Exam 7

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 would the nurse respond? "Your friends will be happy that you are alive." "Tell me more about your concerns." "A therapist can help you resolve your concerns." "With time you will accept your new body."

"Tell me more about your concerns."

A nurse cares for an older adult who is admitted to the hospital with complications of diverticulitis. Which actions would the nurse include in the client's plan of care? (Select all that apply.) Administer pain medications as prescribed. Palpate the abdomen for distention. Assess for sudden changes in mental status. Provide the client with a high-fiber diet. Evaluate stools for occult blood.

Administer pain medications as prescribed. Palpate the abdomen for distention. Assess for sudden changes in mental status. Evaluate stools for occult blood.

The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to which organ functions or dysfunctions? (Select all that apply.) Alanine aminotransferase: biliary system Ammonia: liver Amylase: liver Lipase: pancreas Urine urobilinogen: stomach

Ammonia: liver Lipase: pancreas

The nurse assesses a client who is hospitalized with an exacerbation of Crohn disease. Which assessment finding would the nurse expect? Positive Murphy sign with rebound tenderness to palpitation Dull, hypoactive bowel sounds in the lower abdominal quadrants High-pitched, rushing bowel sounds in the right lower quadrant Reports of abdominal cramping that is worse at night

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

The nurse is teaching a client a client about taking elbasvir for hepatitis C. What information in the client's history would the nurse need prior to drug administration? History of hepatitis B History of kidney disease History of cardiac disease History of rectal bleeding

History of hepatitis B Elbasvir can cause liver toxicity and therefore the nurse would assess for a history of or current hepatitis B.

The nurse documents the vital signs of a client diagnosed with acute pancreatitis: Apical pulse = 116 beats/min Respirations = 28 breaths/min Blood pressure = 92/50 What complication of acute pancreatitis would the nurse suspect that the client might have? Electrolyte imbalance Pleural effusion Internal bleeding Pancreatic pseudocyst

Internal bleeding The client is exhibiting signs of hypovolemia most likely due to internal bleeding or hemorrhage. Due to decreased blood volume, the blood pressure is low and the heart rate increases to compensate for hypovolemia to ensure organ perfusion. Respirations often increase to increase oxygen in the blood.

The nurse is interviewing a client who reports having abdominal cramping, bloating, and diarrhea after drinking milk or ingesting other dairy products. What health problem does the client most likely have? Steatorrhea Ulcerative colitis Crohn disease Lactose intolerance

Lactose intolerance The client is demonstrating signs and symptoms of lactose intolerance because they occur after the client eats or drinks dairy products which contain lactose.

The nurse is caring for a client who has a risk gene for developing cirrhosis. Which racial/ethnic group has this gene most often? Blacks Asian/Pacific Islanders Latinos French

Latinos

To promote comfort and the passage of flatus after a colonoscopy, in what position does the nurse place the client? Left lateral Prone Right lateral Supine

Left lateral After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position.

The nurse is caring for a client with peritonitis. What assessment findings would the nurse expect? (Select all that apply.) Nausea and vomiting Distended rigid abdomen Abdominal pain Bradycardia Decreased urinary output Fever

Nausea and vomiting Abdominal pain Bradycardia Decreased urinary output Fever

A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report? Nausea and vomiting Severe boring abdominal pain Jaundice and itching Elevated temperature

Severe boring abdominal pain

A 7-month-old infant is admitted to the hospital with a diagnosis of acute gastroenteritis. What will be the nursess priority goal of the infants care? a. Prevent fluid and electrolyte imbalance. b. Prevent nutritional deficiency. c. Prevent skin breakdown. d. Prevent malabsorption.

a. Prevent fluid and electrolyte imbalance.

A mother reports that her 2-year-old child experiences constipation frequently. Which food would the nurse recommend to include in the childs diet? a. Cooked vegetables b. Pretzels c. Whole-grain cereal d. Yogurt

c. Whole-grain cereal Dietary modifications for constipation include eating more high-roughage foods such as whole-grain breads and cereals.

The nurse is caring for an 18-pound child who has had one stool of diarrhea. The nurse knows that the child needs to consume how many milliliters of oral fluid to make up for the fluid loss? a. 18 b. 36 c. 64 d. 81

d. 81

The nurse has reviewed dietary restrictions for celiac disease with concerned parents. Which grain will the nurse explain can be eaten with celiac disease? a. Wheat b. Oats c. Barley d. Rice

d. Rice Rice is a gluten-free grain that can be eaten by children afflicted with celiac disease. These children will have a lifelong restriction of wheat, oats, barley, and rye.

A client has an external percutaneous transhepatic biliary catheter inserted for a biliary obstruction. What health teaching about catheter care would the nurse provide for the client? "Cap the catheter drain at night to prevent leakage and skin damage." "Position the drainage bag lower than the catheter insertion site." "Irrigate the catheter with an ounce of saline every night." "Pierce a hole in the top of the drainage bag to get rid of odors." ANS: B

"Position the drainage bag lower than the catheter insertion site."

The primary health care provider documents that a client has a bruit over the abdominal aorta. What teaching will the nurse provide for assistive personnel (AP) based on this assessment finding? "Use warm compresses on the client's abdomen continuously." "Avoid washing the client's abdomen too aggressively." "Apply ice to the client's abdomen every 4 hours." "Massage the client's abdomen to help reduce pain."

"Avoid washing the client's abdomen too aggressively." A bruit heard over the abdominal aorta possible indicates stenosis or an aneurysm which should not be palpated or percussed. Therefore, the AP should wash the client's abdomen very Btestbanks.com gently.

The nurse is caring for a client who is prescribed lactulose. The client states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond? "Diarrhea is expected; that's how your body gets rid of ammonia." "You may take antidiarrheal medication to prevent loose stools." "Do not take any more of the medication until your stools firm up." "We will need to send a stool specimen to the laboratory as soon as possible."

"Diarrhea is expected; that's how your body gets rid of ammonia."

The nurse is caring for a client with hepatitis C. The client's brother states, "I do not want to get this infection, so I'm not going into his hospital room." How would the nurse respond? "Hepatitis C is not spread through casual contact." "If you wear a gown and gloves, you will not get this virus." "This virus is only transmitted through a fecal specimen." "I can give you an update on your brother's status from here."

"Hepatitis C is not spread through casual contact."

The nurse is preparing to teach a client with chronic hepatitis B about lamivudine therapy. What health teaching would the nurse include? "Follow up on all appointments to monitor your lab values." "Do not take amiodorone at any time while on this drug." "Monitor for jaundice, rash, and itchy skin while on this drug." "Report any changes in urinary elimination while on this drug."

"Report any changes in urinary elimination while on this drug." Lamivudine can cause renal impairment and the nurse would remind the client of changes that may indicate kidney damage.

After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client's understanding. Which statement by the client indicates a need for further teaching? "The capsules can be opened and the powder sprinkled on applesauce if needed." "I will wipe my lips carefully after I drink the enzyme preparation." "The best time to take the enzymes is immediately after I have a meal or a snack." "I will not mix the enzyme powder with food or liquids that contain protein."

"The best time to take the enzymes is immediately after I have a meal or a snack."

A client is preparing to have a laparoscopic restorative proctocolectomy with ileo pouch-anal anastomosis (RCA-IPAA). Which preoperative health teaching would the nurse include? "You will have to wear an appliance for your permanent ileostomy." "You should be able to have better bowel continence after healing occurs." "You will have a large abdominal incision that will require irrigation." "This procedure can be performed under general or regional anesthesia."

"You should be able to have better bowel continence after healing occurs."

A nurse assesses a patient who has celiac disease. Which signs and symptoms would the nurse expect? (Select all that apply.) Weight gain Anorexia Constipation Anal fistula Abdominal pain

Anorexia Constipation Abdominal pain

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is appropriate? Allow the client cool liquids only. Assess the client's gag reflex. Remind the client to remain NPO. Tell the client to wait 4 hours.

Assess the client's gag reflex. The local anesthetic used during this procedure depresses the client's gag reflex. After the procedure, the nurse would ensure that the gag reflex is intact before offering food or fluids. The client does not need to be restricted to cool beverages only and is not required to wait 4 hours before oral intake is allowed. Telling the client to remain NPO does not inform the client of when he or she can have fluids, nor does it reflect the client's readiness for them.

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

Baked fish with steamed carrots and a glass of apple juice

The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ? a. Kidneys b. Liver c. Spleen d. Stomach

Liver Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting proteins. The other organs are not related to this issue.

A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse teaches the client and family about the signs of potential complications which include what problems? (Select all that apply.) Cholangitis Pancreatitis Perforation Renal lithiasis Sepsis

Cholangitis Pancreatitis Perforation Sepsis Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP.

A nurse assesses a client who has cholecystitis. Which sign or symptom indicates that this condition is chronic rather than acute? Temperature of 100.1° F (37.8° C) Positive Murphy sign Clay-colored stools Upper abdominal pain after eating

Clay-colored stools Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen in clients with either chronic or acute cholecystitis.

The nurse assesses a client with gastroenteritis. What risk factor would the nurse consider as the most likely cause of this disorder? Consuming too much fruit Consuming fried or pickled foods Consuming dairy products Consuming raw seafood

Consuming raw seafood Raw seafood is often contaminated and unless cooked can would most likely cause gastroenteritis. Any of the other food can also become contaminated if not stored properly or contaminated by workers/cooks who contaminate these foods.

The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.) Decreased hydrochloric acid production Diminished sensation that can lead to constipation Fat not digested as well in older adults Increased peristalsis in the large intestine Pancreatic vessels become calcified

Decreased hydrochloric acid production Diminished sensation that can lead to constipation Fat not digested as well in older adults Pancreatic vessels become calcified

The nurse plans care for a client with Crohn disease who has a heavily draining fistula. Which intervention would be the nurse's priority action? Low-fiber diet Skin protection Antibiotic administration Intravenous glucocorticoids

Skin protection Protecting the client's skin is the priority action for a patient who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected.

Which statement by a mother may indicate a cause of her sons vitamin C deficiency? a. We get our fruits from homemade preserves. b. We use milk from our own goats. c. We grow all our own vegetables. d. Were not big meat eaters.

a. We get our fruits from homemade preserves.

Why are infants more vulnerable to fluid and electrolyte imbalances than adults? a. They have a smaller surface area than adults in proportion to body weight. b. Water needs and losses per kilogram are lower than those for adults. c. A greater percentage of body water in infants is extracellular. d. Infants have a lower metabolic turnover of water.

c. A greater percentage of body water in infants is extracellular.

The nurse is speaking to the parent of a 3-year-old child who has mild diarrhea. What dietary modification would the nurse advise? a. Soft foods with rice, bananas, toast, and applesauce b. Small amounts of clear fluids such as gelatin c. An oral rehydrating solution, such as Pedialyte d. Chicken soup because it is high in sodium

c. An oral rehydrating solution, such as Pedialyte

What does the nurse expect the appearance of the stools of a child with celiac disease to be? a. Ribbon like b. Hard, constipated c. Bulky, frothy d. Loose, foul-smelling

c. Bulky, frothy Celiac disease causes malabsorption. Stools that are large, bulky, and frothy may indicate malabsorption.

The nurse teaches a client who has viral gastroenteritis. Which dietary instruction would the nurse include in the health teaching? "Drink plenty of fluids to prevent dehydration." "You should only drink 1 L of fluids daily." "Increase your protein intake by drinking more milk." "Sips of cola or tea may help to relieve your nausea."

"Drink plenty of fluids to prevent dehydration." The client should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.

A nurse cares for a client with end-stage pancreatic cancer. The client asks, "Why is this happening to me?" How would the nurse respond? "I don't know. I wish I had an answer for you, but I don't." "It's important to keep a positive attitude for your family right now." "Scientists have not determined why cancer develops in certain people." "I think that this is a trial so you can become a better person because of it."

"I don't know. I wish I had an answer for you, but I don't."

The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites? Monitor intake and output. Provide a low-sodium diet. Increase oral fluid intake. Weigh the patient daily.

Provide a low-sodium diet

The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis? Metabolic syndrome Liver cancer Nonalcoholic fatty liver disease Hepatitis C

Hepatitis C

The nurse is caring for a client who is recovering from an open traditional Whipple surgical procedure. What action would the nurse take? Clamp the nasogastric tube. Place the patient in semi-Fowler position. Assess vital signs once every shift. Provide oral rehydration.

Place the patient in semi-Fowler position.

The nurse assesses a patient who is recovering from an ileostomy placement. Which assessment finding would alert the nurse to immediately contact the primary health care provider? Pale and bluish stoma Liquid stool Ostomy pouch intact Blood-tinged output

Pale and bluish stoma

A nurse reviews the electronic health record of a client who has Crohn disease and a draining fistula. Which documentation would alert the nurse to urgently contact the primary health care provider for additional prescriptions? Serum potassium of 2.6 mEq/L (2.6 mmol/L) Client ate 20% of breakfast meal White blood cell count of 8200/mm3 (8.2 109/L) Client's weight decreased by 3 lb (1.4 kg)

Serum potassium of 2.6 mEq/L (2.6 mmol/L) Fistulas place the patient with Crohn disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and would 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 level takes priority.

The nurse assesses a client who has appendicitis. Which assessment finding would the nurse expect? Severe, steady right lower quadrant pain Abdominal pain associated with nausea and vomiting Marked peristalsis and hyperactive bowel sounds Abdominal pain that increases with knee flexion

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

The nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding would require immediate action by the nurse? Urine output via indwelling urinary catheter is 20 mL/hr Blood pressure increases from 110/58 to 120/62 mm Hg Respiratory rate decreases from 22 to 16 breaths/min A decrease in the client's weight by 3 lb (1.4 kg)

Urine output via indwelling urinary catheter is 20 mL/hr

On the second day of hospitalization for a 3-month-old brought in for treatment for gastroenteritis, the nurse makes all of the assessments listed below. Which assessment finding indicates ineffectiveness of treatment? a. Weight loss of 4 ounces b. Dry mucous membranes c. Decreased skin turgor d. Depressed fontanelle

Weight loss of 4 ounces Weight loss is the most significant indicator of dehydration because an infants weight comprises 77% water.

An older adult has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? "Changes in your liver cause drugs to be metabolized differently." "Perhaps you don't need as high a dose of the drug as before." "Stomach muscles atrophy with age and you digest more slowly." "Your body probably can't tolerate as much medication anymore."

"Changes in your liver cause drugs to be metabolized differently." Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugs—possibly to toxic levels. The other options do not accurately explain this age-related change.

The nurse is caring for a client who is prescribed sulfasalazine. Which question would the nurse ask the client before starting this drug? "Are you taking Vitamin C or B? "Do you have any allergy to sulfa drugs?" "Can you swallow pills pretty easily?" "Do you have insurance to cover this drug?

"Do you have any allergy to sulfa drugs?"

After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching? "Some medications have been known to cause hepatitis A." "I may have been exposed when we ate shrimp last weekend." "I was infected with hepatitis A through a recent blood transfusion." "My infection with Epstein-Barr virus can co-infect me with hepatitis A."

"I may have been exposed when we ate shrimp last weekend." The route of transmission for hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish.

The nurse is caring for a client who is scheduled for a paracentesis. Which action is appropriate for the nurse to take? Have the client sign the informed consent form. Get the patient into a chair before the procedure. Help the client lie flat in bed on the right side. Assist the client to void before the procedure.

Assist the client to void before the procedure.

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment would the nurse complete first? Inspection of oral mucosa Recent dietary intake Heart rate and rhythm Percussion of abdomen

Heart rate and rhythm

A nurse is assessing a client reporting right upper quadrant (RUQ) abdominal pain. What technique would the nurse use to assess this client's abdomen? Auscultate after palpating. Avoid any type of palpation. Lightly palpate the RUQ first. Lightly palpate the RUQ last.

Lightly palpate the RUQ last. If pain is present in a certain area of the abdomen, that area would be palpated last to keep the client from tensing which could possibly affect the rest of the examination. Auscultation of the abdomen occurs prior to palpation.

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 further teaching? "I cannot drink any alcohol at all anymore." "I should not take over-the-counter medications." "I need to avoid protein in my diet." "I should eat small, frequent, balanced meals."

"I need to avoid protein in my diet."

The nurse is aware of the most recent American Cancer Society Screening Guidelines for colon cancer, which include which accepted testing modalities for people over the age of 50? (Select all that apply.) Colonoscopy every 10 years Endoscopy every 5 years Computed tomography (CT) colonography every 5 years Double-contrast barium enema every 10 years Flexible sigmoidoscopy every 5 years

Colonoscopy every 10 years Computed tomography (CT) colonography every 5 years Flexible sigmoidoscopy every 5 years

The nurse teaches a client about how to prevent transmission of gastroenteritis. Which statement by the nurse indicates a need for further teaching? "I won't let anyone use my dishes or glasses." "I'll wash my hands with antibacterial soap." "I'll keep my bathroom extra clean." "I'll cook all the meals for my family."

"I'll cook all the meals for my family." All of these statements are correct except for that the client should not prepare meals for others to help prevent transmission of gastroenteritis.

A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? "It's a good thing I love orange and cherry gelatin." "My spouse will be here to drive me home." "I'll avoid ibuprofen for several days before the test." "I'll buy a case of clear Gatorade before the prep."

"It's a good thing I love orange and cherry gelatin." The client would be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show an understanding of the preparation for the procedure.

The nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? "A low-protein diet will help the liver rest and will restore liver function." "Less protein in the diet will help prevent confusion associated with liver failure." "Increasing dietary protein will help the patient gain weight and muscle mass." "Low dietary protein is needed to prevent fluid from leaking into the abdomen."

"Less protein in the diet will help prevent confusion associated with liver failure." Encephalopathy is caused by excess ammonia.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 young client with a new ileostomy. The client states, "I cannot go to prom with an ostomy." How would the nurse respond? "Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance." "The pouch won't be as noticeable if you avoid broccoli and carbonated drinks prior to the prom." "Let's talk to the ostomy nurse about options for ostomy supplies and dress styles." "You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable."

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

A client is scheduled for a hepatobiliary iminodiacetic acid (HIDA) scan. What would the nurse include in client teaching about this diagnostic test? "You'll have to drink a contrast medium right before the test." "You'll need to do a bowel prep the nursing before the test." "You'll be able to drink liquids up until the test begins." "You'll have a large camera close to you during the test."

"You'll have a large camera close to you during the test."

The nurse is caring for a client who has cirrhosis from substance abuse. The client states, "All of my family hates me." How would the nurse respond? "You should make peace with your family." "This is not unusual. My family hates me too." "I will help you identify a support system." "You must attend Alcoholics Anonymous."

"I will help you identify a support system."

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

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

After teaching a client who is prescribed adalimumab for severe ulcerative colitis (UC), the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? "I will avoid large crowds and people who are sick." "I will take this medication with my breakfast each morning." "Nausea and vomiting are common side effects of this drug." "I should wash my hands after I play with my dog."

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

A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. Btestbanks.com The client states, "I'm having right belly pain and have a temperature of 101° F (38.3° C)." How would the nurse respond? "The anti-rejection drugs you are taking make you susceptible to infection." "You should go to the hospital immediately to get checked out." "You should take an additional dose of cyclosporine today." "Take acetaminophen every 4 hours until you feel better soon."

"You should go to the hospital immediately to get checked out." Fever, right abdominal quadrant pain, and jaundice are signs of possible liver transplant rejection; the client would be admitted to the hospital as soon as possible for intervention. Antirejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse would not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.

A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to immediately contact the primary health care provider? Drainage from a fistula Diminished bowel sounds Pain at the incision site Nasogastric (NG) tube drainage

Drainage from a fistula 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.

The nurse reviews the laboratory results for a client who has possible appendicitis. Which laboratory test finding would the nurse expect? Decreased potassium level Increased sodium level Elevated leukocyte count Decreased thrombocyte count

Elevated leukocyte count Appendicitis is an acute inflammatory disorder that frequently results in elevation of leukocytes (white blood cells). Serum electrolytes are not affected because the client does not Btestbanks.com usually have diarrhea. Thrombocyte (platelet) count is unrelated to this GI disorder.

A client had an open traditional Whipple procedure this morning. For what priority complication would the nurse assess?a. Urinary tract infection Btestbanks.com Chronic kidney disease Heart failure Fluid and electrolyte imbalances

Fluid and electrolyte imbalances

A nurse cares for a client who is recovering from a colonoscopy. Which actions would the nurse take? (Select all that apply.) Obtain vital signs every 15 to 30 minutes until alert. Assess the client for rectal bleeding and severe pain. Administer prescribed pain medications as needed. Monitor the client's serum and urine glucose levels. Confirm the client has a ride home and plans to rest.

Obtain vital signs every 15 to 30 minutes until alert. Assess the client for rectal bleeding and severe pain. Confirm the client has a ride home and plans to rest.

The assistive personnel note that a client had a dark stool. What stool test would the nurse obtain for this client? Culture and sensitivity Parasites and ova Occult blood test Total fat content

Occult blood test Dark stools are typical in clients who have lower GI bleeding. Therefore, an fecal occult blood test would be the most appropriate test as a follow-up.

A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride. The client's respiratory rate is 8 breaths/min. What action by the nurse is appropriate? Administer naloxone. Call the Rapid Response Team. Provide physical stimulation. Ventilate with a bag-valve-mask.

Provide physical stimulation. For an EGD, clients are given mild sedation but would still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurse's most appropriate action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for midazolam HCl. The Rapid Response Team is not needed at this point. The client does not need manual ventilation.

A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is appropriate? Ask the client to call back if this happens again today. Instruct the client to go to the emergency department. Remind the client that a small amount of bleeding is possible. Tell the client to come to the clinic this afternoon.

Remind the client that a small amount of bleeding is possible. After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse would remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness.

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

Roasted chicken breast, baked potato with chives, and orange juice