Gastrointestinal-Ch.56

A nurse cares for a client who has a nasogastric (NG) tube. Which actions should the nurse take? (Select all that apply.)

-Assess for proper placement of the tube every 4 hours. -Disconnect suction when auscultating bowel peristalsis. -Monitor the clients skin around the tube site for irritation.

A nurse assesses a male client with an abdominal hernia. Which abdominal hernias are correctly paired with their physiologic processes? (Select all that apply.)

-Direct inguinal hernia A peritoneum sac passes through a weak point in the abdominal wall -Ventral hernia Results from inadequate healing of an incision -Incarcerated hernia Contents of the hernia sac cannot be reduced back into the abdominal cavity

A nurse plans care for a client who is recovering from an inguinal hernia repair. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)

-Encouraging ambulation three times a day -Encouraging normal urination -Providing ice bags and scrotal support

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.)

-Serum potassium of 2.8 mEq/L -Abdominal pain in upper quadrants -Serum sodium of 121 mEq/L

A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this clients assessment? (Select all that apply.)

-Which food types cause an exacerbation of symptoms? -Where is your pain and what does it feel like? -Do you experience nausea associated with defecation?

A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer?

A 72-year-old who eats fast food frequently

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 dont think I need the colonoscopy and would like to cancel it. How should the nurse respond?

A negative fecal occult blood test does not rule out the possibility of colon cancer.

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?

Assess and maintain a patent airway.

An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the clients lower abdomen. Which action should the nurse take first?

Assess for abdominal guarding or rigidity.

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?

Assess the clients bowel sounds.

A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client?

Add vegetables such as broccoli and cauliflower to your new diet.

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the clients understanding. Which menu selection indicates that the client correctly understands the dietary teaching?

Broiled chicken with brown rice, steamed broccoli, glass of apple juice

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?

Contact the provider and recommend computed tomography.

A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which action should the nurse take?

Determine when the client last voided.

A nurse cares for a client who has a new colostomy. Which action should the nurse take?

Empty the pouch frequently to remove excess gas collection.

A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family members. Which action should the nurse take?

Encourage the client to verbalize feelings about the diagnosis.

A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client?

Have you been experiencing any constipation?

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?

I will make a referral to the United Ostomy Associations of America.

After teaching a client who has a femoral hernia, the nurse assesses the clients understanding. Which statement indicates the client needs additional teaching related to the proper use of a truss?

I will put on the truss before I go to bed each night.

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?

Lets talk to the ostomy nurse to help you and your husband work through this.

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?

Stay with the client while providing privacy.

A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this clients plan of care?

Take a stool softener to promote softer stools for ease of defecation.

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?

The stool will always be liquid with this type of colostomy.

A nurse cares for a middle-aged male client who has irritable bowel syndrome (IBS). The client states, I have changed my diet and take bulk-forming laxatives, but my symptoms have not gotten better. I heard about a drug called Amitiza. Do you think it might help? How should the nurse respond?

Unfortunately, lubiprostone is approved only for use in women.

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?

White blood cell (WBC) count of 1500/mm3

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?

You should have a colonoscopy more frequently to identify abnormal polyps early.

After teaching a client who is recovering from a colon resection, the nurse assesses the clients understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.)

-I will use warm water and a soft washcloth to clean around the stoma. -I might start bicycling and swimming again once my incision has healed. -Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown.

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.)

-Performs hand hygiene and positions the client in high-Fowlers position, with pillows behind the head and shoulders -Checks for correct placement by checking the pH of the fluid aspirated from the tube -Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent

A nurse plans care for a client who has chronic diarrhea. Which actions should the nurse include in this clients plan of care? (Select all that apply.)

-Using premoistened disposable wipes for perineal care -Turning the client from right to left every 2 hours -Applying a barrier cream to the skin after cleaning