Final (Prep U)

A client has been receiving intermittent tube feedings for several days at home. The nurse notes the findings as shown in the accompanying documentation. The nurse reports the following as an adverse reaction to the tube feeding:

Fasting blood glucose level

The nurse in the ED is admitting a patient with bloody stools. The nurse documents this finding as being which of the following?

Hematochezia Explanation: The nurse should document the finding of bloody stools as hematochezia. Melena is the term used for tarry black stools with occult blood. Steatorrhea is the term utilized for fatty stools that have an oily appearance and float in water.

An untreated small bowel obstruction can lead to what type of shock?

Hypovolemic shock

Which of the following dietary guidelines should be followed following bariatric surgery? Select all that apply.

• Include two protein snacks per day. • Eat slowly. • Eat three meals per day. Explanation: Dietary guidelines for the patient who has had bariatric surgery include eating slowly, eating three meals per day, and including two protein snacks per day. The patient should avoid eating and drinking at the same time and his or her total meal size should be less than 1 cup.

A nurse is monitoring a client with peptic ulcer disease. Which of the following assessment findings would most likely indicate perforation of the ulcer? Choose all that apply.

• Tachycardia • Hypotension • A rigid, board-like abdomen

Which of the following is the first portion of the small intestine?

Duodenum

A client with a peptic ulcer is about to begin a therapeutic regimen that includes a bland diet, antacids, and famotidine (Pepcid). Before the client is discharged, the nurse should provide which instruction?

"Avoid aspirin and products that contain aspirin" Explanation: The nurse should instruct the client to avoid aspirin because it's a gastric irritant and should not be taken by clients with peptic ulcer to prevent further erosion of the stomach lining. The client should eat small, frequent meals rather than three large ones. Antacids and ranitidine prevent acid accumulation in the stomach; they should be taken even after symptoms subside. Caffeine should be avoided because it increases acid production in the stomach

A patient has a gastric sump tube inserted and attached to low intermittent suction. The physician has ordered the tube to be irrigated with 30 mL of normal saline every 6 hours. When reviewing the patient's intake and output record for the past 24 hours, the nurse would expect to note that the patient received how much fluid with the irrigation?

120 Explanation: The patient receives 30 mL every 6 hours. So over a 24-hour period, the patient would receive 4 irrigations. 4 times 30 mL equals 120 mL.

As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach?

4

Most common cause of small bowel obstructions

Adhesions #1 cause hernias, neoplasma

A longitudinal tear or ulceration in the lining of the anal canal is termed a (an)

Anal-fissure Explanation: Fissures are usually caused by the trauma of passing a large, firm stool or from persistent tightening of the anal canal secondary to stress or anxiety (leading to constipation). An anorectal abscess is an infection in the pararectal spaces. An anal fistula is a tiny, tubular, fibrous tract that extends into the anal canal from an opening located beside the anus. A hemorrhoid is a dilated portion of vein in the anal canal.

The client has just had a central line inserted for parenteral nutrition. The client is awaiting transport to the Radiology Department for catheter placement verification. The client reports feeling anxious. Respirations are 28 breaths/minute. The first action of the nurse is

Auscultate lung sounds. Explanation: Following placement of a central line, the client is at risk for a pneumothorax. The client's report of anxiety and increased respiratory rate may be the first signs and symptoms of a pneumothorax. The nurst first assesses the client by auscultating lung sounds. Other actions include placing the client in Fowler's position and consulting with the healthcare provider about findings.

The nurse is assessing a patient with an ulcer for signs and symptoms of hemorrhage. The nurse interprets which of the following as a sign/symptom of possible hemorrhage?

Hematemesis Explanation: The nurse interprets hematemesis as a sign/symptom of possible hemorrhage from the ulcer. Other signs that can indicate hemorrhage include tachycardia, hypotension, and oliguria/anuria.

Initial symptom of a small bowel obstruction?

Colicky, Crampy pain

The nurse on an evidence-based practice council is making recommendations to ensure patency of nontunneled central venous lines. The nurse recommends that daily saline and diluted heparin flushes be used in which of the following situations?

Daily when not in use Explanation: Daily instillation of normal saline and dilute heparin flush when a nontunneled central catheter is not in use will maintain the line's patency. Continuous infusion maintains the patency of the line. Normal saline and heparin flushes should be used after each time blood is drawn in order to prevent clotting of blood within the line. Normal saline and heparin flush are not needed when a line is being discontinued

The patient is on a continuous tube feeding. How often should the tube placement be checked?

Every shift Explanation: Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding. Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities. Checking for placement every 12 or 24 hours does not meet the standard of care due the patient receiving continuous tube feedings.

Diet therapy for patients diagnosed with IBS include which of the following?

High-fiber diet Explanation: A high-fiber diet is prescribed to help control diarrhea and constipation. Foods that are possible irritants such as caffeine, spicy foods, lactose, beans, fried foods, corn, wheat, alcohol should be avoided. Fluids should not be taken with meals because this results in abdominal distention.

A patient with abdominal extension experiences reflux vomiting, what can lead to acid-base disturbances?

Metabolic Alkalosis Vomiting results in loss of hydrogen & potassium ions, leading to reduction of serum electrolytes (chloride & potassium)

The nurse is caring for a patient who is at receiving continuous enteral tube feedings who is at low risk for aspiration. The nurse assesses the gastric residual volume to be 350 mL. Which of the following is the correct action by the nurse?

Monitor the feeding closely. Explanation: High residual volumes (>200 mL) should alert the nurse to monitor the patient more closely. Increasing the feeding rate will increase the residual volume. Lowering the head of the bed increases the patient's risk for aspiration.

Which of the following represents the medication classification of a proton (gastric acid) pump inhibitor?

Omeprazole (Prilosec) Explanation: Omeprazole decreases gastric acid by slowing the hydrogen-potassium adenosine triphosphatase pump on the surface of the parietal cells. Sucralfate is a cytoprotective drug. Famotidine is a histamine-2 receptor antagonist. Metronidazole is an antibiotic, specifically an amebicide.

The nurse is conducting a community education class on gastritis. The nurse includes that chronic gastritis caused by Helicobacter pylori is implicated in which of the following diseases/conditions?

Peptic ulcers Explanation: Chronic gastritis caused by Helicobacter pylori is implicated in the development of peptic ulcers. Chronic gastritis is sometimes associated with autoimmune disease, such as pernicious anemia, but not as a cause of the anemia. Chronic gastritis is not implicated in system infections and/or colostomies.

Which of the following is the most common symptom of a polyp?

Rectal bleeding Explanation: The most common symptom is rectal bleeding. Lower abdominal pain may also occur. Diarrhea and anorexia are clinical manifestations of ulcerative colitis.

When a central venous catheter dressing becomes moist or loose, what should a nurse do first?

Remove dressing, clean the site, and apply a new dressing. Explanation: A nurse maintaining a central venous catheter should change the dressing every 72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the nurse should use sterile technique to clean around the site in accordance with facility policy. After the cleaning solution has dried, the nurse should cover the site with a transparent semipermeable dressing. A nurse who notes drainage on a wound dressing should draw a circle around the moist spot and note the date and time. She should notify the physician if she observes any catheter-related complications. Only a nurse with the appropriate qualifications may remove a central venous catheter, and a moist or loose dressing isn't a reason to remove the catheter.

Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction?

Sudden, sustained abdominal pain Explanation: Sudden, sustained pain, abdominal distention, and fever are symptoms of perforation in a client with intestinal obstruction. A decrease in blood pressure and decrease in urine output are symptoms of shock. Purulent drainage from the gluteal fold is not a symptom of perforation; it only indicates that the client has developed a condition of anorectal abscess.

Why are antacids administered regularly, rather than as needed, in peptic ulcer disease?

To keep gastric pH at 3.0 to 3.5 Explanation: To maintain a gastric pH of 3.0 to 3.5 throughout each 24-hour period, regular (not as needed) doses of an antacid are needed to treat peptic ulcer disease. Frequent administration of an antacid tends to decrease client compliance rather than promote it. Antacids don't regulate bowel patterns, and they decrease pepsin activity.

The nurse is monitoring a patient with nasoenteric intubation. The nurse contacts the physician when which of the following is noted?

Urinary output 20 mL/hr

The nurse is assessing a patient for constipation. Which of the following is the first review that the nurse should conduct in order to identify the cause of constipation?

Usual pattern of elimination Explanation: Constipation has many possible reasons and assessing the patient's usual pattern of elimination is the first step in identifying the cause. The nurse should obtain a description of the bowel elimination pattern, asking about the frequency, overall appearance and consistency of stool, blood in the stool, pain, and effort necessary to pass stool. It is also essential for the nurse to review the patient's current medications, diet, and activity levels. (less)

A client with complaints of right lower quadrant pain is admitted to the emergency department. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the physician immediately?

White blood cell (WBC) count 22.8/mm3 Explanation: The nurse should report the elevated WBC count. This finding, which is a sign of infection, indicates that the client's appendix might have ruptured. Hematocrit of 42%, serum potassium of 4.2 mEq/L, and serum sodium of 135 mEq/L are within normal limits. Alterations in these levels don't indicate appendicitis.

A graduate nurse is cleaning a central venous access device (CVAD) and is being evaluated by the preceptor nurse. The preceptor nurse makes a recommendation for relearning the skill when she notes the graduate nurse does the following action:

Wipes catheter ports from distal end to insertion site

The nurse is assigned to care for a patient 2 days after an appendectomy due to a ruptured appendix with resultant peritonitis. The nurse has just assisted the patient with ambulation to the bedside commode when the patient points to the surgical site and informs the nurse that "something gave way." What does the nurse suspect may have occurred?

Wound dehiscence has occurred. Explanation: Any suggestion from the patient that an area of the abdomen is tender or painful or "feels as if something just gave way" must be reported. The sudden occurrence of serosanguineous wound drainage strongly suggests wound dehiscence

Initially, which diagnostic should be completed following placement of a NG tube?

X-ray Explanation: Initially an X-ray should be used to confirm tube placement. Subsequently, each time liquids or medications are administered, as well as once per shift for continuous feedings, a combination of three methods is recommended: measurement of tube length, visual assessment of aspirate, and pH measurement of aspirate

A nurse is providing follow-up teaching at a clinic visit for a client recovering from gastric resection. The client reports sweating, diarrhea, nausea, palpitations, and the desire to lie down 15 to 30 minutes after meals. The nurse suspects the client has:

dumping syndrome Explanation: Early manifestations of dumping syndrome occur 15 to 30 minutes after eating. Signs and symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, diarrhea, nausea, and the desire to lie down. Dehiscence of the surgical wound is characterized by pain and a pulling or popping feeling at the surgical site. Peritonitis presents with a rigid, boardlike abdomen, tenderness, and fever. The client's signs and symptoms aren't a normal reaction to surgery.

After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching?

"I'll have to wear an external collection pouch for the rest of my life." Explanation: The client requires additional teaching if he states that he'll have to wear an external collection pouch for the rest of his life. An internal collection pouch, such as the Kock pouch, allows the client to perform self-catheterization for ileal drainage. This pouch is an internal reservoir, eliminating the need for an external collection pouch. A well-balanced diet is essential for healing; the client need not include or exclude particular foods. The client should drink at least eight glasses of fluid daily to prevent calculi formation and urinary tract infection. Intervals between pouch drainings should be increased gradually until the pouch is emptied two to four times daily.

A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.)

"It can be caused by ingestion of strong acids." "You may have ingested some irritating foods." "Is it possible that you are overusing aspirin." Explanation: Acute gastritis is often caused by dietary indiscretion—the person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, and radiation therapy. A more severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforat

Which of the following would a nurse expect to assess in a client with peritonitis?

Board-like abdomen Explanation: The client with peritonitis would typically exhibit a rigid, board-like abdomen, with absent bowel sounds, elevated pulse rate, and rapid, shallow respirations.

Initial treatment of a small bowel obstruction

Decompression of bowel via nasogastric tube (relieves the pressure and calms the the intestine)

A client with a gastrojejunostomy is beginning to take solid food. Which finding would lead the nurse to suspect that the client is experiencing dumping syndrome?

Diarrhea Explanation: Clients with a gastrojejunostomy are at risk for developing the dumping syndrome when they begin to take solid food. This syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramps, and diarrhea, which result from the rapid emptying (dumping) of large amounts of hypertonic chyme (a liquid mass of partly digested food) into the jejunum. This concentrated solution in the gut draws fluid from the circulating blood into the intestine, causing hypovolemia. The drop in blood pressure can produce syncope. As the syndrome progresses, the sudden appearance of carbohydrates in the jejunum stimulates the pancreas to secrete excessive amounts of insulin, which in turn causes hypoglycemia.

The nurse is conducting discharge teaching for a patient with diverticulosis. Which of the following should the nurse include in the teaching?

Drink 8 to 10 glasses of fluid daily. Explanation: The nurse should instruct a patient with diverticulosis to drink at least 8 to 10 large glasses of fluid every day. The patient should include unprocessed bran in the diet because it adds bulk and should avoid the use of laxatives or enemas except when recommended by the physician. In addition, the patient should exercise regularly if his or her current lifestyle is somewhat inactive.

A surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member?

Enterostomal nurse Explanation: The surgeon should collaborate with the enterostomal nurse, who can address the client's concerns. The enterostomal nurse may schedule a visit with a client who has a colostomy to offer support to the client. The clinical educator can provide information about the colostomy when the client is ready to learn. The staff nurse and social worker aren't specialized in colostomy care, so they aren't the best choices for this situation.

Residual content is checked before each intermittent tube feeding. The patient would be reassessed if the residual, on two occasions, was:

Greater than 200 mL.

A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, and labored breathing; the client also appears to be confused. Which of the following complications has the client most likely developed?

Hemorrhage Explanation: Signs of hemorrhage following surgery include cool skin, confusion, increased heart rate, labored breathing, and blood in the stool. Signs of penetration and perforation are severe abdominal pain, rigid and tender abdomen, vomiting, elevated temperature, and increased heart rate. Indicators of pyloric obstruction are nausea, vomiting, distended abdomen, and abdominal pain.

The nurse is caring for a patient diagnosed with abdominal perforation. Which of the following is a clinical manifestation of this disease process?

Hypotension Explanation: Clinical manifestations include hypotension, increased temperature, tachycardia, and elevated ESR.

A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?

NPO

A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake?

Six small meals daily with 120 mL fluid between meals Explanation: After the return of bowel sounds and removal of the nasogastric tube, the nurse may give fluids, followed by food in small portions. Foods are gradually added until the client can eat six small meals a day and drink 120 mL of fluid between meals.

A client with Crohn's disease is prescribed medication therapy. Which of the following would the nurse expect to administer as a first line agent?

Sulfasalazine Explanation: Considered first-line treatment for IBD, 5-ASA drugs contain salicylate, which is bonded to a carrying agent that allows the drug to be absorbed in the intestine. These drugs work by decreasing the inflammatory response. The 5-ASA medications include sulfasalazine (Azulfidine), olsalazine (Dipentum), and mesalamine (Asacol, Pentasa). Corticosteroids (prednisone) are used during acute exacerbations of symptoms and when 5-ASA drugs cannot control the symptoms. Failure to maintain remission necessitates the use of an immune-modulating agent such as mercaptopurine (6-MP) or azathioprine (Imuran).

A client realizes that regular use of laxatives has greatly improved his bowel pattern. However, the nurse cautions this client against the prolonged use of laxatives for which reason?

The client's natural bowel function may become sluggish. Explanation: It is essential for the nurse to caution the client against the prolonged use of laxatives because it decreases muscle tone in the large intestine. Prolonged use of laxatives may cause the client's natural bowel function to become sluggish. Laxatives do not increase the risk of developing inflammatory bowel disease, arthritis, or arthralgia, nor do they cause a loss in appetite.

A nurse is caring for a client who had gastric bypass surgery 2 days ago. Which assessment finding requires immediate intervention?

The client's right lower leg is red and swollen. Explanation: A red, swollen extremity is a possible sign of a thromboembolism, a common complication after gastric surgery because of the fact that the clients are obese and tend to ambulate less than other surgical clients. The nurse should inform the physician of the finding. Pain at the surgical site should be investigated, but the red, swollen leg is a higher priority. It isn't unusual for a client to be nauseated after gastric bypass surgery. The nurse should follow up with the finding, but only after she has notified the physician about the possible thromboembolism. Passing gas is normal and a sign that the client's intestinal system is beginning to mobilize.

A patient has just had a nasogastric (NG) tube inserted and the nurse is waiting for verification of placement of the tube prior to starting tube feedings. Which is the best method of verification the nurse should use for determining new NG tube placement?

X-ray confirmation Explanation: Radiologic identification of tube placement in the stomach is the most reliable method. Gastric fluid may be grassy green, brown, clear, or odorless, whereas an aspirate from the lungs may be off-white or tan. Hence, checking aspirate is not the best method of determining NG tube placement in the stomach. Gastric pH values are typically lower or more acidic than that of the intestinal or respiratory tract, but not always. Air auscultation is not a reliable method for determining NG tube placement in the stomach when used alone

The nurse is preparing to administer all of a patient's medications via feeding tube. The nurse consults the pharmacist and/or physician when the nurse notes on the patient's medication administration record which of the following types of oral medication?

Enteric-coated tablets Explanation: Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change in the form of medication is necessary for patients with tube feedings. Simple compressed tablets may be crushed and dissolved in water for patients receiving oral medications by feeding tube. Buccal or sublingual tablets are absorbed by mucous membranes and may be given as intended to the patient undergoing tube feedings. The nurse may make an opening in the capsule and squeeze out contents for administration by feeding tube.

Decreased potassium levels cause what signs/symptoms?

Hypotension, muscle weakness also...fatigue, anorexia, nausea, vomiting, muscle weakness, polyuria, decreased motility, decreased BP