Colorectal disease/Diverticulosis/Gallbladder/gastroenteritis/abdominal surgery questions CH 7 Success

The client diagnosed with diverticulitis is complains of severe pain in the LLQ and has oral temp of 100.6 which intervention should the nurse implement first? 1. Notify the HCP 2. Document the findings in the chart 3. Administer an oral antipyretic 4. Assess the clients abdomen

4

144. The nurse is caring for clients on a medical unit. Which client information should be brought to the attention of the HCP immediately? 1. A serum sodium of 128 mEq/L in a client diagnosed with obstipation. 2. The client diagnosed with fecal impaction who had two (2) hard formed stools. 3. A serum potassium level of 3.0 mEq/L in a client diagnosed with diarrhea. 4. The client with diarrhea who had two (2) semi-liquid stools totaling 300 mL.

1

42. The nurse caring for a client 1 day postoperative sigmoid resection notes a moderate amount o dark reddish brown drainage on the midline abdominal incision. Which intervention should the nurse implement first? 1. Mark the drainage on the dressing with the time and date. 2. Change the dressing immediately using sterile technique. 3. Notify the health care provider immediately. 4. Reinforce the dressing with a sterile gauze pad.

1

55. The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment the nurse finds a hard rigid abdomen and T 102F. Which intervention should the nurse implement? 1. Notify the HCP 2. Prepare to administer a fleets enema 3. Administer an antipyretic suppository 4. Contour to monitor the client closely

1

66. Which data should the nurse expect to assess in the client who has a UGI series? 1. Chalky white stools 2. Increased HR 3. A firm hard abdomen 4. Hyperactive bowel sounds

1

The 85 year old male client diagnosed with cancer of the colon asks the nurse, "why did I get this cancer"? Which statement is the nurses best response? 1. "Research shows a lack of fiber in the diet can cause colon cancer." 2. It is not common to get colon cancer at your age; it is usually in young people." 3. "No one knows why anyone gets cancer, it just happens to certain people." 4. Women usually get colon cancer more often than men but not always."

1

The client complains to the nurse of unhappiness with the health care provider. Which intervention should the nurse implement next? 1. Call the HCP and suggest he or she talk with the client. 2. Determine what about the HCP is bothering the client. 3. Notify the nursing supervisor to arrange a new HCP to take over. 4. Explain the client cannot request another HCP until after discharge.

2

The client with a new colostomy is being discharged. Which statement made by the client indicates the need for further teaching? 1. "If I notice any skin breakdown, I will call the HCP." 2. "I should drink only liquids until the colostomy starts to work." 3. "I should not take a tub bath until the HCP okays it." 4. "I should not drive or lift more than 5 lbs."

2

111. The client is one (1) day postoperative major abdominal surgery. Which client problem is priority? 1. Impaired skin integrity. 2. Fluid and electrolyte imbalance. 3. Altered bowel elimination. 4. Altered body image.

2 (after abdominal surgery, the body distributes fluids to the affected area as part of the healing process. these fluids are shifted from the intravascular compartment to the interstitial space, which causes potential fluid and electrolyte imbalance)

69. Which assessment data indicate that the client recovering from an open cholecystectomy requires pain medication? 1. The client's pulse is 65 beats per minute. 2. The client has shallow respirations. 3. The client's bowel sounds are 20 per minute. 4. The client uses a pillow to splint when coughing.

2.

116. The post-anesthesia care nurse is caring for a client who has had abdominal surgery. The client is complaining of nausea. Which intervention should the nurse implement first? 1. Medicate the client with a narcotic analgesic IVP. 2. Assess the nasogastric tube for patency. 3. Check the temperature for elevation. 4. Hyperextend the neck to prevent stridor.

2. A client who has had abdominal surgery usually has a nasogastric tube (NGT) in place. If the NGT is not patent, this will cause nausea. Irrigating the NGT may relieve nausea.

143. The nurse is talking ont he phone to a client who has diarrhea. Which intervention should the nurse discuss with a the client? 1. Tell the client to measure the amount of stool. 2. Recommend the client come to the clinic immediately. 3. Explain the client should follow the BRAT diet. 4. Discuss taking an OTC H2blocker.

3

The nurse is admitting a client to a medical floor with a diagnosis of adenocarcinoma of the rectosigmoid colon. Which assessment data support this diagnosis? 1. the client reports up to 20 bloody stools per day. 2. The client has a feeling of fullness after a heavy meal. 3. The client has diarrhea alternating with constipation. 4. the client complains of right lower quadrant pain.

3

The client who has had an abdominal perineal resection is being discharged. Which discharge information should the nurse teach? 1. The stoma should be white, blue, or purple. 2. Limit ambulatory to prevent the pound from coming off. 3. Take pain medication when the pain level is at an "8." 4. Empty the pouch when it is one-third to one-half full.

4

The nurse writes a psychosocial problem of risk for altered sexual functioning related to new colostomy. Which intervention should the nurse implement? 1. Tell the client there should be no intimacy for atleast 3 months. 2. Ensure the client and significant other are able to change the ostomy pouch. 3. Demonstrate with chats possible sexual positions for the client to assume. 4. Teach the client to protect the pouch from becoming dislodged during sex.

4

53. The client is two (2) hours post-colonoscopy. Which assessment data would warrant intermediate intervention by the nurse? 1. The client has a soft, nontender abdomen. 2. The client has a loose, watery stool. 3. The client has hyperactive bowel sounds. 4. The client's pulse is 104 and BP is 98/60.

4. Bowel perforation is a potential complication of a colonoscopy. Therefore signs of hypotension—decreased BP and increased pulse—would warrant immediate intervention from the nurse.

109. The male client has had abdominal surgery and is now diagnosed with peritonitis. Which assessment data support the client's diagnosis of peritonitis? 1. Absent bowel sounds and potassium level of 3.9 mEq/L. 2. Abdominal cramping and hemoglobin of 14 gm/dL. 3. Profuse diarrhea and stool specimen shows Campylobacter. 4. Hard, rigid abdomen and white blood cell count 22,000 mm.

4 (a hard rigid abdomen indicates an inflamed peritoneum (abdominal wall cavity) resulting from an infection, which results in an elevated WBC level)

61. The client is four (4) hours postoperative open cholecystectomy. Which data would warrant immediate intervention by the nurse? 1. Absent bowel sounds in all four (4) quadrants. 2. The T-tube with 60 mL of green drainage. 3. Urine output of 100 mL in the past three (3) hours. 4. Refusal to turn, deep breathe, and cough.

4. Refusing to turn, deep breathe, and cough puts the client at risk for pneumonia. This client needs immediate intervention to prevent complications.

103. Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning? 1. Fluid volume deficit. 2. Nausea. 3. Risk for aspiration. 4. Impaired urinary elimination.

. 1. Fluid volume deficit secondary to diarrhea is the priority because of the potential for metabolic acidosis and hypokalemia, which are both life threatening, especially in the elderly

99. The client is diagnosed with salmonellosis secondary to eating some slightly cooked hamburger meat. Which clinical manifestations would the nurse expect the client to report? 1. Abdominal cramping, nausea, and vomiting. 2. Neuromuscular paralysis and dysphagia. 3. Gross amounts of explosive bloody diarrhea. 4. Frequent "rice water stool" with no fecal odor.

. 1. Symptoms develop 8-48 hours after ingesting the Salmonella bacteria and include diarrhea, abdominal cramping, nausea, and vomiting, along with low-grade fever, chills, and weakness.

112. The client has an eviscerated abdominal wound. Which intervention should the nurse implement? 1. Apply sterile normal saline dressing 2. Use sterile gloves to replace protruding parts. 3. Place the client in reverse trendelenburg position. 4. Administer IV antibiotics STAT.

1

70. The charge nurse monitoring client laboratory values. Which value is expected in the client with cholecysitis who has chronic inflammation? 1. An elevated white blood cell count 2. A decreased lactate dehydrogenase 3. An elevated alkaline phosphatase 4. A decreased direct bilirubin level

1

136. The client has had a stool that is dark, watery, and shiny in appearance. Which intervention should be the nurse's first action? 1. Check for a fecal impaction. 2. Encourage the client to drink fluids. 3. Check the chart for sodium and potassium levels. 4. Apply a protective barrier cream to the perianal area.

1 (this is a symptom of diarrhea moving around an impaction higher up in the colon. the nurse should assess for an impaction when observing this finding.)

57. The client with acute diverticulitis has a NG tube draining green liquid bile. Which intervention should the nurse implement? 1. Document the findings as normal 2. Assess the clients bowel sounds 3. Determine the clients last bowel movement 4. Insert the N/G tube at least two more inches

1 green bile contains HCL and should be draining from the NG tube so the nurse should take no action and document

64. Which signs and symptoms should the nurse report to the HCP for the client recovering from an open cholecystectomy? (Select all that apply) 1. Clay colored stools 2. Yellow tinted sclera 3. Amber colored urine 4. Wound approximated 5. Abdominal pain

1, 2, & 5.

146. The 70-year-old client is admitted to the medical unit diagnosed with acute diverticulitis. Which interventions should the nurse implement? Select all that apply. 1. Tell the client not to eat or drink. 2. Start an IV line. 3. Asses client for abdominal tenderness. 4. Have the dietitian consult for low residue diet. 5. Place the client on bedrest with bathroom privileges.

1, 2, 3, & 5.

The nurse is planning the care of a client who has had abdominal-perineal resection for cancer of the colon. Which interventions should the nurse implement? Select all that apply. 1. Provide meticulous skin care to soma. 2. Asses the flank incision. 3. Maintain the indwelling catheter. 4. Irrigate the (JP) drains every shift. 5. Position the client semirecumbent.

1, 3, & 5.

142. The client presents to the emergency department experiencing frequent watery, bloody stools after eating some undercooked meat at a fast food restaurant. Which intervention should be implemented first? 1. Provide the client with a specimen collection hat to collect a stool sample. 2. Initiate antibiotic therapy intravenously. 3. Have the laboratory draw a complete blood count. 4. Administer the antidiarrheal medication Lomotil.

1. This client may have developed an infection from the undercooked meat. The nurse should try to get a specimen for the laboratory to analyze and for the nurse to be able to assess. The client's complaint of "bloody diarrhea" needs to be investigated by the nurse, who should observe the amount, color, and characteristics of the stool.

118. The client has a nasogastric tube. The health-care provider orders IV fluid replacement based on the previous hour's output plus the baseline IV fluid ordered of 125 mL/hr. From 0800 to 0900 the client's N/G tube drained 45 mL. At 0900, what rate should the nurse set the IV pump?_______

170 mL/hr

62. The client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement? 1. Apply a heating pad to the abdomen for 15 to 20 minutes. 2. Administer morphine sulfate intravenously after diluting with saline. 3. Contact the surgeon for an order to x-ray the right shoulder. 4. Apply a sling to the right arm that was injured in surgery.

1. A heating pad should be applied for 15 to 20 minutes to assist the migration of the CO2 used to insufflate the abdomen.

58. The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis? Select all that apply. 1. Eat a high-fiber diet. 2. Increase fluid intake. 3. Elevate the HOB after eating. 4. Walk 30 minutes a day. 5. Take an antacid every two (2) hours.

1. A high-fiber diet will help to prevent constipation, which is the primary reason for diverticulitis. 2. Increased fluids will help keep the stool soft and prevent constipation. 4. Exercise will help prevent constipation

139. The client diagnosed with AIDS is experiencing voluminous diarrhea. Which interventions should the nurse implement? Select all that apply. 1. Monitor diarrhea, charting amount, character, and consistency. 2. Assess the client's tissue turgor every day. 3. Encourage the client to drink carbonated soft drinks. 4. Weigh the client daily in the same clothes and at the same time. 5. Assist the client with a warm sitz bath PRN.

1. It is important to keep track of the amounts, color, and other characteristics of all body fluids lost. 4. Daily weights are the best method of determining fluid loss and gain. 5. Sitz baths will assist in keeping the client's perianal area clean without having to rub. The warm water is soothing, providing comfort.

115. The client who has had an abdominal surgery has a Jackson Pratt (JP) drainage tube. Which assessment data would warrant immediate intervention by the nurse? 1. The bulb is round and has 40 mL of fluid. 2. The drainage tube is pinned to the dressing. 3. The JP insertion site is pink and has no drainage. 4. The JP bulb has suction and is sunken in.

1. The JP bulb should be depressed, which indicates suction is being applied. A round bulb indicates that the bulb is full and needs to be emptied and suction reapplied.

134. The nurse is caring for a client who uses cathartics frequently. Which statement made by the client indicates an understanding of the discharge teaching? 1. "In the future I will eat a banana every time I take the Medicine." 2. "I don't have to have a bowel movement every day." 3. "I should limit the fluids I drink with my meals." 4. "If I feel sluggish, I will eat a lot of cheese and dairy products."

2

37. The occupation health nurse is preparing a presentation to a group of factory workers about preventing colon cancer. Which information should be included in the presentation? 1. Wear a high-filtration mask when around chemicals. 2. Eat several servings of cruciferous vegetables. 3. Take a multiple vitamin every day. 4. Do not engage in high-risk sexual behaviors.

2

138. The dietician and nurse in a long-term care facility are planning the menu for the day. Which foods would be recommended for the immobile clients for whom swallowing is not an issue? 1. Cheeseburger and milk shake. 2. Canned peaches and a sandwich on whole-wheat bread. 3. Mashed potatoes and mechanically ground red meat. 4. Biscuits and gravy with bacon.

2 (canned peaches are soft and can be chewed and swallowed easily while providing some fiber; whole wheat bread is higher in fiber than white bread. these foods will be helpful for clients whose gastric motility is slowed as a result of lack of exercise or immobility.)

63. The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching was effective? 1. "I will take my lipid-lowering medicine at the same time each night." 2. "I may experience some discomfort when I eat a high-fat meal." 3. "I need someone to stay with me for about a week after surgery." 4. "I should not splint my incision when I deep breathe and cough."

2. After removal of the gallbladder, some clients experience abdominal discomfort when eating fatty foods.

107. Which nursing interventions should be included in the care plan for the 84-year-old client diagnosed with acute gastroenteritis? Select all that apply. 1. Assess the skin turgor on the back of the client's hands. 2. Monitor the client for orthostatic hypotension. 3. Record the frequency and characteristics of sputum. 4. Use standard precautions when caring for the client. 5. Institute safety precautions when ambulating the client.

2. Orthostatic hypotension indicates fluid volume deficit, which can occur in an elderly client who is having many episodes of diarrhea, which occurs with acute gastroenteritis. 4. Standard precautions, including wearing gloves and hand washing, help prevent the spread of the infection to others. 5. The elderly client is at risk for orthostatic hypotension; therefore safety precautions should be instituted to ensure the client doesn't fall as a result of a decrease in blood pressure.

105. The 79-year-old client diagnosed with acute gastroenteritis is admitted to the medical unit. Which nursing task would be most appropriate for the nurse to delegate to the unlicensed nursing assistant? 1. Evaluate the client's intake and output. 2. Take the client's vital signs. 3. Change the client's intravenous solution. 4. Assess the client's perianal area.

2. The assistant can take the vital signs for a client who is stable; the nurse must interpret and evaluate the vital signs.

60. The client is admitted to the medical floor with acute diverticulitis. Which collaborative intervention would the nurse anticipate the health-care provider ordering? 1. Administer total parenteral nutrition. 2. Maintain NPO and nasogastric tube. 3. Maintain on a high-fiber diet and increase fluids. 4. Obtain consent for abdominal surgery.

2. The bowel must be put at rest. Therefore, the nurse should anticipate orders for maintaining NPO and a nasogastric tube

97. The female client came to the clinic complaining of abdominal cramping and has had at least 10 episodes of diarrhea every day for the last 2 days. The client reported that she had been in Mexico on a mission trip and just returned yesterday. Which intervention should the nurse implement? 1. Instruct the client to take a cathartic laxative daily. 2. Encourage the client to drink lots of Gatorade. 3. Discuss the need to increase protein in the diet. 4. Explain that the client should weigh herself daily.

2. The client probably has traveler's diarrhea, and oral rehydration is the preferred choice for replacing fluids lost as a result of diarrhea. An oral glucose electrolyte solution, such as Gatorade, All-Sport, or Pedialyte, is recommended.

54. The nurse is preparing to administer an aminoglycoside antibiotic to the client just admitted with a diagnosis of acute diverticulitis. Which intervention should the nurse implement? 1. Obtain a serum trough level. 2. Ask about drug allergies. 3. Monitor the peak level. 4. Assess the vital signs.

2. The nurse should always ask about allergies to medication when administering medications, but especially when administering antibiotics, which are notorious for allergic reactions.

137. The charge nurse has completed report. Which client should be seen first? 1. The client diagnosed with Crohn's disease who had two (2) semi-formed stools on the previous shift. 2. The elderly client admitted from another facility who is complaining of constipation. 3. The client diagnosed with AIDS who had a 200-mL diarrhea stool and has elastic skin tissue turgor. 4. The client diagnosed with hemorrhoids who had some spotting of bright red blood on the toilet tissue.

2. This client has just arrived so the nurse does not know if the complaint is valid and needs intervention unless this client is seen and assessed. The elderly have difficulty with constipation as a result of decreased gastric motility, medications, poor diet, and immobility.

119. The nurse is caring for the following clients on a surgical unit. Which client would the nurse assess first? 1. The client who had an inguinal hernia repair and has not voided in four (4) hours. 2. The client who was admitted with abdominal pain who suddenly has no pain. 3. The client four (4) hours postoperative abdominal surgery with no bowel sounds. 4. The client who is one (1) day postoperative appendectomy who is being discharged.

2. This could indicate a ruptured appendix, which could lead to peritonitis, a lifethreatening complication; therefore, the nurse should assess this client first.

101. The client diagnosed with gastroenteritis is being discharged from the emergency department. Which intervention should the nurse include in the discharge teaching? 1. If diarrhea persists for more than 96 hours, contact the physician. 2. Instruct the client to wash hands thoroughly before handling any type of food. 3. Explain the importance of decreasing steroids gradually as instructed. 4. Discuss how to collect all stool samples for the next 24 hours.

2. This should be done by the client at all times, but especially when the client has gastroenteritis. The bacteria in feces may be transferred to other people via food if hands are not washed properly.

106. Which statement indicates to the ED nurse the client diagnosed with acute gastroenteritis understand the discharge teaching? 1. "I will probably have some leg cramps while I have gastroenteritis." 2. "I should decrease my fluid intake until the diarrhea subsides." 3. "I should reintroduce solid foods very slowly back into my diet." 4. "I should only drink bottled water until the abdominal cramping stops."

3

117. The nurse is assessing the client recovering from abdominal surgery who has a patient controlled analgesia pump. The client has shallow respirations and refuses to deep breathe. Which intervention should the nurse implement? 1. Insist the client take deep breaths. 2. Notify the surgeon to request a chest x ray. 3. Determine the last time the client used the PCA pump. 4. Administer oxygen at 2L/min via NC.

3

149. The client presents to the outpatient clinic c/o diarrhea for 2days. Which lab data should be monitored? 1. Sodium 2. Albumin 3. Potassium 4. Glucose

3

150. The clinic nurse is returning client calls. Which client should the nurse call first? 1. The 39 year old client c/o headache pain with a 3 on the pain scale. 2. The 45 year old client who needs a prescription refill for warfarin. 3. The 54 yr old client diagnosed with diabetes type 1 who has been vomiting. 4. The 60 year old client who can not afford to buy food and needs assistance.

3

48.The client presents with a complete blockage of the large intestine from a tumor. Which healthcare providers order would the nurse question? 1. Obtain consent for a colonoscopy and biopsy 2. Start an IV of 0.9% saline at 125mL/hr 3. Administer 3L of GoLYTELY 4. Give tap water enemas until it is clear

3

51. The client is admitted to the medical unit with a diagnosis of acute diverticulitis. Which health care providers order should the nurse question? 1. Insert a nasogastric tube. 2. Start an IV with D5W at 125 mL/hr 3. Put the client on a clear liquid diet. 4. Place the client on bedrest with bathroom privileges

3

52. The nurse is discussing the therapeutic diet for the client diagnosed with diverticulosis. Which meal indicates the client understands the discharge teaching? 1. Fried fish, mashed potatoes, and iced tea. 2. Ham sandwich, applesauce, and whole milk. 3. Chicken salad on whole-wheat bread and water. 4. Lettuce, tomato, and cucumber salad and coffee.

3

59. The nurse is working in an outpatient clinic. Which client is most likely to have a diagnosis of diverticulosis? 1. A 60 yr old male with a secondary lifestyle 2. A 72 yr old female with multiple child births 3. A 63 yr old female with hemorrhoids 4. A 40 yr old male with a family history of diverticulosis

3

65. The nurse is caring for the immediate postoperative client who has a laparoscopic cholecystectomy. Which task could the nurse delegate to the UAP? 1. Check abdominal dressing for bleeding. 2. Increase the IV fluid if the b/p is low. 3. Ambulated the client to the bathroom. 4. Auscultate the breath sounds in all lobes.

3

72. The nurse assesses a large amount of red drainage on the dressing of a client who is six (6) hours postoperative open cholecystectomy. Which intervention should the nurse implement? 1. Measure the abdominal girth. 2. Palpate the lower abdomen for a mass. 3. Turn client onto side to assess for further drainage. 4. Remove the dressing to determine the source.

3

The nurse is caring for client in an outpatient clinic. Which information should the nurse teach regarding the American cancer society's recommendations for the early detection of colon cancer? 1. Beginning at the age 60 a digital rectal examination should be done yearly. 2. After reaching middle age a yearly fecal occult blood test should be done. 3. Have a colonoscopy at age 50 and then once every 5-10 years. 4. A flexible sigmoid should e done yearly after age 40.

3

102. Which medication would the nurse expect the health-care provider to order to treat the client diagnosed with botulism secondary to eating contaminated canned goods? 1. An antidiarrheal medication. 2. An aminoglycoside antibiotic. 3. An antitoxin medication. 4. An ACE inhibitor medication.

3. A botulism antitoxin neutralizes the circulating toxin and is prescribed for a client with botulism.

108. The nurse has received the A.M. shift report. Which client should the nurse assess first? 1. The 44-year-old client diagnosed with peptic ulcer disease who is complaining of acute epigastric pain. 2. The 74-year-old client diagnosed with acute gastroenteritis who has had four (4) diarrhea stools during the night. 3. The 65-year-old client diagnosed with inflammatory bowel disease who has a hard, rigid abdomen and elevated temperature. 4. The 15-year-old client diagnosed with food poisoning who has vomited several times during the night shift.

3. A hard, rigid abdomen and an elevated temperature are abnormal in any circumstance and the nurse should assess this client first. These are clinical manifestations of peritonitis, a potentially lifethreatening condition

110. The client has had abdominal surgery and tells the nurse, "I felt as something just gave way in my stomach." Which action should the nurse implement first? 1. Notify the surgeon immediately. 2. Instruct the client to splint the incision. 3. Assess for serosanguineous wound drainage. 4. Administer pain medication intravenously

3. Assessing the surgical incision is the first intervention because this may indicate the client has wound dehiscence.

113. The client is diagnosed with peritonitis. Which assessment data indicate the client's condition is improving? 1. The client is using more pain medication on a daily basis. 2. The client's nasogastric tube is draining coffee-ground material. 3. The client has a decrease in temperature and a soft abdomen. 4. The client has had two (2) soft, formed bowel movements

3. Because the signs of peritonitis are elevated temperature and rigid abdomen, a reversal of these signs would indicate the client is getting better.

120. The 84-year-old client comes to the clinic complaining of right lower abdominal pain. Which question would be most appropriate for the nurse to ask the client? 1. "When was your last bowel movement?" 2. "Did you have a high-fat meal last night?" 3. "How long have you had this pain?" 4. "Have you been experiencing any gas?"

3. Elderly clients usually display a high tolerance to pain and frequently may have a ruptured appendix with minimal pain, therefore the nurse should assess the characteristic and etiology of the pain.

100. The client is diagnosed with gastroenteritis. Which laboratory data would warrant immediate intervention by the nurse? 1. A serum sodium level of 137 mEq/L. 2. An arterial blood gas of pH 7.37, PaO2 95, PaCO2 43, HCO3 24. 3. A serum potassium level of 3.3 mEq/L. 4. A stool sample that is positive for fecal leukocytes.

3. In gastroenteritis, diarrhea often results in metabolic acidosis and loss of potassium. The normal serum potassium level is 3.5-5.5 mEq/L; therefore a 3.3 mEq/L would require immediate intervention. Hypokalemia (a low potassium level) can lead to life-threatening cardiac dysrhythmias.

133. The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented? 1. Administer an antidiarrheal medication, every day and PRN. 2. Perform bowel training every two (2) hours. 3. Administer oil retention enemas. 4. Prepare for an upper gastrointestinal (UGI) series x-ray.

3. Oil retention enemas will help to soften the feces and evacuate the stool.

67. The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care? 1. Instruct the client to cough forcefully. 2. Encourage early ambulation. 3. Assess for return of a gag reflex. 4. Administer held medications.

3. The endoscopic retrograde cholangiopancreatogram (ERCP) requires that an anesthetic spray be used prior to insertion of the endoscope. If medications, food, or fluid is given orally prior to the return of the gag reflex, the client may aspirate, causing pneumonia that could be fatal.

140. The nurse, a licensed practical nurse, and an unlicensed nursing assistant are caring for clients on a medical floor. Which nursing task would be most appropriate to assign to the licensed practical nurse? 1. Assist the unlicensed nursing assistant to learn to perform blood glucose checks. 2. Monitor the potassium levels of a client with diarrhea. 3. Administer a bulk laxative to a client diagnosed with constipation. 4. Assess the abdomen of a client who has had complaints of pain.

3. The licensed practical nurse could administer a laxative

104. Which data should the nurse expect to assess in the client diagnosed with acute gastroenteritis? 1. Decreased gurgling sounds on auscultation of the abdominal wall. 2. A hard firm, edematous abdomen on palpitation. 3. Frequent, small melena type liquid bowel movements. 4. Bowel assessment reveals loud, rushing bowel sounds.

4

114. The client developed a paralytic ileum after abdominal surgery. Which intervention should the nurse include in the plan of care? 1. Administer a laxative of choice? 2. Encourage the client to increase oral fluids. 3. Encourage the client to take deep breaths. 4. Maintain a patent NG tube.

4

151. The occupational health nurse has a had five liens come to the clinic complaining of abdominal cramping, nausea, and vomiting. Which information should the nurse teach the employees to decrease the spread of this condition? 1. Teach the employees to cough into the sleeve. 2. Teach the housekeepers to use an antibacterial soap. 3. Teach the coworkers to get a hepatitis vaccine. 4. Teach the employees to wash their hands frequently.

4

50. The nurse is teaching the client diagnosed with diverticulosis. Which instruction should the nurse include in the teaching session? 1. Discuss the importance of drinking 1,000 mL of water daily 2. Instruct the client to exercise at least three time a week 3. Teach the client about eating a low residue diet. 4. Explain the need to have daily bowel movements

4

68. Which outcome should the nurse identify for the client schedule to have cholecystectomy? 1. Decreased pain management. 2. Ambulated first day postop. 3. No break in skin integrity. 4. Knowledge of postop care.

4

71. Which problem is highest priority for the nurse to identify in the client who had an open cholecystectomy surgery? 1. Alteration in nutrition 2. Alteration in skin integrity 3. Alteration in urinary pattern 4. Alteration in comfort

4

135. The client has been experiencing difficulty and straining when expelling feces. Which intervention should be taught to the client? 1. Explain that some blood in the stool will be normal for the client. 2. Instruct the client in manual removal of feces. 3. Encourage the client to use a cathartic laxative on a daily basis. 4. Place the client on a high-fiber diet.

4. A high-fiber diet provides bulk for the colon to use in removing the waste products of metabolism. Bulk laxatives and fiber from vegetables and bran assist the colon to work more effectively.

98. Which intervention should the nurse include when discussing ways to help prevent potential episodes of gastroenteritis from Clostridium botulism? 1. Make sure that all hamburger meat is well cooked. 2. Ensure that all dairy products are refrigerated. 3. Discuss that campers should drink only bottled water. 4. Discard all canned goods that are damaged.

4. Any food that is discolored or comes from a can or jar that has been damaged or does not have a tight seal should be destroyed without tasting or touching it.

141. The client is placed on percutaneous gastrostomy (PEG) tube feedings. Which occurrence would warrant immediate intervention by the nurse? 1. The client tolerates the feedings being infused at 50 mL/hour. 2. The client pulls the nasogastric feeding tube out. 3. The client complains of being thirsty. 4. The client has green, watery stool.

4. This client needs to be cleaned immediately; the abdomen must be assessed; and a determination must be made regarding the type of feeding and the additives and medications being administered and skin damage occurring. This client is priority

56. The nurse is preparing to administer a 250-mL intravenous antibiotic to the client. The medication must infuse in one (1) hour. An intravenous pump is not available and the nurse must administer the medication via gravity with IV tubing 10 gtts/min. At what rate should the nurse infuse the medication?_______

42 gtts per minute