Review 120 week 2

A nurse is planning care for a client who is receiving enteral feedings through an NG tube. What action should the nurse plan to take first?

Aspirate the client's stomach - The first action the nurse should take using the nursing process is to ASSESS the residual stomach contents. The nurse should measure the stomach content to assess whether the feeding is being absorbed by the client

A nurse is providing teaching for a client who has experienced an acute episode of gastritis. Which of the following instructions should the nurse include in the teaching?

Avoid drinking alchol

A nurse is assessing a client who is receiving TPN therapy via an infusion pump. Which action should the nurse take next?

Change the IV tubing every 24 hr

A nurse is planning care for a client who has cirrhosis and ascites. Which intervention should the nurse include in the plan of care?

Decrease the client's fluid intake - The nurse should restrict fluids for a client who has cirrhosis and ascites due to client's risk for increased fluid retention

A nurse is caring for a client who is receiving TPN. the pharmacy is delayed in supplying the client's next container of TPN. What fluid should the nurse infuse until the next container arrives?

Dextrose 10% in water TPN contains high concentrations of dextrose and proteins. To avoid hypoglycemia, the nurse should infuse dextrose 10% to 20% in water until the next container of TPN arrives

A nurse is caring for a client following the surgical placement of a colostomy. What statement indicates the client understands the dietary teaching

Eating yogurt can help decrease the amount of gas that I have

A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices and portal hypertension. The nurse recognizes which of the following laboratory findings, as indicating the client's GI tract is digesting and absorbing blood?

Elevated blood urea nitrogen (BUN)

A nurse is developing a teaching plan for a client who has an ileostomy and will require stoma care. What information should the nurse include?

Empty the pouch when it is 1/2 full. - the nurse should instruct the patient to empty the pouch when its 1/3 to 1/2 full

A nurse is interviewing a client who has acute pancreatitis. Which of the following should the nurse anticipate finding in the client's history?

Gallstones

A nurse is caring for a newborn whose mother is positive for HepB surface antigen. Which of the following should the infant receive?

Hep B immune globulin and Hep B vaccine within 12 hours of birth

A nurse is preparing a client who is scheduled to undergo a paracentesis. Into which of the following positions should the nurse assist the client for this procedure?

High fowler

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control?

I will call for pain meds before the previous dose medication wears off

A nurse is reviewing the medication list for a client who has new diagnosis of a small bowel obstruction. The nurse should withhold which of the following medication>

Senna -Laxatives are contraindicated in clients who have fecal impaction, bowel obstruction and acute abdominal surgery to prevent prerforation

A nurse is caring for a client who requires TPN. which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly?

Sit the client upright and slow the infusion rate

A nurse is instructing a client who has GERD about positions that can help minimize the effect of reflux during sleep. What position should the patient sleep in?

Sleep on the right side

A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowel disease and is to start a low-lactose diet. Which food is the best choice for the client?

Soy milk

A nurse is admitting a client who has HepC. What precautions should the nurse implement

Standard

A nurse is caring for a client who has peptic ulcer disease. the nurse should monitor the client for which of the following findings as indication of GI perforation

Sudden abdominal pain

A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the follow interventions should the nurse include in the plan?

Wipe perianal area with warm water and apply a barrier cream

A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

Withhold oral fluids and food

Correct steps to follow for initate the feeding tube?

Verify tube placement Check the residual feeding contents Administer the feeding Evaluate the clients tolerance to feeding

A nurse is caring for a client who has cirrhosis and a new prescription for lactulose. Which of the following manifestations indicates an adverse effect of the medication

Vomiting

A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching?

You may experience a small amount of bleeding around the stoma