NUR148 Exam 9 Chapters 48-55

The nurse is teaching a group of clients on the complications of obesity that develop when weight is not controlled through diet and exercise. Which lifestyle change does the nurse emphasize? (Select all that apply.) Select all that apply. A) "Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." B) "Begin a weight-training program for building muscle mass." C) "Liquid dietary supplements can be substituted safely for solid food." D) "Engage in moderate physical activity for at least 30 minutes each day." E) "Foods eaten away from home tend to be higher in fat than foods made at home." F) "Eat a variety of foods, especially grain products, vegetables, and fruits."

A) "Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." D) "Engage in moderate physical activity for at least 30 minutes each day." E) "Foods eaten away from home tend to be higher in fat than foods made at home." F) "Eat a variety of foods, especially grain products, vegetables, and fruits." Lifestyle changes the nurse emphasizes include consuming a diet that is moderate in salt and sugar and low in fats and cholesterol, and moderate physical activity for at least 30 minutes each day. Eating a variety of foods, especially grain products, vegetables, and fruits, helps people achieve weight loss. These are foods that "burn" more calories as they are metabolized. Many foods eaten away from home tend to be higher in fat than foods prepared at home. A weight-training program for building muscle mass does not need to be included in a weight loss program. Muscle weighs more and tends to increase weight in people who weight-train. Liquid dietary supplements cannot safely be substituted for solid food while attempting to lose weight. These types of liquid diets should be carefully supervised by a health care provider with special education in weight management.

The nurse is caring for a client who has been diagnosed with esophageal cancer. The client appears anxious, and asks the nurse, "Does this mean I am going to die?". Which nursing response is appropriate? (Select all that apply.) A) "Let me sit with you for awhile and we can discuss how you are feeling about this." B) "You can beat this disease if you just put your mind to it." C) "No, surgery can cure you." D) "It sounds like death frightens you." E) "Let me call the hospital chaplain to talk with you."

A) "Let me sit with you for awhile and we can discuss how you are feeling about this." D) "It sounds like death frightens you." Acknowledging that death may frighten the client, and offering to talk about how the client is feeling, are therapeutic nursing interventions. Telling the client that surgery is curative, and promising the client can beat the disease, are nontherapeutic responses that provide false hope. Although talking with the chaplain at a later time may be requested by the client, the immediate need is to allow the client to express feelings to the nurse.

The family of a client who has hepatic encephalopathy asks why the client is restricted to moderate amounts of dietary protein and has to take lactulose. What is an appropriate response by the nurse? A) "These interventions help to reduce the ammonia level." B) "These interventions help to prevent heart failure." C) "These interventions help the client's jaundice improve." D) "These interventions help to prevent nausea and vomiting."

A) "These interventions help to reduce the ammonia level." The client's high ammonia level has caused encephalopathy which can become so severe that it causes death. These interventions help to reduce ammonia in the body so that this condition does not worsen.

The nurse is performing a health assessment on a client with obesity who states, "I have tried many diets in an effort to lose weight, but have been unsuccessful." How does the nurse assess whether the client's response to stress is related to the client's obesity? A) "What do you usually do that helps to relieve stress?" B) "What is it about your size that causes you to feel uncomfortable?" C) "Do you usually use alcohol or drugs when you feel stressed?" D) "Do you have a history of mental health concerns?"

A) "What do you usually do that helps to relieve stress?" The appropriate way to assess the client's response to stress is to ask an open-ended type of question because it cannot be answered with a "yes" or "no." From that answer, the nurse can better determine if the client eats in response to stress. Asking the client about mental health problems may cause the client to feel uncomfortable with the assessment and shut down. This subject can be more gently introduced later, if needed, based on the nurse's initial assessment. More effective methods can be used to determine the client's alcohol and drug habits. Having the client tell you what makes him or her uncomfortable about size will only cause the client to restate the obvious. It does not determine the effect that stress has on the client.

An RN receives the change-of-shift report about these four clients. Which client will the nurse assess first? A) A 75 year old with dementia on nasogastric feedings with a respiratory rate of 38 breaths/min B) A 50 year old receiving total parenteral nutrition (TPN) with a blood glucose (BG) level of 300 mg/dL (16.7 mmol/L) C) A 30 year old admitted 2 hours ago with malnutrition associated with malabsorption syndrome D) A 45 year old who had gastric bypass surgery and is reporting severe incisional pain

A) A 75 year old with dementia on nasogastric feedings with a respiratory rate of 38 breaths/min The nurse first assesses the client with dementia who has a respiratory rate of 38 breaths/min. This client needs immediate respiratory assessment and interventions. Aspiration is a major complication in clients receiving tube feedings, especially in clients with an altered level of consciousness. The client with malnutrition associated with malabsorption syndrome, the client with incisional pain from gastric bypass surgery, and the client receiving TPN with a BG of 300 mg/dL (16.7 mmol/L) all need assessments and/or interventions by the RN, but maintaining respiratory function in the client with tachypnea is the highest priority.

The nurse is caring for a client who had a Whipple surgical procedure yesterday. For what serum laboratory test results would the nurse want to monitor frequently and carefully? A) Blood glucose B) Blood urea nitrogen C) Phosphorus D) Platelet count

A) Blood glucose During a Whipple procedure, most or all of the pancreas is manipulated, stressed, and possibly removed. Therefore, the client is at risk for hyperglycemia or hypoglycemia and blood glucose would need careful monitoring with a possible need for treatment.

The nurse is reviewing laboratory results of a client recently admitted with a diagnosis of acute pancreatitis. Which values would the nurse expect to be elevated? (Select all that apply.) A) Elastase B) Amylase C) Glucose D) Lipase E) Trypsin F) Calcium

A) Elastase B) Amylase C) Glucose D) Lipase E) Trypsin The client who has acute pancreatitis experiences elevation of all pancreatic enzymes and glucose. The serum calcium level is usually decreased (rather than elevated) because the release of fatty acids combined with available calcium.

When caring for a client with portal hypertension, the nurse assesses for which potential complications? (Select all that apply.) A) Esophageal varices B) Ascites C) Hematuria D) Hemorrhoids E) Fever

A) Esophageal varices B) Ascites D) Hemorrhoids Potential complications of portal hypertension include esophageal varices, ascites, and hemorrhoids. Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid). Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.

The nurse is caring for a client with peptic ulcer disease who has been vomiting profusely at home before coming to the emergency department. For which vital sign change will the nurse expect for this client? A) Hypotension B) Tachypnea C) Oxygen desaturation D) Bradycardia

A) Hypotension The client who is vomiting profusely is losing fluids from the body causing dehydration. A client who is dehydrated has hypovolemia resulting in hypotension and tachycardia.

A client with obesity has been taking orlistat as prescribed for 4 weeks but has only lost 10 lb (4.5 kg). The health care provider doubles the dosage and asks the nurse to provide further teaching. What behavioral change does the nurse include in the teaching plan? (Select all that apply.) Select all that apply. A) Keep a daily food diary. B) Set daily reasonable goals for eating. C) Increase exercise. D) Identify emotional and situational factors that stimulate eating. E) Identify a healthy individual that can be role-modeled.

A) Keep a daily food diary. B) Set daily reasonable goals for eating. C) Increase exercise. D) Identify emotional and situational factors that stimulate eating. Techniques the nurse includes in the teaching plan are keeping a record of foods eaten (food diary) (to look at daily trends), identifying emotional and situational factors that stimulate eating (which can be modified after identification), and increasing exercise (to burn calories). Setting daily reasonable goals helps the client focus on how to be healthy now instead of setting unreasonable future goals that cause the client to give up if not quickly achieved. The client should not look to role-model other people, as what works for them may not work for the client. The client should focus on his or her own behaviors in order to identify trends and make reasonable changes.

The nurse is caring for a client who recently had an external percutaneous transhepatic biliary catheter placed for severe biliary obstruction. What is the nurse's priority intervention when caring for this client? A) Keeping the biliary drainage bag below the level of the catheter-insertion site B) Checking the client's blood glucose frequently to monitor for diabetes C) Managing pain with continuous opioid patient-controlled analgesia (PCA) D) Capping the catheter if it starts to leak around the insertion site

A) Keeping the biliary drainage bag below the level of the catheter-insertion site The client who has an external percutaneous transhepatic biliary catheter drains by gravity and therefore needs to have the drainage bag placed lower that the catheter-insertion site. The catheter is not capped if jaundice or leakage around the catheter site occurs. Opioids are not needed while the client has the catheter however, if it is in place for an extended period of time, it needs to be changed.

Which nursing care activity for an undernourished client does the nurse safely delegate to an assistive personnel (AP)? A) Measuring current height and weight B) Determining body mass index (BMI) C) Estimating body fat using skinfold measurements D) Completing the Mini Nutritional Assessment

A) Measuring current height and weight Determining height and weight is the only activity that the nurse can safely delegated to an AP. The nurse is responsible for completing the Mini Nutritional Assessment, determining the client's BMI, and estimating body fat using skinfold measurements, as these assessments fall within the scope of practice of a registered nurse.

The nurse is caring for a client who was recently diagnosed with Helicobacter. pylori infection. Which drugs does the nurse and anticipate would be used for this client to manage the infection? (Select all that apply.) A) Metronidazole B) Lansoprazole C) Azithromycin D) Tetracycline E) Hydroxychloroquine

A) Metronidazole B) Lansoprazole D) Tetracycline Most clients who have this type of infection are prescribed to take a proton pump inhibitor, such as lansoprazole, and two antimicrobial drugs, such as metronidazole and tetracycline. Clarithromycin and amoxicillin may be used as alternative antibiotics.

The nurse is caring for a client who states that her mother had "gallbladder problems" and wonders if she is at risk for this disorder. What major risk factor places women most at risk for gallbladder disease? A) Obesity B) Birth control pills C) Infertility D) Advanced age

A) Obesity Obese women who are middle age and have had multiple children are at the highest risk for gallbladder disease, although it can occur in anyone.

The nurse is caring for a client who reports stomach pain and heartburn. Which assessment finding is most significant suggesting the client's ulcer is duodenal and not gastric? A) Pain occurs 1½ to 3 hours after a meal, usually at night. B) The client is a man older than 50 years. C) Pain is worsened by the ingestion of food. D) The client has a malnourished appearance.

A) Pain occurs 1½ to 3 hours after a meal, usually at night. A key symptom of duodenal ulcers is that pain usually awakens the client between 1:00 a.m. and 2:00 a.m. (0100 and 0200) and occurs 1½ to 3 hours after a meal. Pain that is worsened with ingestion of food and a malnourished appearance are key features of gastric ulcers. A male over 50 years is a finding that could apply to either type of ulcer.

Which practice does the nurse include when teaching a client about proper oral hygiene? A) Perform self-examination of the mouth every week, and report any unusual findings. B) Brush the teeth daily and floss as needed. C) Wear dentures that fit a bit loosely for movement when chewing. D) Use mouthwash with alcohol unless lesions are present.

A) Perform self-examination of the mouth every week, and report any unusual findings. The nurse will teach the client that proper oral care involves self-examination of the mouth every week and to report any unusual findings to the Health Care Provider. Clients need to brush teeth and floss every day—not just as needed. Clients are taught to avoid contact with agents that may cause inflammation of the mouth (such as, alcohol-based mouthwashes). Dentures should fit snugly, not loosely.

The nurse is teaching a client how to maintain effective oral health. Which measure does the nurse include in the teaching plan? (Select all that apply.) A) Regular dental checkups. B) Eating a balanced diet. C) Use of mouthwashes containing alcohol. D) Managing stress as much as possible. E) Ensuring that dentures are slightly loose-fitting.

A) Regular dental checkups. B) Eating a balanced diet. D) Managing stress as much as possible. Regular dental checkups are important, so potential problems can be prevented or attended to promptly. Stress suppresses the immune system, which can increase the client's risk for infections such as Candida albicans. Eating a balanced diet can reduce the risk for dental caries and infections such as C. albicans or stomatitis. Mouthwashes that contain alcohol may irritate tissues and cause inflammation, and should be avoided. Dentures must be in good repair and need to fit properly, not loosely.

A client is admitted to the emergency department with possible acute pancreatitis. What is the nurse's priority assessment at this time? A) Respiratory assessment B) Cardiovascular assessment C) Abdominal assessment D) Pain intensity assessment

A) Respiratory assessment As for any client, the nurse would want to continually assess for airway, breathing, and circulation. Clients who have acute pancreatitis often develop pleural infusions, atelectasis, or pneumonia. Necrotizing hemorrhagic pancreatitis places the client at risk for acute respiratory distress syndrome (ARDS).

When assessing a client with hepatitis B, the nurse anticipates which assessment findings? (Select all that apply.) A) Right upper quadrant tenderness B) Itching C) Recent influenza infection D) Brown stool E) Tea-colored urine

A) Right upper quadrant tenderness B) Itching E) Tea-colored urine Assessment findings the nurse expects to find in a client with hepatitis B include brown, tea-, or cola-colored urine, right upper quadrant pain d/t liver inflammation, & itching d/t irritating skin caused by bilirubin on skin secondary to high levels. Hept B virus not influenza causes hepatitis B and stool in hepatitis is usually tan or clay colored. right upper quadrant pain due to inflammation of the liver and itching, irritating skin caused by deposits of bilirubin on the skin secondary to high bilirubin levels and jaundice. Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored, not typically brown.

The nurse teaches the client who has cirrhosis about foods and other substances that should be avoided to prevent worsening of the disease. Which substance(s) will the nurse include in that health teaching? (Select all that apply.) A) Smoking B) Alcohol C) Illicit drugs D) Acetaminophen E) Sodium F) Protein

A) Smoking B) Alcohol C) Illicit drugs D) Acetaminophen Protein and sodium should be moderately restricted but not completely avoided. The other substances can worsen the disease process, especially drugs and alcohol which are normally metabolized by the liver.

A client who has undergone a bariatric surgical procedure is recuperating after surgery. Which nursing intervention most effectively prevents a client injury during repositioning? A) Using a weight-rated extra-wide bed for the client B) Administering pain medication C) Monitoring skinfold areas and keeping them clean and dry D) Making sure not to move the client's nasogastric (NG) tube

A) Using a weight-rated extra-wide bed for the client The most effective way to reposition a postoperative bariatric client and prevent injury is to use a special weight-related extra wide bed. This will allow adequate room for repositioning the client comfortably without causing the bed rails to touch his or her body, causing pressure and injury. Pain medication and monitoring skinfold areas will not prevent injury to the client that might occur during repositioning. Not moving the client's NG tube will prevent disruption of the suture line, but will not prevent repositioning injuries.

The nurse is preparing to instruct a client with chronic pancreatitis who is to begin taking pancrelipase. Which instruction does the nurse include when teaching the client about this medication? A) Wipe your lips after taking pancrelipase. B) Take pancrelipase before meals. C) Administer pancrelipase before taking an antacid. D) Chew tablets before swallowing.

A) Wipe your lips after taking pancrelipase. The nurse will instruct the client to wipe the lips after taking pancrelipase. Pancrelipase is a pancreatic enzyme used for enzyme replacement for clients with chronic pancreatitis. To avoid skin irritation and breakdown from residual enzymes, the lips should be wiped. Pancrelipase should be administered after, and not before, antacids or histamine2 blockers are taken. It should not be chewed to minimize oral irritation and allow the drug to be released more slowly. It should be taken with meals and snacks, and not before, and followed with a glass of water.

While undergoing radiation treatment for oral cancer, a client develops xerostomia. What collaborative resource does the nurse suggest for this client's care? A) Dentist B) Occupational therapist C) Speech therapist D) Psychiatrist

A)Dentist Xerostomia is the subjective feeling of oral dryness. It is a long-term effect of radiation therapy and requires ongoing oral care such as the use of saliva substitutes and follow-up dental visits.

Which factor does the nurse identify that places a client at risk for gastrointestinal (GI) problems? Select all that apply. A. Smoking a half-pack of cigarettes per day B. Taking nonsteroidal anti-inflammatory drugs (NSAIDs) C. Financial concerns D. Eating a high-fiber diet E. Use of herbal preparations

A, B, C, E

Which teaching will the nurse include when educating a client who is schedule to have an esophagogastroduodenoscopy (EGD)? Select all that apply. A. "Anesthesia will be used for sedation." B. "The procedure takes about 20 to 30 minutes to complete." C. "Informed consent will be needed prior to the procedure." D. "A separate test will be required to obtain any needed biopsies." E. "You will need to refrain from eating for at least 6 to 8 hours before the EGD."

A, B, D, E

Which daily behavior of a client with GI problems requires further nursing assessment? Select all that apply. A. Smokes a pack of cigarettes B. Uses Fleet enemas frequently to assist with bowel movements C. Practices intentional relaxation D. Eats multiple servings of fruits E. Takes 325 mg of aspirin at night for arthritic pain F. Exercises for 30 minutes three times weekly G. Travels extensively across the world

A, B, E, G

Which teaching will the nurse provide to a community group about early detection of colorectal cancer? Select all that apply. A. Home testing kits are available with a prescription B. Sigmoidoscopy should be performed every 10 years. C. People over 40 years old should be tested for colon cancer. D. Bowel preparation is necessary prior to performance of a colonoscopy. E. Virtual colonoscopies (CT colonography) can be performed every 5 years.

A, D, E

While working in the outpatient procedure unit, the RN is assigned to four clients. Which client will the nurse assess first? A. A 51 year old who just had an endoscopic retrograde cholangiopancreatography (ERCP). B. A 58 year old who has just arrived for a sigmoidoscopy. C. A 60 year old with questions about an endoscopic ultrasound examination. D. A 54 year old who is ready for discharge following a colonoscopy.

A. A 51 year old who just had an endoscopic retrograde cholangiopancreatography (ERCP).

The nurse is assessing an alert client who had abdominal surgery yesterday. Which assessment method will the nurse use to most accurately determine whether peristalsis has resumed? A. Ask if the client has passed flatus (gas) within the previous 12 to 24 hours. B. Perform auscultation with the diaphragm of the stethoscope. C. Listen for bowel sounds in all abdominal quadrants. D. Count the number of bowel sounds in each abdominal quadrant over 1 minute.

A. Ask if the client has passed flatus (gas) within the previous 12 to 24 hours.

While taking a client history, which report is least likely to contribute to GI problems? A. Eating a high-fiber diet B. Smoking a half-pack of cigarettes per day C. Use of herbal preparations D. Taking NSAIDS daily

A. Eating a high-fiber diet

An emergency room physician is observed asking a client inhale fully, while the provider pressed her hand under the client's right ribcage then asking the client to exhale. The nurse understands that which of the following is being assessed? A. The client's liver B. The client's spleen C. The client's lung expansion D. The client's diaphragmatic excursion

A. The client's liver

The nurse is caring for a client who has been diagnosed with cirrhosis. Which laboratory result(s) would the nurse expect for this client? (Select all that apply.) A) Increased serum bilirubin B) Increased lactate dehydrogenase C) Decreased serum albumin D) Increased serum alanine aminotransferase E) Increased aspartate aminotransferase F) Increased serum ammonia

ALL OF THE ABOVE Cirrhosis is a chronic disease in which the liver progressively degenerates. As a result, liver enzymes and bilirubin increase. Additionally, the liver is unable to synthesize protein leading to decreased serum albumin. Elevated serum ammonia results from the inability of the liver to detoxify protein by-products.

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

ANS: 25 mL 110 lb = 50 kg. 50 kg (5 mg/kg) = 250 mg. 250/100 x 10= 25 mL

3. A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this clients teaching? a. Drink plenty of fluids to prevent dehydration. b. You should only drink 1 liter of fluids daily. c. Increase your protein intake by drinking more milk. d. Sips of cola or tea may help to relieve your nausea.

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

A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this client's assessment? (Select all that apply.) a. "Which food types cause an exacerbation of symptoms?" b. "Where is your pain and what does it feel like?" c. "Have you lost a significant amount of weight lately?" d. "Are your stools soft, watery, and black in color?" e. "Do you experience nausea and vomiting?"

ANS: A, B The nurse would ask the client about factors that may cause exacerbations of symptoms, including food, stress, and anxiety. The nurse would also assess the location, intensity, and quality of the patient's pain or discomfort. Clients who have IBS do not usually lose weight, have nausea and vomiting, or have stools that are black.

The nurse is caring for a client who just had a minimally invasive inguinal hernia repair. Which nursing actions would the nurse implement? (Select all that apply.) a. Apply ice to the surgical area for the first 24 hours after surgery. b. Encourage ambulation with assistance within the first few hours after surgery. c. Encourage deep breathing after surgery but teach the client to avoid coughing. d. Assess vital signs frequently for the first few hours after surgery. e. Teach the client to rest for several days after surgery when at home. f. Teach the client not to lift more than 10 lb (4.5 kg) until allowed by the surgeon.

ANS: A, B, C, D, E, F all of these nursing actions are appropriate for the client having MIS for inguinal hernia repair

The nurse assists the wound care/ostomy nurse assess a client prior to ostomy surgery. Which assessments would the nurse complete before marking the placement for the ostomy? (Select all that apply.) a. Contour of the abdomen when standing b. Location of the client's belt line c. Contour of the abdomen when lying d. Location of abdominal muscles e. Contour of the abdomen when sitting

ANS: A, B, C, E Before marking the placement for the ostomy, the nurse would consider the contour of the abdomen in lying, sitting, and standing positions, the location of the belt line and possible location in the rectus muscle. The location of abdominal muscles is not considered.

A nurse plans care for a client who is recovering from an inguinal hernia repair. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Encouraging ambulation three times a day b. Encouraging normal urination c. Encouraging deep breathing and coughing d. Providing ice bags and scrotal support e. Forcibly reducing the hernia

ANS: A, B, D Postoperative care for clients with an inguinal hernia includes all general postoperative care except coughing. The nurse should promote lung expansion by encouraging deep breathing and ambulation. The nurse should encourage normal urination, including allowing the client to stand, and should provide scrotal support and ice bags to prevent swelling. A hernia should never be forcibly reduced, and this procedure is not part of postoperative care. DIF: Applying/Application REF: 1148 KEY: Herniation| postoperative care MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A nurse plans care for a client who has chronic diarrhea. Which actions should the nurse include in this client's plan of care? (Select all that apply.) a. Using premoistened disposable wipes for perineal care b. Turning the client from right to left every 2 hours c. Using an antibacterial soap to clean after each stool d. Applying a barrier cream to the skin after cleaning e. Keeping broken skin areas open to air to promote healing

ANS: A, B, D The nurse should use premoistened disposable wipes instead of toilet paper for perineal care, or mild soap and warm water after each stool. Antibacterial soap would be too abrasive and damage good bacteria on the skin. The nurse should apply a thin layer of a medicated protective barrier after cleaning the skin. The client should be re-positioned frequently so that he or she is kept off the affected area, and open skin areas should be covered with DuoDerm or Tegaderm occlusive dressing to promote rapid healing. DIF: Remembering/Knowledge REF: 1166 KEY: Bowel care MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

7. A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding Erosion of the bowel wall b. Abscess formation Localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon Transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction Paralysis of colon resulting from colorectal cancer e. Fistula Dilation and colonic ileus caused by paralysis of the colon

ANS: A, B, D Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon.

6. A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Distended abdomen b. Inability to pass flatus c. Bradycardia d. Hyperactive bowel sounds e. Decreased urine output

ANS: A, B, E A client with peritonitis may present with a distended abdomen, diminished bowel sounds, inability to pass flatus or feces, tachycardia, and decreased urine output secondary to dehydration. Bradycardia and hyperactive bowel sounds are not associated with peritonitis.

5. After teaching a client with an anal fissure, a nurse assesses the clients understanding. Which client actions indicate that the client correctly understands the teaching? (Select all that apply.) a. Taking a warm sitz bath several times each day b. Utilizing a daily enema to prevent constipation c. Using bulk-producing agents to aid elimination d. Self-administering anti-inflammatory suppositories e. Taking a laxative each morning

ANS: A, C, D Taking warm sitz baths each day, using bulk-producing agents, and administering anti-inflammatory suppositories are all appropriate actions for the client with an anal fissure. The client should not use enemas or laxatives to promote elimination, but rather should rely on bulk-producing agents such as psyllium hydrophilic mucilloid (Metamucil).

2. A nurse teaches a client how to avoid becoming ill with Salmonella infection again. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Wash leafy vegetables carefully before eating or cooking them. b. Do not ingest water from the garden hose or the pool. c. Wash your hands before and after using the bathroom. d. Be sure meat is cooked to the proper temperature. e. Avoid eating eggs that are sunny side up or undercooked.

ANS: A, C, D, E Salmonella is usually contracted via contaminated eggs, beef, poultry, and green leafy vegetables. It is not transmitted through water in garden hoses or pools. Clients should wash leafy vegetables well, wash hands before and after using the restroom, make sure meat and eggs are cooked properly, and, because it can be transmitted by flies, keep flies off of food.

A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with this diagnosis? (Select all that apply.) a. Serum potassium of 2.8 mEq/L b. Loss of 15 pounds without dieting c. Abdominal pain in upper quadrants d. Low-pitched bowel sounds e. Serum sodium of 121 mEq/L

ANS: A, C, E Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range is 3.5 to 5.0 mEq/L) and hyponatremic (normal range is 136 to 145 mEq/L). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions. DIF: Applying/Application REF: 1159 KEY: Intestinal obstruction| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.) a. Performs hand hygiene and positions the client in high-Fowler's position, with pillows behind the head and shoulders b. Instructs the client to extend the neck against the pillow once the NG tube has reached the oropharynx c. Checks for correct placement by checking the pH of the fluid aspirated from the tube d. Secures the NG tube by taping it to the client's nose and pinning the end to the pillowcase e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent

ANS: A, C, E The client's head should be flexed forward once the NG tube has reached the oropharynx. The NG tube should be secured to the client's gown, not to the pillowcase, because it could become dislodged easily. All the other actions are appropriate. DIF: Applying/Application REF: 1159 KEY: Intestinal obstruction MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. A nurse teaches a community group about food poisoning and gastroenteritis. Which statements should the nurse include in this groups teaching? (Select all that apply.) a. Rotavirus is more common among infants and younger children. b. Escherichia coli diarrhea is transmitted by contact with infected animals. c. To prevent E. coli infection, dont drink water when swimming. d. Clients who have botulism should be quarantined within their home. e. Parasitic diseases may not show up for 1 to 2 weeks after infection.

ANS: A, C, E Rotavirus is more common among the youngest of clients. Not drinking water while swimming can help prevent E. coli infection. Parasitic diseases may take up to 2 weeks to become symptomatic. People with botulism need to be hospitalized to monitor for respiratory failure and paralysis. Escherichia coli is not transmitted by contact with infected animals.

The nurse is caring for a client who has perineal surgical wound. Which actions would the nurse take to promote comfort and wound healing? (Select all that apply.) a. Assist the client into a side-lying position. b. Use a rubber donut device when sitting up. c. Apply warm compresses three to four times a day. d. Instruct the client to wear boxer shorts. e. Place an absorbent dressing over the wound.

ANS: A, C, E The nurse would place an absorbent pad over the wound and apply warm compresses to the wound area. The nurse would also instruct the male client to wear jockey-type shorts for support rather than boxers, assume a side-lying position in bed, avoid sitting for long periods, and use foam pads or soft pillows whenever in a sitting position. The patient should avoid the use of air rings or rubber donut devices.

3. A nurse teaches a community group ways to prevent Escherichia coli infection. Which statements should the nurse include in this groups teaching? (Select all that apply.) a. Wash your hands after any contact with animals. b. It is not necessary to buy a meat thermometer. c. Stay away from people who are ill with diarrhea. d.Use separate cutting boards for meat and vegetables. e. Avoid swimming in backyard pools and using hot tubs.

ANS: A, D Washing hands after contact with animals and using separate cutting boards for meat and other foods will help prevent E. coli infection. The other statements are not related to preventing E. coli infection.

A nurse cares for a client who has a nasogastric (NG) tube. Which actions should the nurse take? (Select all that apply.) a. Assess for proper placement of the tube every 4 hours. b. Flush the tube with water every hour to ensure patency. c. Secure the NG tube to the client's upper lip. d. Disconnect suction when auscultating bowel peristalsis. e. Monitor the client's skin around the tube site for irritation.

ANS: A, D, E The nurse should assess for proper placement, tube patency, and output every 4 hours. The nurse should also monitor the skin around the tube for irritation and secure the tube to the client's nose. When auscultating bowel sounds for peristalsis, the nurse should disconnect suction. DIF: Applying/Application REF: 1159 KEY: Drain MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

5. A nurse prepares to discharge a client who is newly diagnosed with a chronic inflammatory bowel disease. Which questions would the nurse ask in preparation for discharge? (Select all that apply.) a. Does your gym provide yoga classes? b. When should you contact your provider? c. What do you plan to eat for dinner? d. Do you have a scale for daily weights? e. How many bathrooms are in your home?

ANS: A,B,C,E A home assessment for a client who has a chronic inflammatory bowel disease would include identifying adequacy and availability of bathroom facilities, opportunities for rest and relaxation, and the client's knowledge of dietary therapy, and when to contact the primary health care provider. The client does not need to perform daily weights.

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

ANS: A,B,C,E When caring for an older adult who has diverticulitis, the nurse would administer analgesics as prescribed, palpate the abdomen for distention and tenderness, assess for confusion and sudden changes in mental status, and check stools for occult or frank bleeding. A low-fiber/residue diet would be provided when symptoms are present and a high-fiber diet when inflammation resolves.

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

ANS: A,B,C,E,F Peritonitis is an acute inflammatory disorder. Therefore, the client would likely have all of these signs and symptoms but would have tachycardia rather than bradycardia due to dehydration from fever.

6. After teaching a patient who has a permanent ileostomy, a nurse assesses the client's understanding. Which dietary items chosen for dinner indicate that the client needs further teaching? (Select all that apply.) a. Corn b. String beans c. Carrots d. Wheat rice e. Squash

ANS: A,B,D Clients with an ileostomy should be cautious of high-fiber and high-cellulose foods including corn, string beans, and rice. Carrots and squash are low-fiber items.

2. The nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding—erosion of the bowel wall b. Abscess formation—localized pockets of infection develop in the ulcerated bowellining c. Toxic megacolon—transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction—paralysis of colon resulting from colorectalcancer e. Fistula—dilation and colonic ileus caused by paralysis of the colon

ANS: A,B,D Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon.

8. The nurse is caring for a client who is diagnosed with celiac disease and preparing to start natalizumab. Which health teaching would the nurse include in the teaching? (Select all that apply.) a. Need to have drug administered by a primary health care provider. b. Need to avoid crowds and individuals who have infection. c. Need to report injection reactions such as redness and swelling. d. Awareness of a rare but potentially fatal drug complication. e. Need to report any signs and symptoms of infection immediately.

ANS: A,B,D,E All of these choices are correct except that the drug is given intravenously. Therefore, there is no need to teach the client to report injection reactions because the client does not self-administer the medication subcutaneously. Natalizumab can cause progressive multifocal leukoencephalopathy (PML), bGuRt iAt iDsEaSveLryABra.reCdOisMorder causing cognitive, sensory, and/or motor changes.

A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client? a. "Have you been experiencing any constipation?" b. "Are you eating a diet high in fiber and fluids?" c. "Do you have a history of high blood pressure?" d. "What vitamins and supplements are you taking?"

ANS: A. "Have you been experiencing any constipation?" Ischemic colitis is a life-threatening complication of alosetron. The nurse should assess the client for constipation. The other questions do not identify complications related to alosetron. DIF: Applying/Application REF: 1146 KEY: Medications| adverse effects MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapi

A nurse cares for a client who states, "My husband is repulsed by my colostomy and refuses to be intimate with me." How should the nurse respond? a. "Let's talk to the ostomy nurse to help you and your husband work through this." b. "You could try to wear longer lingerie that will better hide the ostomy appliance." c. "You should empty the pouch first so it will be less noticeable for your husband." d. "If you are not careful, you can hurt the stoma if you engage in sexual activity."

ANS: A. "Let's talk to the ostomy nurse to help you and your husband work through this." The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the client's concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by engaging in sexual activity. DIF: Applying/Application REF: 1156 KEY: Ostomy care| support| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

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

ANS: A. "The stool will always be liquid with this type of colostomy." The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet or with the passage of time. DIF: Applying/Application REF: 1151 KEY: Ostomy care MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

12. A nurse assesses a client with Crohns disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Distended abdomen b. Temperature of 100.0 F (37.8 C) c. Loose and bloody stool d. Lower abdominal cramps

ANS: A. Distended abdomen The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the clients provider should be notified right away. Low-grade fever, bloody diarrhea, and abdominal cramps are common symptoms of Crohns disease.

A nurse cares for a client who has a new colostomy. Which action should the nurse take? a. Empty the pouch frequently to remove excess gas collection. b. Change the ostomy pouch and wafer every morning. c. Allow the pouch to completely fill with stool prior to emptying it. d. Use surgical tape to secure the pouch and prevent leakage.

ANS: A. Empty the pouch frequently to remove excess gas collection. The nurse should empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy wafers with paste should be used to secure and seal the ostomy appliance; surgical tape should not be used. DIF: Applying/Application REF: 1154 KEY: Ostomy care MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

22. A nurse cares for a client with ulcerative colitis. The client states, I feel like I am tied to the toilet. This disease is controlling my life. How should the nurse respond? a. Lets discuss potential factors that increase your symptoms. b. If you take the prescribed medications, you will no longer have diarrhea. c. To decrease distress, do not eat anything before you go out. d. You must retake control of your life. I will consult a therapist to help.

ANS: A. Lets discuss potential factors that increase your symptoms. Clients with ulcerative colitis often express that the disorder is disruptive to their lives. Stress factors can increase symptoms. These factors should be identified so that the client will have more control over his or her condition. Prescription medications and anorexia will not eliminate exacerbations. Although a therapist may assist the client, this is not an appropriate response.

17. A nurse cares for a client who has a Giardia infection. Which medication should the nurse anticipate being prescribed for this client? a. Metronidazole (Flagyl) b. Ciprofloxacin (Cipro) c. Sulfasalazine (Azulfidine) d. Ceftriaxone (Rocephin)

ANS: A. Metronidazole (Flagyl) Metronidazole is the drug of choice for a Giardia infection. Ciprofloxacin and ceftriaxone are antibiotics used for bacterial infections. Sulfasalazine is used for ulcerative colitis and Crohns disease.

20. A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Pale and bluish stoma b. Liquid stool c. Ostomy pouch intact d. Blood-smeared output

ANS: A. Pale and bluish stoma The nurse should assess the stoma for color and contact the health care provider if the stoma is pale, bluish, or dark. The nurse should expect the client to have an intact ostomy pouch with dark green liquid stool that may contain some blood.

13. A nurse reviews the chart of a client who has Crohns disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions? a. Serum potassium of 2.6 mEq/L b. Client ate 20% of breakfast meal c. White blood cell count of 8200/mm3 d. Clients weight decreased by 3 pounds

ANS: A. Serum potassium of 2.6 mEq/L Fistulas place the client with Crohns disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium level takes priority.

1. A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find? a. Severe, steady right lower quadrant pain b. Abdominal pain associated with nausea and vomiting c. Marked peristalsis and hyperactive bowel sounds d. Abdominal pain that increases with knee flexion

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

A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider? a. White blood cell (WBC) count of 1500/mm3 b. Fatigue c. Nausea and diarrhea d. Mucositis and oral ulcers

ANS: A. White blood cell (WBC) count of 1500/mm3. Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the client's WBC count is very low (normal range is 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately. DIF: Applying/Application REF: 1151 KEY: Colorectal cancer| medications| adverse effects MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

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

ANS: B Sulfasalazine is a sulfa drug given for clients who have ulcerative colitis. However, it should not be given to those who have an allergy to sulfa and sulfa drugs to prevent a hypersensitivity reaction.

2. A nurse cares for an older adult client who has Salmonella food poisoning. The clients vital signs are heart rate: 102 beats/min, blood pressure: 98/55 mm Hg, respiratory rate: 22 breaths/min, and oxygen saturation: 92%. Which action should the nurse complete first? a. Apply oxygen via nasal cannula. b. Administer intravenous fluids. c. Provide perineal care with a premedicated wipe. d. Teach proper food preparation to prevent contamination.

ANS: B Administer IV fluids Dehydration caused by diarrhea can occur quickly in older clients with Salmonella food poisoning, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions but are of lower priority than fluid replacement. The nurse should teach the client about proper hand hygiene to prevent the spread of infection, and preparation of food and beverages to prevent contamination.

4. After teaching a client who was hospitalized for Salmonella food poisoning, a nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I will let my husband do all of the cooking for my family. b. Ill take the ciprofloxacin until the diarrhea has resolved. c. I should wash my hands with antibacterial soap before each meal. d. I must place my dishes into the dishwasher after each meal.

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

1. After teaching a client with a parasitic gastrointestinal infection, a nurse assesses the clients understanding. Which statements made by the client indicate that the client correctly understands the teaching? (Select all that apply.) a. Ill have my housekeeper keep my toilet clean. b. I must take a shower or bathe every day. c. I should have my well water tested. d. I will ask my sexual partner to have a stool test. e. I must only eat raw vegetables from my own garden.

ANS: B, C, D Parasitic infections can be transmitted to other people. The client himself or herself should keep the toilet area clean instead of possibly exposing another person to the disease. Parasites are transmitted via unclean water sources and sexual practices with rectal contact. The client should test his or her well water and ask sexual partners to have their stool examined for parasites. Raw vegetables are not associated with parasitic gastrointestinal infections. The client can eat vegetables from the store or a home garden as long as the water source is clean.

The nurse is teaching a client who had a descending colostomy 2 days ago about the ostomy stoma. Which changes in the stoma would the nurse teach the client to report to the primary health care provider? (Select all that apply.) a. Stool consistency is similar to paste. b. Stoma becomes dark and dull. c. Skin around the stoma becomes excoriated. d. Skin around stoma becomes protruded. e. Stoma becomes retracted into the abdomen.

ANS: B, C, D, E A colostomy placed in the descending colon would be expect to have a paste-like stool consistency. However, if the stoma becomes retracted or discolored, the client should report those changes to the primary health care provider. Skin around the stoma that becomes protruded would suggest the formation of a peristomal hernia, and skin excoriation needs appropriate management. Therefore, both of those skin changes would need to be reported to the primary health care provider.

The nurse is caring for a client with probable colorectal cancer (CRC). What assessment findings would the nurse expect? (Select all that apply.) a. Weight gain b. Rectal bleeding c. Anemia d. Change in stool shape e. Electrolyte imbalances f. Abdominal discomfort

ANS: B, C, D, F The client who has CRC usually experiences unintentional weight loss and rectal bleeding, either gross or occult. As a result of bleeding, the client has anemia and fatigue. Electrolyte imbalances are not common, but the client may note that the shape or consistency of stool has changed.

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

ANS: B,C,E Signs and symptoms of celiac disease include weight loss, anorexia, constipation, and abdominal pain. Anal fistulas are not associated with celiac disease.

7. A nurse cares for a patient who has a chronic inflammatory bowel disease. Which actions would the nurse take to prevent skin excoriation? (Select all that apply.) a. Cleanse the perineum with an antibacterial soap. b. Use medicated wipes instead of toilet paper. c. Identify foods that decrease constipation. d. Apply a thin coat of aloe cream to the perineum. e. Gently pat the perineum dry after cleansing.

ANS: B,D,E To prevent skin excoriation from frequent bowel movements associated with inflammatory bowel disease, the nurse would encourage good skin care with a mild soap and water and gently patting the area dry after each bowel movement. Using medicated wipes instead of toilet paper and applying a thin coat of aloe cream are appropriate. The client should identify and avoid foods that increase diarrhea. Antibacterial soaps are harsh and should not be used.

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

ANS: B. "You should be able to have better bowel continence after healing occurs." A RCA-IPAA can improve bowel continence although leakage may still occur for some clients. The procedure is a 2-step process performed under general anesthesia using a laparoscope which does not require an abdominal incision or permanent ileostomy.

An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first? a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Obtain the client's complete health history.

ANS: B. Assess for abdominal guarding or rigidity. On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present, because this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or obtaining a complete health history is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity. DIF: Applying/Application REF: 1162 KEY: Gastrointestinal trauma| hemorrhage MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk

ANS: B. Broiled chicken with brown rice, steamed broccoli, glass of apple juice Clients with IBS are advised to eat a high-fiber diet (30 to 40 g/day), with 8 to 10 cups of liquid daily. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants. DIF: Applying/Application REF: 1145 KEY: Irritable bowel| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family members. Which action should the nurse take? a. Contact the provider and recommend a psychiatric consult for the client. b. Encourage the client to verbalize feelings about the diagnosis. c. Provide education about new treatment options with successful outcomes. d. Ask family and friends to visit the client and provide emotional support.

ANS: B. Encourage the client to verbalize feelings about the diagnosis. The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the client's feelings with discussions related to cancer prognosis and treatment. The nurse should not assume that the client desires family or friends to visit or provide emotional support. DIF: Applying/Application REF: 1155 KEY: Colorectal cancer| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

8. After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? a. Ill rinse my rectal area with warm water after each stool and apply zinc oxide ointment. b. I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel. c. I must take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry. d. I shall clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment.

ANS: B. I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel. Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not an effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry.

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

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

19. A nurse plans care for a client with Crohns disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this clients plan of care? a. Low-fiber diet b. Skin protection c. Antibiotic administration d. Intravenous glucocorticoids

ANS: B. Skin protection Protecting the clients skin is the priority action for a client who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohns disease includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids.

15. A nurse assesses a client who is hospitalized for botulism. The clients vital signs are temperature: 99.8 F (37.6 C), heart rate: 100 beats/min, respiratory rate: 10 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take? a. Decrease stimulation and allow the client to rest. b. Stay with the client while another nurse calls the provider. c. Increase the clients intravenous fluid replacement rate. d. Check the clients blood glucose and administer orange juice.

ANS: B. Stay with the client while another nurse calls the provider. A client with botulism is at risk for respiratory failure. This clients respiratory rate is slow, which could indicate impending respiratory distress or failure. The nurse should remain with the client while another nurse notifies the provider. The nurse should monitor and document the IV infusion per protocol, but this client does not require additional intravenous fluids. Allowing the client to rest or checking the clients blood glucose and administering orange juice are not appropriate actions.

A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, "I need to have a bowel movement." Which action should the nurse take? a. Obtain a bedside commode for the client to use. b. Stay with the client while providing privacy. c. Make sure the call light is in reach to signal completion. d. Gather supplies to collect a stool sample for the laboratory.

ANS: B. Stay with the client while providing privacy. The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure the call light is within reach is an important nursing action too, but it does not take priority over client safety. Obtaining a bedside commode and taking a stool sample are not needed in this situation. DIF: Applying/Application REF: 1165 KEY: Postoperative care| syncope MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

21. A nurse cares for a client with a new ileostomy. The client states, I dont think my friends will accept me with this ostomy. How should the nurse respond? a. Your friends will be happy that you are alive. b. Tell me more about your concerns. c. A therapist can help you resolve your concerns. d. With time you will accept your new body.

ANS: B. Tell me more about your concerns Social anxiety and apprehension are common in clients with a new ileostomy. The nurse should encourage the client to discuss concerns. The nurse should not minimize the clients concerns or provide false reassurance.

14. After teaching a client who has a new colostomy, the nurse provides feedback based on the clients ability to complete self-care activities. Which statement should the nurse include in this feedback? a. I realize that you had a tough time today, but it will get easier with practice. b. You cleaned the stoma well. Now you need to practice putting on the appliance. c. You seem to understand what I taught you today. What else can I help you with? d. You seem uncomfortable. Do you want your daughter to care for your ostomy?

ANS: B. You cleaned the stoma well. Now you need to practice putting on the appliance. The nurse should provide both approval and room for improvement in feedback after a teaching session. Feedback should be objective and constructive, and not evaluative. Reassuring the client that things will improve does not offer anything concrete for the client to work on, nor does it let him or her know what was done well. The nurse should not make the client convey learning needs because the client may not know what else he or she needs to understand. The client needs to become the expert in self-management of the ostomy, and the nurse should not offer to teach the daughter instead of the client.

5. A nurse assesses a client who is hospitalized with an exacerbation of Crohns disease. Which clinical manifestation should the nurse expect to find? a. Positive Murphys sign with rebound tenderness to palpitation b. Dull, hypoactive bowel sounds in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Reports of abdominal cramping that is worse at night

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

A nurse assesses a male client with an abdominal hernia. Which abdominal hernias are correctly paired with their physiologic processes? (Select all that apply.) a. Indirect inguinal hernia - An enlarged plug of fat eventually pulls the peritoneum and often the bladder into a sac b. Femoral hernia - A peritoneum sac pushes downward and may descend into the scrotum c. Direct inguinal hernia - A peritoneum sac passes through a weak point in the abdominal wall d. Ventral hernia - Results from inadequate healing of an incision e. Incarcerated hernia - Contents of the hernia sac cannot be reduced back into the abdominal cavity

ANS: C, D, E A direct inguinal hernia occurs when a peritoneum sac passes through a weak point in the abdominal wall. A ventral hernia results from inadequate healing of an incision. An incarcerated hernia cannot be reduced or placed back into the abdominal cavity. An indirect inguinal hernia is a sac formed from the peritoneum that contains a portion of the intestine and pushes downward at an angle into the inguinal canal. An indirect inguinal hernia often descends into the scrotum. A femoral hernia protrudes through the femoral ring and, as the clot enlarges, pulls the peritoneum and often the urinary bladder into the sac. DIF: Applying/Application REF: 1146 KEY: Herniation MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

After teaching a client who is recovering from a colon resection to treat early-stage colorectal cancer (CRC), the nurse assesses the client's understanding. Which statements by the client indicate understanding of the teaching? (Select all that apply.) a. "I must change the ostomy appliance daily and as needed." b. "I will use warm water and a soft washcloth to clean around the stoma." c. "I might start bicycling and swimming again once my incision has healed." d. "I will make sure that I make lifestyle changes to prevent constipation." e. "I will be sure to have the recommended colonoscopies."

ANS: C, D, E The client has had a colon resection for early CRC and there is no indication that the client also had a colostomy. Follow up with recommended colonoscopies are essential to monitor for CRC recurrence. Avoiding constipation will help improve intestinal motility which helps to decrease the risk for CRC recurrence. Exercise and other activities do not need to be restricted after the client has healed.

A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, "My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it." How should the nurse respond? a. "Your doctor should not have given you that information prior to the colonoscopy." b. "The colonoscopy is required due to the high percentage of false negatives with the blood test." c. "A negative fecal occult blood test does not rule out the possibility of colon cancer." d. "I will contact your doctor so that you can discuss your concerns about the procedure

ANS: C. "A negative fecal occult blood test does not rule out the possibility of colon cancer." A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the client's concerns prior to contacting the provider. DIF: Understanding/Comprehension REF: 1151 KEY: Colorectal cancer| assessment/diagnostic examination MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

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

ANS: C. "Add vegetables such as broccoli and cauliflower to your new diet." The client should be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer. DIF: Applying/Application REF: 1149 KEY: Colorectal cancer| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

A nurse cares for a client with colon cancer who has a new colostomy. The client states, "I think it would be helpful to talk with someone who has had a similar experience." How should the nurse respond? a. "I have a good friend with a colostomy who would be willing to talk with you." b. "The enterostomal therapist will be able to answer all of your questions." c. "I will make a referral to the United Ostomy Associations of America." d. "You'll find that most people with colostomies don't want to talk about them."

ANS: C. "I will make a referral to the United Ostomy Associations of America." Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). The nurse should not suggest that the client speak with a personal contact of the nurse. Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse should not brush aside the client's request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others. DIF: Applying/Application REF: 1157 KEY: Colorectal cancer| ostomy care| coping| support MSC: Integrated Process: Caring NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this client's plan of care? a. "You may experience nausea and vomiting for the first few weeks." b. "Carbonated beverages can help decrease acid reflux from anastomosis sites." c. "Take a stool softener to promote softer stools for ease of defecation." d. "You may return to your normal workout schedule, including weight lifting."

ANS: C. "Take a stool softener to promote softer stools for ease of defecation." Clients recovering from a colon resection should take a stool softener as prescribed to keep stools a soft consistency for ease of passage. Nausea and vomiting are symptoms of intestinal obstruction and perforation and should be reported to the provider immediately. The client should be advised to avoid gas-producing foods and carbonated beverages, and avoid lifting heavy objects or straining on defecation. DIF: Applying/Application REF: 1155 KEY: Colorectal cancer| postoperative nursing| bowel care MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

10. A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, I am having trouble swallowing this pill. Which action should the nurse take? a. Contact the clinical pharmacist and request the medication in suspension form. b. Empty the contents of the capsule into applesauce or pudding for administration. c. Ask the health care provider to prescribe the medication as an enema instead. d. Crush the pill carefully and administer it in applesauce or pudding.

ANS: C. Ask the health care provider to prescribe the medication as an enema instead Asacol is the oral formula for mesalamine and is produced as an enteric-coated pill that should not be crushed, chewed, or broken. Asacol is not available as a suspension or elixir. If the client is unable to swallow the Asacol pill, a mesalamine enema (Rowasa) may be administered instead, with a providers order.

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

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

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

ANS: C. Heart rate and rhythm Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this client than heart rate and rhythm.

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

ANS: C. Heart rate and rhythm Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client would have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this patient than heart rate and rhythm.

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

ANS: C. I will take a laxative nightly at bedtime to avoid becoming constipated. Laxatives are not recommended for clients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining.

7. A nurse cares for a teenage girl with a new ileostomy. The client states, I cannot go to prom with an ostomy. How should the nurse respond? a. Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance. b. The pouch wont be as noticeable if you avoid broccoli and carbonated drinks prior to the prom. c. Lets talk to the enterostomal therapist about options for ostomy supplies and dress styles. d. You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable.

ANS: C. Lets talk to the enterostomal therapist about options for ostomy supplies and dress styles. The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible.

A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action should the nurse take? a. Ask if the client is experiencing pain in the right shoulder. b. Perform a rectal examination and assess for polyps. c. Recommend computed tomography. d. Administer a laxative to increase bowel movement activity.

ANS: C. Recommend computed tomography The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. The nurse should contact the provider with these results and recommend a computed tomography scan for further diagnostic testing. This assessment finding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The registered nurse is not qualified to complete a rectal examination for polyps, and laxatives would not help this client.

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

ANS: D Baked fish with steamed carrots and a glass of apple juice. Clients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup of bean soup) should be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet.

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

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

A nurse cares for a client who has a family history of colon cancer. The client states, "My father and my brother had colon cancer. What is the chance that I will get cancer?" How should the nurse respond? a. "If you eat a low-fat and low-fiber diet, your chances decrease significantly." b. "You are safe. This is an autosomal dominant disorder that skips generations." c. "Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer." d. "You should have a colonoscopy more frequently to identify abnormal polyps early."

ANS: D. "You should have a colonoscopy more frequently to identify abnormal polyps early." The nurse should encourage the client to have frequent colonoscopies to identify abnormal polyps and cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer. Changing the client's diet, preemptive chemotherapy, and removal of polyps will decrease the client's risk but will not prevent cancer. However, a client at risk for colon cancer should eat a low-fat and high-fiber diet. DIF: Applying/Application REF: 1155 KEY: Colorectal cancer| genetics MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

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

ANS: D. A 72-year-old who eats fast food frequently Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer. DIF: Applying/Application REF: 1149 KEY: Colorectal cancer| health screening MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

An emergency room nurse cares for a client who has been shot in the abdomen and is hemorrhaging heavily. Which action should the nurse take first? a. Send a blood sample for a type and crossmatch. b. Insert a large intravenous line for fluid resuscitation. c. Obtain the heart rate and blood pressure. d. Assess and maintain a patent airway.

ANS: D. Assess and maintain a patent airway. All of the options are important nursing actions in the care of a trauma client. However, airway always comes first. The client must have a patent airway, or other interventions will not be helpful. DIF: Applying/Application REF: 1162 KEY: GI trauma| emergency nursing MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

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

ANS: D. Assess the client's bowel sounds. A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse should not medicate the client until the provider has been notified of the change in his or her condition. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse need not insert a nasogastric tube for decompression. DIF: Applying/Application REF: 1157 KEY: Intestinal obstruction| pain management MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

18. A nurse cares for a client who has food poisoning resulting from a Clostridium botulinum infection. Which assessment should the nurse complete first? a. Heart rate and rhythm b. Bowel sounds c. Urinary output d. Respiratory rate

ANS: D. Respiratory rate Severe infection with C. botulinum can lead to respiratory failure, so assessments of oxygen saturation and respiratory rate are of high priority for clients with suspected C. botulinum infection. The other assessments may be completed after the respiratory system has been assessed.

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

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

The nurse is teaching a preoperative client who is scheduled for a laparoscopic cholecystectomy ("lap chole"). What statement by the client indicates a need for further teaching? A) "I will likely need oral pain medications for the first few days after my surgery." B) "I should only be hospitalized for 2 to 3 days after my surgery." C) "I will probably not be at risk for complications from this surgery." D) "I should be able to go back to work in the next week or so."

B) "I should only be hospitalized for 2 to 3 days after my surgery." A "lap chole" surgery has many advantages over the open traditional surgical method, including a short hospital stay, usually same-day surgery, minimal risk for complications, and the ability to achieve pain control by using oral analgesics.

Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? A) "The scars on my liver create problems with blood circulation." B) "My liver is scarred, but the cells can regenerate themselves and repair the damage." C) "Because of the scars on my liver, blood clotting and blood pressure are affected." D) "Cirrhosis is a chronic disease that has scarred my liver."

B) "My liver is scarred, but the cells can regenerate themselves and repair the damage." The client's statement that, although his liver is scarred, the cells can regenerate and repair the damage indicates that further instruction is needed. Although cells and tissues will attempt to regenerate, destroyed liver cells will result in permanent scarring and irreparable damage.

A client with peptic ulcer disease (PUD) asks the nurse whether licorice and slippery elm might be useful in managing the disease. What is the nurse's best response? A) "No, they probably won't be useful. You should use only prescription medications in your treatment plan." B) "These herbs could be helpful. However, you should talk with your primary health care provider before adding them to your treatment regimen." C) "No, herbs are not useful for managing this disease. You can use any type of over-the-counter drugs though. They have been shown to be safe." D) "Yes, these are known to be effective in managing this disease but make sure you research the herbs thoroughly before taking them."

B) "These herbs could be helpful. However, you should talk with your primary health care provider before adding them to your treatment regimen." The nurse's best response is that although licorice and slippery elm may be helpful in managing PUD, the client must consult his or her primary health care provider before making a change in the treatment regimen. Alternative therapies may or may not be helpful in managing PUD. The client should not use over-the-counter medications without first discussing it with his or her primary health care provider.

A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? A) Assist the client to assume a position of comfort. B) Administer opioid analgesic medication. C) Do not administer food or fluids by mouth. D) Measure intake and output every shift.

B) Administer opioid analgesic medication. Pain relief is the highest priority for the client with acute pancreatitis. Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority.

The nurse is teaching a client and family about home care following a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. Which client finding would the nurse teach the family to report to the primary health care provider immediately? A) Decreased ascitic fluid B) Changes in consciousness or behavior C) Fatigue and weakness D) Decreased pulse rate

B) Changes in consciousness or behavior Although serious complications of the TIPS are not common, the client needs to be monitored for hepatic encephalopathy. This complication is manifested by changes in consciousness, mental status, and/or behavior. A decreased pulse rate and ascitic fluid are expected and clients with cirrhosis are usually fatigued and weak.

A client has undergone the Whipple procedure (radical pancreaticoduodenectomy) for pancreatic cancer. Which nursing actions would the nurse implement to prevent potential complications? (Select all that apply.) A) Ensure that drainage color is clear. B) Check blood glucose often. C) Place the client in the supine position. D) Check bowel sounds and stools. E) Monitor mental status.

B) Check blood glucose often. D) Check bowel sounds and stools. E) Monitor mental status. To prevent potential complications after a Whipple procedure, the nurse would check the client's glucose often to monitor for diabetes mellitus. Bowels sounds and stools would be checked to monitor for bowel obstruction. A change in mental status or level of consciousness could be indicative of hemorrhage. Clear, colorless, bile-tinged drainage or frank blood with increased output may indicate disruption or leakage of a site of anastomosis but is not a precautionary action for the nurse to implement. The client should be placed in semi-Fowler and not supine position to reduce tension on the suture line and the anastomosis site and to optimize lung expansion.

The nurse and the registered dietitian nutritionist are planning sample diet menus for a client who is experiencing dumping syndrome. Which sample meal is most appropriate for this client? A) Liver, bacon, and onions B) Chicken and white rice C) Chicken salad on whole wheat bread D) Green vegetable salad with buttermilk ranch dressing

B) Chicken and white rice Chicken and rice is the most appropriate sample meal for this client. It is the only selection suitable for the client who is experiencing dumping syndrome because it contains high protein without the addition of milk or wheat products. The client with dumping syndrome should not have much mayonnaise, onions, or buttermilk ranch dressing. Buttermilk dressing is made from milk products. The client may have whole wheat bread only in very limited amounts.

The nurse is caring for a client who just had a paracentesis. Which client finding indicates that the procedure was effective? A) Increased blood pressure B) Decreased weight C) Increased pulse D) Decreased pain

B) Decreased weight A paracentesis is performed to remove ascitic fluid from the abdomen. Therefore, the client should weigh less after the procedure than before. Blood pressure should decrease due to less fluid volume and the pulse rate may not be affected. The client may report less abdominal discomfort or ease in breathing, but pain is not a common problem for cirrhotic clients.

An older adult with severe rheumatoid arthritis in the upper extremities is undernourished. What does the nurse anticipate may be a contributing factor? A) Inadequate income to purchase sufficient food B) Diminishing ability to manipulate eating utensils C) A decrease in appetite D) Metabolic requirements that are increased due to immobility

B) Diminishing ability to manipulate eating utensils The client's severe rheumatoid arthritis in the hands and arms would produce a decrease in the client's ability to manipulate utensils. No evidence suggests that the client is experiencing a decrease in appetite or is financially unable to purchase adequate food. No evidence suggests that the client is immobile. Metabolic requirements would decrease, not increase, with less mobility.

The nurse is monitoring a client who is receiving an intravenous fat emulsion (IVFE) nutritional supplement. What action does the nurse take after reviewing the client's laboratory report, and seeing an increase in triglycerides? (Select all that apply.) Select all that apply. A) Document the findings and continues to monitor. B) Discontinue the IVFE infusion. C) Slow the rate of flow of the IVFE infusion. D) Offer small bites of oral foods. E) Notify the health care provider.

B) Discontinue the IVFE infusion. E) Notify the health care provider. If a client receiving an IVFE nutritional supplement develops fever, increased triglycerides, clotting problems, or symptoms of multi-system organ failure, the nurse must discontinue the IVFE and notify the HCP. These symptoms may indicate fat overload syndrome, especially in a critically ill patient. Only documenting the findings and continuing to monitor could have serious repercussions for this client. Slowing the rate of flow of the IVFE infusion, or offering small bites of oral foods, can also present a serious safety risk.

The nurse is assessing a client who is diagnosed as having Hepatitis A and asks how someone gets this disease. What is the most likely cause of the client's Hepatitis A? A) Being exposed to blood or blood products B) Eating contaminated food or water C) Having unprotected sex D) Sharing needles for illicit drugs

B) Eating contaminated food or water Hepatitis A is transmitted through the fecal-oral route rather than via blood. Therefore, contaminated food or water with Escherichia coli or other microbes can cause this liver infection.

The nurse is assessing a client who is suspected of having early gastric cancer. What signs and symptoms would the nurse expect? (Select all that apply.) A) Fatigue B) Feeling of fullness C) Dyspepsia D) Weakness E) Weight loss F) Nausea and vomiting

B) Feeling of fullness C) Dyspepsia The client who has early gastric cancer usually has no or few signs and symptoms, but may have dyspepsia and a feeling of fullness. More distressing changes are manifested when the cancer becomes more advanced.

The nurse is caring for a client who has a gastric ulcer. For which potentially life-threatening complication would the nurse monitor for this client? A) Hypokalemia B) Hemorrhage C) Nausea and vomiting D) Infection

B) Hemorrhage Clients who have gastric ulcers are particularly at risk for upper GI bleeding, or hemorrhage. They may also experience nausea and vomiting causing dehydration. However, hemorrhage is most serious.

A client with oral cancer who is to have a radical neck dissection reports being depressed. What is the nurse's priority response? A) Suggest seeking support from a community group. B) Listen to the client's concerns. C) Explain the grieving process. D) Reassure that it is normal to feel depressed about the diagnosis.

B) Listen to the client's concerns. The nurse's priority response is to listen to the client and allow him or her to process feelings. After the client has processed feelings, he or she is more open to learning about the normalcy of feeling depressed about this diagnosis, understanding the grieving process, and considering referral to a community group of clients undergoing a similar experience.

The nurse is caring for a client diagnosed with aphthous (Canker sore) ulcers. Which food will the nurse recommend that the client avoid? (Select all that apply.) A) Apples B) Pasta C) Baked potato D) Nuts E) Cheese

B) Pasta C) Baked potato D) Nuts E) Cheese Aphthous ulcers (canker sores) are small, shallow lesions that develop on the soft tissues in the mouth or at the base of the gums. The nurse tells the client that certain foods such as cheese, nuts, potatoes, and foods containing gluten (like pasta) may trigger allergic responses that cause aphthous ulcers and should be avoided.

A client who is receiving total enteral nutrition exhibits acute confusion and shallow breathing and says, "I feel weak." As the client begin to experience a seizure, how does the nurse interpret this client's signs and symptoms? A) Abdominal distention is present. B) Refeeding syndrome may be occurring. C) Severe hyperglycemia is present. D) The enteral tube is dislodged.

B) Refeeding syndrome may be occurring. Refeeding syndrome is a syndrome consisting of metabolic disturbances that occur as a result of reinstitution of nutrition to clients who are starved, severely malnourished, or metabolically stressed due to severe illness. Symptoms of refeeding syndrome include heart failure, peripheral edema, rhabdomyolysis, seizures, and hemolysis. If the enteral tube becomes misplaced or dislodged, the client may develop aspiration pneumonia displayed by increased temperature, increased pulse, dehydration, diminished breath sounds, and shortness of breath. Abdominal distention is most frequently accompanied by nausea and vomiting. In refeeding syndrome, insulin secretion decreases in response to the physiologic changes in the body, so hyperglycemia is not present. When refeeding begins, insulin production resumes and the cells take up glucose and electrolytes from the bloodstream, thus depleting serum levels, resulting in hypoglycemia.

The nurse is caring for a client who is diagnosed with a perforated duodenal ulcer. Which assessment finding would the nurse expect? A) Positive McBurney point B) Rigid, board-like and tender abdomen C) Nausea and profuse vomiting D) Absent bowel sounds in all four quadrants

B) Rigid, board-like and tender abdomen Perforation allows intestinal contents to escape into the peritoneal cavity causing peritonitis. The classic assessment finding for a client who has peritonitis is a rigid, board-like abdomen that is tender or painful.

When caring for a client with Laennec cirrhosis, which of these findings does the nurse expect to find on assessment? (Select all that apply.) A) Elevated magnesium B) Swollen abdomen C) Prolonged partial thromboplastin time D) Elevated amylase level E) Currant jelly stool F) Icterus of skin

B) Swollen abdomen C) Prolonged partial thromboplastin time F) Icterus of skin Clients with Laennec cirrhosis have damaged clotting factors, so 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. Elevated magnesium is not related to cirrhosis. Amylase is typically elevated in pancreatitis. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. The client with cirrhosis may develop hypocalcemia and/or hypokalemia. It is also consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase.

The nurse obtains assessment data on a client who had bariatric surgery today. Which finding does the nurse report to the surgeon immediately? A) Reports pain of "6" on 0-10 scale when being repositioned. B) Urine output total is 15 mL for the past 2 hours. C) Skin under the panniculus is excoriated. D) Bowel sounds are not audible in all quadrants.

B) Urine output total is 15 mL for the past 2 hours. The nurse reports a urine output total of 15 mL for the past 2 hours. Normal urine output needs to be at least 30 mL/hr. Oliguria (scant urine output) may indicate severe postoperative complications such as anastomotic leaks or acute kidney failure. Inaudible bowel sounds would typically require intervention, but on the day of surgery, absent bowel sounds are an expected finding. The other findings, excoriated skin under the panniculus and subjective reports of pain, may require nursing interventions, but do not require an immediate report to the surgeon.

A client who has undergone surgery and completed radiation therapy to treat oral cancer reports persistent dry mouth. What will the nurse teach this client about managing this symptom? A) This condition is common but is temporary. B) Use saliva substitutes, especially when eating dry foods. C) This indicates a complication of therapy. D) Use lozenges and hard candies to prevent dry mouth

B) Use saliva substitutes, especially when eating dry foods. Xerostomia is a common effect of oral irradiation. Clients should be advised to use saliva substitutes. The condition is common, but often permanent. Dry mouth is a side effect of therapy, not a symptom of complications. Taking frequent sips of water is the preferred method of treating xerostomia during radiation therapy.

A client is preparing to undergo a stool DNA (sDNA) test to screen for colon cancer. What preprocedure teaching does the nurse provide? A. "Do not eat or drink anything for 12 hours before the test." B. "No special preparation is needed prior to completing this test." C. "Give yourself tap water enemas until the fluid returns are clear." D. "Begin a clear liquid diet at least 24 hours before the test."

B. "No special preparation is needed prior to completing this test."

The nurse is teaching an older adult client. Which gastrointestinal problem does the nurse discuss that takes place during the normal aging process? A. Increased peristalsis B. Decreased hydrochloric acid levels C. Increased liver size D. Excess lipase production

B. Decreased hydrochloric acid levels

The nurse and health care provider are discussing a client who has pernicious anemia. The nurse anticipates that the client has which deficiency? A. Hydrochloric acid B. Intrinsic factor C. Glucagon D. Pepsinogen

B. Intrinsic factor

A client is being observed after a routine sigmoidoscopy with a tissue biopsy. Which assessment finding will the nurse report to the health care provider? A. Flatulence B. Rectal bleeding C. Mild abdominal pain D. Borborygmi

B. Rectal bleeding

A hospitalized client with ongoing abdominal tenderness reports an increase in generalized abdominal pain today. Which assessment technique will the nurse perform first? A. Auscultate beginning in the RLQ. B. Visually observe for contour and symmetry C. Percuss to determine size of liver and spleen. D. Deeply palpate the area of tenderness.

B. Visually observe for contour and symmetry

The nurse is teaching a client about dietary choices to prevent dumping syndrome after gastric bypass surgery. Which statement by the client indicates a need for further teaching? A) "I cannot drink alcohol at all." B) "I will need to avoid sweetened fruit juice beverages." C) "I can eat ice cream in moderation." D) "It is okay to have a serving of sugar-free pudding."

C) "I can eat ice cream in moderation." A need for further teaching about dietary changes related to dumping syndrome is indicated when the client says that ice cream can be eaten in moderation. Milk products such as ice cream must be eliminated from the diet of a patient with dumping syndrome.

A client is preparing to have a hepatobiliary scan (HIDA scan). What health teaching would the nurse include about what the client can expect during the test? A) "This test measures how inflamed your gallbladder and liver may be." B) "You may eat and drink as much as you'd like before you have this test." C) "You will have to lie still for some time while the camera is very close to your body." D) "I need to know if you are allergic to shellfish because the contrast will be iodine-based."

C) "You will have to lie still for some time while the camera is very close to your body." The HIDA scan requires the injection of radioactive medium which is given about 20 minutes before a large camera is positioned very close to the body. The camera moves to assess for biliary flow and to determine if any obstruction is present.

Which action by the nurse would most likely help to relieve symptoms associated with ascites? A) Monitoring serum albumin levels B) Lowering the head of the bed C) Administering oxygen therapy D) Administering intravenous fluids

C) Administering oxygen therapy The best action by the nurse caring for a client with ascites is to elevate the head of the bed and provide supplemental oxygen. The enlarged abdomen of ascites limits respiratory excursion. Fowler position will increase excursion and reduce shortness of breath. Monitoring serum albumin levels will detect anticipated decreased levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.

How does the nurse accurately calculate a client's body mass index (BMI)? A) BMI = weight (lb)/height (in inches)2 B) BMI = weight (kg)/height (in meters) C) BMI = weight (kg)/height (in meters)2 D) BMI = weight (lb)/height (in meters)

C) BMI = weight (kg)/height (in meters)2 The correct formula to accurately calculate a client's body mass index (BMI) is: BMI = weight (kg)/height (in meters)2.

A client reports ongoing episodes of "heartburn." Which food will the nurse recommend that the client eliminate from the diet? A) Steak B) Carrots C) Chocolate D) Popcorn

C) Chocolate Foods that decrease esophageal sphincter pressure, such as fatty foods, caffeine, and chocolate, should be avoided. Steak, carrots, and popcorn do not decrease esophageal sphincter pressure.

A client receiving total parenteral nutrition (TPN) exhibits symptoms of heart failure (CHF) and pulmonary edema. Which complication of TPN does the nurse recognize that the client is experiencing? A) Potassium imbalance B) Fluid volume deficit C) Fluid volume overload D) Calcium imbalance

C) Fluid volume overload This client is most likely experiencing fluid volume overload. Heart failure and pulmonary edema are symptoms of this condition. Calcium imbalance, fluid volume deficit, and potassium imbalance do not manifest with heart failure and pulmonary edema. The nurse tells the client to expect loose stools, abdominal cramps, and nausea. These are side effects unique to orlistat (Xenical). Dry mouth, constipation, and insomnia are not side effects of orlistat. Insomnia, dry mouth, blurred vision, palpitations, constipation, and restlessness are all side effects of short-term therapy drugs such as phentermine (Adipex-P), diethylpropion (Tenuate), and phendimetrazine (Bontril).

What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? A) Drink only bottled water and avoid ice. B) Avoid sharing the bathroom with the client. C) Members of the household must not share toothbrushes. D) The client must not consume alcohol.

C) Members of the household must not share toothbrushes. The nurse teaches the family of a client with hepatitis C that toothbrushes, razors, towels, and any other items may spread blood and body fluids and must not be shared. The client should not consume alcohol, but abstention will not prevent spread of the virus. The client may share a bathroom if he or she is continent. To prevent hepatitis A when traveling to foreign countries, bottled water should be consumed and ice made from tap water needs to be avoided.

When providing community education, the nurse emphasizes that which group needs to receive immunization for hepatitis B? A) Clients who work with shellfish. B) Clients with elevations of aspartate aminotransferase and alanine aminotransferase. C) Men who engage in sex with men. D) Clients traveling to a third-world country.

C) Men who engage in sex with men. Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity. Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A. Hepatitis B is not of concern, unless the client is exposed to blood and body fluids during travel. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B.

The nurse is caring for a client with peptic ulcer disease who has been vomiting profusely at home before coming to the emergency department. For which acid-base imbalance will the nurse expect for this client? A) Respiratory acidosis B) Respiratory alkalosis C) Metabolic alkalosis D) Metabolic acidosis

C) Metabolic alkalosis Gastric contents are rich in acid (hydrogen and chloride ions). When this fluid is lost through vomiting, the client has less acid causing an alkalotic state.

A young adult man says that he cannot stay on a diet because of trouble finding one that will incorporate his food preferences. How does the nurse most effectively plan nutritional care for this client? A) Calculates his body mass index (BMI). B) Measures his accurate height and weight measurements. C) Obtains a 24-hour recall (diary) of his food intake. D) Records a 24-hour diary of his physical activities.

C) Obtains a 24-hour recall (diary) of his food intake. The most effective way to plan nutritional care for a client is to obtain a 24-hour recall of food intake. This will determine the client's food preferences and eating patterns so that they can be incorporated into the diet. Although calculating a BMI and measuring height and weight are important parts of a nutritional assessment, they do not address the issue of the client's food preferences. Keeping an activity diary will also not reveal any information related to the client's food preferences.

A client who had a Whipple surgical procedure develops an internal fistula between the pancreas and stomach. For which complication would the nurse monitor? A) Cirrhosis B) Crohn disease C) Peritonitis D) Peptic ulcer disease

C) Peritonitis Leakage of pancreatic enzymes, bile, and/or gastric secretions into the abdomen (peritoneal cavity) often causes peritonitis, which requires IV antibiotic therapy to manage.

When caring for a client with oral cancer who has developed stomatitis as a complication of radiation and chemotherapy, which action does the nurse delegate to the assistive personnel (AP)? A) Instruct how to use nystatin oral rinses. B) Assist with making appropriate dietary choices that do not irritate tissues. C) Provide oral care using a soft toothbrush. D) Inspect the oral mucosa for evidence of oral candidiasis.

C) Provide oral care using a soft toothbrush. Providing oral care using a soft toothbrush for a client with oral lesions is an appropriate assignment for an AP. Assessments, client teaching, and assisting clients with oral problems in making appropriate dietary choices are the responsibilities of licensed nursing staff.

The nurse is providing instructions to a client with a history of stomatitis. Which instructions does the nurse include in the teaching plan? A) Encourage the client to eat acidic foods to decrease bacteria. B) Mouth care should be performed twice daily at the maximum. C) Rinse the mouth frequently with warm saline or sodium bicarbonate. D) Use a medium-bristled toothbrush for oral care.

C) Rinse the mouth frequently with warm saline or sodium bicarbonate. Rinsing the mouth frequently with warm saline or sodium bicarbonate or a combination of the two decreases inflammation and pain. Acidic foods increase inflammation and should be avoided. Mouth care should be done after each meal and as often as needed, at the minimum of twice daily. If stomatitis is not controlled, mouth care may have to be done every 2 hours or more frequently. A soft toothbrush, not medium-bristled one, needs to be used for oral care.

Which food does the nurse teach a client undergoing chemotherapy with secondary stomatitis to avoid? A) Broiled fish B) Ice cream C) Salted pretzels D) Scrambled eggs

C) Salted pretzels Salty foods like pretzels can further irritate ulcers in the client's mouth, causing pain.Cool or cold foods and foods high in protein, such as fish, eggs, and ice cream, may be included in the diet of the client with stomatitis.

The community nurse is discussing risk factors for esophageal cancer with a group of clients. Which client behavior requires further teaching? A) Eats a small snack each night before bedtime. B) Walks at the shopping mall three times weekly. C) Smokes 1/3 of a pack of cigarettes daily. D) Elevates pillows at night.

C) Smokes 1/3 of a pack of cigarettes daily. Tobacco use is one of the primary risk factors for esophageal cancer. This client behavior requires teaching about lifestyle risks that could increase the risk for esophageal cancer.

The nurse finds a client vomiting coffee-ground emesis. On assessment, the client has a blood pressure of 100/74 mm Hg, is acutely confused, and has a weak and thready pulse. Which intervention is the nurse's first priority? A) Administer antianxiety medication. B) Initiate enteral nutrition. C) Start intravenous (IV) fluids, D) Administer histamine (H2) antagonist.

C) Start intravenous (IV) fluids The nurse's first priority is to administer intravenous (IV) fluids. Administering IV fluids is necessary to treat the hypovolemia caused by acute gastrointestinal (GI) bleeding.

The nurse is planning health teaching about omeprazole for a client who has acute gastritis. What would the nurse include in the health teaching? A) Crushing the drug and mixing in applesauce B) Avoiding alcohol while taking this drug C) Taking the drug 30 minutes before a meal D) Taking the drug when the client has gastric pain

C) Taking the drug 30 minutes before a meal This drug is a proton pump inhibitor and is activated by the presence of food in the stomach. Therefore, it should be taken before a meal.

The nurse is teaching a client with gallbladder disease about diet modification. Which meal would the nurse suggest to the client? A) Sausage and scrambled eggs B) Steak and french fries C)Turkey sandwich on wheat bread D)Fried chicken and mashed potatoes

C) Turkey sandwich on wheat bread Turkey is an appropriate low-fat selection for this client. High fiber, from the wheat bread, also helps reduce the risk. Typically, diets high in fat, high in calories, low in fiber, and high in refined white carbohydrates place clients at higher risk for developing gallstones. Steak, french fries, fried chicken and mashed potatoes, and sausage are too fatty. Eggs are too high in cholesterol for a client with gallbladder disease.

Based on nutritional screening findings and assessments, which client does the nurse identify that meets criteria for surgical treatment of obesity? A) Woman with a BMI of 38, weight 50% above ideal body weight B) Man with a body mass index (BMI) of 40, weight 75% above ideal body weight C) Woman with a BMI of 42, weight 100% above ideal body weight D) Man with a BMI of 41, weight 80% above ideal body weight

C) Woman with a BMI of 42, weight 100% above ideal body weight The client who will be most successful with surgical intervention is the client with a BMI of 40 or more and a weight 100% above the ideal body weight. The other clients do not have a high enough BMI-to-weight ratio to be considered for surgical intervention.

After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? A) Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL (13.1 mmol/L). B) Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain. C) Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. D) Middle-age client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography.

C) Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. The nurse would first assess the young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. Airway and breathing are the two most important criteria the nurse will use to determine which client to assess first. The dyspneic client is at greatest risk for rapid deterioration and requires immediate assessment and intervention. Acute respiratory distress syndrome is a possible complication of acute pancreatitis. The client with cholecystitis and the client with an elevated temperature will require further assessment and intervention, but these are not medical emergencies requiring the nurse's immediate attention. The older adult client's glucose level will require intervention but, again, is not a medical emergency.

The nurse is caring for a client who has cirrhosis of the liver. The client's latest laboratory testing shows a prolonged prothrombin time. For what assessment finding would the nurse monitor A) deep vein thrombosis. B) jaundice. C) hematemesis. D) pressure injury.

C) hematemesis. The client who has cirrhosis is at risk for bleeding due to decreased production of prothrombin by the liver. Portal hypertension that occurs in clients with cirrhosis causes esophageal blood veins to become fragile, distended, and tortuous. Therefore, these veins tend to bleed as evidenced by either hematemesis or melena.

A hospitalized client with ongoing abdominal tenderness reports an increase in generalized abdominal pain today. Which assessment technique will the nurse perform? Select all that apply. A. Percuss to determine size of liver and spleen. B. Auscultate beginning in the RLQ. C. Visually observe for contour and symmetry. D. Ask for a pain scale rating on a scale of 0-10. E. Deeply palpate the area of tenderness.

C, D

Immediately following a colonoscopy, which client behavior will the nurse report to the health care provider? Select all that apply. A. Passing of flatus B. Blood pressure 128/80 mm Hg C. Abdominal guarding D. Change in mental status E. Report of mild abdominal cramping

C, D

When assessing a client experiencing a GI bleed, which laboratory finding supports suspected anemia? A. A WBC count of 13,000 B. A hemoglobin of 14 C. A hematocrit of 20 D. A systolic BP of 100

C. A hematocrit of 20

Immediately following a colonoscopy, which client behavior will the nurse report to the health care provider? A. Passing of flatus B. Blood pressure 128/80 C. Abdominal guarding D. Mild abdominal cramping

C. Abdominal guarding

A client is diagnosed with a duodenal ulcer. The nurse understands that the location of the ulcer is where? A. In the corpus body of the stomach B. In the fundus of the stomach C. At the beginning of the small intestine D. In the cardia of the stomach

C. At the beginning of the small intestine

The nurse is assessing a very thin client who has come to the emergency department with acute abdominal pain. Upon assessment, visible peristaltic movements are noted. What is the appropriate nursing action? A. Prepare to administer antibiotics as prescribed. B. Report finding to the health care provider. C. Monitor laboratory values for possible pancreatitis. D. Toilet quickly as diarrhea is imminent.

C. Monitor laboratory values for possible pancreatitis.

While performing an abdominal assessment on a client, the nurse noted a bruit over the aorta. What is the appropriate nursing action? A. Consult another nurse to verify the bruit B. Auscultate each quadrant for 5 minutes each C. Notify the health care provider of the findings D. Perform light palpation to further assess the pulsation

C. Notify the health care provider of the findings

The nurse is teaching a client how to prevent recurrent chronic gastritis symptoms before discharge. Which statement by the client demonstrates a correct understanding of the nurse's instruction? A) "I will need to take vitamin B12 shots for the rest of my life." B) "I should eat small meals about six times a day." C) "It is okay to continue to drink coffee in the morning when I get to work." D) "I should avoid alcohol and tobacco of any type."

D) "I should avoid alcohol and tobacco of any type." The client's statement that he or she needs to avoid alcohol and tobacco shows that the client correctly understands the nurse's instructions. The client also needs to eliminate caffeine from the diet. The client will need to take vitamin B12 shots only if he or she has pernicious anemia. The client would also not eat six small meals daily. This practice may actually stimulate gastric acid secretion.

The nurse is assessing a client who reports having a history of gastroesophageal reflux disease (GERD). Which assessment finding does the nurse report to the primary health care provider? A) "My family likes to eat small meals every 3 to 4 hours throughout the day." B) "When I buy meat, I ask for the leanest cut that is available." C) "I quit smoking 6 months ago." D) "Sometimes I wake up gasping for air in the middle of the night."

D) "Sometimes I wake up gasping for air in the middle of the night." Gasping for air upon waking in the middle of the night can be a sign of sleep apnea. The nurse must report this finding to the primary health care provider. Often patients who have one condition (sleep apnea or GERD) also experience the other. Quitting smoking 6 months ago, eating small meals, and eating lean meats are favorable findings that do not need to be reported.

When preparing a client to undergo paracentesis, which action is necessary to reduce potential injury as a result of the procedure? A) Assist the provider to insert a trocar catheter into the abdomen. B) Position the client with the head of the bed flat. C) Encourage the client to take deep breaths and cough. D) Ask the client to void prior to the procedure.

D) Ask the client to void prior to the procedure. To avoid injury to the bladder during a paracentesis, the client would be asked to void prior to the procedure. Taking deep breaths and coughing does not prevent complications or injury as a result of paracentesis. Clients would be positioned with the head of the bed elevated. The trocar catheter is used to drain the ascetic fluid and does not reduce the risk of damage to the bladder.

An older adult client is at risk for undernutrition. Which nursing intervention is appropriate to ensure optimum nutritional intake? A) Administering antiemetics and analgesics after meals B) Reminding APs to allow the client to remain in bed during meals C) Turning on the television during meals to provide distraction D) Assisting the client with toileting and oral care prior to meals

D) Assisting the client with toileting and oral care prior to meals The appropriate intervention to ensure optimum nutritional intake in an older adult client at risk for undernutrition is to assist the client with toileting and oral care prior to meals for comfort and to prevent these from distracting clients from meals. Antiemetics and analgesics should be provided prior to meals. Clients need to be free from distractions while eating. When possible, clients are placed in chairs for eating.

It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication? A) Right shoulder pain B) Bone marrow suppression C) Polyuria D) Bleeding

D) Bleeding A potential complication of hepatic artery embolization for hepatic cancer is bleeding. Prompt detection of hemorrhage is the priority. Discomfort such as right shoulder pain may be present, but the priority is to assess for hemorrhage. The nurse must assess for signs of shock, not polyuria. Embolization does not suppress the bone marrow. If chemotherapy or immune modulators is used, the nurse then assesses for bone marrow suppression.

The nurse is monitoring a client with gastric cancer for signs and symptoms of upper gastrointestinal bleeding. Which change in vital signs would the nurse expect? A) Temperature from 97.9° to 98.9° F (36.6° to 37.2° C) B) Respiratory rate from 24 to 20 breaths/min C) Apical pulse from 80 to 72 beats/min D) Blood pressure from 140/90 to 110/70 mm Hg

D) Blood pressure from 140/90 to 110/70 mm Hg A decrease in blood pressure from 140/90 to 110/70 indicates that the client has hypovolemia from loss of body fluid (in this case, blood).

The nurse is caring for a client who was recently diagnosed with Laennec cirrhosis. What is the nurse's priority assessment during client care? A) Cardiovascular assessment B) Abdominal assessment, including bowel sounds C) Respiratory assessment D) Cognitive and neurologic assessment

D) Cognitive and neurologic assessment The type of cirrhosis that this client has is caused by alcoholism. Withdrawal from alcohol can cause cognitive and neurologic changes, such as confusion and delirium tremens (DTs).

The nurse is recovering a client who had an esophagogastroduodenoscopy (EGD). What assessment would the nurse perform before determining if the client can have fluids to drink? A) Bowel sounds B) Orientation C) Presence of bruit D) Gag reflex

D) Gag reflex The nurse would check for the return of the client's gag reflex before allowing the client to drink or eat to prevent aspiration.

The nurse is caring for a client who had a liver transplant last week. For which complication will the nurse teach the client and family to monitor? A) Acute kidney injury B) Hypertension C) Pulmonary edema D) Infection

D) Infection The client is at the most risk for rejection of the transplant which can be the result of an infection if not identified and managed effectively. Therefore, the nurse would teach the client and family to report cough, fever, skin redness, and other signs of infection.

A client has recently developed acute sialadenitis (salivary gland infection ). Which intervention does the nurse include in this client's care? A) Request a prescription for an opioid to manage pain. B) Restrict fluids. C) Apply cold compresses. D) Massage the salivary gland

D) Massage the salivary gland. Sialadenitis is inflammation of a salivary gland. The salivary gland is massaged to stimulate the flow of saliva. This is done by milking the edematous gland with the fingertips toward the ductal opening. To promote the flow of saliva, warm (not cold) compresses are applied to the affected salivary gland. Pain from this condition is managed with NSAIDs, not opioids. Hydration promotes salivary flow.

A client has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the client about this therapy, the nurse advises the client not to mix enzyme preparations with foods containing which element? A) High fat B) High fiber C) Carbohydrates D) Protein

D) Protein The nurse tells the client not to mix enzyme preparations with foods containing protein because the enzymes will dissolve the food into a watery substance. Pancreatic-enzyme replacement therapy (PERT) is the standard of care to prevent malnutrition, malabsorption, and excessive weight loss. Pancrelipase is usually prescribed in capsule or tablet form and contains varying amounts of amylase, lipase, and protease. No evidence suggests that enzyme preparations should not be mixed with carbohydrates, food with highfat content, and food with high-fiber content.

An older adult client needs additional dietary protein, but refuses to drink the prescribed liquid protein supplements. Which nursing intervention helps the client to increase protein intake? A) Keeping a food and fluid intake diary for at least 3 days B) Administering the liquid supplement with routine medications C) Giving a glucose polymer modular supplement D) Providing protein modular supplements in the form of puddings

D) Providing protein modular supplements in the form of puddings To increase the client's protein intake is to provide protein modular supplements in the form of puddings. This would increase the client's protein intake in a format other than a liquid supplement. Administering the liquid supplement with routine medications will not be effective because the client has already refused to drink the supplements. Glucose polymer modular supplements will increase the client's calorie intake but not protein intake. A food and fluid diary will provide information about the client's typical intake pattern, but will not increase protein intake.

How would the home care nurse best modify the client's home environment to manage side effects of lactulose? A) Obtains a walker for the client. B) Rearranges furniture to declutter the home. C) Removes throw rugs to prevent falls. D) Requests a bedside commode for the client.

D) Requests a bedside commode for the client. The home care nurse would modify the client's home environment to manage side effects of lactulose by making a bedside commode available to the client. Lactulose therapy increases the frequency of stools. A bedside commode is especially necessary if the client has difficulty reaching the toilet.

The nurse collaborates with the registered dietitian nutritionist in providing teaching for a client who has ascites from cirrhosis. What daily dietary restriction would the nurse include in the health teaching? A) Calcium B) Potassium C) Magnesium D) Sodium

D) Sodium Mild to moderate sodium restriction is often tried as the first intervention to decrease body fluid retention, including ascites.

When teaching about colonoscopy, which statement does the nurse recognize as indicating a need for clarification? A. "I will be sedated during the procedure.." B. "I will need to sign an informed consent." C. "I will have only clear liquids the day before the procedure." D. "If I do not complete my prep, the doctor can clean me out while I am sedated."

D. "If I do not complete my prep, the doctor can clean me out while I am sedated."

Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit? A. A 40 year old who needs administration of IV midazolam hydrochloride during an upper endoscopy. B. A 36 year old who needs teaching about an endoscopic retrograde cholangiopancreatography. C. A 46 year old who is admitted with abdominal cramping and diarrhea of unknown causes. D. A 32 year old with constipation who has received a laxative.

D. A 32 year old with constipation who has received a laxative.

Which client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) clinic? A. Client admitted with nausea, abdominal pain, and abdominal distention. B. Client who needs discharge teaching after an endoscopic retrograde cholangiopancreatography (ERCP). C. Client with epigastric pain who needs conscious sedation during endoscopy. D. Client who has had laxatives administered and needs monitoring before a colonoscopy.

D. Client who has had laxatives administered and needs monitoring before a colonoscopy.

A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client? A. Has the client lie in a supine position with legs straight and arms above the head. B. Assesses the following sequence: inspection, palpation, percussion, auscultation. C. Palpates any bulging mass very gently and documents findings. D. Examines the RUQ of the abdomen last following all other assessment techniques.

D. Examines the RUQ of the abdomen last following all other assessment techniques.

The nurse is caring for a client who has been prescribed lubiprostone for IBS-C. What health teaching will the nurse include about taking this drug? a. "This drug will make you very dry because it will decrease your diarrhea." b. "Be sure to take this drug with food and water to help manage constipation." c. "Avoid people who have infection as this drug will suppress your immune system." d. "Include high-fiber foods in your diet to help produce more solid stools."

b. "Be sure to take this drug with food and water to help manage constipation." Lubiprostone is an oral laxative approved for women who have IBS with constipation (IBS-C). Water and food will also help to improve constipation. The drug is not used for clients who have diarrhea and does not affect the immune system. Although high-fiber foods are important for clients who have IBS, this client does not need fiber to help make stool more solid. Instead the fiber will help prevent constipation.

The nurse is caring for a client who is planning to have a laparoscopic colon resection for colorectal cancer tomorrow. Which statement made by the client indicates a need for further testing? a. "I should have less pain after this surgery compared to having a large incision." b. "I will probably be in the hospital for 3 to 4 days after surgery." c. "I will be able to walk around a little on the same day as the surgery." d. "I will be able to return to work in a week or two depending on how I do."

b. "I will probably be in the hospital for 3-4 days after surgery." All of these statements are correct about having minimally invasive laparoscopic surgery except that the hospital stay will likely be only 1-2 days

A client is preparing to have a fecal occult blood test (FOBT). What health teaching would the nurse include prior to the test? a. "This test will determine whether you have colorectal cancer." b. "You need to avoid red meat and NSAIDs for 48 hours before the test." c. "You don't need to have this test because you can have a virtual colonoscopy." d. "This test can determine your genetic risk for developing colorectal cancer."

b. "You need to avoid red meat and NSAIDs for 48 hours before this test." The FOBT is a screening that is sometimes used to assess for microscopic lower GI bleeding. To help prevent false positive results, the client needs to avoid red meat, vitamin C, and NSAIDs. The test is not diagnostic nor does it determine a client's genetic risk for colorectal cancer

The nurse is caring for a client who has a postoperative paralytic ileus following abdominal surgery. What drug is appropriate to manage this nonmechanical bowel obstruction? a. Alosetron b. Alvimopan c. Amitiptyline d. Amlodipine

b. Alvimopan Alvimopan is the appropriate drug to promote peristalsis for clients who have a paralytic ileus. The others do not affect intestinal activity

The nurse is caring for a client who is diagnosed with a complete small bowel obstruction. For what priority problem is this client most likely at risk? a. Abdominal distention b. Nausea c. Electrolyte imbalance d. Obstipation

c. Electrolyte imbalance the client who has a small bowel obstruction is at the highest risk for fluid and electrolyte imbalances, especially with dehydration and hypokalemia due to profuse vomiting. Nausea, abdominal distention, and obstipation are also usually present, but these problems are not as life threatening as the imbalances in electrolytes

A client is admitted with a diagnosis of possible strangulated inguinal hernia. For which complication would the nurse monitor? a. Paralytic ileus b. Bowel volvulus c. Sepsis d. Colitis

c. Sepsis The client who has a strangulated inguinal hernia would likely develop bowel necrosis which can lead to sepsis. The nurse would observe for early signs and symptoms of sepsis such as fever, tachypnea, and tachycardia. If the client's condition is not promptly managed, bowel perforation, septic shock, and death can result.

The nurse is caring for a client with a large bowel obstruction due to fecal impaction. What position would be appropriate for a client while in bed? a. Prone b. Supine c. Recumbent d. Semi-fowler

d. Semi-fowler Having the client in a semi sitting position helps to decrease the pressure caused by abdominal distention and promotes thoracic expansion to facilitate breathing