Inflammatory Intestinal Disorders and Liver Problems
A nurse is teaching a client who recently began taking sulfasalazine (Azulfidine) about the drug. What does the nurse tell the client to report to the health care provider? Select all that apply. A. Anorexia B. Depression C. Drowsiness D. Frequent urination E. Headache F. Vomiting
A, E, F
When caring for a client with Laennec's cirrhosis, which of these does the nurse expect to find on assessment? Select all that apply. A. Prolonged partial thromboplastin time (PTT) B. Icterus of skin C. Swollen abdomen D. Elevated magnesium E. Currant jelly stool F. Elevated amylase level
A-C: The liver produces clotting factors; when damaged, prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The client with cirrhosis may develop ascites, or fluid in the abdominal cavity. Currant jelly stool is consistent with intussusception, a type of bowel obstruction.
A male client with a long history of ulcerative colitis (UC) experienced massive bleeding and had emergency surgery for creation of an ileostomy. He is very concerned that sexual intercourse with his wife will be impossible because of his new ileostomy pouch. How does the nurse respond? A. "A change in position may be what is needed for you to have intercourse with your wife." B. "Have you considered going to see a marriage counselor with your wife?" C. "What has your wife said about your pouch system?" D. "You must get clearance from your health care provider before you attempt to have sexual intercourse."
A. A simple change in positioning during intercourse may alleviate the client's apprehension and facilitate sexual relations with his wife.
A 21-year-old woman has abdominal pain, cramping, and diarrhea. She reports having 10 to 12 liquid bloody stools per day. A stool sample for ova and parasites is negative. A diagnosis of ulcerative colitis (UC) is made. She is to be discharged on loperamide (Imodium) for symptomatic management of diarrhea. What does a nurse include in the teaching about this medication? A. "Be aware of the symptoms (as we discussed) of toxic megacolon." B. "If diarrhea increases, you should let your health care provider know." C. "Pregnancy should be avoided." D. "You will need to decrease the dose of sulfasalazine (Azulfidine)."
A. Antidiarrheal drugs may precipitate colonic dilation and toxic megacolon. Toxic megacolon is characterized by an enlarged colon with fever, leukocytosis, and tachycardia.
A client is scheduled for discharge after surgery for inflammatory bowel disease (IBD). The client's spouse will be assisting home health services with the client's care. What is most important for the home health nurse to assess in the client and the spouse with regard to the client's home care? A. Ability of the couple to perform incision care and dressing changes B. Effective coping mechanisms for both of them after the client's surgical experience C. Knowledge about the client's requested pain medications D. Understanding of the importance of keeping scheduled follow-up appointments
A. Assessing the client's and the spouse's ability to carry out incision care and dressing changes is essential for avoiding further development of the infectious process, as well as infection of the surgical incision itself.
A 38-year-old male is admitted with severe gastroenteritis. He states, "I've had watery diarrhea and frequent vomiting for the past couple of days; I am becoming very weak." A health care provider prescribes an IV for him. The IV has been started, but the client continues with excessive diarrhea. He is given the maximum amount of an antispasmodic agent and yet continues to have diarrhea. What is additionally prescribed to decrease the watery volume of his stools? A. Bismuth subsalicylate (Pepto-Bismol) B. Loperamide (Imodium) C. Olsalazine (Dipentum) D. Sulfasalazine (Azulfidine)
A. Bismuth subsalicylate (Pepto-Bismol) 30 mL or 2 tablets every 30 minutes for a maximum of eight doses can be given to reduce the watery volume of the stool.
A client with a history of osteoarthritis has a 10-inch incision following a colon resection. The incision has become infected, and the wound requires extensive irrigation and packing. What aspect of the client's care does the nurse make certain to discuss with the health care provider before the client's discharge? A. Having a home health consultation for wound care B. Requesting an antianxiety medication C. Requesting pain medication for the client's osteoarthritis D. Placing the client in a skilled nursing facility for rehabilitation.
A. Home health services are most appropriate for this client because wound care will be extensive and the client's mobility may be limited.
A 38-year-old male is admitted with severe gastroenteritis. He states, "I've had watery diarrhea and frequent vomiting for the past couple of days; I am becoming very weak." A health care provider prescribes an IV for him. What fluid does the nurse expect to be administered? A. 0.45% normal saline B. 0.9% normal saline C. D10W (10% dextrose and water) D. Lactated Ringer's solution
A. Hypotonic fluids such as 0.45% normal saline, with or without potassium supplements, are usually infused, as prescribed.
The nurse is providing discharge teaching for the client with advanced liver disease. Which statement by the client indicates a need for further teaching? A. "I don't need hospice because I'm only 55 years old." B. "I'll ask my wife to contact our local support group." C. "I plan to talk with the pastor at our church." D. "My wife and I plan to get Meals on Wheels."
A. No age range is attached to the benefits of hospice services. The nurse should clarify this misunderstanding because a client with advanced liver disease would benefit from hospice services for comfort and end-of-life planning. Local support groups are a good community resource for clients and families dealing with advanced liver disease. Clergy can provide a spiritually supportive connection that may benefit clients and families during this challenging time. Meals on Wheels can provide nutritious meals and relieve some of the burden of meal preparation.
A client with ulcerative colitis (UC) has stage 1 of a restorative proctocolectomy with ileoanal anastomosis (RPC-IPAA) procedure performed. The client asks the nurse, "How long do people with this procedure usually have a temporary ileostomy?" How does the nurse respond? A. "It is usually ready to be closed in about 1 to 2 months." B. "This is something that you will have to discuss with your health care provider." C. "The period of time is indefinite-I am sorry that I cannot say." D. "You will probably have it for 6 months or longer, until things heal.
A. The RPC-IPAA has become the most effective method of creating an alternate method for UC clients who have surgery to remove diseased portions of intestines. Stage 1 creates an ileostomy while the internally created pouch is healing. Stage 2 closes the ileostomy, and the client begins to use the pouch for storage of stool. The time between the surgeries is generally 1 to 2 months.
When caring for the client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)? A. Kidney failure B. Refractory ascites C. Fetor hepaticus D. Paracentesis scheduled for today
A. The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic.
A nurse is teaching a client with Crohn's disease (CD) about managing the disease with the drug adalimumab (Humira). Which instruction does the nurse emphasize to the client? A. "Avoid large crowds and anyone who is sick." B. "Do not take the medication if you are allergic to foods with fatty acids." C. "Expect difficulty with wound healing while you are taking this drug." D. "Monitor your blood pressure and report any significant decrease in it."
A. The client should avoid being around large crowds to avoid developing an infection.
A client has a total colectomy, and a continent ileostomy is created. Which postoperative instruction does the nurse emphasize to this client? A. A small dressing must be worn over the stoma at all times. B. The client must always wear an external pouch system. C. The ileostomy must be drained once a day. D. No sensation will indicate when the ileostomy needs emptying.
A. The client will need to wear a small dressing over the stoma to keep it moist.
When caring for a client awaiting liver transplantation, the nurse recognizes that the client will be excluded from the procedure if which of these is present? A. Colon cancer with metastasis to the liver B. Hypertension C. Hepatic encephalopathy D. Ascites & SOB
A. Transplantation is performed for hepatitis and primary liver cancers.
An older adult has a perforated appendix and is scheduled for emergent surgery. What assessment findings will the nurse expect the client to have before surgery? Select all that apply. A. Bradycardia B. Dizziness C. Distended abdomen D. Fever E. Diarrhea F. Fistulas G. Incontinence
B,C,D: Perforation of the appendix also results in peritonitis with a temperature of greater than 101° F (38.3° C) and a rise in pulse rate. When the lumen is blocked, the mucosa secretes fluid, increasing the internal pressure and causing abdominal distention. Dizziness is a result of the infectious process. Clients with a perforated appendix experience an increase in pulse rate as opposed to bradycardia. Clients with appendicitis often have constipation. Fistula formation and incontinence of stool or urine are not common occurrences with a perforated appendix.
The RN has just received change-of-shift report on a client medical unit. Which client should the RN see first? A. The client with ascites who had a paracentesis 2 hours ago and is reporting a headache B. The client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse C. The client with hepatic cirrhosis and jaundice who has hemoglobin of 10.9 g/dL and thrombocytopenia D. The client with hepatitis A who has elevated LFTs
B. A change in the level of consciousness of the client with PSE is the greatest concern; actions to improve the client's level of consciousness should be rapidly implemented.
A client has developed gastroenteritis while traveling outside the country. What is the likely cause of the client's symptoms? A. Bacteria on the client's hands B. Ingestion of parasites in water C. Insufficient vaccinations D. Overcooked food
B. A main cause of gastroenteritis when traveling outside the country is ingestion of water infested with parasites.
The nurse is caring for a client with an exacerbation of ulcerative colitis. Which laboratory finding for the client will the nurse expect? A. Decreased erythrocyte sedimentation rate B. Decreased serum potassium C. Decreased C-reactive protein D. Decreased platelet count
B. Blood levels of sodium, potassium, and chloride may be low as a result of frequent diarrheal stools and malabsorption through the diseased bowel. The ESR and C-reactive protein will be elevated in a client with ulcerative colititis as a result of the inflammatory process. Platelet counts remain unchanged by the disease process of ulcerative colitis.
A client has vague symptoms that indicate an acute inflammatory bowel disorder (IBD). Which symptom is most indicative of Crohn's disease (CD)? A. Abdominal pain relieved by bending the knees B. Chronic diarrhea, abdominal pain, and fever C. Epigastric cramping D. Hypotension with vomiting
B. Chronic diarrhea, abdominal pain, and fever are symptoms more indicative of Crohn's disease (CD) than of other acute inflammatory bowel disorders.
In caring for the client who has undergone paracentesis, which changes in the client's status should be promptly reported to the provider? A. Increased blood pressure, increased respiratory rate B. Decreased blood pressure, increased heart rate C. Increased respiratory rate, increased apical pulse, pallor D. Tachypnea, diaphoresis, increased blood pressure
B. Decreased blood pressure and increased heart rate are indicative of shock.
The nurse is providing teaching to the client with hepatitis C. Which information is essential to include? A. Pegylated interferon alpha may cause myalgia. B. When ribavirin is taken, contraception must be used. C. Immunoglobulin B should be received upon diagnosis. D. A diet moderate in protein, fats, and carbohydrates should be consumed.
B. Fetal abnormalities are associated with ribavirin; this is essential information.
Which is a correct statement differentiating Crohn's disease (CD) from ulcerative colitis (UC)? A. Clients with CD experience about 20 loose, bloody stools daily. B. Clients with UC may experience hemorrhage. C. The peak incidence of UC is between 15 and 40 years of age. D. Very few complications are associated with CD.
B. Hemorrhage is commonly experienced in clients with UC.
A 38-year-old male is admitted with severe gastroenteritis. He states, "I've had watery diarrhea and frequent vomiting for the past couple of days; I am becoming very weak." A health care provider prescribes an IV for him. The IV has been started, but the client continues with excessive diarrhea. Which medication does the nurse ask the health care provider about prescribing? A. Balsalazide (Colazal) B. Loperamide (Imodium) C. Mesalamine (Asacol) D. Milk of Magnesia (MOM)
B. If the health care provider determines that antiperistaltic agents are necessary, an initial dose of loperamide (Imodium) 4 mg can be administered orally, followed by 2 mg after each loose stool, up to 16 mg daily.
A certified wound, ostomy, continence nurse (CWOCN) nurse is teaching a client about caring for a new ileostomy. What information is most important to include? A. "After surgery, output from your ileostomy may be a loose, dark green liquid with some blood present." B. "Call the health care provider if your stoma has a bluish or pale look." C. "Notify the health care provider if output from your stoma has a sweetish odor." D. "Remember that you must wear a pouch system at all times."
B. If the stoma has a bluish, pale, or dark look, its blood supply may be compromised, and the health care provider must be notified immediately.
The client is scheduled to undergo a liver transplantation. Which nursing intervention is most likely to prevent the complications of bile leakage and abscess formation? A. Prevent hypotension. B. Keep the T-tube in a dependent position. C. Administer antibiotic vaccinations. D. Administer immune suppressant drugs.
B. Keeping the T-tube in a dependent position and secured to the client is likely to prevent bile leakage, abscess formation, and hepatic thrombosis.
When providing community education, the nurse emphasizes that which group should receive immunization for hepatitis B? A. Clients who work with shellfish B. Men who prefer sex with men C. Clients traveling to Third World country D. Clients with elevations of AST, ALT
B. Men who prefer sex with men are at increased risk for hepatitis B, which is spread by exchange of blood and body fluids during sexual activity.
A client with a recent, surgically created ileostomy refuses to look at the stoma and asks the nurse to perform all required stoma care. What does the nurse do next? A. Asks the client whether family members could be trained in stoma care B. Has another client with a stoma-who performs self-care-come and talk with the client C. Requests that the health care provider request antidepressants and a psychiatric consult for the client D. Suggests that the health care provider request a home health consultation for the client, so that stoma care can be performed by a home health nurse
B. Talking with another client who successfully cares for his or her stoma may give the client the confidence to begin his or her own self-care.
Which client does the charge nurse assign to an experienced LPN/LVN? A. 28-year-old who needs teaching about how to catheterize a Kock's ileostomy B. 30-year-old who needs to receive neomycin sulfate (Mycifradin) before colectomy C. 34-year-old with ulcerative colitis (UC) who has a white blood cell count of 23,000/mm3 D. 38-year-old with gastroenteritis who is receiving IV fluids at 250 mL/hr
B. The LPN/LVN should be familiar with the purpose, adverse effects, and client teaching required for neomycin.
The nurse is caring for clients in the outpatient clinic. Which of these phone calls should the nurse return first? A. From the client with hepatitis A reporting severe and ongoing itching B. From the client with severe ascites who has a temperature of 101.4° F (38° C) C. From the client with cirrhosis who has had a 3-pound weight gain over 2 days D. From the client with esophageal varices and mild right upper quadrant pain
B. The client with ascites and an elevated temperature may have spontaneous bacterial peritonitis; the nurse should call this client first.
Which activity by the nurse will best relieve symptoms associated with ascites? A. Administering oxygen B. Elevating the head of the bed C. Monitoring serum albumin levels D. Administering intravenous fluids
B. The enlarged abdomen of ascites limits respiratory excursion; Fowler's position will increase excursion and reduce shortness of breath.
A nurse is teaching a client about dietary methods to help manage exacerbations ("flare-ups") of diverticulitis. What does the nurse advise the client? A. "Be sure to maintain an exclusive low-fiber diet to prevent pain on defecation." B. "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." C. "Maintain a high-fiber diet to prevent the development of hemorrhoids that frequently accompany this condition." D. "Make sure you consume a high-fiber diet while diverticulitis is active. When inflammation resolves, consume a low-fiber diet."
B. The most effective way to manage diverticulitis is with a low-fiber diet while inflammation is present, followed by a high-fiber diet once the inflammation has subsided.
An RN receives a change-of-shift report about four clients. Which client does the nurse assess first? A. 20-year-old with ulcerative colitis (UC) who had six liquid stools during the previous shift B. 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102° F C. 56-year-old who had a colon resection earlier in the day and whose colostomy bag does not have any stool in it D. 60-year-old admitted with acute gastroenteritis who is reporting severe cramping and nausea
B. This client may have developed perforation and may be at risk for peritonitis. Rapid assessment and possible surgical intervention are needed.
When providing dietary teaching to the client with hepatitis, the nurse includes which information? A. Larger meal early in the morning B. Increased carbohydrates and moderate protein C. Fluids restricted to 1500 mL per day D. Alcoholic beverages limited to once weekly
B. To repair the liver, the client should have a high-carbohydrate and moderate-protein diet; fats may cause dyspepsia.
When caring for a client with advanced cirrhosis, what laboratory assessment findings will the nurse expect? Select all that apply. A. Increased serum albumin B. Decreased bilirubin in the urine C. Increased alanine aminotransferase D. Increased alkaline phosphatase E. Decreased bilirubin in the stool F. Increased platelets
C,D,E: Serum levels of alanine aminotransferase (ALT) may be elevated because these enzymes are released into the blood during hepatic inflammation. Alkaline phosphatase is also increased. Fecal urobilinogen concentration is decreased in clients with biliary tract obstruction; these clients have light- or clay-colored stools. Total serum albumin levels are decreased in clients with severe or chronic liver disease as a result of decreased synthesis by the liver. Bilirubin in the urine would be increased—when liver function is impaired or when biliary drainage is blocked, conjugated bilirubin leaks out of the hepatocytes and appears in the urine, turning the urine dark amber. Platelets would be decreased—splenomegaly often occurs with cirrhosis and results from the backup of blood into the spleen. The enlarged spleen destroys platelets, causing thrombocytopenia (low serum platelet count) and an increased risk for bleeding.
When assessing a client with hepatitis B, the nurse anticipates finding which of these? Select all that apply. A. Recent influenza infection B. Brown stool C. Tea-colored urine D. Right upper quadrant tenderness E. Itching
C-E: The urine may be brown, tea, or cola colored in clients with hepatitis. Inflammation of the liver may cause right upper quadrant pain. Deposits of bilirubin on the skin, secondary to high bilirubin levels, and jaundice irritate the skin and cause itching. Hepatitis B virus, not the influenza virus, is spread by blood and body fluids.The stool in hepatitis may be tan or clay colored.
When assessing a client for hepatic cancer, the nurse anticipates finding an elevation in which of these? A. Hemoglobin and hematocrit B. Leukocytes C. Alpha-fetoprotein D. Serum albumin
C. Fetal hemoglobin is abnormal in adults; it is a tumor marker indicative of cancers.
A client attending a summer camp develops an Escherichia coli infection. What does the camp nurse tell campers about how to prevent this infection? A. "Do not touch other campers' towels or bed linens." B.. "Don't use dishes or eating utensils that are not disposable." C. "If you are swimming, avoid swallowing the water." D. "You should avoid drinking pasteurized dairy products."
C. Infection with E. coli can develop by swallowing water while swimming.
A client has newly diagnosed ulcerative colitis (UC). What does the nurse tell the client about diet and lifestyle choices? A. "Drinking carbonated beverages will help with your abdominal distress." B. "It's OK to smoke cigarettes, but you should limit them to ½ pack per day." C. "Lactose-containing foods should be reduced or eliminated from your diet." D. "Raw vegetables and high-fiber foods may help to diminish your symptoms."
C. Lactose-containing foods are often poorly tolerated and should be reduced or eliminated from the diet of clients with UC.
The nurse administers lactulose (Cephulac) to the client with cirrhosis for which purpose? A. Provides enzymes necessary to digest dairy productions B. Reduces portal pressure C. Promotes gastrointestinal excretion of ammonia D. Decreases gastrointestinal bleeding
C. Lactulose reduces serum ammonia levels by excreting ammonia through the GI tract.
A home health client has had severe diarrhea for the past 24 hours. Which nursing action does the RN delegate to a home health aide (unlicensed assistive personnel [UAP]) who assists the client with self-care? A. Instructing the client about the use of electrolyte-containing oral rehydration products B. Administering loperamide (Imodium) 4 mg from the client's medicine cabinet C. Checking and reporting the client's heart rate and blood pressure-in lying, sitting, and standing positions D. Teaching the client how to clean the perineal area after each loose stool
C. Obtaining blood pressure and heart rate is included in the education of home health aides and other unlicensed assistive personnel (UAP).
A 21-year-old woman has abdominal pain, cramping, and diarrhea. She reports having 10 to 12 liquid bloody stools per day. A stool sample for ova and parasites is negative. A diagnosis of ulcerative colitis (UC) is made, and she is prescribed sulfasalazine (Azulfidine) and corticosteroid therapy. As the disease improves, what change does the nurse expect in her medication regimen? A. Stop the corticosteroid therapy. B. Stop the sulfasalazine (Azulfidine). C. Taper the corticosteroid therapy. D. Taper the sulfasalazine (Azulfidine).
C. Once clinical improvement has been established, corticosteroids are tapered over a 2- to 3-month period.
The health care provider prescribes sulfasalazine (Azulfidine) for a client with ulcerative colitis. What nursing action is most important before the client begins the medication? A. Determine if the client's insurance pays for the drug. B. Ask the client if he smokes or drinks alcohol. C. Ask the client if he has any allergies to sulfa-type drugs. D. Teach the client the importance of avoiding crowds.
C. Sulfasalazine is in the same family as sulfonamide antibiotics. Therefore a client who has an allergy to sulfonamide or other drugs that contain sulfa should not take this drug. Determining whether the client's insurance company will cover the medication should never be a priority when the client's health is at stake. Consumption of alcohol and smoking should be discouraged in all clients with ulcerative colitis regardless of the drug therapy prescribed. Sulfasalazine does not suppress the immune system, so the client is not required to avoid large crowds.
The nursing team consists of an RN, an LPN/LVN, and a nursing assistant. Which client should be assigned to the RN? A. A client who is taking lactulose and has diarrhea B. A client with hepatitis C who requires a dressing change C. A client with end-stage cirrhosis who needs teaching about a low-sodium diet D. An obtunded client with alcoholic encephalopathy for whom a blood draw has been requested
C. The RN is responsible for client teaching.
A nurse is caring for a client who returns to the unit after having an exploratory abdominal laparotomy. How does the nurse position this client after the client is situated in bed? A. High Fowler's B. Lateral Sims' (side-lying) C. Semi-Fowler's D. Supine
C. The client is maintained in semi-Fowler's position to facilitate the drainage of peritoneal contents into the lower region of the abdominal cavity after an abdominal laparotomy. This position also helps increase lung expansion.
A client with a history of esophageal varices has just been admitted to the emergency department after vomiting a large quantity of blood. Which action should the nurse take first? A. Obtain the charts from the previous admission. B. Listen for bowel sounds in all quadrants. C. Obtain pulse and blood pressure. D. Ask about abdominal pain.
C. The nurse assesses vital signs to detect hypovolemic shock caused by hemorrhage.
An older adult with a history of diverticulitis is admitted to the emergency department stating that she has severe abdominal pain and has not had a bowel movement in 6 days. What priority assessment will the nurse perform? A. Listen to the client's breath sounds. B. Take the client's height and weight. C. Auscultate the client's bowel sounds. D. Perform a rectal examination.
C. The nurse should auscultate the abdomen for bowel sounds and the presence of peristalsis. Listening to lung sounds and obtaining height and weight are not a priority in the client with abdominal pain. A rectal examination may be part of the assessment at some point, but is not a priority considering the symptoms this client is experiencing.
An obese client is discharged 10 days after being hospitalized for peritonitis, which resulted in an exploratory laparotomy. Which assessment finding by the client's home health nurse requires immediate action? A. Reports pain when coughing B. Reports, "I am too tired to walk very much" C. States, "I feel like the incision is splitting open" D. Temperature is 100.8° F (38.2° C).
C. This client is at risk for poor wound healing and possible wound dehiscence; the nurse should immediately assess the wound and notify the health care provider.
Which problem for the client with cirrhosis takes priority? A. Insufficient knowledge related to prognosis of disease process B. Discomfort related to progression of disease process C. Potential for injury related to hemorrhage D. Inadequate nutrition related to inability to tolerate usual dietary intake
C. This is the priority client problem because this complication could be life threatening.
What teaching does the home care nurse give the client and family to prevent spread of hepatitis C? A. Do not consume alcohol. B. Avoid sharing the bathroom with the client. C. Prohibit members of the household from sharing toothbrushes. D. Drink only bottled water, and avoid ice.
C. Toothbrushes, razors, towels, and items that may spread blood and body fluids are not shared.
The health care worker believes that he may have been exposed to hepatitis A. Which intervention is the highest priority to prevent him from developing the disease? A. Requesting vaccination for hepatitis A B. Using a needleless system in daily work C. Getting the three-part hepatitis B vaccine D. Requesting injection of immunoglobulin
D. Administration of immunoglobulin, antibodies to hepatitis A, may prevent development of the disease.
Which statement by the client with cirrhosis indicates that further instruction is needed about the disease? A. "Cirrhosis is a chronic disease that has scarred my liver." B. "The scars on my liver create problems with blood circulation." C. "Because of the scars on my liver, blood clotting and blood pressure are affected." D. "My liver is scarred, but the cells can regenerate themselves and repair the damage."
D. Although cells and tissues will attempt to regenerate, this will result in permanent scarring and irreparable damage.
It is essential that the nurse should monitor the client returning from hepatic artery embolization for hepatic cancer for which of these? A. Right shoulder pain B. Polyuria C. Bone marrow suppression D. Bleeding
D. An arterial approach is taken; therefore prompt detection of hemorrhage is the priority.
An 80-year-old client with a 2-day history of myalgia, nausea, vomiting, and diarrhea is admitted to a medical-surgical unit with a diagnosis of gastroenteritis. Which health care provider request does the nurse implement first? A. Administer acetaminophen (Tylenol) 650 mg rectally. B. Draw blood for complete blood count (CBC) and serum electrolytes. C. Obtain a stool specimen for culture and sensitivity. D. Start an intravenous (IV) solution of 5% dextrose in 0.45 normal saline at 125 mL/hr.
D. Fluid therapy is the focus of treatment for clients with gastroenteritis. Older clients are at increased risk for the complications of dehydration such as hypovolemia and acute kidney failure.
A client who had surgery for inflammatory bowel disease (IBD) is being discharged. The case manager will arrange for home health care follow-up. The client tells the nurse that family members will also be helping with care. What information is critically important for the nurse to provide to these collaborating members? A .A list of medical supply facilities where wound care supplies may be purchased B. Information on proper handwashing techniques to avoid cross-contamination of the client's wound C. Information on the amount of pain medication that the client is allowed to take in each dose D. Written and oral instructions regarding symptoms to report to the health care provider
D. It is most important to provide the client and case manager with both written and oral instructions on reportable symptoms to avoid the development of complications.
How does the home care nurse best modify the home environment to manage side effects of lactulose? A. Provides small frequent meals for the client B. Suggests taking daily potassium supplements C. Elevates the head of the bed in high Fowler's position D. Requests a bedside commode for the client
D. Lactulose therapy increases the frequency of stools; a bedside commode should be made available to the client, especially if he or she has difficulty reaching the toilet.
The nurse asks the client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record? A. Positive Babinski's sign B. Hyperreflexia C. Kehr's sign D. Asterixis
D. Liver flap or asterixis is related to increased serum ammonia levels. The dorsiflexed hands begin to flap upward and downward when outstretched for a few moments.
When providing discharge teaching to the client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? A. Vitamin K-containing products B. Potassium-sparing diuretics C. Nonabsorbable antibiotics D. Nonsteroidal anti-inflammatory drugs
D. Nonsteroidal anti-inflammatory drugs may predispose to bleeding and are to be avoided.
Following paracentesis, during which 2500 mL of fluid has been removed, which assessment finding is most important to communicate to the physician? A. The dressing has a 2-cm area of serous drainage. B. The client's platelet count is 135,000/mm3. C. The client's albumin level is 2.8 mg/dL. D. The client's heart rate is 122.
D. Rapid removal of fluid may cause symptoms of shock; report tachycardia, especially when associated with hypotension.
A 21-year-old woman has abdominal pain, cramping, and diarrhea. She reports having 10 to 12 liquid, bloody stools per day. A stool sample for ova and parasites is negative. A diagnosis of ulcerative colitis (UC) is made, and she is started on sulfasalazine (Azulfidine). What does the nurse tell her about why she is receiving this therapy? A. "It is to stop the diarrhea and bloody stools." B. "This will minimize your GI discomfort." C. "With this medication, your cramping will be relieved." D. "Your intestinal inflammation will be reduced."
D. Sulfasalazine (Azulfidine) is one of the primary treatments for UC. It is thought to inhibit prostaglandin synthesis and thereby to reduce inflammation.
An intensive care unit (ICU) RN is "floated" to the medical-surgical unit. Which client does the charge nurse assign to the float nurse? A. 28-year-old with an exacerbation of Crohn's disease (CD) who has a draining enterocutaneous fistula B. 32-year-old with ulcerative colitis (UC) who needs discharge teaching about the use of hydrocortisone enemas C. 34-year-old who has questions about how to care for a newly created ileoanal reservoir D. 36-year-old with peritonitis who just returned from surgery with multiple drains in place
D. The ICU nurse is familiar with the care of a client with peritonitis, including monitoring for complications such as sepsis and kidney failure.
A client demonstrates the manifestations of appendicitis with a suspected complication of peritonitis. What is the priority nursing intervention? A. Assessing the client for changes in vital signs B. Medicating the client for pain C. Monitoring for changes in the client's mentation D. Preparing the client for emergency surgery
D. The highest priority for this client is to prepare him or her for emergency surgery so that the source of the infection can be removed.
Which is important for the nurse to include in the plan of care for a client who is to undergo paracentesis later today? A. Measure and record drainage. B. Monitor LFTs C. Obtain informed consent for the procedure. D. Have the client void before the procedure is performed.
D. Voiding before the procedure prevents bladder injury.
A client has an anal fissure. Which nursing intervention most effectively promotes perineal comfort for the client? A. Administering a Fleet's enema when needed B. Applying heat to acute inflammation for pain relief C. Avoiding the use of bulk-forming agents D. Using witch hazel wipes to relieve pain
D. Witch hazel wipes may be effective in relieving the pain associated with anal fissures.
