GI/GU QUESTIONS

A client with a brain tumor is admitted for surgery. The health care provider prescribes levetiracetam. The client asks why. What is the nurse's response? 1. "It destroys tumor cells and helps shrink the tumor." 2. "It prevents seizure development." 3. "It prevents blood clots in legs." 4. "It reduces swelling around the tumor."

2 Levetiracetam (Keppra) is used to treat seizures.

An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60 mmHg. Which prescribed intervention should the nurse implement first? 1. Administer IV antibiotics 2. Infuse bolus of IV normal saline 3. Prepare to assist with lumbar puncture 4. Transport client for head CT scan

2 Meningitis is inflammation of the meninges covering the brain and spinal cord and increases ICP • S/S: severe HA, fever, N/V, nuchal rigidity, photophobia, AMS • Always do ABCs first (airway, breathing, circulation). For a patient in this condition, the course of action would be to: 1. Increase blood volume thru NS IV 2. Administer vasopressors 3. Obtain blood cultures 4. Administer antibiotics (client will continue to decline without antibiotic therapy) 5. CT scan 6. Lumbar puncture

A client receiving total parenteral nutrition complains of nausea, abdominal pain, and excessive thirst. What is the best action for the nurse to take? 1.Assess the client's vital signs 2.Check the client's blood glucose 3.Report the findings to the health care provider 4.Slow down the rate of infusion

2 Parenteral nutrition contains dextrose, which can cause hyperglycemia. Common signs/symptoms of hypoglycemia include excessive thirst, increase urination, fatigue, and blurred vision. Option 1: Assessing vitals will not confirm hyperglycemia. Option 2: Checking blood glucose will obviously confirm hyperglycemia. Option 3: Findings cannot be reported to the HCP until they are...found. Option 4: Slowing down the infusion rate can resolve hyperglycemia, but it needs to be confirmed as hyperglycemia first.

The nurse is counseling a client with obesity who is starting a weight reduction diet. The client reports consuming 4-5 regular cola beverages daily. Which of the following beverages should the nurse recommend as healthier substitutes? Select all that apply. 1.Commercial fruit juice 2.Flavored club soda 3.Fresh vegetable juice 4.Sports beverages 5.Unsweetened tea

2, 3, 5 Option 1: Fruit juice contains no pulp (no fiber) and can be just as sugary as soda Option 4: Sports beverages can contain just as much sugar as soda

The nurse is caring for a client who has undergone a colonoscopy. Which client assessment finding should most concern the nurse?1.Abdominal cramping 2.Frequent, watery stools 3.Positive rebound tenderness 4.Recurring flatus

3 Option 1: Abdominal cramping is caused by the stimulation of peristalsis from the bowel being inflated with air during the procedure. Option 2: The preparation prior to the procedure (GoLYTELY) cleanses the colon and the symptoms may persist even after the procedure is complete. Option 3: Positive rebound tenderness, guarding, abdominal distension, and a boardlike abdomen are signs of a perforated bowel. Option 4: Air inserted into the bowel for the procedure causes gas.

The nurse is admitting a client with cholelithiasis and acute cholecystitis. Suddenly, the client vomits 250 mL of greenish-yellow stomach contents and reports severe pain in the right upper quadrant with radiation to the right shoulder. Which intervention would have the highest priority? 1.Administer promethazine 25 mg suppository 2.Infuse normal saline 100 mL/hour 3.Insert nasogastric tube to low suction 4.Maintain nothing-by-mouth (NPO) status

4 Cholelithiasis is the formation of gallstones, while cholecystitis is an inflamed gallbladder. Option 1: Promethazine suppository promotes relief of nausea and vomiting, and would minimize further fluid loss. This is the second priority intervention (related to circulation). Option 2: NS saline will replace lost fluid and electrolytes from vomiting. This is the third priority intervention related to circulation). Option 3: NG tube suction will alleviate gastric distention/promote gastric decompression and help alleviate nausea; this is a comfort measure and will be the last priority. Option 4: Although "airway, breathing, and circulation" are always the priority interventions, maintaining NPO status does not take any time and should be established first, before any interventions; NPO will prevent any further gallbladder stimulation

Appendicitis

Appendicitis may lead to a rupture appendix, which can cause peritonitis (infection of the peritoneum) which is life threatening.

The nurse assessing a client with an upper gastrointestinal bleed would expect the client's stool to have which appearance? 1.Black tarry 2.Bright red bloody 3.Light gray "clay-colored" 4.Small, dry, rocky-hard masses

1 Option 1: Black tarry stool (melena) indicates an upper GI bleed, as the blood is digested in the GI tract. Option 2: Bright red blood (hematochezia) indicates a lower GI hemorrhage, as the blood would not be digested this far into the GI tract. Option 3: Clay-colored stool indicates a lack of bile due to a biliary obstruction. Option 4: Small, dry, hard masses indicate constipation, asthere is not enough fluid in the diet.

A healthy 50-year-old client asks the nurse, "What must I do in preparation for my screening colonoscopy?" Which statements by the nurse correctly answer the client's question? Select all that apply. 1. "No food or drink is allowed 8 hours prior to the test." 2. "Prophylactic antibiotics are taken as prescribed." 3. "Smoking must be avoided after midnight." 4. "The day prior to the procedure your diet will be clear liquids." 5. "You will drink polyethylene glycol as directed the day before."

1, 4, 5 A colonoscopy is a procedure in which colonoscope (long, flexible tube) is placed inside the colon a tube is inserted into the colon to inspect for abnormalities. In order for the doctor to see clearly, the colon must be cleaned out. • No food or drinks are allowed 8-12 hours prio • Polyethylene glycol (GoLYTELY) helps clear out the colon prior to the procedure

After performing a physical assessment and obtaining vital signs for a client immediately after a laparoscopic cholecystectomy, which nursing intervention is the priority? 1. Apply anti-embolism stockings 2. Assist with early ambulation 3. Offer stool softeners 4. Provide low-fat foods

2 Post-op care for a client after a cholecystectomy is prevention of complications. CO2 is used in this procedure to expand the abdominal cavity, which can irritate the phrenic nerve and diaphragm, causing shallow breathing. Option 1: Compression stockings can prevent thromboemboli, but they are not as effective as ambulation. Option 2: Early ambulation after surgery decreases the risk of thromboembolism, stimulates peristalsis, and facilitates dissipation of CO2 (along with deep breathing exercises). Option 3: Post-op clients may have decreased peristalsis due to anesthesia and opioids, but early ambulation promotes GI motility. Option 4: Clients needs to remain on a clear liquid diet until bowel sounds return.

A client is receiving an infusion of total parenteral nutrition (TPN) with 20% dextrose through a central line at 75 mL/hr. The nurse responds to the client's IV pump alarm, which indicates that the bag is empty. The new bag is not expected to arrive from the pharmacy for an hour. What is the most appropriate nursing action? 1. Hang 0.9% normal saline until new bag arrives, then increase TPN to 150 mL/hr for 1 hour 2. Hang 10% dextrose in water until the new bag arrives, then resume TPN at 75 mL/hr 3. Hang dextran in saline until the new bag arrives, then resume TPN at 75 mL/hr 4. Hang lactated Ringer's until the new bag arrives, then resume TPN at 75 mL/hr

2 TPN is high in sugar, so a sudden loss in sugar intake can cause hypoglycemia. When TPN is being discontinued, the infusion is slowly reduced in rate, and then replaced with a solution containing dextrose. Option 1: NS does not contain any dextrose, and rapid infusion of an isotonic solution can cause fluid overload. Option 2: 10% dextrose in water will help prevent hypoglycemia. It should be infused at the same rate as the TPN (75 ml/hr). Option 3: Dextran is a colloid used to expand intravascular volume in clients with hypovolemia. It can cause fluid overload and will not prevent hypoglycemia. Option 4: LR contains electrolytes, but not glucose.

The nurse assesses a client with suspected acute pancreatitis and anticipates the client reporting pain in which anatomical area? 1. Left flank radiating to the left groin are 2. Left upper quadrant radiating to the back 3. Periumbilical area shifting to the right lower quadrant 4. Right upper quadrant radiating to the right shoulder

2 The pancreas is located towards the left upper quadrant of the abdomen; towards the back. • Client will report sudden onset, severe pain • Pain improves with leaning forward, worsens when lying flat • N/V are common • At risk for: hypovolemia (third spacing occurs), ARDs (intense systemic inflammatory response)

During the immediate postoperative period after a colostomy, which stoma appearance requires the nurse to contact the health care provider (HCP) immediately? 1.Brick red with slight moisture noted 2.Dusky with moderate edema present 3.Pink with slight oozing of blood 4.Rosy with no stool produced

2 The stoma being pink or red indicates vascularity and viability. Since it's a new stoma, it may bleed slightly and be edematous for a few weeks. Dusky color indicates no blood flow and tissue death may follow.

The nurse on the medical-surgical unit receives report on assigned clients. Which client warrants immediate attention? 1.Client experiencing abdominal cramps 2 hours after colonoscopy 2.Client reporting white stools 8 hours after barium swallow study 3.Client with epigastric pain after endoscopic retrograde cholangiopancreatography 4.Client with small bowel obstruction with copious, greenish-brown drainage from the nasogastric tube

3 A ERCP is a procedure in which an endoscope is passed through the mouth into the duodenum to assess the pancreatic and biliary ducts. Irritation or perforation during the procedure can cause acute pancreatitis. Option 1: Air during inflation of a colonoscopy can cause cramping Option 2: Barium contrast solution can make a client's stool white for 3 days; encourage fluids to expel the contrast medium Option 3: This may indicate acute pancreatitis; other s/s include LUQ pain, radiating back pain, rapid rise in pancreatic enzymes (amylase, lipase) Option 4: Greenish-brown drainage indicates bile, which is expected if there is a small bowel obstruction; the nurse needs to watch for signs of electrolyte imbalances, dehydration, and metabolic alkalosis

The nurse provides discharge instructions to a client one day after laparoscopic cholecystectomy. Which statement by the client indicates that further teaching is required? 1."I can resume a regular diet but will avoid fatty foods for several weeks after surgery." 2."I can return to work within a week of surgery." 3."I will report to the health care provider if my temperature is higher than 101 F (38.3 C)." 4."Tomorrow I can remove the puncture site bandages and take a bath."

4

The nurse is teaching the home health client how to perform colostomy irrigation. Which client action reveals that further teaching is required? 1.Attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place 2.Fills irrigation container with 500-1000 mL of lukewarm tap water and flushes the irrigation tubing 3.Hangs the irrigation container on a hook at the level of the shoulder approximately 22 inches above the stoma 4.Slowly opens the roller clamp, allowing the irrigation solution to flow, but clamps the tubing when cramping occurs

1 A descending or sigmoid colostomy drains stool that is more formed and similar to a normal bowel movement. A colostomy can be irrigated to create a bowel regimen that allows them to wear a smaller pouch. It allows for increased control over the passage of stool when irrigated daily. An enema set is never used to irrigate a colostomy, as a stoma irrigation kit contained a cone-tip application specifically made to avoid damaging the stoma.

A nurse is caring for a client who developed paralytic ileus after a stroke. The client reports nausea, abdominal discomfort, and distension; bowel sounds are absent. Which prescription does the nurse question? 1.Hydrocodone 5/325 mg 1 tab every 4 hours PRN for moderate pain 2.Increase continuous IV normal saline rate from 75 to 100 mL/hr 3.Insert nasogastric tube and attach to wall suction 4.Ondansetron 4 mg IVP every 4 hours PRN for nausea

1 A paralytic ileus is a temporary paralysis of the intestines, affecting peristalsis and bowel motility. It can be caused by certain meds, abdominal surgery, or immobility. Option 1: Opioids decrease bowel motility and can further exacerbate the paralytic ileus. Also, the client should remain NPO to prevent further abdominal distention Option 2: IV fluid and electrolyte replacement may be necessary to replace what is lost due to nasogastric suctioning Option 3: NG suctioning may be required to decrease gas build up and distention of the stomach Option 4: Ondansetron is an anti-emetic, which can relieve the nausea and vomiting associated with a paralytic ileus

A client is 1-day postoperative abdominoplasty and is discharged to go home with a Jackson-Pratt (JP) closed-wound system drain in place. The nurse teaches the client how to care for the drain and empty the collection bulb. Which statement indicates that the client needs further instruction? 1."I'll empty the JP bulb when it is totally full so that I don't have to unplug it so many times." 2."I'll pull the plug on the JP bulb and pour the drainage into the measurable specimen cup." 3."I'll squeeze the JP bulb from side-to-side as I hold it in my hand." 4."While the JP bulb is totally compressed, I'll clean the spout with alcohol and replace the plug."

1 An abdominoplasty is a procedure in which excess skin and fat are removed from the abdomen. Drains are commonly used with abdominal procedures. The purpose of the drain is to prevent fluid buildup in a closed space, which can put tension on the suture line and compromise the integrity of the incision, increase the risk for infection, and decrease wound healing. The JP drain should be emptied every 4-12 hours or when it's 2/3rds full max; as it fills up, negative pressure decreases and it stops sucking in fluid as effectively.

The nurse who is caring for a client with acute diverticulitis will immediately report which finding to the health care provider?1.Abdominal pain has progressed to the left upper quadrant 2.Hemoglobin of 11.2 g/dL 3.Lying on side with knees drawn up to abdomen and trunk flexed 4.White blood cell count of 12,000/mm3 (12.0 x 109/L)

1 Diverticulosis is a condition in which an individual has diverticula (protrusions of the large intestine caused by increase intraluminal pressure due to chronic constipation). When these become inflamed (diverticulitis), pain in the left lower quadrant and infection can occur. Option 1: pain in any part of the abdomen besides LLQ may indicate peritonitis (inflammation of the peritoneum; inner lining of abdomen and organs); this is potentially life threatening Option 2: Hemoglobin is normally 14-18 for men and 12-16 for women. Bleeding is typical with diverticulitis., and a Hgb of 11.2 g/dL is slightly below normal. Option 3: This position could be due to pain, but it doesn't indicate anything specific Option 4: Normal leukocyte count is 4.5-11 mm3; an elevated leukocyte count is expected, as diverticulitis can cause an infection

A client with diabetes receiving peritoneal dialysis experiences chills and abdominal discomfort. The nurse assesses the client's abdomen by pressing one hand firmly into the abdominal wall. The client experiences pain when the nurse quickly withdraws the hand. The client's most recent blood glucose level is 210 mg/dL. What is the priority action by the nurse? 1.Collect peritoneal fluid for culture and sensitivity 2.Heat the remaining dialysate fluid and increase the dwell time 3.Place the client in high Fowler's position 4.Prepare to administer regular insulin intravenously

1 Peritonitis is a common but serious complication of peritoneal dialysis that typically occurs as a result of contamination during infusion. The earliest indication of peritonitis is cloudy peritoneal fluid. Later symptoms are a low grade fever, chills, abd pain, and rebound tenderness (pain on removal after pressing against abdomen). Option 1: Check to see if the peritoneal effluent is cloudy is the easiest way to assess for peritonitis. Option 2: Dialysate is already pre-warmed prior to dialysis. Dwell time is specific to the client and should not be changed without a prescription. Option 3: High Fowler's can worsen abdominal pain. Option 4: Glucose is the osmotic agent in dialysis, so an increase in blood glucose is expected. A blood glucose of 210 mg/dL does not necessitate IV administration of insulin.

The post-anesthesia care unit nurse receives report on a client after abdominal surgery. What sounds would the nurse expect to hear when auscultating the bowel? 1.Absent bowel sounds 2.Borborygmi sounds 3.High-pitched and gurgling sounds 4.Swishing or buzzing sounds

1 Procedures that require bowel manipulation cause a temporary halting of peristalsis (paralytic ileus) for 24-48 hours. Small intestine peristalsis usually starts within 24 hours, but large intestine peristalsis may start within 3-5 days. Bowel sounds are normal if they are heard every 5-15 seconds. Option 1: Absent bowel tones are normal post-op from GI surgery Option 2: Borborygmi sounds are gurgling sounds heard in increased peristalsis and are attributable to the passage of fluid and gas in the intestine; this would not be heard after abdominal surgery, as the bowels are paralyzed Option 3: High-pitched, gurgling sounds are normal bowel sounds; these wouldn't be heard after abdominal surgery Option 4: A swishing, or buzzing sound (a bruit) indicates turbulent blood flow, and occurs with artery dilation (aneurism) or narrowing (obstruction) of a vessel.

A homeless man known to have chronic alcoholism and who has not eaten for 8 days is undergoing nutritional rehabilitation via oral and enteral feedings. Which of the following findings would indicate that the client is developing refeeding syndrome? 1.Phosphorus 2.0 mg/dL, potassium 2.9 mEq/L, magnesium 1.0 mEq/L 2.Phosphorus 4.0 mg/dL, potassium 3.5 mEq/L, magnesium 2.0 mEq/L 3.Blood glucose 60 mg/dL, sodium 120 mEq/dL, calcium 7.0 mg/dL 4.Blood glucose 100 mg/dL, sodium 140 mEq/dL, calcium 10.0 mg/dL

1 Refeeding syndrome is a life-threatening complication of nutritional replenishment in insignificantly malnourished clients after a period of starvation. Carbohydrate-rich nutrition (glucose) stimulates insulin production along with a shift of electrolytes from the blood into tissue cells, causing an ion shift. • hypophosphatemia, hypokalemia, hypomagnesemia • hyperglycemia, sodium retention, fluid overload • baseline electrolytes need to be obtained • closely monitor electrolytes during refeeding • gradually increase caloric intake • Normal phosphorous: 2.5-4.5 mg/dL • Normal potassium: 3.5-5.0 mEq/L • Normal magnesium: 1.5-2.5 mEq/L

Which statement made by the client demonstrates a correct understanding of the home care of an ascending colostomy? 1."I will avoid eating foods such as broccoli and cauliflower." 2."I will empty the pouch when it is one-half full of stool." 3."I will irrigate the colostomy to promote regular bowel movements." 4."I will restrict my fluid intake to 2,000 milliliters of fluid a day."

1 A colostomy is a surgical procedure that creates an opening (stoma) in the abdominal wall for the passage of stool to bypass the obstructed/diseased portion of the intestine. Option 1: foods that cause gas and odor should be eliminated from the diet (beans, cruciferous veggies) Option 2: pouch should be emptied when it is 1/3 full to prevent leaks and decrease pouch weight Option 3: the role of the ascending colon is to reabsorb water; since this is being bypassed, the stool will be semi-liquid and there is no need for irrigation Option 4: 2-3 L a day of fluid is necessary for anybody with no contraindications to prevent dehydration

During assessment of a client who had major abdominal surgery a week ago, the nurse notes that the incision has dehisced and evisceration has occurred. The nurse stays with the client while another staff member gets sterile gauze and saline. How should the nurse position the client while waiting to cover the wound? 1. Low Fowler's position with knees bent 2. Prone to prevent further evisceration 3. Side-lying lateral position 4. Supine with head of the bed flat

1 Dehiscence is splitting of the incision, and evisceration is when organs protrude from the incision. Evisceration is a rare but severe surgical complication and typically occurs ~a week after surgery and is an emergency. It commonly occurs when there is poor wound healing or obesity. The RN should stay with the patient, apply a sterile dressing, and call the HCP. Option 1: Low Fowler's lessons tension on the surgical incision and prevents further evisceration. Option 2: Prone puts more pressure on the incision and can cause further evisceration. Option 3: Lateral will not lesson tension on the wound. Option 4: Supine will put more tension on the surgical incision and could open it more.

The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg. Which assessments would the nurse perform to determine if the client's condition has progressed to hepatic encephalopathy? Select all that apply. 1. Ask if the client knows what day it is 2. Ask the client to extend the arms 3. Assess for telangiectasia (spider nevi) 4. Determine if the conjunctiva is jaundiced 5. Note amylase and lipase serum levels

1, 2 Hepatic encephalopathy (HE) is caused by ammonia build up due to the liver's inability to process it into urea from excretion by the kidneys. The build up of ammonia in the blood causes AMS, sleep disturbances, lethargy, and coma. Option 1: Asking the day assesses for orientation. Option 2: Asterixis (flapping hand tremors) is a common finding in HE, and can be observed when arms are extended. The cause is neurological. Option 3: Telangiectasia are spider angiomas (small blood vessels with red center) occur with liver dysfunction and are caused by altered metabolism of hormones, not neurological. Option 4: Jaundice is common with liver dysfunction and is caused by a decreased ability of the liver to process and dispose of bilirubin. Option 5: Amylase and lipase are enzymes produced by the pancreas and would not indicate liver damage, let alone HE. ALT and AST are liver enzymes that could indicate liver damage, but still would not indicate HE.

The nurse is caring for a client in the post-anesthesia care unit following a gastroduodenostomy. Which of the following nursing interventions are appropriate? Select all that apply. 1.Applying bilateral sequential compression devices 2.Encouraging splinting of the incision with a pillow when coughing 3.Keeping the client NPO until bowel sounds return 4.Maintaining supine positioning at all times 5.Repositioning and irrigating a clogged nasogastric tube PRN

1, 2, 3 A gastroduodenostomy is the removal of two-thirds of the stomach and connecting the remainder to the duodenum. It is done in cases of stomach cancer, a malfunctioning pyloric valve, gastric obstruction, or peptic ulcers. Option 1: Post-op clients are at a higher risk for venous thromboembolism (VTE) and require VTE prophylaxis Option 2: Splinting an incision means holding it together with your hands; this should be encouraged so that the pressure from a cough does not open the wound edges during normal coughing, and during turn/cough/deep breathe exercises to prevent atelectasis Option 3: To not exacerbate any pressure build up and abdominal distention while the client has a paralytic ileus, they should remain NPO until bowel sounds return Option 4: Remaining supine can be uncomfortable, and it's an aspiration risk; only clients who experience dumping syndrome should be placed supine (and only after meals) Option 5: An NG tube may be placed for gastric decompression; any clogs should be reported to the HCP, as manipulating this can cause a perforation or hemorrhage

The nurse prepares to admit a client with worsening cirrhosis who is on the waiting list for a liver transplant. The nurse should anticipate which assessment findings? Select all that apply. 1. Ascites 2. Bruising 3. Altered mental status

1, 2, 3 Cirrhosis of the liver occurs when a chronic liver disease (such as a hep C infection) causes scar tissue and decreases hepatic function. It eventually leads to liver failure. Option 1: Ascites is accumulation of fluid in the peritoneal cavity. Cirrhosis slows blood flow to the liver, which then backs up and builds pressure in the portal vein, causing fluid to leak into surrounding tissues; indicates advanced liver disease. Option 2: Poor liver function causes a decrease in prothrombin and other clotting factors synthesized by the liver, leading to increased bleeding Option 3: When the living can no longer efficiently break down ammonia into urea to excrete through urine, it builds up and causes encephalopathy (changes in brain function).

During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply. 1.Assess the client's hand movements with the arms extended 2.Compare current mental status findings with those from previous shifts 3.Contact the health care provider to request a blood draw for ammonia level 4.Encourage the client to ambulate in the hallway 5.Hold the client's morning dose of lactulose

1, 2, 3 Hepatic encephalopathy is a serious complication of end-stage liver disease (ESLD) that results from inadequate detoxification of ammonia from the blood (i.e. ammonia levels build up in the blood because the liver fails to break them down into urea). It causes confusion, lethargy, and altered mental status. Option 1: Assessing for asterixis (flapping tremors) indicates hepatic encephalopathy. Option 2: If mental status is degrading compared to base line, then the patient cannot go home. Option 3: Ammonia build-up in the blood causes HE. Option 4: If the client is sleepy and confused, then having them ambulate puts them at an unnecessary fall risk and will not help their HE. Option 5: Lactulose is the drug used to treat HE by helping excrete excess ammonia through the bowels.

A hospitalized client with acute pancreatitis has nausea, vomiting, epigastric pain, and tachycardia. Laboratory results show elevated serum lipase levels. Which interventions would the nurse anticipate being prescribed for the client? Select all that apply. 1.Administer hydromorphone IV PRN for pain 2.Administer intravenous fluids 3.Insert a nasogastric tube for nasogastric suction 4.Maintain client in a supine position, with head of bed flat 5.Provide small, frequent, high-carbohydrate, high-calorie meals

1, 2, 3 Option 1: Nothing should be given PO, so IV hydromorphone is a good choice. Option 2: Pancreatic inflammation releases chemicals that cause increased capillary permeability and third spacing, causing hypovolemia. Fluids needs to be replaced to prevent hypovolemic shock. Option 3: Pancreatitis can increase intra-abdominal pressure and pain; an NG tube for suction can release those trapped gases and easy discomfort. Option 4: Supine positioning will increase intra-abdominal pressure and pain; Semi-Fowler's or side-lying with knees drawn up will decrease abdominal tension. Option 5: The patient should remain PO to inhibit stimulation of pancreatic enzymes.

The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of teaching? Select all that apply. 1."I need to avoid taking medicines like ibuprofen without a prescription." 2."I should avoid drinking excess coffee or cola." 3."I should enroll in a smoking cessation program." 4."I should reduce or eliminate my intake of alcoholic beverages." 5."I will eliminate whole wheat foods, like breads and cereals, from my diet."

1, 2, 3, 4 Peptic ulcer disease causes ulcerations in the mucosa of the esophagus, stomach, and/or duodenum. Digestive enzymes are then able to digest underlying tissues, causing perforation and gastric bleeding. Risk factors: H. pylori infection, chronic NSAID use, stress, diet, lifestyle Option 1: NSAIDs like aspirin, ibuprofen, and naproxen block prostaglandins, which decrease acid and increase mucosa secretion in the stomach; this causes acid to eat away at the mucosa Option 2: Caffeine stimulates stomach acid secretion Option 3: Tobacco increases secretion of stomach acid and delays ulcer healing Option 4: Alcohol stimulates acid secretions Option 5: Whole wheat foods do not exacerbate PUD. However, the client should avoid foods that exacerbate their symptoms, if there are any. It's best to eat multiple small meals and not eat before sleeping.

The nurse assesses for cancer risk factors during a screening event at a gastroenterology clinic. Which of the following client statements include risk factors for esophageal cancer? Select all that apply. 1."A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week." 2."I am proud that I was able to lose 10 lb, but I'm still considered obese for my height." 3."I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently." 4."I have struggled with daily episodes of acid reflux for years, especially at nighttime." 5."I snack on a lot of salted foods like popcorn and peanuts."

1, 2, 3, 4 Risk factors for esophageal cancer include other cancer diagnoses, alcohol use, tobacco use, esophageal diseases or injuries, GERD, and obesity

The nurse is teaching about the importance of dietary fiber at a community health fair. Which health benefits of consuming a fiber-rich diet should the nurse include in the teaching plan? Select all that apply. 1.Helps prevent colorectal cancer 2.Improves glycemic control 3.Promotes weight loss 4.Reduces risk of vascular disease 5.Regulates bowel movements

1, 2, 3, 4, 5

An older client comes to the outpatient clinic for a routine physical examination and health screening. Which findings does the nurse recognize as possible indications of colorectal cancer? Select all that apply. 1.Abdominal pain 2.Blood in the stools 3.Change in bowel habits 4.Low hemoglobin level 5.Unexplained weight loss

1, 2, 3, 4, 5 Colorectal cancer occurs most often in adults over age 50. Risk factors include history of colon polyps; family history of colorectal cancer; inflammatory bowel disease (eg, Crohn disease, ulcerative colitis); and history of other cancers (eg, gastric, ovarian). Option 1: Abdominal pain or discomfort can be caused by the cancerous masses, although it's not common. Option 2: Bloody stool can be caused by the polyps or tumors rupturing Option 3: Polyp/tumor obstruction can cause a change in bowel habits Option 4: Intestinal bleeding from the polyps/tumors can occur, resulting in anemia, fatigue, and dyspnea Option 5: Impaired nutrition and altered intestinal absorption can cause weight loss

The nurse cares for a client with ulcerative colitis who is having abdominal pain and ≥10 bloody stools per day. Which of the following interventions should be included in the client's plan of care? Select all that apply. 1. Administer prescribed analgesic medications as needed 2. Encourage the client to discuss feelings about illness 3. Initiate strict, hourly intake and output monitoring 4. Investigate the client's compliance with the medication regimen 5. Offer the client high-protein foods during meals and snacks

1, 2, 3, 4, 5 Ulcerative colitis (UC) is a chronic inflammatory bowel disease characterized by inflammation and ulceration of the large intestine (colon) that results in abdominal pain, frequent bouts of bloody diarrhea, anorexia, and anemia. Option 1: UC can cause severe abdominal pain. Option 2: Chronic illnesses such as UC can icnrease the feelings of depression, hopelessness, and frustration. Option 3: Diarrhea, blood loss, and poor oral intake can cause dehydration in a patient with UC; this should be monitored to ensure adequate hydration. Option 4: UC exacerbations may just be spontaneous, or they may be precipitated by certain foods or lack of treatment adherence. Option 5: People with UC are at risk of anorexia and decreased nutrient absorption; foods should be nutrient dense and high in protein.

The nurse will implement which nursing actions when caring for a client recently diagnosed with a hiatal hernia? Select all that apply. 1.Elevate the head of the hospital bed 2.Instruct the client to avoid tobacco and caffeine 3.Offer small, frequent, low-fat meals 4.Provide a girdle to reduce the hernia 5.Teach the client to avoid lifting or straining

1, 2, 3, 5 A hiatal hernia is when the stomach protrudes into the esophagus due to weakened muscle tone of the lower esophageal sphincter (LES). Signs/symptoms may include GERD, dysphagia, and pain from increased abdominal pressure. Option 1: Elevating the HOB >30 degrees can help prevent symptoms Option 2: Tobacco and caffeine increase stomach acid secretions, which will exacerbate symptoms Option 3: Small, frequent, low fat meals decrease gastric distention. Large, high fat or high acidity meals exacerbate symptoms. Avoid lying down or bending over after meals. Option 4: A girdle will increase intra-abdominal pressure, exacerbating symptoms. A girdle (hernia truss) may only be used with inguinal hernias to keep organs from protruding through the abdominal wall. Option 5: Lifting or straining will increase intra-abdominal pressure, causing worsening symptoms and may make the hiatal hernia worse.

The nurse is caring for a client who has a postoperative paralytic ileus following a bowel resection for colon cancer. The client is receiving patient-controlled analgesia (PCA) with morphine. Which nursing diagnoses (NDs) are appropriate to include in the client's care plan? Select all that apply. 1.Acute pain 2.Dysfunctional gastric motility 3.Imbalanced nutrition, less than body requirements 4.Ineffective self-health management 5.Risk for infection

1, 2, 3, 5 A paralytic ileus is a condition in which peristalsis has slowed or stopped, causing a blocked intestine. This can be caused by bowel surgery, inflammation, or drugs (ex. opioids, anesthesia) Option 1: Acute pain as evidenced by the PCA with morphine Option 2: Dysfunctional gastric motility as evidenced by bowel resection surgery (common complication) Option 3: Increased metabolic demand due to wound healing, inability to ingest adequate caloric intake due to paralytic ileus Option 4: There is no evidence to suggest the client is ineffective at health management Option 5: Risk for infection as evidenced by bowel resection surgery, colon cancer diagnosis

A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should be included in the discharge teaching plan to reduce the risk of future episodes? Select all that apply. 1. Drink plenty of fluids 2. Exercise regularly 3. Follow a low-residue diet 4. Include whole grains, fruits, and vegetables in the diet 5. Increase intake of red meat

1, 2, 4 Diverticulosis is a disease in which sac-like protrusion (diverticula) occur on the colon. Diverticulitis occurs when the diverticula become infected and inflamed, which can cause fistula formation (), abscess, intestinal obstruction (mechanical ileus), bleeding (when vessels next to the diverticula bursts), peritonitis, and sepsis. Diverticular disease occurs due to chronic constipation (↑ intracolonic pressure). Option 1: High fluid diet can ease passage of stool, preventing diverticulitis and easy symptoms. Option 2: Exercising can facilitate GI motility Option 3: Low residue (low fiber diets) will increase the risk of constipation Option 4: A high fiber diet (whole grains, fruits, veggies) will ease constipation. Option 5: High fat foods such as red meat can cause constipation and increase the risk of diverticulitis.

The nurse is providing discharge teaching to a client newly diagnosed with ulcerative colitis. Which of the following statements by the client indicate that teaching has been effective? Select all that apply. 1."I need to eat a diet high in calories and protein so that I avoid losing weight." 2."I need to take multivitamins containing calcium daily." 3."I should avoid consuming alcoholic beverages." 4."I should drink at least 2 liters of water daily and more when I have diarrhea." 5."I will keep a symptom journal to note what I eat and drink during the day."

1, 2, 4, 3, 5 Ulcerative colitis (UC) is an inflammatory bowel disease characterized by periods of mucosal irritation in the large intestine, resulting in profuse, bloody diarrhea. Option 1: diets should be high in calories and protein to prevent weight loss and muscle waisting Option 2: people with UC tend to be on corticosteroids to decrease inflammation; steroids decrease bone density Option 3: Alcohol (along with caffeine and tobacco) are gastric irritants Option 4: People with UC can have 10+ liquid stools a day during a flare up, placing them at risk for dehydration Option 5: Tracking foods can help you determine what triggers flare ups

Which nursing interventions would the nurse implement when caring for a client newly diagnosed with acute, viral hepatitis B? Select all that apply. 1.Offer small, frequent meals to prevent nausea 2.Promote rest periods between periods of activity 3.Provide a diet high in fat and low in carbohydrates 4.Teach the client not to share razors or toothbrushes with others 5.Teach the client to abstain from drinking alcohol

1, 2, 4, 5 Hep B is a viral infection of the liver that results in impaired liver function: decreased bile production, decreased blood detoxification, and decreased drug and nutrient metabolism. Option 1: The liver cannot keep up with metabolism, so smaller meals can reduce metabolic demand and decrease nausea. Option 2: Clients with cirrhosis tend to fatigue easily. Option 3: High fat diets will increase nausea and digestion difficulties due to low bile production and should be avoided; promote a diet high in carbs, protein, and calories, as well as adequate water consumption. Option 4: Hep B is transmitted through sexual contact and blood. Option 5: Hepatotoxins (acetaminophen, alcohol) can cause further damage to liver cells.

During the admission assessment of a client with a small-bowel obstruction, the nurse anticipates which clinical manifestations? Select all that apply. 1.Abdominal distension 2.Absolute constipation 3.Colicky abdominal pain 4.Frequent vomiting 5.Pain during defecation

1, 3, 4 A small bowel obstruction can have a mechanical cause (surgical adhesions, hernias, intussusception, tumors) or a non-mechanical cause (paralytic ileus from abd surgery or narcotics). Option 1, 3, 4: A bowel obstruction prevents gas from moving through the GI tract, causing a build up proximal to the obstruction; that can cause pain and rapid onset nausea and vomiting. Option 2: Absolute constipation would not occur right away in a small bowel obstruction, as there is still fecal matter distal to the obstruction that would work its way through the GI tract. Option 5: Pain during defection usually indicates a rectal problem such as hemorrhoids or anal fissures.

The nurse is reviewing lifestyle and nutritional strategies to help reduce symptoms in a client with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? Select all that apply. 1.Choose foods that are low in fat 2.Do not consume any foods containing dairy 3.Eat three large meals a day and minimize snacking 4.Limit or eliminate the use of alcohol and tobacco 5.Try to avoid caffeine, chocolate, and peppermint.

1, 3, 4, 5 Gastroesophageal reflux disease (GERD) occurs when stomach acid is able to enter and inflame the esophagus. Sleeping and eating with HOB elevated, weight loss (↓ gastric pressure), chewing gum (promotes salivation to clear acid from esophagus) may alleviate GERD symptoms. Option 1: High fat foods delay gastric emptying, which can lead to reflux of acid into the esophagus for a longer amount of time Option 2: Dairy does not affect GERD Option 3: Large meals increase gastric pressure and stay in the stomach longer, causing more stomach acid production; small meals and sips of water will facilitate passage of stomach content. Options 4, 5: Alcohol, tobacco, caffeine, high fat foods, chocolate, peppermint, spicy foods, and carbonated beverages all exacerbate GERD.

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain. The health care provider requests that the nurse prepare the client for a paracentesis. Which nursing actions would the nurse implement prior to the procedure? Select all that apply. 1.Educate client about the procedure and obtain informed consent 2.Initiate NPO status 6 hours prior to the procedure 3.Obtain baseline vital signs, abdominal circumference, and weight 4.Place client in high Fowler position or as upright as possible 5.Request that the client empty the bladder

1, 3, 4, 5 Option 1: A paracentesis is an invasive procedure of sticking a needle into the abdominal cavity to drain fluid (ascites); informed consent is required. Option 2: NPO status is not required for the procedure; it is completed at bedside with a local anesthetic. Option 3: Baseline abd girth, weight, and vital signs should be recorded. Option 4: Placing the patient as upright as possible so the fluid collects in a single area. Option 5: The client should void to prevent puncturing the bladder during the procedure

The nurse is caring for a client with acute diverticulitis who has nausea, vomiting, and rates pain as 8 on a scale of 0-10. Which of the following interventions should be included in the plan of care? 1.Administer morphine sulfate as prescribed for pain control 2.Insert a rectal tube to protect the client's skin from diarrhea 3.Instruct the client to avoid straining 4.Maintain NPO status 5.Start IV infusion of normal saline

1, 3, 4, 5 Option 1: Morphine will reduce pain and decrease GI motility, allowing the bowel to rest. Option 2: Inserting a tube into the large intestine with diverticulitis increases the risk of GI bleed and perforation. Option 3: Straining increases the risk of rupturing blood vessels. Option 4: NPO status allows the bowel a chance to rest. If the case is less severe, a clear liquid diet can be permitted. Option 5: IV fluids will prevent dehydration.

A client admitted 3 days ago with upper gastrointestinal bleeding underwent an endoscopic procedure to stop the bleeding. The client is started on a clear liquid diet today. Which foods are appropriate for the nurse to offer the client? Select all that apply. 1.Apple juice 2.Cherry popsicle 3.Chicken broth4.Frozen yogurt 5.Unsweetened tea 6.Vanilla ice cream

1, 3, 5 Although popsicles are part of a clear liquid diet, red dyes should not be given to clients with GI bleeds because it can leave a residue in the bowel that resembles blood, making it more difficult to assess if GI bleed symptoms are improving or not.

The nurse understands that which of these body substances are modes of transmission for hepatitis B? Select all that apply. 1. Blood 2. Feces 3. Semen 4. Urine 5. Vaginal secretions

1, 3, 5 Viral hepatitis is a disease of the liver characterized by inflammation, necrosis, and cirrhosis (scarring). Hepatitis B is primary contracted through blood, semen, and vaginal secretions (i.e. not the GI tract). Early symptoms of Hep B include malaise, N/V, and abdominal pain. Late symptoms include jaundice (unable to process bilirubin), weight loss, clay-colored stools (↓ bile production of blockage), and thrombocytopenia (clotting factor synthesis is decreased).

The clinic nurse educator is developing a teaching plan for the following 6 clients. The nurse should instruct which client to avoid the Valsalva maneuver when defecating? Select all that apply. 1. 22-year-old man with a head injury sustained during a college football game 2. 30-year-old woman recently hospitalized for reconstructive augmentation mammoplasty 3. 56-year-old man 2 weeks post myocardial infarction 4. 68-year-old woman recently diagnosed with pancreatic cancer 5. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis 6. 82-year-old woman 1 week post cataract surgery

1, 3, 5, 6 The Valsalva maneuver (straining during defecation) involves holding the breath while bearing down on the perineum. Anybody with a head injury, stroke, or heart problems should avoid straining. Straining: • Increases ICP (option 1) • Stimulates the vagus nerve, slowing down heart and causing heart complications (option 3) • Increases abd and thoracic pressure, causing small veins to rupture called variceal bleeding (option 5) • Increases intraocular pressure (IOP)

The clinic nurse educator is developing a teaching plan for the following 6 clients. The nurse should instruct which client to avoid the Valsalva maneuver when defecating? Select all that apply. 1. 22-year-old man with a head injury sustained during a college football game 2. 30-year-old woman recently hospitalized for reconstructive augmentation mammoplasty 3. 56-year-old man 2 weeks post myocardial infarction 4. 68-year-old woman recently diagnosed with pancreatic cancer 5. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis 6. 82-year-old woman 1 week post cataract surgery

1, 3, 5, 6 The Valsalva maneuver is a breathing technique used to slow a tachycardic heart and used to increase pressure in the GI tract when defacating. It is performed by forcefully attempting to exhale against a closed airway (closing mouth, pinching nose). Option 1: The Valsalva maneuver increases intra-cranial pressure (ICP); clients with head injuries already be may have increased ICP or are at risk of increased ICP. Option 3: The Valsalva maneuver will put increased strain on the heart. Option 5: The Valsalva maneuver will increase pressure in vessels and may lead to vessel rupture. Option 6: The Valsalva maneuver increases intra-ocular pressure (IOP).

The nurse is reinforcing discharge instructions with a client following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome? Select all that apply. 1.Add high-protein foods to diet 2.Consume high-carbohydrate meals 3.Eat small, frequent meals 4.Increase intake of fluids with meals 5.Lie down after eating

1, 3,5 A gastrectomy is the surgical removal of part of the stomach, and can cause dumping syndrome (gastric contents empty too rapidly into the duodenum, causing a fluid shift into the small intestine and diarrhea and poor nutrient absorption). Option 1: The client should eat foods high in protein, fat, and fiber because these take longer than digest and will remain in the stomach longer. Option 2: Carbs should be avoided, as they are digested quickly. Option 3: Small, frequent meals reduce the amount of food in the stomach, and reduce symptoms of dumping syndrome. Option 4: Fluids should be avoided with meals, because they increase the risk of dumping syndrome. Option 5: Gravity increases gastric emptying, so lying down after eat with help prevent dumping syndrome.

A nurse is precepting a new graduate nurse who is caring for a client with a paralytic ileus and a Salem sump tube attached to continuous suction. The preceptor should intervene when the graduate nurse performs which interventions? Select all that apply. 1.Checks for residual every 4 hours 2.Places client in semi-Fowler's position 3.Plugs the air vent if gastric content refluxes 4.Provides mouth care every 4 hours 5.Turns off suction when auscultating bowel sounds

1, 5 Option 1: Residual volume refers to the volume of fluid remaining in the stomach at a point in time during enteral nutrition feedings. This is done to measure the rate of gastric emptying and prevent aspiration (and aspiration pneumonia). The salem sump tube is being used for suction, not feeding. Option 2: The client is placed in semi-fowler's position to prevent the NG tube from lying against the stomach wall. Option 3: The air vent provides a continuous flow of atmospheric air to prevent excess suction force. This vent is kept above the level of the client's stomach to prevent reflux. Option 4: Oral care will help keep oral mucosa moisturized and promote client comfort. Option 5: The suction sound can be mistaken for bowel sounds during auscultation if not turned off.

The health care provider orders a small bowel follow-through (SBFT) for a client. Which instructions should the nurse include when teaching the client about this test? 1."After the test, you may notice your stools are tarry black for a few days." 2."During the test, a series of x-rays will be taken to assess the function of the small bowel." 3."The HCP will use an endoscope to visualize your small bowel." 4."Your examination is scheduled for 8:00 AM. Please drink all of the polyethylene glycol by midnight."

2 An SBFT examines the anatomy and function of the small intestine using x-ray images taken in succession. Barium is ingested, and x-ray images are taken every 15-60 minutes to visualize the barium as it passes through the small intestine. It's used to identify fistulas, decreased motility (paralytic ileus), obstructions (mechanical ileus), or increased motility (malabsorption syndromes) Option 1: Barium will make the stool white and chalky, not tarry and black. Black stools (melena) are a sign of an upper GI bleed and need to be reported to the HCP. Normal stool should return within 72 hours. Option 2: The test usually takes 60-120 minutes. Option 3: No tools are inserted into the patient for this procedure. Option 4: Patients should not eat 8 hours prior to the exam, but they do not have to drink polyethylene glycol to clear themselves out.

The registered nurse (RN) is supervising a graduate nurse (GN) providing postoperative teaching for a male client after an inguinal hernia repair. Which statement by the GN would cause the RN to intervene? 1."Elevate your scrotum and apply an ice bag to reduce swelling." 2."Practice coughing to clear secretions and prevent pneumonia." 3."Stand up to use the urinal if you have difficulty voiding." 4."Turn in bed and perform deep breathing every 2 hours."

2 An inguinal hernia is the protrusion of abdominal contents through the inguinal canal, which appears as a bulge in the lateral groin. Herniation occurs spontaneously or results from increased intraabdominal pressure (eg, heavy lifting). Inguinal hernias occur most commonly in male clients and are usually repaired with minimally invasive surgery. If intestinal strangulation develops, the client requires emergency treatment to prevent bowel ischemia or perforation. Coughing should be avoided (or cough with mouth open), as this increases intra-abdominal pressure and hernia reoccurrence.

A student nurse asks why enteral (tube) feedings, rather than total parenteral nutrition (TPN), are being administered to a client with sepsis and respiratory failure. Which is the best response by the registered nurse? 1. "Enteral feedings have no complications." 2. "Enteral feedings maintain gut integrity and help prevent stress ulcers." 3. "Enteral feedings provide higher calorie content." 4. "Risk of hyperglycemia is lower with enteral feedings than with TPN."

2 Enteral feedings are nutrition that passes thru the intestines and are given via a tube from the nose, mouth, or percutaneously through the abdominal wall into the stomach. Total parenteral nutrition is given via a central line and bypasses the intestines. The enteral route is always preferred. Option 1: Enteral feedings have their own set of complications and depend on which route it takes (aspiration, tube displacement, hyperglycemia, diarrhea, abd distention, clogging) Option 2: enteral feedings utilize the digestive tract, which helps maintain gut bacteria; stress ulcers develop in critically ill patients because the GI tract is not as vital as other organs in times of stress, and blood is shunted away; enteral feedings preserve GI function Option 3: Caloric needs can be met by either enteral or parenteral feedings Option 4: hyperglycemia can occur with both enteral and parenteral feedings

The nurse is caring for a client with cirrhosis of the liver. Which blood test values would the nurse typically anticipate to be elevated when reviewing the client's morning laboratory results? Select all that apply. 1.Albumin 2.Ammonia 3.Bilirubin 4.Prothrombin time 5.Sodium

2, 3, 4 Cirrhosis is the end stage of many chronic liver diseases and is characterized by scarring (hepatic fibrosis), decreased blood flow, and decreased liver function. Option 1: Albumin is decreased because the liver is unable to synthesize albumin. This causes fluid to leak out of vessels and third spacing occurs, causing edema and ascites. Option 2: Ammonia is a byproduct of digestion of amino acids, and normally goes the liver and is converted to urea to be excreted by the kidneys. The liver cannot convert the urea and the levels rise. Option 3: Bilirubin is elevated because the liver is unable to conjugate and excrete the bilirubin, and jaundice occurs Option 4: Prothrombin time (normal range 11-14 seconds) would be increased because the liver is unable to synthesize clotting factors, so bleeding will increase Option 5: Due to the third spacing that occurs with cirrhosis, the kidneys will assume that the patient is hypovolemic, so it will retain more water, causing dilutional hyponatremia

The hospitalized client with anorexia nervosa is started on nutrition via enteral and parenteral routes. Which client assessment is the most important for the nurse to check during the first 24-48 hours of administration? 1.Serum albumin level and body weight[31%] 2.Serum potassium and phosphate[41%] 3.Symptoms of dumping syndrome[24%] 4.White blood cell count and neutrophils[2%]

2 Option 1: Daily weights and albumin level can help evaluate the efficacy of treatment, but not checking these will not result in death, so they are not the priority. Option 2: Refeeding syndrome is a potentially fat complication in severely malnourished patients. A lack of oral intake results in pancreas making less insulin and once nutrition is received, insulin spikes, resulting in a shift of phosphorous, potassium and magnesium into cells. This can cause muscle weakness and respiratory failure (hypophosphatemia) and cardiac arrhythmias (hypokalemia, hypomagnesemia). Electrolyte repletion is necessary to prevent cardiopulmonary failure. Option 3: Dumping syndrome is decrease storage area in the stomach, resulting in feed being rapidly "dumped" into the small intestine. This can cause poor absorption, diaphoresis, cramping, and diarrhea within 30 minutes after eating. Since the client is on parenteral nutrition (via IV), this is not an issue. Option 4: Due to central line placement (for TPN administration), there is risk for infection. However, this isn't a priority.

A client with end-stage liver disease is admitted for a transplant workup. The client's spouse states that the client has not stopped drinking alcohol and may be unable to quit for 6 months before the transplant. Which is the most appropriate action for the nurse to implement? 1.Ask the transplant team to place a palliative care referral so the client can learn about the option of hospice instead of transplant 2.Assess the client's motivation to make the necessary self-care changes before and after the transplant 3.Schedule a meeting to enlist the help of family members in encouraging the client to stay sober until the transplant 4.Tell the nurse manager that the client may not be an appropriate transplant candidate

2 Option 1: This does not specifically address whether the client is a candidate for a transplant or not. Option 2: The client may not be an appropriate transplant candidate, but it's too early to make that decision from one statement alone. Additional information needs to be assessed: drinking habits and motivation. The nurse should speak to the client directly about these concerns. Option 3: It's too early to plan interventions with family members at this point. Option 4: It is not the nurse's duty or responsibility to decide who is and who is not eligible for a transplant.

The unlicensed assistive personnel (UAP) assists a client with cirrhosis who underwent paracentesis 4 hours ago. The UAP reports to the nurse that the client was lightheaded and unsteady while ambulating to the chair. Which action should the nurse implement first? 1.Ask the UAP to take a set of vital signs 2.Assess the symptoms reported by the UAP 3.Hold the prescribed diuretic medications 4.Instruct the UAP to assist the client to bed

2 Paracentesis is a procedure that involves removal of excess fluid from the peritoneal cavity (ascites) and is performed to relieve dyspnea and discomfort related to increased intra-abdominal pressure and fluid volume. Hypovolemia is an associated complication related to intravascular fluid shifts that occur during and post-procedure and also to high volume peritoneal fluid removal (>5 L). Option 1: Vital signs are monitored every hour for the first 4 hours after a paracentesis, so this should already have been done. Option 2: The nurse needs to validate the UAP's claims by assessing for for lightheadedness, unsteady gait, monitor vital signs, and assess for hypovolemia (tachycardia, reduced HR, ortho hypotension). Option 3: Diuretics are prescribed for clients with ascites and help prevent ascites from reoccurring as quickly. The diuretics may need to be withheld if hypovolemia is suspected, but it shouldn't be the first intervention. Option 4: This can be completed for comfort, but it's not a priority intervention.

The registered nurse is developing a nursing care plan for a client who has just undergone surgery for treatment of ulcerative colitis with the creation of a permanent ileostomy. What is the priority outcome for this client? 1.The client will contact the United Ostomy Association of America 2.The client will look at and touch the stoma 3.The client will read the materials provided on ostomy care 4.The client will verbalize methods to control gas and odor

2 The priority outcome should always be independent self-care, which requires the client to adapt to their altered body image and manipulate the stoma and bag.

The nurse is caring for a client with a balloon tamponade tube in place due to bleeding esophageal varices. The client suddenly develops respiratory distress, and the nurse finds that the tube has been partially pulled out. Which intervention should be the nurse's priority? 1. Contact the health care provider 2. Cut the tube with scissors 3. Increase gastric suction level 4. Place the client in high Fowler position

2 A balloon tamponade tube is used to temporarily control bleeding from esophageal varices. It contains 2 balloons and 3 lumens. Th esophageal balloon compresses compresses bleeding above the esophageal sphincter, the gastric balloon compresses from below, and the gastric lumen drains stomach contents. If the tube becomes displaced and ends up in the oropharynx, it can be cut with scissors to rapidly deflate it and remove the tube.

The nurse is providing nutritional teaching for a client with a new ileostomy. Which foods should the nurse instruct the client to avoid? Select all that apply. 1.Bananas 2.Broccoli with cheese 3.Multigrain bagel 4.Popcorn 5.Spaghetti with sauce

2, 3, 4 An ileostomy is a surgically created opening (stoma) in the abdominal wall that connects the ileum of the small intestine to the external abdomen, bypassing the colon. The function of the colon is to reabsorb water and electrolytes, resulting in liquid stool and hydration/ electrolyte deficits. After a new ileostomy placement, the client should follow a low residue (low fiber diet) and slowly reintroduce fibrous foods. Option 1: Pitted, peeled, or cooked vegetables are OK after an ileostomy (peeled peaches, bananas, peeled potatoes) Option 2: Stringy or cruciferous vegetables should be avoided (broccoli, cabbage, celery, asparagus) Option 3: High fiber foods should be avoided (popcorn, brown rice, whole wheat) Option 4: Seeds should be avoided (strawberries, raspberries, sunflower seeds, popcorn) Option 5: Lower fiber carbs are OK after an ileostomy; a low residue diet helps prevent obstruction of the narrow lumen of the stoma.

The nurse is reinforcing strategies to manage symptoms for a client with irritable bowel syndrome. Which of the following instructions should the nurse include? Select all that apply. 1.Consume only clear liquids with severe symptoms 2.Keep a record of symptoms, diet, and stress levels 3.Limit dietary intake of gas-producing foods like legumes 4.Perform aerobic exercise at least three times weekly 5.Reduce the amount of caffeine consumed each day

2, 3, 4, 5 Irritable bowel syndrome (IBS) is a chronic GI disorder characterized by abdominal pain and altered bowel motility (diarrhea or constipation). Option 1: IBS clients are at risk for malnutrition, so they need to consume calories and nutrients whenever possible. A clear liquid diet would not provide adequate nutrition. Option 2: Keeping a record can determine what foods cause flare ups. Option 3: Gas-producing foods can exacerbate symptoms; beans, cruciferous vegetables, and fructose should be avoided. Option 4: Physical exercise can improves GI motility and may prevent bloating and constipation, and may also reduce stress (another potential cause of IBS flare ups) Option 5: Caffeine affects bowel motility and can exacerbate symptoms

The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion? Select all that apply. 1. Asymmetrical pupillary constriction 2. Brief loss of consciousness 3. Headache 4. Loss of vision 5. Retrograde amnesia

2, 3, 5 A concussion can cause a loss of consciousness, headache, and amnesia. • Treatment includes: rest, light diet, and no strenuous activity for 1-2 days • Monitor for signs of: worsening headache, vomiting (sign of increased ICP), sleepiness, confusion, visual changes, or weakness Options 1 and 4: indicate a more serious brain injury

The nurse is caring for a client with right upper quadrant pain and jaundice. The client's alanine aminotransferase /aspartate aminotransferase (ALT/AST) levels are 7 times the normal values. What questions would be most helpful regarding the etiology for these findings? Select all that apply. 1.Do you have black tarry stool? 2.Do you use intravenous (IV) illicit drugs? 3.How much alcohol do you typically drink? 4.Were you recently immunized for pneumonia? 5.What over-the-counter drugs do you take?

2, 3, 5 RUQ pain, jaundice, and elevated ALT and AST levels are signs of liver damage. Alcohol and OTC drugs like acetaminophen cause liver damage, and IV illicit drugs increase the risk of contracting hepatitis B and C infections, which are viral infections of the liver. Black, tarry stool is a sign of an upper GI bleed.

The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote the client's comfort? Select all that apply. 1.Encourage adequate sodium intake 2.Place client in semi-Fowler position 3.Place client in Trendelenburg position 4.Provide alternating air pressure mattress 5.Use music to provide a distraction

2, 4, 5 Ascites causes discomfort due to the pressure of the fluid on the surrounding organs and shortness of breath due to the pressure on the diaphragm. Option 1: Water follows sodium, so increasing sodium intake will increase water retention, exacerbating their symptoms from the edema and ascites. Option 2: Semi-fowler's (as opposed to supine) will decrease pressure on the diaphragm and ease breathing. Side-lying is also favorable because it allows the heavy/enlarged abdomen to rest on the bed. Option 3: Trendelenburg position will increase pressure on the diaphragm. Option 4: Edema, ascites, and pruritis (a symptom of cirrhosis) causes altered skin integrity and puts the client as risk for skin breakdown. Patient should be on q2H turn schedule. Option 5: Distractions take the client's mind off of their discomfort.

The emergency department nurse cares for 5 clients. Which of the clients below are at risk for developing metabolic acidosis? Select all that apply. 1. 25-year-old client with claustrophobia who was stuck in an elevator for 2 hours 2. 36-year-old client with food poisoning and severe diarrhea for the past 3 days 3. 40-year-old client with 3-day history of chemotherapy-induced vomiting 4. 75-year-old client with pyelonephritis and hypotension 5. 82-year-old client due for hemodialysis with clotted arteriovenous shunt

2, 4, 5 Metabolic acidosis is due to an increase in production of acid, retention of acid, or depletion of base via the kidneys or GI tract. Option 1: Claustrophobia will lead to panic and increased respiratory rate. This would increase CO2 and lead to respiratory acidosis. Option 2: "Below the waist, lose base." Diarrhea causes a loss of bicarbonate, which would cause metabolic acidosis. Option 3: Vomiting will cause a loss of hydrogen ions from stomach acid, which would cause metabolic alkalosis. Option 4: Pyelonephritis (kidney infection, usually caused by a UTI) causes impaired kidney function, which makes the kidneys unable to adequately filter out hydrogen and ammonium ions. Option 5: Much like pyelonephritis, a client who needs dialysis has impaired kidney function, therefore there is a build up of acid in their blood.

The nurse admits a client with cirrhosis who has an upper gastrointestinal bleed from suspected gastroesophageal varices. Which new prescription should the nurse question? 1.Administer pantoprazole IV piggyback every 12 hours 2.Initiate continuous octreotide IV infusion 3.Insert and maintain a nasogastric tube 4.Maintain NPO status except for PO medications

3 An upper gastrointestinal bleed (UGIB) can be a life-threatening condition caused by peptic ulcers or by variceal rupture (rupture of esophageal varices; fragile, distended veins caused by cirrhosis). Variceal rupture can occur from increased portal venous pressure (straining, coughing, vomiting) or mechanical injury (eating hard foods, chest trauma). Option 1: Pantoprazole is a proton pump inhibitor that reduces gastric acid secretion and helps prevent mucosal damage and ulceration; this will keep the upper GI bleed from getting worse Option 2: Octreotide reduces portal venous pressure, which will reduce bleeding in the GI tract Option 3: Insertion of an NG tube without visualization of the esophagus may cause further variceal rupture and cause a hemorrhage; an NG tube may be inserted with visualization for gastric decompression. Option 4: NPO status may be prescribed to prepare the client for an invasive diagnostic procedure or surgery

A graduate nurse is caring for a client with acute appendicitis who is awaiting surgery. Which action by the GN would require the precepting nurse to intervene? 1.Administers morphine IV PRN for pain 2.Initiates continuous normal saline IV 3.Provides a heating pad for abdominal discomfort 4.Teaches client about prescribed strict NPO status

3 Anything that stimulates or further inflames the appendix may cause it to rupture, including eating, drinking, antacids, laxatives, or heating pads.

A 78-year-old client recovering from a hip fracture tells the home health nurse, "I haven't had much of an appetite lately and have been really tired. I'm worried I'm not eating enough." Which question is the priority for the nurse to ask? 1."Are you able to prepare your own meals?" 2."Are you feeling lonely or depressed?" 3."Have you lost any weight unintentionally?" 4."How many meals do you eat each day?"

3 Before determining the cause of the client not eating enough food, the nurse needs to determine if this is the case or not (i.e. is the client malnourished?). Options 1, 2, 4: These questions attempt to discover why the client has inadequate nutritional intake; we want to discover if there even is inadequate intake first.

An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse? 1."I will refer you to the dietitian." 2."It should take about 6-8 weeks before you see improvement in your symptoms." 3."Tell me what you had to eat yesterday." 4."You must not be following your diet."[0%]

3 Celiac disease is an autoimmune disorder in which eating gluten (barley, rye, oats, and wheat) leads to damage of the lining of the small intestine, causing diarrhea, gloating, gas, fatigue, anemia, and osteoporosis. Option 1: Referral to a dietitian may be necessary if the client doesn't understand what to eat, but the nurse needs to find out why the client isn't responding to therapy first. Option 2: Most people experience relief of symptoms within a few days of a change of diet. Option 3: Finding out what the client ate can help determine if their diet is not appropriate for their disease. Option 4: This is chastising the client and isn't appropriate. It's non-therapeutic.

The nurse provides discharge instructions to a client with cirrhosis who has portal hypertension, ascites, and esophageal varices. Which statement by the client indicates that the teaching was effective? 1."I may have one alcoholic drink a day, but no more." 2."I may take aspirin instead of acetaminophen for fever or pain." 3."I should avoid straining while having a bowel movement." 4."I should eat a protein- and sodium-restricted diet."

3 Cirrhosis is scarring/dysfunction of the liver, portal hypertension is increased pressure in the portal vein that brings blood from the intestine to the liver and is caused by the liver's inability to process blood inefficiently, and esophageal varices are weak/enlarged veins due to increased blood flow/pressure in esophageal veins (cirrhosis is the #1 cause). Option 1: Alcoholism is the leading cause of cirrhosis, so alcohol should be avoided Option 2: Aspirin and acetaminophen can increase GI bleeding; this client is at a high risk for bleeds due to the portal hypertension and varices, so these should be avoided. Option 3: Straining increases GI pressure, which can increase bleeding from the portal vein and esophageal varices. Option 4: Sodium restriction can ease hypertension, but patients with cirrhosis usually are malnourished and need the protein.

The nurse is providing postoperative care to a client returning from a hemorrhoidectomy. Which action is the priority for the nurse to perform? 1.Administer docusate and teach the client to avoid straining during defecation 2.Give pain medications and instructions related to pain control 3.Remove the rectal dressing and check the client for bleeding 4.Teach the client how to self-administer a sitz bath 2-3 times daily

3 Hemorrhoids are distended, inflamed veins on the anus or lower rectum caused by anorectal pressure (straining, constipation). A hemorrhoidectomy is a minor procedure that can cause severe pain due to the spasms of the anal sphincter. Option 1: Docusate is given to ease bowel movements to prevent bleeding and pain. Patients should also eat a high fiber diet with adequate fluid intake. Option 2: Usually, NSAIDs are given, as opioids may worsen constipation. This would be the second priority intervention to prevent constipation (if the patient refuses a bowel movement due to pain). Option 3: Priority actions are always: airway, breathing, circulation. Bleeding post-op is a bigger priority than pain. Option 4: Sitz baths are used to relieve pain a few days post-op.

The nurse is assessing 4 clients in the emergency department. Which client should the nurse prioritize for care? 1.Client with liver cirrhosis and ascites who has increasing abdominal distension and needs therapeutic paracentesis 2.Client with new-onset ascites from a suspected ovarian mass who needs paracentesis for diagnostic studies 3.Client with ulcerative colitis who has fever, bloody diarrhea, and abdominal distension and needs an abdominal x-ray 4.Nursing home client with dementia who has stool impaction and abdominal distension and needs stool disimpaction

3 Option 1: Clients with advanced stage cirrhosis will occasionally need paracentesis and diuretics to relieve distension. This is therapeutic, and is not an emergency. Option 2: This is to test for malignancy (cancer) of the ovarian mass causing ascites; it is not an emergency. Option 3: A client with a UC flare-up (bloody diarrhea, abdominal distension) who is also experiencing a fever may have an infection. The symptoms presented are likely toxic megacolon, which is common in UC and is caused by c. diff bacteria. Option 4: Elderly clients with dementia have decreased mobility (↓ GI motility), drink less fluids, and do not eat adequate fiber and are at a higher risk of constipation. This client is not a priority.

An 80-year-old client has been hospitalized with pneumonia and malnutrition. Physical assessment findings include weakness and decreased muscle mass. Which finding best indicates that the client is responding to treatment? 1.Client consuming 90% of each meal 2.Serum albumin of 3.6 g/dL (36 g/L) 3.Weight gain of 2 lb (0.9 kg) in 2 weeks 4.White blood cell count of 15,000/mm 3 (15.0 × 109/L)

3 Option 1: although consuming 90% of a meal indicates they are intaking more nutrition, it's not conclusive evidence that the client is responding to treatment Option 2: Visceral protein stores (like albumin) are poor indicators of nutritional status because: protein synthesis by the liver decreases during inflammation, so the client may have inflammation but the albumin won't reflect that change for a few weeks, since albumin has a long half-life. Albumin range is 3.5-5 g/dL. Option 3: A weight gain of 2 pounds shows that whatever treatment they're doing is working, as weight gain is observable and objective Option 4: A WBC count of 15/mm3 is elevated (normal is 4-11/mm3); this indicates the pneumonia has not been resolved

The nurse is caring for a client with end-stage liver failure from hepatitis C who is being seen in the clinic for worsening ascites. The client is treated in the infusion center with intravenous (IV) albumin, IV furosemide, and oral spironolactone. The following day the nurse checks the client's labs. Which of the following lab findings is most important for the nurse to communicate to the health care provider? 1.Albumin 2.5 g/dL (25 g/L) 2.INR 1.4 3.Potassium 3.0 mEq/L (3.0 mmol/L) 4.Sodium 131 mEq/L (131 mmol/L)

3 Option 1: normal albumin levels are 3.5-5 g/dL; lower albumin levels are normal with liver failure due to decrease protein synthesis. Option 2: Normal INR is <1 second. However, liver failure causes a decrease in clotting factor synthesis, so prothrombin time and INR would be increased. Intervention is only indicated if there is evidence of increased bleeding. Option 3: Normal potassium is 3.5 to 5 mmol/L. A potassium of 3.0 is considered very low and may be caused by the diuretics. Hypokalemia must be corrected to prevent arrhythmias and hepatic encephalopathy. Option 4: Normal sodium is 135-145 mmol/L, so this is slightly lower. This may be due to the diuretics and is not a major concern as it's barely lower normal.

A client calls the primary care clinic reporting diarrhea for 4 days and a low grade fever. What instruction is most important for the nurse to give to the client? 1.Encourage client to eat bulk-forming foods such as whole grain bread 2.Encourage rest, fluids, and acetaminophen for the fever 3.Make an appointment for the client with the health care provider today 4.Take 2 tablets of loperamide followed by 1 tablet after each loose stool

3 Options 1, 2: These will treat the symptoms, but not the underlying cause Option 3: Any client whose diarrhea lasts >48 hours should be seen by their HCP. This is especially true if accompanied by a fever or bloody stools. After 4 days of diarrhea, the client is at risk of a fluid and electrolyte imbalance. Option 4: Loperamide (Imodium) is an anti-diarrheal drug, and will treat the symptoms but not the underlying cause. It should never be used for more than 2 days. It should also never be used with a fever, as it solidifies diarrhea, retaining it in the intestines longer, and may make whatever toxin is causing the fever remain in the intestines longer; this can cause toxic megacolon.

A client with a 10-year history of unipolar major depression has relapsed and is now hospitalized. The client is currently on phenelzine and weighs 115 lb but weighed 150 lb 3 months prior to admission. Which foods would be the best for this client? 1.Crackers and cheddar cheese 2.Hard-boiled egg with tomatoes 3.Steamed fish and potatoes 4.Tortilla chips with avocado dip

3 Reduced appetite and unintentional weight loss are part of the diagnostic criteria for depression. The client needs a diet high in calories and nutrients. Option 1: Phenelzine is a MAOI; foods high in tyramines (aged cheese, yogurt, cured meats, fermented foods, chocolate) are contraindicated. Option 2: Eggs and tomatoes would give a lot of protein but it's low in calories. Option 3: Fish and potatoes are high in protein and calories. Option 4: Chips and avocado dip is not nutritious.

The nurse assessing a client's pain would expect the client to make which statement when describing the abdominal pain associated with appendicitis? 1."My pain is a burning sensation in my upper abdomen." 2."My pain is an 8 out of 10 and on my left side below my belly button." 3."My pain is excruciating in my lower abdomen above my right hip." 4."My pain is intermittent in my abdomen and right shoulder."

3 The appendix is a pouch connected to the ileum of the small intestine. When it becomes infected or obstructed, it becomes inflamed. Option 1: Upper abdominal pain may be due to peptic ulcers, or if it's severe and radiating to the back, it may be appendicitis (LUQ pain) Option 2: LLQ pain indicates diverticulitis Option 3: Pre-umbilical to RLQ pain indicates appendicitis Option 4: Epigastric (upper middle) or RUQ pain indicate cholecystitis, especially if it radiates to the right shoulder.

A highly intoxicated client was brought to the emergency department after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking next? 1. Administer atropine for bradycardia 2. Administer nifedipine for hypertension 3. Have CT scan performed to rule out an intracranial bleed 4. Perform hourly neurologic checks with Glasgow coma scale (GCS)

3 The underlying cause of their symptoms needs to be discovered in order to properly treat it; treat the cause, not the symptoms. Option 1: he is tachycardic, not bradycardic. Option 2: Nifedipine is a calcium channel blocker that would decrease his BP, but we need to know why his BP is so high first Option 4: this is important, but no the priority; also, hourly is not often enough with a patient in this condition

A client is admitted to the hospital for severe headaches. The client has a history of increased intracranial pressure (ICP), which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, "That's weird, I didn't even feel nauseated." Which action by the nurse is the most appropriate? 1. Document the amount of emesis 2. Lower the head of the bed 3. Notify the health care provider (HCP) 4. Offer anti-nausea medication

3 Unexpected vomiting can be a sign of increased ICP in a patient with a history of increased HCP • gets worse in a lowered head position • best course of action: take vitals and notify HCP

The nurse administers lactulose to a client diagnosed with cirrhosis and hepatic encephalopathy. Which nursing action is inappropriate when administering this medication? 1.Assess mental status and orientation 2.Give on an empty stomach for rapid effect 3.Hold if 3 soft stools occur in a day 4.Mix with fruit juice to improve flavor

3 Hepatic encephalopathy is a reversible neurological complication of cirrhosis caused primarily by increased ammonia levels in the blood, due to ammonia created in the intestines not being broken down into urea by the liver to be excreted. Lactulose is a treatment for HE to reduce ammonia levels, and causes diarrhea. Option 1: Increased ammonia levels cause lethargy, AMS, and coma; mental status and orientation need to be assessed to see if treatment is working. Option 2, 4: Lactulose can be given on an empty stomach, or with liquids, or as an enema. Option 3: The desired therapeutic effect of lactulose is 2-3 loose stools a day. It should never be withheld, but maintained at a titrated rate until improved mental status and decreased ammonia levels are achieved.

The nurse is developing teaching materials for a client diagnosed with ulcerative colitis. The client will receive sulfasalazine. Which of the following instructions are included in the discharge teaching plan? Select all that apply. 1.Avoid small, frequent meals 2.Can have a cup of coffee with each meal 3.Eat a low-residue, high-protein, high-calorie diet 4.Increase fluid intake to at least 2000 mL/day 5.Medication should be continued even after the resolution of symptoms 6.Take daily vitamin and mineral supplements

3, 4, 5, 6 Sulfasalazine is a disease-modifying anti-rheumatic drug (DMARD) that reduces inflammation; it is used to treat ulcerative colitis and rheumatoid arthritis. Option 1: Small, frequent meals should be eaten to lessen the amount of fecal matter present in the GI tract Option 2: Caffeine, alcohol, and tobacco are gastric irritants and stimulate GI motility Option 3: Fiber will increase bulks, causing more trauma to the GI tract. Avoid raw fruits and veggies, whole grains, highly seasoned foods, and high fat foods. Option 4: Increased fluid will ease passage of stool, as well as ensure hydration. People with ulcerative colitis have poor absorption of fluids during flare-ups and are at a higher risk for dehydration. Option 5: Sulfasalazine should be continued even after symptoms subside to prevent a relapse. Option 6: People with UC are at a higher risk for nutritional deficits due to malabsorption and altered diet. Sulfasalazine also hinders folate absorption.

When assessing a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination? Select all that apply. 1.Flank pain radiating to the groin 2.High-protein food ingestion before the onset of pain 3.Low-grade fever with chills 4.Pain at the umbilicus 5.Right upper-quadrant (RUQ) pain radiating to the right shoulder

3, 5 Cholelithiasis (gallstones) can cause cholecystitis (inflamed gallbladder) due to obstruction of the cystic bile duct. This increases pressure in the gall bladder and causes Murphy's sign (palpation over the RUQ causes pain/inability to take a deep breath. Signs of cholecystitis include: RUQ pain referred to right shoulder, low grade fever, chills, N/V, and anorexia. Option 1: Flank pain radiating to groin is caused by renal colic (ureter stones). Option 2: Cholecystitis is triggered from fat, as it signals the gallbladder to contract and empty bile into the duodenum (but it can't do that if it's blocked, and pressure builds up). Option 4: Sudden onset pain at the umbilicus is seen with appendicitis.

A client comes to the clinic for a follow-up visit after a Billroth II surgery (gastrojejunostomy). The client reports occasional episodes of sweating, palpitations, and dizziness 30 minutes after eating. Which nursing action is most appropriate? 1.Check serum blood glucose for hypoglycemia 2.Ensure that the client consumes fluids with meals 3.Take the client's blood pressure while lying and standing 4.Teach the client to lie down after eating

4 A gastrojejunostomy is a surgical procedure in which the jejunum is connected to the stomach, shortening the stomach and upper GI tract. Dumping syndrome is a complication after a partial gastrectomy when gastric contents empty too rapidly into the duodenum, causing a fluid shift into the small intestine. Option 1: Hypoglycemia can cause similar symptoms (sweating, dizziness) but would be unlikely to occur 30 minutes after a meal. Option 2: Clients with dumping syndrome should not drink fluids with their meals, as causes stomach contents to pass faster into the jejunum. Option 3: Although dumping syndrome can cause hypotension (and the client's symptoms may indicate hypotension). This should be assessed, but it will not help the client's symptoms. Option 4: Lying down after eating will slow gastric emptying.

Which prescription should the nurse question when caring for a hospitalized client diagnosed with acute diverticulitis?1.Metronidazole 500 mg IV every 8 hours 2.Nasogastric (NG) tube to suction 3.Nothing by mouth (NPO) 4.Prepare for barium enema in AM

4 Acute care of diverticulitis focuses on allowing the colon to rest and the inflammation to resolve. Option 1: Metronidazole (Flagyl) is an antibiotic used to treat any bacteria causing the flare up. Option 2: NG tube suction can reduce any intra-abdominal pressure and distention, as well as relieve nausea and vomiting. Option 3: NPO status allows the colon time to rest. If food can be tolerated, it should be clear liquids or a low residue diet only. Option 4: Any procedure that increase intra-abdominal pressure (coughing, bending), increases, peristalsis (laxatives, enemas), or leads to perforation should be avoided.

The nurse is evaluating a client with liver cirrhosis who received IV albumin after a paracentesis to drain ascites. Which assessment finding indicates that the albumin has been effective? 1.Abdominal circumference reduced from admission recording 2.Flapping tremor no longer visible with arm extension 3.Shortness of breath no longer experienced in supine position 4.Vital signs remain within the client's normal parameters

4 Ascites is the accumulation of fluid in the peritoneal space that often occurs in clients with liver cirrhosis, as the portal vein gets backed up and fluid leaks out into surrounding tissues (third spacing. Option 1: A reduction in abdominal circumference indicates the ascites successfully drained out a significant amount of the fluid in the abd cavity. Option 2: Reduced flapping tremors (asterixis) would indicate ammonia is not building up to toxic levels in the blood. Option 3: A reduction in SOB indicates the ascites as been reduced and the fluid is no longer pushing up on the diaphragm. Option 4: Albumin is low in clients with cirrhosis; increasing albumin will increase oncotic pressure, pulling fluids back into the intravascular compartment and out of surrounding tissues. Low vascular fluid volume would cause hypotension and tachycardia. Adequate fluid volume in vessels would hopefully stabilize vitals.

The nurse prepares to administer intravenous albumin to a client with severe liver disease who has a low serum albumin level of 1.5 g/dL (15 g/L). Which characteristic finding associated with hypoalbuminemia should the nurse anticipate assessing? 1.Altered mental status 2.Easy bruising 3.Loss of body hair 4.Pitting edema

4 Fluid is pulled back into the intravascular compartment (vessels) via osmotic pressure. Albumin is the major component that controls osmotic pressure (↑ albumin in vessels = ↑ osmotic pressure = ↑ pulling force into vessels). When serum albumin is low, fluid is not pulled back into vessels and will leak into interstitial spaces. Normal albumin is 3.5-5 g/dL. Clients with severe liver disease may have hypoalbuminemia, because the liver synthesizes albumin. Option 1: AMS is a sign of liver disease; hepatic encephalopathy (condition in which brain function is altered) is due to elevated serum ammonia levels, as the liver fails to process ammonia into urea as waste. Option 2: Easy bruising is a sign of liver disease; the liver is unable to produce prothrombin (clotting factors) Option 3: Body hair loss is a sign of liver disease; liver is unable to metabolism hormones effectively Option 4: Pitting edema is fluid that's collected in interstitial space

The nurse receives report for 4 clients in the emergency department. Which client should be seen first? 1. 30-year-old with a spinal cord injury at L3 sustained in a motor cycle accident who reports lower abdominal pain and difficulty urinating 2. 33-year-old with a seizure disorder admitted with phenytoin toxicity who reports slurred speech and unsteady gait 3. 65-year-old with suspected brain tumor waiting to be admitted for biopsy who reports throbbing headache and had emesis of 250 mL 4. 70-year-old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL

4 Head injuries always have a risk of increase intracranial pressure, which can be life threatening if pressure gets too high. • Also: because the patient has afib, he may be on anticoagulants and could have a brain bleed • Conduct a neuro assessment (LOC, pupil response, vitals) immediately Option 1: A L3 injury is not life-threatening Option 2: slurred speech and unsteady gait with phenytoin toxicity is to be expected Option 3: a brain tumor can eventually increase ICP, but it's gradual and not a priority

A 70-year-old client is admitted to the hospital with a lower gastrointestinal bleed. After assisting the client back to bed, the nurse finds approximately 600 mL of frank red blood in the commode. The client is now pale and diaphoretic and reports dizziness. Which action should the nurse perform first? 1.Check the vital signs 2.Draw blood for hemoglobin and hematocrit 3.Lower the head of the bed 4.Maintain an IV line with normal saline

4 Human bodies contain 4-5 liters of blood. Allowable blood loss (ABL) is dependent on age/gender/weight and is 1000 L or less for an adult. Any loss of blood greater than 40% is considered exsanguination and would cause irreversible shock. Option 1: Checking vital signs is always important, but this is not the priority. Option 2: Monitoring Hgb and Hct status is important and can indicate the need for transfusion, but it's not the priority right now; also, changes in RBC status take a few hours after blood loss to show up on labs. Option 3: Lowering the head of the bed (especially if Trendelenburg) can help prevent shock by maintaining perfusion to the brain and vital organs. Option 4: After acute blood loss, blood volume is the priority to maintain blood pressure and tissue perfusion. NS is isotonic and can expand intravascular volume.

The nurse is reinforcing education to a client with irritable bowel syndrome who is experiencing diarrhea. Which of these meals selected by the client indicates an understanding of diet management? 1.Beans, yogurt, and a fruit cup 2.Beef, broccoli, and a glass of wine 3.Eggs, a bagel, and black coffee 4.Steak, tomato basil soup, and cornbread

4 IBS is a chronic condition in which peristalsis is affected, causing diarrhea, constipation, and abdominal pain. A lot of clients find relief by sticking to a low FODMAP diet and increasing fiber intake. Gas-producing foods, high fructose corn syrup, spices, and non-fermented dairy products should be avoided. Option 1: Beans increase gas and should be avoided; yogurt and fruit without small seeds are ok. Option 2: Broccoli increases gas and alcohol is a GI irritant. Option 3: Eggs are OK, but bagels are gas-producing and coffee is a GI irritant. Hot beverages should be avoided. Option 4: Protein, breads and whole grains, and non-spicy foods low in fat are OK.

The clinic nurse provides teaching for a client scheduled for a barium enema the next day. Which statement by the client shows a need for further instruction? 1."I can expect chalky white stool after the procedure." 2."I cannot eat or drink 8 hours before the procedure." 3."I may have abdominal cramping during the procedure." 4."I will avoid laxatives after the procedure."

4 Laxatives can be used to help expel the barium from the body after the procedure. The client should be encouraged plenty of fluids and a high fiber diet to facilitate expulsion and prevent constipation.

The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which assessment finding does the nurse anticipate? 1.Constipation and polyuria 2.Increased thirst and dry mucous membranes 3.Leg weakness and soft, flabby muscles 4.Tremors and brisk deep-tendon reflexes

4 Normal magnesium levels are 1.5-2.5 mEq/L. Hypomagnesemia is associated with alcohol abuse, due to poor absorption and poor nutritional intake. Option 1: Constipation and polyuria are signs of hypercalcemia, as calcium as a diuretic effect Option 2: Increased thirst and dry mucous membranes are signs of hypernatremia, as increased sodium signals the kidneys to excrete more water and flush out the excess sodium Option 3: Muscle weakness is a sign of hypokalemia, along with paralytic ileus and cardiac arrhythmias. Option 4: Low magnesium is associated with neuromuscular excitability; other signs would be a positive Trousseau and Chvostek signs, and seizures

The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed? 1."I need to raise the head of my bed on blocks by at least 6 inches." 2."I will remain sitting up for several hours after I eat any food." 3."If my reflux and abd pain don't improve, I might need surgery." 4."Losing weight may reduce my reflux, so I plan to take a weight-lifting class."

4 Option 1, 2: Raising the HOB and remaining sitting up after meals can help prevent heart burn and GERD caused by a hiatal hernia. Option 4: Weight loss can reduce reflux associated with a hiatal hernia, but weight-lifting classes cause strain, which can make the hernia worse.

The nurse is assessing a client who had an esophagogastro-duodenoscopy (EGD) 2 hours ago. Which finding requires an immediate report to the health care provider? 1.Blood pressure drop from 122/88 mm Hg to 106/72 mm Hg 2.Gag reflex has not returned 3.Sore throat when swallowing 4.Temperature spike to 101.2 F (38.4 C)

4 Option 1: 106/72 mmHg is still within normal range; if there are no other symptoms to indicate something more severe is going on (blood loss, sepsis) then it's likely just from the sedation Option 2: Gag reflex may takes a few hours after an EGD to return; report to HCP if gag reflex has not returned after 6 hours Option 3: A sore throat is expected after an EGD Option 4: Fever after an EGD or colonoscopy indicates an infection from a perforation

The nurse is caring for a client with acute pancreatitis admitted 2 days ago. Which assessment finding is most concerning? 1. Blood glucose levels for the past 24 hours are ≥250 mg/dL 2.Client is lying with knees drawn up to the abdomen to alleviate pain 3.Five large, liquid stools that are yellow and foul-smelling 4.Temperature of 102.2 F (39 C) with increasing abdominal pain

4 Option 1: The pancreas produces insulin, and with pancreatitis it will not be functioning properly, so elevated glucose levels are expected. This may necessitate insulin administration. Option 2: Acute pancreatitis causes severe midepigastric pain that radiates to the back, so this is an expected response to reduce abdominal pressure and pain. Option 3: The pancreas produces lipase, an enzyme that facilitates digestion of fats. When the pancreas is inflamed, fat may not be digested and steatorrhea (fatty, liquid stools) can occur. Option 4: A fever and increasing pain may indicate the pancreas ruptured, which could cause an abscess (infected, pus-filled) or peritonitis (inflammation of the peritoneum)

A client is admitted with severe acute pancreatitis. While obtaining the client's blood pressure, the nurse notices a carpal spasm. What laboratory result would the nurse assess in response to this symptom? 1.Decreased albumin 2.Elevated troponin 3.Hyperkalemia 4.Hypocalcemia

4 Pancreatitis can cause hyperglycemia (pancreas is no longer producing insulin), hypovolemia (capillaries leak and third spacing occurs), hypoxia or ARDs (inflammatory chemicals constrict blood flow to all organs, including lungs), peritonitis, and hypocalcemia Option 1: Decreased albumin is seen with malnutrition Option 2: Elevated troponin is seen with an MI Option 3: Hyperkalemia is more likely seen with hemolysis (rupturing blood vessels) due to cell and muscle damage Option 4: A sign of hypocalcemia is a positive Trousseau's sign. Hypocalcemia also causes tetany and decreased cardiac contractility.

A client is admitted to the emergency room with right lower quadrant pain and suspected acute appendicitis. Which health care provider prescription should the nurse implement first? 1. Administer 5-325 mg hydrocodone/acetaminophen PO for pain 2. Draw blood for complete blood count and electrolyte levels 3. Obtain urine specimen for urinalysis 4. Start intravenous (IV) line with normal saline 100 mL/hr

4 Remember: ABC (airway, breathing, circulation) 1. Start IV and infuse NS 2. Draw blood samples 3. Obtain urine specimen 4. Administer pain meds (IV only*) *Acute appendicitis may require surgery, therefore patient must remain NPO

The nurse assesses a client who has followed a vegan diet for several years. Which client statement indicates a potential nutritional deficiency? 1."I have had some visual disturbances while driving at night." 2."I have had trouble falling asleep over the past few months." 3."Scaly patches of skin are developing on my elbows and knees." 4."Sometimes my hands and feet get a tingling sensation."

4 Vegan diets do not contain enough cobalamin (B12); a vitamin found mostly in animal products. B12 deficiencies can cause megaloblastic anemia and neurological symptoms, such as tingling, numbness, balance problems, and memory loss