PRiority Spring GI/TPN?

4 (Fluid and electrolyte imbalance can cause cardiac dysrhythmias This is the priority problem)

11 The nurse is planning care of a client dx with acute gastroenteritis. which nursing problem is priority? 1. Altered nutrition 2. self care deficit 3. impaired body image 4. F & E imbalance

3

33 Which behavior by the UAP warrants intervention by the HH nurse? The client tells the HH nurse the UAP: 1. Would not accept a birthday gift 2. Gave the client a vase of flowers from the UAPS garden 3. Picked up the clients prescriptions from the pharmacy 4 Cleaned the clients bathroom, including scrubbing the commode

3 (A mucosal barrier agent must be administered before the client eats in order for the med to coat the gastric mucosa. this med should be administered first)

12 The nurse is preparing to admin the morning meds to clients on a medical unit. Which medication should the nurse admin first? 1. Methylprednisolone (Solu-Medrol), a steroid to a client diagnosed with Crohns 2. Donepazil (Aricept) an acetylcholinesterase inhibitor, to a client with dementia 3. Sucralfate (carafate) a mucosal barrier agent to a client dx with ulcer disease 4. Enoxaparin (Lovenox) an anticoag to a client on bed rest after abd surgery

3 (The location of the incision for a cholecystectomy, the general anesthesia needed and the heavy smoking history make this client at high risk for pulm complications)

15 The nurse is preparing clients for surgery. Which client has the greatest potential for experiencing complications? 1. The client scheduled for removal of an abd mass who is overweight 2. The client scheduled for gastrectomy who has arterial HTN 3. The client scheduled for a open cholecystectomy who smokes two packs of cigs a day 4. The client scheduled for an emergency appendectomy who smokes marijuana on a daily basis

3 2 1 4 5

16 The nurse is performing ostomy care for a client who had an abdominal peritoneal resection with a perm sigmoid colostomy. Rank the interventions in order of priority 1. cleanse the stomal site with mild soap and water 2. assess the stoma for a pink moist appearance 3 monitor the drainage in the ostomy drainage bag 4. apply the stoma adhesive paste to the skin around the stoma 5. attach the ostomy drainage bag to the abdomen

1 (The RN must first obtain the operative permit, or determine whether it has been signed by the client prior to implementing any other orders)

17 The nurse is transcribing the HCP orders for a client who is scheduled for an emergency appendectomy and is being transferred from the emergency dept to the surgical unit. Which order should the nurse implement first? 1 obtain the clients informed consent 2. admin 2 mg of IV morphine q 4 hours PRN 3. shave the LRQ 4. Admin the on-call IVPB antibiotic

1

18 The client 1 day post op abdominal surgery has an evisceration of the wound. Which intervention should the nurse implement first? 1. Place sterile NS gauze on the eviscerated area 2.. Reinforce the abd dressing with an ABD pad 3. Assess the clients bowel sounds 4. Place the client in the L lateral position

3 (Wound dehiscence is the premature bursting open of a wound along surgical suture, and is an emergency that would require the nurse to assess this pt first)

19 The med surg nurse has just received the am shift report. Which client should the nurse assess first? 1. the client who has paralytic ileus and has absent bowel sounds 2. The client 2 day post op abd surgery and has a soft tender abd 3. the client who is 6hr post op and has abd wound dehiscence 4 The client who had a liver transplant and is being transferred to the rehab unit

2 (Pain is a priority because the nurse must determine if this is expected postop pain or complication of surgery. This client should be assessed first.)

21 The nurse is caring for clients on a surgical unit. Which client should the nurse assess first? 1 The client who has been vomiting for 2 days and has an ABG of PH 7.47, PaO2 95, PaCO2 44, HCO3 30. 2. The client who is 8 hr postop for splenectomy and who is complaining of abd pain, rating a 9 on scale of 1-10 3 The client who is 12 hr post op abd surgery and has dark green bile draining in the NG tube 4. The client who is 2 days post op for hiatal hernia repair and complaining of feeling constipated

1 (The nurse should frist appraise the situation and not do anything . This is the pivotal point at which the nurse can return the anger or reappraise the situation. The most important action is to empathize with the UAP and try to find out the provocation for the behavior)

22 The UAP tells the nurse angrily, "you are the worst nurse I have ever worked with and I really hate working with you" Which action should the nurse implement first? 1. dont respond to the comment and appraise the situation 2. Tell the UAP to leave the unit immed 3. Report this comment and behavior to the charge nurse 4. Explain to the UAP that she cannot talk to the primary nurse like this

2 (The nurse should first inform the HCP so the order can be written in the chart The HCP must write the DNR order before the clients wishes can be honored)

24 The client admitted to the CCU tells the nurse " I have an advance directive and I do not want CPR" Which intervention should the nurse implement first? 1. Ask the client for a copy of the AD so that it can be placed in the chart 2. Inform the HCP of the clients request ASAP 3. Determine whether the client has a durable power of attorney for healthcare 4. Request the hospital chaplain to come and talk to the client about the request

3 (The clients apical pulse is above the normal and the BP is low which are signs of hypovolemic shock, which warrants immed intervention by the nurse. #4 WRONG because coffee ground indicates old blood, which not expected in esophageal bleeding)

25 The client diagnosed with esophageal bleeding. Which of the following assessment data warrants immediate intervention by the nurse? 1. The clients hemoglobin/hematocrit is 11.4/32 2. The clients abd is soft to touch and non-tender 3. The clients VS are 99 114 18 88/60 4. The clients NG tube has coffee ground drainage

1

30 The LPN tells the nurse the client dx with liver failure is getting more confused. Which intervention should the nurse implement first? 1. assess the neuro status 2. notify the clients HCP 3. request a STAT ammonia serum level 4. Tell the LPN to obtain the clients VS

3 (The nurse must have knowledge of disease processes. The client verbalizing signs of acute diverticulitis, which requires the client to be NPS and prescribed antibiotics. The client needs to receive immed medical attention)

34 The female client dx with diverticulosis called the HHA and told the nurse "I am having really bad pain in my LL stomach, and I think I have a fever" Which action should the nurse take? 1 recommend the client take an antacid and lie flat in the bed 2. Instruct one of the nurses to visit the client immed 3. Tell the client to have someone drive them to the ED 4. Ask the client what she has had to eat in the last 8 hrs

1 (The actions of the colleague indicate poss drug or alcohol impairment. The staff nurse is not in position of authority to require the potentially impaired nurse to submit to a drug test. The admin supervisor should assess the situation and initiate the follow up. The nurse must make sure an impaired nurse is not allowed to care for clients)

45 the staff nurse is working with a colleague who begins to act erratically and is loud and argumentative Which action should be taken by the nurse? 1. Ask the supervisor to come to the unit 2. Determine what is bothering the nurse 3. Suggest the nurse go home 4. Smell the nurses breath for alcohol

3 (this client is exhibiting symptoms of asthma a complication of GERD, therefore the client should be assigned to the most experienced nurse)

46 The charge nurse is making assignments on a med surg unit. Which client should be assigned to the most experienced nurse? 1. The client dx with lower esophageal dysfunction who is experiencing regurgitation 2. The client dx with Barretts esophagitis who is scheduled for an endoscopy 3 The client dx with gastroesophageal reflux disease who has bilateral wheezes 4. The client dx with 1 day postop hiatal hernia who has pain rated a 4 on a pain scale of 1-10

1 (post op the CO2 migrates to shoulder and causes shoulder pain)

51 The client 2 days post op from a laparoscopic cholecystectomy tells the nurse "My right shoulder hurts so bad I cant stand it" Which statement is the nurses best response? 1.. This is a result of the CO2 gas used in surgery 2. Call 911 and go to the ED immed 3. Increase the pain med the surgeon ordered 4. You need to ambulate in the hall to walk off the gas pains

1,3,4 (1 The HCP must order insertion of a Sengstaken-Blakemore tube, so this is collaborative 3. This is a collab intervention the nurse should implement needs HCP orders 4. Obtaining lab data requires HCP orders)

53 The nurse is caring for a client who is hemorrhaging from a duodenal ulcer. Which collaborative interventions should the nurse implement? SATA 1. Prepare to admin a SEngstaken-Blakemore tube 2. Assess the VS 3. Admin PPI IV 4.. Obtain a type and crossmatch for 4 units of blood 5. Monitor the I&O's

1 (The nurse should first determine if the client is hypovolemic prior to taking any other action This will determine the nurses next action)

55 The nurse is caring for a client 1 day post op sigmoid resect. There is a large amount of bright red blood on the dressing. Which intervention should the nurse implement first? 1. assess the clients apical pulse and BP 2. Auscultate the clients bowel sounds 3. Notify the HCP immed 4. REinforce the dressing with a sterile guaze pad

106 gtt/min

56 The nurse is preparing to hang a new bag of TPN. on a client who has had an abdominal perineal resection The bag has 2000 mL of 50% dextrose, 10 mL of trace elements, 20 mL of multivitamins, 20 mL of KCL, and 500 mL of lipids. The bag is to infuse over the next 24 hrs. At what rate should the nurse set the pump? ____________gtt/min

4 (The staff nurse should be part of the solution, volunteering to be on a committee of peers is the best action to effect change)

6 The nurse is concerned about the documentation form for blood administration, and other staff members agree the documentation is cumbersome and needs to be revised. Which action is most appropriate for the nurse to implement first? 1. discuss the blood administration flow sheet with the chief nursing officer 2. Contact an individual to help design a new blood transfusion flow sheet 3. learn to adapt to the present form and do not take any further action 4. volunteer to be on an ad hoc committee to research alternate blood flow sheets

2 (Milk thistle has an active ingredient silymarin, which has been used to treat liver disease for more than 2000 years. It is a powerful oxidant and promotes liver cell growth. This response gives the client factual information)

60 The client with hepatitis asks the nurse "Is there any herb I can take to help my liver get better? Which statement is the nurses best response? 1. you should ask your HCP about taking herbs 2. Milk thistle is a powerful oxidant and promotes liver cell growth 3. you should not take any med that is not prescribed 4. why would you want to take any herbs?

1 (Pain should be assessed even if expected for the clients dx, if the other clients are stable)

64 The nurse has recieved the am shift report. Which client should the nurse assess first? 1. The client with peptic ulcer disease who is complaining of acute epigastric pain 2 The client with acute gastroenteritis who is upset and wants to go home 3. The client with IBD who is receiving TPN 4. The client with Hep B who is complaining and who is jaundiced and anorexic

3 (Assessing the surgical incision is the first intervention because this may indicate wound dehiscence)

65 The client who has had abd surgery is complaining of pain and tells the nurse "I felt something pop in my stomach" Which intervention should the nurse implement first? 1. Check the clients apical pulse and BP 2. Determine the clients pain on a 1-10 scale 3. Assess the surgical wound site 4. Admin the pain med IV

2 (This client was just transferred from the PACU therefore the nurse should assess this client first to perform baseline assessments and ensure the client is stable)

67 The nurse is caring for the following clients on a surgical unit. Which client should the nurse assess first? 1. The client with inguinal hernia repair who has urine output of 160 mL in 4 hrs 2. The client with emergency appendectomy who was transferred from PACU 3. The client who is 4 hours post op abd surgery who has flatulence 4. The client 6 hrs post procedure colonoscopy and is being discharged

1 (The client that is morbidly obese will have a lg abd that prevents the lungs from expanding , and predisposes the client to respiratory complication. Having the client use an incentive spirometer will help prevent resp complications)

68 The client who is morbid obese is 8 hrs postop gastric bypass surgery. Which nursing intervention is of the greatest priority? 1. Instruct the client to use the incentive spirometer 2 Weigh the client daily in the same clothes at the same time 3. Apply SCDs to the clients lower extremities 4. assist the client to sit in the bedside chair

3 (The LPN can admin medications to the client)

70 The nurse, a LPN and a UAP are on a medical floor. Which nursing task is most appropriate to assign/delegate? 1. Instruct the UAP to DC the TPN 2. Ask the UAP to give the client 30 mL Maalox for heartburn 3. Tell the LPN to admin a bulk laxative to a client dx with constipation 4. Request the LPN to assess the abd of a client with complaints of pain

2 (This client is being prepped for a test in the morning and is the least acute of the clients listed.)

8 The charge nurse is making assignments on a medical unit. Which client should the nurse assign to the graduate nurse? 1. The client who has received 3 units of PRBCs 2. The client scheduled for an esophagogastroduodenoscopy in the morning 3 The client with short bowel syndrome who has diarrhea and a K level of 3.3 4. The client who has returned from surgery for a sigmoid colostomy

1,2,5 (1,2,5 The nurse should not admin any PO meds since the client is NPO)

9. At 0830 The day shift nurse is preparing to admin medications to the client NPO for an endoscopy. Which medication should the nurse question administering? SATA 1. Lanoxin (digoxin) 0.125 mg PO qd 2. furosemide 40 mg PO bid 3. Zantac (ranitidine) 150 mg in 250 mL NS IV continuous infusion q 24 hr 4 Vancomycin 850 mg IVPB q24h 5 Mylanta 30 mL PO PRN heartburn

4 (During TPN admin the client needs to reg monitored for hyperglycemia. The client may require insulin to improve glucose metabolism. The client should also be watched for signs and symptoms of hypoglycemia, which may occur if the body overproduces insulin in response to high glucose intake or if too much insulin is administered. Tachy or htn is not indicative of the ability to metabolize. An elevated BUN would indicate renal status and fluid balance)

A client is receiving TPN solution. The nurse should assess the clients ability to metabolize the TPN solution adequately by monitoring the client for which sign? SATA 1. tachycardia 2. HTN 3. elevated BUN 4. hyperglycemia

2 (The TPN is usually a HYPERtonic dextrose solution. The greater the concentration of dextrose in the solution, the greater the tonicity. Hypertonic dextrose solutions are used to meet the bodies calorie demands in a volume of fluid that will not overload the cardiovascular system. An isotonic dextrose solution; ie; 5% dextrose in water or a hypotonic dextrose solution will not provide enough calories to meet metabolic needs. Colloid are plasma expanders, and blood products are not used in TPN)

A client with inflammatory bowel disease is receiving TPN The basic component of the clients TPN solution is most likely to be: 1. an isotonic dextrose solution 2. a hypertonic dextrose solution 3. hypotonic dextrose solution 4. a colloid dextrose solution

4 (The client should be asked to perform the Valsalva maneuver; take a deep breath and hold it during insertion and removal of a CVAD. This increases central venous pressure during the procedure and prevents air embolism. Trendelenburg is the preferred position for CVAD insert and removal. If not possible supine position is sufficient for CVAD removal. The client should HOLD the breath and not exhale)

A nurse assisting with the removal of a central venous access device (CVAD) The nurse should; 1. turn the client to the left side 2. have the client exhale slowly and evenly 3. elevate the HOB 4. instruct the client to take a deep breath and hold it

1 (Pyrosis is heartburn and expected in client dx with GERD. The new grad can care for this client and admin antacid)

GCS 1/ RN is making assignments. Which client should be assigned to the grad nurse who has been on the unit 1 month? 1. The client dx with lower esophageal dysfunction who is complaining of pyrosis 2. The client who had an endoscopy this morning and has absent bowel sounds 3. The client with gastroesophageal reflux disease who has bilateral wheezing 4. The who is 1 day post op open cholecystectomy and refused to deep breathe

3

GCS 10/ Ms Kathy is making rounds on the unit. Which client should Ms. Kathy assess first? 1. The client dx with peptic ulcer disease who is receiving blood and has a hemoglobin of 10.4 and hematocrit 35 2. the client dx with ulcerative colitis who has had 10 loose stools and has a K level of 3.5 3. The client who is 1 day post op abd surgery, with a hard, rigid abd and elevated temp 4. The client diagnosed with acute diverticulitis whose NG tube is draining green bile

2 (The clients K is wnl, so the nurse would continue to monitor the client, the norm is 3.5-5.5)

GCS 2/ The client dx with inflammatory bowel disease has a serum K of 4.4 Which intervention should the nurse implement first? 1 Notify the HCP 2. Continue to monitor the client 3.. Request telemetry for the client 4. Prepare to admin K IV

1,2 (An admission assess is independent, 2 eval BP is independent.)

GCS 3The client admitted to the hospital with hemorrhaging from a duodenal ulcer. Which interventions should Ms. Kathy instruct the primary nurse to implement? SATA 1. complete the admission assessment 2. evaluate BP lying, sitting, and standing 3. Admin IV antibiotics 4. admin blood products 5. obtain hemoglobin and hematocrit

94 mL/hr

GCS 5/ The nurse is preparing to hang a new bag of TPN on a client who has an abd perineal resect. The bag has 2000 mL 50% Dextrose, 15 mL of trace elements, 30 mL of multivitamins, 20 mL of KCL, and 200 mL of lipids. The bag is to infuse of the next 24 hrs. At what rate should the nurse set the pump?__________mL/hr

3 (Invasive tests are not completed during an acute exacerbation of diverticulosis)

GCS 6/ The client admitted to the medical unit with a dx of acute diverticulitis. Which order should Ms Kathy clarify with the HCP? 1. insert a NG tube 2. Start IV D5W at 125 mL/hr 3 schedule the client for sigmoidoscopy 4 Place the client on bed rest with bathroom privileges

2 (First have the nurse complete the adverse occurrence report, so there is written documentation of the incident.)

GCS 8/ One of the primary nurses tells Ms Kathy that she stuck herself in the finger with a used needle and cleaned the site with soap and water. Which intervention should ms Kathy implement first? 1.. notify the infection control nurse 2. complete an adverse occurrence report 3. request post exposure prophylaxis 4. check the hepatitis status of the client

2 (TPN is hypertonic, high cal, high protein IV fluiid that should be provided to clients who do not have functioning GI tract motility. TPN is prescribed once daily, based on client electrolyte and fluid balance, and must be handled with strict aseptic technique due to high glucose content, it is perfect for bacterial growth. Also because of high tonicity, TPN must be admin thru a central Line, not a peripheral line. there is no specific need to auscultate bowel sounds)

TPN is prescribed for a client who has recently had a small and large bowel resection and who is currently NPO. The nurse should: 1. admin TPN thru a NG tube or gastrostomy tube 2. handle TPN using strict aseptic techniques 3. auscultate for the presence of bowel sounds 4. designate a peripheral IV site for TPN admin

1 (TPN is to meet the clients nutrition needs, its hypertonic with carbs, amino acids, electrolytes, trace elements, and vitamins. it is administered to provide a positive nitrogen balance)

TPN is prescribed for a client with Crohns disease. The TPN solution is having an intended outcome when: 1. The clients nutritional needs are met 2 The client does not have metabolic acidosis 3. The client is hydrated 4. The client is in a negative nitrogen balance

2 (The nurse administers the PRBCs using a separate infusino line and appropriate tubing, with NS as the priming solution. IT is NOT necessary to DC the TPN infusion or wait for the TPN to finish infusing)

The client has anemia resulting form bleeding from ulcerative colitis and is to receive 2 units PRBCs. The client is receiving an infusion of TPN. In preparing to admin the PRBCs, what should the nurse do to ensure client comfort and safety? 1. DC the TPN infusion 2. Start an IV of NS 3. Admin the PRBCs in the same IV as the TPN 4. Wait until the TPN infusion is completed and use the same IV line to infuse the PRBCs

1 (The admin of fat emulsion solution provides additional calories and essential fatty acids to meet the bodies energy needs. )

The nurse administers fat emulsion solution during TPN as prescribed based on the understanding that this type of solution: 1 provides essential fatty acids 2. provides extra carbs 3. promotes effective metabolism of glucose 4. maintains a normal body weight

4 (When TPN fluids are infused too rapidly or too slowly the HCP should be notified. TPN solutions must be carefully and accurately infused. RAte adjustments should not be made without a written prescription from the HCP. Significant alterations in rate (10% increase or decrease) can result in fluctuations of blood glucose levels. Speeding up the solution can result in too much glucose entering the system)

The nurse discovers the clients TPN solution was running at an incorrect rate and is now 2 hrs behind schedule. Which action is most appropriate for the nurse to take to correct the problem? 1. REadjust the solution to infuse the desired amount 2. continue the infusion at the current rate but run the next bottle at an increased rate 3. double the infusion rate for 2 hrs 4. notify the HCP

3 (The nurse should first obtain a culture specimen The presence of drainage is a potential indication of infection and the cath may need to be removed. Since removing the cath will be required in the presence of infection, the nurse would not clean and redress the area. While the temp increase would indicate an infection a culture needs to be obtained to determine the organism)

The nurse is changing the subclavian dressing of a client who is receiving TPN When assessing the catheter insertion site, the nurse notes the presence of yellow drainage from around the sutures that are anchoring the catheter. What should the nurse do first? 1. Clean the insertion site and redress the area 2. Document assessment findings in the clients chart 3. Request a prescription to obtain a culture of the drainage 4. Check the clients temp

1,2,4 (Complications assoc with admin of TPN through a central line include infection and air embolism. To prevent these complications, strict aseptic technique is used for all dressing changes, the insertion site is covered with an air occlusive dressing and all connections of the system must be secure. Ambulation and ADLs are encouraged and not limited during the admin of TPN)

To prevent complications associated with TPN admin through a central line, the nurse should: SATA 1 use strict aseptic technique for all dressing changes 2. secure all connections of the system 3. encourage bed rest 4. cover the insertion site with a moisture proof dressing

1

Using a sliding scale schedule, the nurse preparing to admin an evening dose of reg insulin to a client who is receiving TPN. The nurse should base the dosage on the: 1. glucometer reading of the clients glucose level obtained immed before administering the insulin 2. fasting blood glucose level obtained earlier in the day 3. amount of TPN fluid the client received since the last dose of insulin 4. clients dietary intake for the evening meal and snack

2 (Too rapid of TPN can lead to circ overload. The client should be carefully assessed for indications FVE. A neg nitrogen balance occurs in nutritionally depleted individuals, not with TPN fluids in excess. When TPN is administered to rapidly, the client is at risk for receiving an excess of dextrose and electrolytes, therefore the client is at risk for HYPER glycemia and HYPER kalemia)

Which adverse effects occur when there is too rapid an infusion of TPN solution? 1. negative nitrogen balance 2. circulatory overload 3. hypoglycemia 4. hypokalemia

4 (an elevated temp can be indication of infection at insertion site or in the cath. VS should be taken q2-4 hr after initiation of TPN to detect early signs of complications. Glycosuria is expected during the first few days of therapy until the pancreas adjusts by secreting more insulin. A gradual weight gain is expected as nutritional status improves. Some clients experience decreased appetite during therapy)

Which finding indicates a complication after the first few days of TPN therapy? 1 glycosuria 2. 1-2 lb weight gain 3. decreased appetite 4. elevated temp