Gastrointestinal

A nurse is caring for a client with a retroperitoneal abscess who is receiving gentamicin 300 mg intravenously every 8 hours. Which client data would the nurse monitor? Select all that apply. 1. hearing 2. urine output 3.HCT 4. BUN and serum creatinine levels 5. serum calcium level 6. muscle tone

1,2,4

The nurse is evaluating how a client with hepatitis A understands the discharge teaching given. Which client statements indicate that further teaching is needed? Select all that apply. 1. "I can have an occasional glass of wine with my meal as I recover." 2. "My family and I do not need to take any special precautions as long as I take my medication." 3. "My bath towels shouldn't be used by any other family members." 4. "My family members should receive the hepatitis A vaccine to prevent them from getting the disease." 5. "My spouse and I can have intercourse and kiss." 6. "I should wear a mask when visitors come."

1,2,5,6

A nurse is caring for a client following gastric bypass surgery. At the 6-week appointment, the client reports symptoms of nausea, abdominal pain and cramping following meals, and shakiness and sweating up to 3 hours later. Which nursing interventions would help reduce the symptoms and be included in the plan of care? Select all that apply. 1. Eat small, frequent meals. 2. Limit sodium intake. 3. Reduce high concentrated sugars. 4. Ingest fluids at the end of meals. 5. Refer the client to a dietician

1,3,5

The nurse is caring for a client admitted with cirrhosis of the liver. Which laboratory results are consistent with the disease process? Select all that apply. 1. prothrombin time 22 seconds 2. potassium 4.0 mEq/L (4.0 mmol/L) 3. albumin 7.2 g/di (72 g/L) 4. ammonia 96 mg/dl (68.54 mmol/L) 5. platelets 75,000 cells/mm' (75 10/L) 6. amylase 250 units/L (4.18 ukat/L)

1,4,5

A nurse is caring for a client who recently had a bowel resection. The client has a hemoglobin level of 8 g/d and HCT of 30%. Dextrose 5% in half-normal saline solution (D$½NS) is infusing through a triple-lumen central catheter at 125 ml/ hour. The health care provider's orders include: • gentamicin 80 mg intravenous piggyback in 50 ml DsW over 30 minutes • ranitidine 50 mg intravenous in 50 ml • D5W piggyback over 30 minutes • one unit of 250 ml of packed red blood cells (RBCs) over 3 hours • nasogastric tube flushes with 30 ml of normal saline solution every 2 hours How many milliliters would the nurse document as the total intake for the 8-hour shift? Record your answer as a whole number.

1470

A nurse is calling report to the medical surgical floor staff regarding a client with acute diverticulitis. Which symptoms does the nurse anticipate? Select all that apply. 1. esophagitis 2. cramping pain in the left lower abdominal quadrant 3. bowel irregularity 4. heartburn 5. intervals of diarrhea 6. hiccuping

2,3,5

While preparing a client for an upper Gl endoscopy (esophagogastroduodenoscopy), the nurse would be correct to implement which intervention? Select all that apply. 1. Administer a preparation to cleanse the GI tract, such as GOLYTELY or Fleets Phospho-Soda. 2. Instruct not to eat or drink for 6 to 12 hours before the procedure. 3. Teach only to ingest a clear liquid diet for 24 hours before the procedure. 4. Inform the client of receiving a sedative before the procedure. 5. Encourage the client to eat and drink immediately after the procedure.

2,4

The registered nurse (RN) is assigned a client with stomach cancer, who has just returned from a subtotal gastrectomy. Which nursing interventions would be delegated to either a licensed practical/vocational nurse (LPN/VN) or a nursing assistant/unregistered health care worker (UHW)? Select all that apply. 1. Administer carboplatin 750 mg intravenously. 2. Document intake and output in the electronic medical record. 3. Assess bowel sounds in all four quadrants. 4. Reinforce tape over an abdominal incision 5. Ambulate in the hall for the first time after surgery. 6. Provide report for the next shift.

2,4,6

The nurse is assisting a client to ambulate to the bathroom following a bowel resection for diverticulitis. Suddenly, the client reports a sharp abdominal pain. The nurse assesses the client and determines the wound has eviscerated. Prioritize the following nursing actions in chronological order to show how the nurse would respond. All options must be used. 1. Assess the client's response. 2. Call for assistance from other nursing personnel. 3. Document the incident, including the client's condition. 4. Cover the wound with sterile, nonadherent dressing moistened with sterile normal saline solution. 5. Place the client in low Fowler's position. 6. Notify the surgeon.

2,5,4,1,6,3

The client has been admitted to the emergency department with severe midepigastric, upper quadrant abdominal pain. Based on the signs and symptoms and laboratory data documented in the chart below, the nurse would anticipate preparing for which diagnosis? 1. peptic ulcer 2. Crohn's disease 3. pancreatitis 4. irritable bowel syndrome

3

The nurse is preparing to administer a 75% strength tube-feeding formula. The full-strength formula is available. To prepare 500 ml of feeding, the nurse would plan to dilute how many milliliters of the full-strength formula with water? Record your answer as a whole number.

375

A client is admitted with inflammatory bowel syndrome (Crohn's disease). When planning care for the health care team, which would be included? Select all that apply. 1. lactulose therapy 2. high-fiber diet 3. high-protein milkshakes 4. corticosteroid therapy 5. antidiarrheal medications

4,5

A client returns from the operating room after undergoing extensive abdominal surgery. The client is receiving 1,000 ml of lactated Ringer's solution via a central line infusion. The health care provider orders the intravenous fluid to be infused at 125 ml/hour and additional intravenous fluids based on total output of the last hour. The drip factor of the tubing is 15 gtt/ml, and the output for the previous hour was 75 ml via Foley catheter, 50 ml via nasogastric tube, and 10 ml via Jackson-Pratt tube. For how many drops (gtt) per minute would the nurse set the intravenous flow rate to deliver the correct amount of fluid? Record your answer as a whole number.

65

A client diagnosed with gastroenteritis and mild dehydration has a history of being unable to tolerate oral intake for 3 days. Intravenous therapy is prescribed. The nurse anticipates administering what solution to treat the mild dehydration?

D5.45 NS solution injection usp

A nurse is assessing the abdomen of a client who was admitted to the emergency department with suspected appendicitis. Identify the area of the abdomen that the nurse would palpate last.

RLL