintain a high intake of fluid and fiber in the diet. Increased fluid intake and a high-fiber diet reduce the incidence of constipation caused by immobility, medications, and other factors. Fluid and fiber provide bulk that in turn increases peristalsis and bowel motility. Analgesics taken for lung cancer probably cannot be reduced. Other medications may decrease constipation, but it is best to avoid laxatives. Eating several small meals per day and position do not facilitate bowel motility. Defecation is easiest when the person sits on the commode with the knees higher than the hips.

Radiation therapy is used to treat colon cancer before surgery for which of the following reasons? a Reducing the size of the tumor b Eliminating the malignant cells c Curing the cancer d Helping the bowel heal after surgery

a. Radiation therapy is used to treat colon cancer before surgery to reduce the size of the tumor, making it easier to be resected. Radiation therapy isn't curative, can't eliminate the malignant cells (though it helps define tumor margins), can could slow postoperative healing.

The client has been admitted with a diagnosis of acute pancreatitis. The nurse would assess this client for pain that is: a Severe and unrelenting, located in the epigastric area and radiating to the back. b Severe and unrelenting, located in the left lower quadrant and radiating to the groin. c Burning and aching, located in the epigastric area and radiating to the umbilicus. d Burning and aching, located in the left lower quadrant and radiating to the hip.

a. The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back.

The wound, ostomy, and continence (WOC) nurse selects the site where the ostomy will be placed. What should be included in the consideration for the site? a. The patient must be able to see the site. b. Outside the rectus muscle area is the best site. c. It is easier to seal the drainage bag to a protruding area. d. The ostomy will need irrigation, so area should not be tender.

a. The patient must be able to see the site. In selection of the ostomy site, the WOC nurse will want a site visible to the patient so the patient can take care of it, within the rectus muscle to avoid hernias, and on a flat surface to more easily create a good seal with the drainage bag.

When teaching a community group about measures to prevent colon cancer, which instruction should the nurse include? a "Limit fat intake to 20% to 25% of your total daily calories." b "Include 15 to 20 grams of fiber into your daily diet." c "Get an annual rectal examination after age 35." d "Undergo sigmoidoscopy annually after age 50."

a. To help prevent colon cancer, fats should account for no more than 20% to 25% of total daily calories and the diet should include 25 to 30 grams of fiber per day. A digital rectal examination isn't recommended as a stand-alone test for colorectal cancer. For colorectal cancer screening, the American Cancer society advises clients over age 50 to have a flexible sigmoidoscopy every 5 years, yearly fecal occult blood tests, yearly fecal occult blood tests PLUS a flexible sigmoidoscopy every 5 years, a double-contrast barium enema every 5 years, or a colonoscopy every 10 years.

The nurse explains to the patient undergoing ostomy surgery that the procedure that maintains the most normal functioning of the bowel is: a. a sigmoid colostomy b. a transverse colostomy c. a descending colostomy d. an ascending colostomy

a. a sigmoid colostomy Rationale: The more distal the ostomy is, the more the intestinal contents resemble feces eliminated from an intact colon and rectum. Output from a sigmoid colostomy resembles normally formed stool, and some patients are able to regulate emptying time so they do not need to wear a collection bag.

The nurse is instructing a patient with chronic pancreatitis on measures to prevent further attacks. What information should be provided (select all that apply) a. avoid nicotine b. eat bland foods c. observe stools for steatorrhea d. eat high fat, low protein, high carbohydrate meals e. take prescribed pancreatic enzymes immediately following meals

a. avoid nicotine b. eat bland foods c. observe stools for steatorrhea Measures to prevent attacks of pancreatitis are those that decrease stimulation of the pancreas. lower fat intake, and foods that are irritating (eat bland), higher carbs are less stimulating, avoid alcohol and nicotine, monitor for steatorrhea (fat in feces). Pancreatic enzymes should be taken with meals, not after.

Identify the prophylactic immunologic agents that are used for the following: a. pre-exposure protection to HBV b. post-exposure protection to HBV

a. hepatitis B vaccine (Recombivax HB) b. hepatitis B immune globulin (HBIG) and hepatitis B vaccine

Two days following a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result of a. impaired peristalsis. b. irritation of the bowel. c. nasogastric suctioning. d. inflammation of the incision site.

a. impaired peristalsis. Until peristalsis returns to normal following anesthesia, the patient may experience slowed gastrointestinal motility leading to gas pains and abdominal distention. Irritation of the bowel, nasogastric suctioning, and inflammation of the surgical site do not cause gas pains or abdominal distention.

The appropriate collaborative therapy for the patient with acute diarrhea caused by a viral infection is to: a. increase fluid intake b. administer an antibiotic c. administer antimotality drugs d. quarantine the patient to prevent spread of the virus

a. increase fluid intake Rationale: Acute diarrhea resulting from infectious causes (e.g., virus) is usually self-limiting. The major concerns are transmission prevention, fluid and electrolyte replacement, and resolution of the diarrhea. Antidiarrheal agents are contraindicated in the treatment of infectious diarrhea because they potentially prolong exposure to the infectious organism. Antibiotics are rarely used to treat acute diarrhea. To prevent transmission of diarrhea caused by a virus, hands should be washed before and after contact with the patient and when body fluids of any kind are handled. Vomitus and stool should be flushed down the toilet, and contaminated clothing should be washed immediately with soap and hot water.

The patient with suspected gallbladder disease is scheduled for an ultrasound of the gallbladder. The nurse explains to the patient that this test a. is noninvasive and is a very reliable method of detecting gallstones b. is used only when other tests cannot be used because of allergy to contrast media c. is an adjunct to liver function tests to determine whether the gallbladder is inflamed d. will outline the gallbladder and the ductal system to enable visualization of stones

a. is noninvasive and is a very reliable method of detecting gallstones Ultrasonography is 90-95% accurate in detecting gallstones, and is noninvasive. Liver function tests will be elevated if there is damage to the liver, not with gallbladder.

Describe the pathophysiologic changes of cirrhosis that cause the following a. Portal hypertension b. Esophageal varices

a. scarring and nodular changes in liver lead to compression of the veins and sinusoids, causing resistance of blood flow through the liver from the portal vein b. development of collateral channels of circulation in inelastic, fragile esophageal veins as a result of portal hypertension

The nurse determines that the goals of dietary teaching have been met when the patient with celiac disease selects from the menu: a. scrambled eggs and sausage b. buckwheat pancakes with syrup c. oatmeal, skim milk, and orange juice d. yogurt, strawberries, and rye toast with butter

a. scrambled eggs and sausage Rationale: Celiac disease is treated with lifelong avoidance of dietary gluten. Wheat, barley, oats, and rye products must be avoided. Although pure oats do not contain gluten, oat products can become contaminated with wheat, rye, and barley during the milling process. Gluten is also found in some medications and in many food additives, preservatives, and stabilizers.

The nurse is admitting a client with the diagnosis of appendicitis to the surgical unit. Which question is essential to ask? A."When did you last eat?" B."Have you had surgery before?" C."Have you ever had this type of pain before?" D."What do you usually take to relieve your pain?"

answer A. When a person is admitted with possible appendicitis, the nurse should anticipate surgery. It will be important to know when she last ate when considering the type of anesthesia so that the chance of aspiration can be minimized. The other inoformation is "nice to know", but not essential.

Which of the nursing interventions should be implemented to manage appendicitis? a. Assess pain b. encourage oral intake of clear fluids. c. provide discharge teaching D. assess for symptoms of peritonitis.

answer D. Monitor for peritonitis because if the appendix ruptures, bacteria can enter the peritoneum. Pain will be managed with analgesics, and pt should be NPO for surgery. Discharge is not done at this time

Teaching in relation to home management after a laparoscopic cholecystectomy should include a. keeping the bandages on the puncture sites for 48 hours. b. reporting any bile-colored drainage or pus from any incision. c. using over-the-counter antiemetics if nausea and vomiting occur. d. emptying and measuring the contents of the bile bag from the T tube every day. (Lewis 1042)

b Rationale: The following discharge instructions are taught to the patient and caregiver after a laparoscopic cholecystectomy: First, remove the bandages on the puncture site the day after surgery and shower. Second, notify the surgeon if any of the following signs and symptoms occur: redness, swelling, bile-colored drainage or pus from any incision; and severe abdominal pain, nausea, vomiting, fever, or chills. Third, gradually resume normal activities. Fourth, return to work within 1 week of surgery. Fifth, resume a usual diet, but a low-fat diet is usually better tolerated for several weeks after surgery.

A client is admitted with acute pancreatitis. What will the nurse expect to find upon assessment of this client? select all that apply a Hyperactive bowel sounds b Brown foamy urine c Heart rate 72 and regular d Constipation e Elevated blood pressure f Diarrhea

b, f brown foamy urine is due to bile being excreted through the kidneys. Abdominal pain, other GI manifestations, skin changes, cardiopulmonary changes, neurological changes, renal changes, hematologic changes, and electrolyte imbalances.

A patient who is given a bisacodyl (Dulcolax) suppository asks the nurse how long it will take to work. The nurse replies that the patient will probably need to use the bedpan or commode within which time frame after administration? a. 2-5 minutes b. 15-60 minutes c. 2-4 hours d. 6-8 hours

b. 15-60 minutes Bisacodyl suppositories usually are effective within 15 to 60 minutes of administration, so the nurse should plan accordingly to assist the patient to use the bedpan or commode.

A 61-year-old patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times? a. 7:00 AM, 10:00 AM, and 1:00 PM b. 8:00 AM, 12:00 PM, and 4:00 PM c. 9:00 AM and 3:00 PM d. 9:00 AM, 12:00 PM, and 3:00 PM

b. 8:00 AM, 12:00 PM, and 4:00 PM A nasogastric tube should be checked for patency routinely at 4-hour intervals. Thus if the tube were inserted at 4:00 AM, it would be due to be checked at 8:00 AM, 12:00 PM, and 4:00 PM.

A colectomy is scheduled for a 38-year-old woman with ulcerative colitis. The nurse should plan to include what prescribed measure in the preoperative preparation of this patient? a. Instruction on irrigating a colostomy b. Administration of a cleansing enema c. A high-fiber diet the day before surgery d. Administration of IV antibiotics for bowel preparation

b. Administration of a cleansing enema Preoperative preparation for bowel surgery typically includes bowel cleansing with antibiotics, such as oral neomycin and cleansing enemas, including Fleet enemas. Instructions to irrigate the colostomy will be done postoperatively. Oral antibiotics are given preoperatively, and an IV antibiotic may be used in the OR. A clear liquid diet will be used the day before surgery with the bowel cleansing.

The nurse is planning care for a 68-year-old patient with an abdominal mass and suspected bowel obstruction. Which factor in the patient's history increases the patient's risk for colorectal cancer? a. Osteoarthritis b. History of colorectal polyps c. History of lactose intolerance d. Use of herbs as dietary supplements

b. History of colorectal polyps A history of colorectal polyps places this patient at risk for colorectal cancer. This tissue can degenerate over time and become malignant. Osteoarthritis, lactose intolerance, and the use of herbs do not pose additional risk to the patient.

The nurse should administer an as-needed dose of magnesium hydroxide (MOM) after noting what information while reviewing a patient's medical record? a. Abdominal pain and bloating b. No bowel movement for 3 days c. A decrease in appetite by 50% over 24 hours d. Muscle tremors and other signs of hypomagnesemia

b. No bowel movement for 3 days MOM is an osmotic laxative that produces a soft, semisolid stool usually within 15 minutes to 3 hours. This medication would benefit the patient who has not had a bowel movement for 3 days. MOM would not be given for abdominal pain and bloating, decreased appetite, or signs of hypomagnesemia.

During a diagnostic test, a client is found to have an accessory pancreatic duct. The nurse interprets this finding as: a A disorder that will decrease the amount of pancreatic enzymes. b A disorder that will decrease the amount of bile flow to the duodenum. c Normal. d A disorder that is causing this client to have hyperglycemia.

c A second accessory duct exists in approximately 70 percent of people.

A patient with pancreatic cancer is admitted to the hospital for evaluation of possible treatment options. The patient asks the nurse to explain the Whipple procedure that the surgeon has described. The explanation includes the information that a Whipple procedure involves a. creating a bypass around the obstruction caused by the tumor by joining the gallbladder to the jejunum. b. resection of the entire pancreas and the distal portion of the stomach, with anastomosis of the common bile duct and the stomach into the duodenum. c. removal of part of the pancreas, part of the stomach, the duodenum, and the gallbladder, with joining of the pancreatic duct, the common bile duct, and the stomach into the jejunum. d. radical removal of the pancreas, the duodenum, and the spleen, and attachment of the stomach to the jejunum, which requires oral supplementation of pancreatic digestive enzymes and insulin replacement therapy. (Lewis 1042)

c Rationale: The classic operation for pancreatic cancer is a radical pancreaticoduodenectomy, or Whipple procedure. This entails resection of the proximal pancreas (i.e., proximal pancreatectomy), the adjoining duodenum (i.e., duodenectomy), the distal portion of the stomach (i.e., partial gastrectomy), and the distal segment of the common bile duct. The pancreatic duct, common bile duct, and stomach are anastomosed to the jejunum.

Which clinical manifestations of inflammatory bowel disease are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply)? a. Restricted to rectum b. Strictures are common. c. Bloody, diarrhea stools d. Cramping abdominal pain e. Lesions penetrate intestine.

c & d Clinical manifestations of UC and Crohn's disease include bloody diarrhea, cramping abdominal pain, and nutritional disorders. Intestinal lesions associated with UC are usually restricted to the rectum before moving into the colon. Lesions that penetrate the intestine or cause strictures are characteristic of Crohn's disease.

A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find? a) Decreased white blood cell count b) Increased serum calcium levels c) Elevated urine amylase levels d) Decreased liver enzyme levels

c) Elevated urine amylase levels Elevated serum and urine amylase, lipase, and liver enzyme levels accompany significant pancreatitis. If the common bile duct is obstructed, the bilirubin level is above normal. Blood glucose levels and white blood cell counts can be elevated. Serum electrolyte levels (calcium, potassium, and magnesium) are low.

A patient receives atropine, an anticholinergic drug, in preparation for surgery. The nurse expects this drug to affect the GI tract by: a) increasing gastric emptying b) relaxing pyloric and ileocecal sphincters c) decreasing secretions and peristaltic action d) stimulating the nervous system of the GI tract

c) decreasing secretions and peristaltic action The parasympathetic nervous system increasing motility and secretions and relaxing sphincters to promote movement of contents. A drug that blocks this activity decreases secretions and peristalsis, slows gastric emptying, and contracts sphincters. The enteric nervous system of the GI tract is modulated by sympathetic and parasympathetic influence

When caring for a patient who has had most of the stomach surgically removed, the nurse plans to teach the client a) that extra iron will need to be taken to prevent anemia b) to avoid foods with lactose to prevent diarrhea and bloating c) that lifelong supplementation of cobalamin will be needed d) that, because of the absence of digestive enzymes, protein malnurition is likely

c) that lifelong supplementation of cobalamin will be needed The stomach secretes intrinsic factor necessary for cobalamin absorption in the intestine. In removal of part or all of the stomach, cobalamin must be supplemented for life.

When assessing a client's pain level the nurse concludes the client is experiencing acute pancreatitis. What did the nurse assess? select all that apply a Over-the-counter pain relievers take the pain away b Pain is relieved with the passing of flatus c Pain is sharp, like a knife, occurs without warning d Pain is less when the client leans forward e Pain settles in the right shoulder f Pain is relieved with coughing

c, d Pain is the most consistent complaint associated with acute pancreatitis and is a high-priority assessment. Pain is sudden onset, sharp, knifelike, twisting, deep, and radiates to the flank, chest, abdomen. Pain may be relieved by leaning forward or assuming the fetal position.

A client is found to have a malfunction in his ability to manufacture and secrete secretin. The nurse realizes this hormone: select all that apply a Tells the pancreas to release elastase. b Raises the pH of the stomach. c Tells the pancreas to release bicarbonate and water. d Tells the pancreas to release trypsin. e Regulates intestinal pH. f Keeps intestinal mucosa acidic.

c, e This is the mechanism to maintain the intestinal pH. Secretin is essential in the regulation of intestinal pH.

Following bowel resection, a patient has a nasogastric (NG) tube to suction, but complains of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority action by the nurse? a. Notify the physician. b. Auscultate for bowel sounds. c. Reposition the tube and check for placement. d. Remove the tube and replace it with a new one.

c. Reposition the tube and check for placement. The tube may be resting against the stomach wall. The first action by the nurse (since this is intestinal surgery and not gastric surgery) is to reposition the tube and check it again for placement. The physician does not need to be notified unless the tube function cannot be restored by the nurse. The patient does not have bowel sounds, which is why the NG tube is in place. The NG tube would not be removed and replaced unless it was no longer in the stomach or the obstruction of the tube could not be relieved.

The patient with chronic pancreatitis is more likely than the patient with acute pancreatitis to a. need to abstain from alcohol b. experience acute abdominal pain c. have malabsorption and diabetes mellitus d. require a high carbohydrate, high protein, low fat diet

c. have malabsorption and diabetes mellitus Chronic damage to the pancreas causes pancreatic exocrine and endocrine insufficiency, resulting in a deficiency of digestive enzymes and insulin. Malabsorption and diabetes often result.

The nurse determines that further discharge instruction is needed when the patient with acure pancreatitis states, a. i should observe for fat in my stools b. i must not use alcohol to prevent future attacks of pancreatitis c. i shouldn't eat salty foods or foods with high amounts of sodium d. i will need to continue to monitor my blood glucose levels until my pancreas is healed

c. i shouldn't eat salty foods or foods with high amounts of sodium Sodium restriction isn't indicated for pancreatitis

In planning care for the patient with Crohn's disease, the nurse recognizes that a major difference between ulcerative colitis and Crohn's disease is that Crohn's disease: a. frequently results in toxic megacolon b. causes fever nutritional deficiencies than ulcerative colitis c. often recurs after surgery, whereas ulcerative colitis is curable with a colectomy d. is manifested by rectal bleeding and anemia more frequently than is ulcerative colitis

c. often recurs after surgery, whereas ulcerative colitis is curable with a colectomy Rationale: Ulcerative colitis affects only the colon and rectum; it can cause megacolon and rectal bleeding, but not nutrient malabsorption. Surgical removal of the colon and rectum cures it. Crohn's disease usually involves the ileum, where bile salts and vitamin cobalamin are absorbed. After surgical treatment, disease recurrence at the site is common.

A patient with cholelithiasis needs to have the gallbladder removed. Which patient assessment is a contraindication for a cholecystectomy? Low-grade fever of 100° F and dehydration Abscess in the right upper quadrant of the abdomen Activated partial thromboplastin time (aPTT) of 54 seconds

ctivated partial thromboplastin time (aPTT) of 54 seconds Multiple obstructions in the cystic and common bile duct An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given to eliminate the dehydration; the abscess can be assessed, and the obstructions in the cystic and common bile duct would be relieved with the cholecystectomy.

A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor? a) The client may eat a light meal before either test. b) Both tests need to be done before breakfast. c) The upper GI should be scheduled before the ultrasonography. d) The ultrasonography should be scheduled before the GI procedure.

d) The ultrasonography should be scheduled before the GI procedure Both an upper GI procedure with barium ingestion and an ultrasonography may be completed on the same day. The ultrasonography test should be completed first, because the barium solution could interfere with the transmission of the sound waves. The ultrasonography test uses sound waves that are passed into internal body structures, and the echoes are recorded as they strike tissues. Fluid in the abdomen prevents transmission of ultrasound.

The nurse is caring for a postoperative patient with a colostomy. The nurse is preparing to administer a dose of famotidine (Pepcid) when the patient asks why the medication was ordered since the patient does not have a history of heartburn or gastroesophageal reflux disease (GERD). What response by the nurse would be the most appropriate? a. "This will prevent air from accumulating in the stomach, causing gas pains." b. "This will prevent the heartburn that occurs as a side effect of general anesthesia." c. "The stress of surgery is likely to cause stomach bleeding if you do not receive it." d. "This will reduce the amount of HCl in the stomach until the nasogastric tube is removed and you can eat a regular diet again."

d. "This will reduce the amount of HCl in the stomach until the nasogastric tube is removed and you can eat a regular diet again." Famotidine is an H2-receptor antagonist that inhibits gastric HCl secretion and thus minimizes damage to gastric mucosa while the patient is not eating a regular diet after surgery. Famotidine does not prevent air from accumulating in the stomach or stop the stomach from bleeding. Heartburn is not a side effect of general anesthesia.

The nurse asks a 68-year-old patient scheduled for colectomy to sign the operative permit as directed in the physician's preoperative orders. The patient states that the physician has not really explained very well what is involved in the surgical procedure. What is the most appropriate action by the nurse? a. Ask family members whether they have discussed the surgical procedure with the physician. b. Have the patient sign the form and state the physician will visit to explain the procedure before surgery. c. Explain the planned surgical procedure as well as possible and have the patient sign the consent form. d. Delay the patient's signature on the consent and notify the physician about the conversation with the patient.

d. Delay the patient's signature on the consent and notify the physician about the conversation with the patient. The patient should not be asked to sign a consent form unless the procedure has been explained to the satisfaction of the patient. The nurse should notify the physician, who has the responsibility for obtaining consent.

The nurse is caring for a 68-year-old patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass, and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? a. Low-pitched and rumbling above the area of obstruction b. High-pitched and hypoactive below the area of obstruction c. Low-pitched and hyperactive below the area of obstruction d. High-pitched and hyperactive above the area of obstruction

d. High-pitched and hyperactive above the area of obstruction Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high-pitched, sometimes referred to as "tinkling" above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.

The nurse is preparing to administer a dose of bisacodyl (Dulcolax). In explaining the medication to the patient, the nurse would explain that it acts in what way? a. Increases bulk in the stool b. Lubricates the intestinal tract to soften feces c. Increases fluid retention in the intestinal tract d. Increases peristalsis by stimulating nerves in the colon wall

d. Increases peristalsis by stimulating nerves in the colon wall Bisacodyl is a stimulant laxative that aids in producing a bowel movement by irritating the colon wall and stimulating enteric nerves. It is available in oral and suppository forms. Fiber and bulk forming drugs increase bulk in the stool; water and stool softeners soften feces, and saline and osmotic solutions cause fluid retention in the intestinal tract.

What should a patient be taught after a hemorrhoidectomy? a. Take a mineral oil before bedtime b. Eat a low-fiber diet to rest the colon c. Administer oil-retention enema to empty the colon d. Use prescribed pain medication before a bowel movement

d. Use prescribed pain medication before a bowel movement Rationale: After a hemorrhoidectomy, the patient usually dreads the first bowel movement and often resists the urge to defecate. Pain medication may be given before the bowel movement to reduce discomfort. The patient should avoid constipation and straining. A high-fiber diet can reduce constipation. A stool softener such as docusate (Colace) is usually ordered for the first few postoperative days. If the patient does not have a bowel movement within 2 to 3 days, an oil-retention enema is administered.

A patient with cirrhosis asks the nurse about the possibility of a liver transplant. The best response by the nurse is a. Liver transplants are only indicated in children with irreversible liver disease b. if you are interested in a transplant, you really should talk to your doctor about it c. rejection is such a problem in liver transplants that is seldom attempted in patients with cirrhosis d. cirrhosis is an indication for transplantation in some cases. Have you talked to your doctor about this?

d. cirrhosis is an indication for transplantation in some cases. Have you talked to your doctor about this?

Fluid sequestering in the peritoneal cavity results in _____________ vascular volume, _________________ blood return to the heart, and ________ cardiac output

decreased, decreased, decreased

The retained fluid has low oncotic colloidal pressure, and it escapes into the interstitial spaces, causing ___________________

peripheral edema