GI
After a gastrectomy, a client has a nasogastric tube to low continuous suction. The client begins to hyperventilate. How does the nurse anticipate that this breathing pattern will alter the client's arterial blood gases? 1 Increase the PO2 level 2 Decrease the pH level 3 Increase the HCO3 level 4 Decrease the Pco2 level
I put 3 Ans: 4 Hyperventilation results in the increased elimination of carbon dioxide from the blood. The PO2 level is not affected. The pH level will increase. The carbonic acid level will decrease.
A nurse receives a telephone report from the postanesthesia care unit for a client status following a colon resection with anastomosis. Place the nursing actions in order of priority when the nurse receives this client from the postanesthesia care unit. 1. Monitor respiratory rate and quality 2. Assess the client's level of consciousness 3. Check the abdominal dressing 4. Assess airway 5. Obtain the heart rate and blood pressure
The nurse assesses consciousness, airway, breathing, and circulation almost simultaneously as the nurse approaches the client upon admission from the postanesthesia unit. Level of consciousness will be directly affected by the client's respiratory effort and circulation. Upon arrival to the inpatient unit, the nurse should visually assess consciousness (1), then move quickly to respiratory patency (2), effort and symmetry (3) as well as adequate oxygenation. Heart rate and blood pressure are an indirect measurement of circulation (3). Assessing the amount of drainage on the surgical dressing is important, however, it is not priority over consciousness, airway, breathing, and circulation.
Which clinical findings would the nurse expect a client diagnosed with ulcerative colitis to report? Select all that apply. 1 Fever 2 Diarrhea 3 Gain in weight 4 Spitting up blood 5 Abdominal cramps
correct ans- 1, 2, 5 The inflammatory process can promote a fever and tends to increase peristalsis, causing intestinal spasms and diarrhea. As ulceration occurs, the loss of blood leads to anemia. The client will lose weight (not gain it) because of anorexia and malabsorption. Also, hemoptysis (coughing up blood from the respiratory tract) is not a related sign.
A nurse is providing dietary teaching for a client who is receiving a high-protein diet while recovering from an acute episode of colitis. What should the nurse include in the rationale for this diet? 1 Repairs tissues 2 Slows peristalsis 3 Corrects the anemia 4 Improves muscle tone
correct ans- 1 Protein is required for the building and repair of intestinal tissues. Increased protein will not affect peristalsis significantly. Anemia may result from chronic bleeding; usually, it is corrected with increased iron intake. Muscle tone is affected by exercise or lack of exercise.
An exploratory laparotomy is performed on a client with melena, and gastric cancer is discovered. A partial gastrectomy is performed, and a jejunostomy tube is surgically implanted. A nasogastric tube to suction is in place. What should the nurse expect regarding the client's nasogastric tube drainage during the first 24 hours after surgery? 1 Minimal to no drainage 2 Contains some blood and clots 3 Contains large amounts of frank blood 4 Similar to coffee grounds in color and consistency
correct ans- 2 Containing some blood and clots is an expected response during the first 24 hours after a gastric resection because of oozing of blood and blood coagulation. There will be a moderate amount of drainage, not minimal or no drainage. Green and viscid are normal characteristics of gastric contents, which are unexpected after gastric surgery. Containing large amounts of frank blood indicates hemorrhage, which is unexpected. Coffee ground material results from blood that has been digested by the gastric acid; gastric bleeding with a nasogastric tube in place will be red because gastric acids will not have time to act on the blood.
When assessing a client's abdomen, the nurse palpates the area directly above the umbilicus. By what term is this area known? 1 Iliac area 2 Epigastric area 3 Hypogastric area 4 Suprasternal area
correct ans- 2 The stomach is located within the sternal angle, known as the epigastric area. The iliac area is in the area of the iliac bones. The hypogastric area is the lowest middle abdominal area. The suprasternal area is the area above the sternum.
An older client with a history of chronic constipation develops acute appendicitis. Prior to arrival at the hospital, the client attempted self-care at home. Which self-care measures could potentially lead to rupture of the appendix? 1 Avoiding food and liquids due to nausea 2 Applying an ice pack to the abdomen 3 Self-administering a small volume enema 4 Taking acetaminophen (Tylenol) for pain
correct ans- 3 Enemas can increase pressure in the intestines and cause rupture of an inflamed appendix. Fasting from food and liquids or applying an ice pack will not lead to rupture of the appendix. Masking the symptoms by taking acetaminophen may delay treatment but will not directly increase the risk of rupture of the appendix.
A client is recently diagnosed with an oral cancerous lesion. Which question should the nurse ask when assessing the client's need for instruction in relation to this condition? 1 "Are you having difficulty sleeping?" 2 "Do feel like your gums are inflamed?" 3 "How frequently are you seeing the dentist?" 4 "Have you noticed any change in your appetite?"
correct ans- 4 Problems involving the oral cavity often result in nutritional problems and weight loss needing nursing intervention. The question, "Have you noticed any change in your appetite?" will elicit more information. The nurse needs to determine a client's past and current appetite and nutritional status. Difficulty sleeping is not usually a characteristic symptom of cancer of the oral cavity although it may occur after the diagnosis due to anxiety. Gum infections are not typically an early problem after an oral cancer diagnosis. Although a dentist may be the first to identify oral cancer, medical treatment is needed.
A nurse advises a client receiving furosemide about potassium intake. Which fruits should the nurse encourage the client to eat? Select all that apply. 1 Apple 2 Orange 3 Banana 4 Pineapple 5 Dried fruit
i put 1, 2, 3 ans- 2, 3, 5 Foods high in potassium include oranges, bananas, and dried fruits. Furosemide is a diuretic that causes the body to lose potassium. Apples and pineapple are low in potassium.
A client has a paracentesis during which 1500 mL of fluid is removed. The nurse should monitor the client carefully for what reaction? 1 Hypertensive crisis 2 Hypovolemic shock 3 Abdominal distention 4 Tenting of the integument
Correct Ans: 2 Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemia and compensatory tachycardia. Fluid shifts can cause hypovolemia with resulting hypotension, not hypertension. A paracentesis should decrease the degree of abdominal distention. Tenting of the integument, a sign of dehydration, may occur. However, this assessment is not as vital as assessing for signs of shock.
A client is admitted to the hospital with a diagnosis of peptic ulcer. Which most common complication should the nurse assess for in this client? 1 Perforation 2 Hemorrhage 3 Pyloric obstruction 4 Esophageal varices
Correct Ans: 2 Hemorrhage because of erosion of blood vessel walls is the most common complication of peptic ulcer disease. The complication of gastric perforation usually occurs after, and is not as common as, hemorrhage. Pyloric obstruction is not a common complication of peptic ulcer disease. Esophageal varices occur with portal hypertension, not peptic ulcer disease.
A nurse is caring for a client who is admitted to the hospital with ascites and a diagnosis of cirrhosis of the liver. What does the nurse conclude is the probable cause of ascites? 1 Impaired portal venous return 2 Inadequate secretion of bile salts 3 Excess production of serum albumin 4 Decreased interstitial osmotic pressure
Correct Ans: 1 An enlarged liver impairs venous return, leading to an increased portal vein hydrostatic pressure and a fluid shift into the abdominal cavity. Bile plays an important role in digestion of fats, but it is not a major factor in fluid balance. Increased serum albumin causes hypervolemia, not ascites. Ascites is not associated with the interstitial fluid compartment.
An obese client asks the nurse how to lose weight. What should the nurse include in the response that explains when long-term weight loss occurs best? 1 Fats are limited in the diet. 2 Eating patterns are altered. 3 Carbohydrates are restricted. 4 Exercise is a major component.
Correct Ans: 2 A new dietary regimen, with a balance of foods following MyPlate (Canada's Food Guide), must be established and continued for weight reduction to occur and be maintained. Although fats and carbohydrates are limited in weight-reduction diets, the change must become a lifestyle for long-term results. Exercise is one part of a weight-reduction regimen; usually an obese individual's caloric intake exceeds energy expenditure, and lifestyle changes are required.
The nurse is caring for a client with biliary cancer. The associated jaundice gets progressively worse. The nurse is most concerned about the potential complication of what symptom? 1 Pruritus 2 Bleeding 3 Flatulence 4 Hypokalemia
Correct Ans: 2 Obstruction of bile flow impairs absorption of phytonadione, a fat-soluble vitamin; prothrombin is not produced, and the clotting process is prolonged. Although deposition of bile salts in the skin may lead to pruritus, this is not life threatening. Although there may be an increase in flatulence with biliary disease, it is not life threatening. Obstructive jaundice does not affect potassium levels.
A client with an acute attack of cholecystitis has a cholecystectomy with a choledochostomy. The client returns from surgery with a T-tube connected to a drainage bag. What does the nurse conclude is the purpose of the T-tube? 1 Decrease edema 2 Permit drainage of bile 3 Insert antibiotic medication 4 Provide for irrigation of the gallbladder
Correct Ans: 2 The T-tube provides a passageway for bile to move through the common bile duct in the presence of edema; it does not reduce edema. When the common bile duct is explored, the T-tube maintains patency until edema subsides. The T-tube will not reduce edema. Antibiotics usually are not necessary postoperatively unless infected bile or pus is in the ducts (cholangitis). The gallbladder has been excised and therefore cannot be irrigated.
A client who has had right upper quadrant pain for several months now experiences clay-colored stools. Laboratory results reveal elevated liver enzymes, and a needle biopsy of the liver is scheduled. What should the nurse include in the client's teaching about the procedure? 1 The procedure is painless because general anesthesia is used. 2 Disfiguring scars are minimal because a small incision is made. 3 Lying on the right side after the procedure is required because it will decrease the risk of hemorrhage. 4 A light meal should be eaten two hours before the procedure because it stimulates gastrointestinal secretions.
Correct Ans: 3 Because of the vascularity of the liver, compression of the needle insertion site limits the risk of hemorrhage; also, it decreases the risk of bile leakage. The procedure is performed under local anesthesia, and some discomfort may be felt during instillation of the anesthetic as well as when the needle enters the liver. There is no scarring because a surgical incision is not necessary for a needle biopsy. The client is kept nothing by mouth for at least six hours before the procedure to prevent nausea and vomiting.
An obese client has had an abdominal cholecystectomy. How does the nurse plan to alleviate tension on the surgical wound after surgery? 1 Limiting deep breathing 2 Maintaining T-tube patency 3 Maintaining nasogastric tube patency 4 Encouraging the right side-lying position
Correct Ans: 3 Maintaining nasogastric tube patency ensures gastric decompression, thus preventing abdominal distention, which places tension on the incision. Deep breathing should be encouraged to prevent respiratory complications. Maintaining T-tube patency only ensures a portal of exit for bile drainage; the tube is not irrigated, and an obstruction will lead to jaundice rather than tension on the surgical wound. The right side-lying position after a cholecystectomy can increase, not decrease, tension in the operative area.
A nurse is eliciting a health history from a client with ulcerative colitis. Which factor does the nurse consider to be most likely associated with the client's colitis? 1 Food allergy 2 Infectious agent 3 Dietary components 4 Genetic predisposition
Correct Ans: 4 Studies indicate that inflammatory bowel diseases, which include ulcerative colitis and Crohn disease, are familial, which suggests that they are hereditary. Although food allergy and infectious agent may be causative factors, they are not the most common factors. No specific dietary component has been identified.
A client is admitted to the hospital for surgery for a total abdominoperineal resection. What position should the nurse encourage the client to maintain when in bed to promote perineal wound healing after surgery? 1 Knee-chest 2 Dorsal recumbent 3 Left or right Sims 4 Left or right side-lying
Correct Ans: 4 The left or right side-lying position puts the least strain or pressure on the perineal suture line. The knee-chest position is difficult to maintain and places stress on the suture line. The dorsal recumbent position places undue stress on the suture line and is the most uncomfortable position. Flexion of one hip and knee will increase tension on the perineal suture line.
For two months a client has been taking nonprescription medications and has made dietary changes for symptoms of gastritis. Following assessment by a primary healthcare provider, a diagnosis of extensive carcinoma of the stomach is made. The client asks how the disease got so advanced. On which information about carcinoma of the stomach should the nurse base a response? 1 Presents symptoms of severe pain for the client when in the early stages of the disease process 2 Is a risk factor for clients who have an absence of pylori in the stomach 3 Usually is diagnosed after the discovery of enlarged lymph nodes in the epigastric area 4 Often is diagnosed late because symptoms are nonspecific during the early stages
Correct Ans: 4 This cancer usually is asymptomatic in the early stages; the stomach accommodates the mass. Gastric cancer is painless in its early stages. There is an increased risk of developing stomach cancer if the client has an infection with H. pylori. Hodgkin disease, not gastric carcinoma, usually is diagnosed after the discovery of enlarged lymph nodes in the epigastric area.
A client is discharged the same day after ambulatory surgery for a laparoscopic cholecystectomy. The nurse is providing discharge teaching about how many days the client should wait to engage in certain activities. Place in order the activities from the first to the last in which the client may engage. 1. Showering 2. Driving a car 3. Performing light exercise 4. Lifting objects of more than 10 lb (4.5 kg) 5. Getting out of bed in a chair
Getting out of bed is the activity that should be implemented first. It allows the client to adjust to the upright position before ambulating. Light exercise, such as walking, can begin after tolerating sitting in a chair. A client may shower or bathe one to two days after surgery. A client may drive three to four days after surgery. Objects exceeding 10 lb (4.5 kg) may be lifted one week after surgery.
A nurse is teaching a newly admitted client who has acute pancreatitis about dietary restrictions. What should the education include? 1 Use of IV fluids 2 Season foods sparingly 3 Eat small meals frequently 4 Limit coffee to three cups per day
I put 3 Ans: 1 Acute pancreatitis requires an NPO status to allow the pancreas to rest. IV fluids are administered. Spicy, seasoned foods stimulate the pancreas and should be avoided, not just sparingly used. Small, frequent feedings place less demand on the pancreas to release digestive enzymes and are instituted when the acute phase is resolved. Fats stimulate the release of lipase from the pancreas, whether they are saturated or unsaturated fats, and should be avoided. Coffee stimulates pancreatic secretions and should be avoided.
A nurse is assessing different clients. Which female client has the greatest risk of developing gallbladder disease? 1 Older than age 40 and obese 2 Older than age 40 with a low serum cholesterol level 3 Less than 40 years of age with a history of high fat intake 4 Less than 40 years of age with a family history of gallstones
I put 3 Ans: 1 These characteristics are well-established risk factors for gallbladder disease (4 Fs: female, fat, forty, and fertile). Gallbladder clients have an increase in serum cholesterol. A high fat intake does not predispose one to cholecystitis. Although there is an increased risk with a family history of gallstones, gallbladder clients usually are older than the age of 40.
A nurse designs a health education program specifically for a client who had a gastrectomy. What should this plan include? 1 Information about how to limit and prevent dumping syndrome 2 An explanation of the therapeutic effect of a high-roughage diet 3 A list of foods that cause gas in the intestine and how to avoid them 4 Encouragement to resume previous eating habits as soon as possible
correct ans- 1 Symptoms of dumping syndrome occur to some degree in about 50% of all individuals who have undergone a gastrectomy. They include weakness, faintness, heart palpitations, and diaphoresis. It is therefore important to explain to the client that such symptoms can be minimized by reclining after meals, eating small meals, and omitting concentrated and highly refined carbohydrates. Modification of roughage is part of the management of intestinal rather than gastric disorders. Gas-forming foods affect the intestines, not the stomach. Eating habits must be modified to prevent rapid emptying of the stomach.
A client with jaundice associated with hepatitis expresses concern over the change in skin color. What does the nurse explain is the cause of this color change? 1 Stimulation of the liver to produce an excess quantity of bile pigments 2 Inability of the liver to remove normal amounts of bilirubin from the blood 3 Increased destruction of red blood cells during the acute phase of the disease 4 Decreased prothrombin levels, leading to multiple sites of intradermal bleeding
correct ans- 2 Damage to liver cells affects the ability to facilitate removal of bilirubin from the blood, with resulting deposition in the skin and sclera. With hepatitis, the liver does not secrete excess bile. Destruction of red blood cells does not increase in hepatitis. Decreased prothrombin levels cause spontaneous bleeding, not jaundice.
A healthcare provider schedules a paracentesis for a client with ascites. What should the nurse include in the client's teaching plan? 1 Maintaining a supine position during the procedure 2 Consuming a diet low in fat for three days before the procedure 3 Emptying the bladder immediately before the procedure 4 Staying on a liquid diet for 24 hours after the procedure
correct ans- 3 The bladder must be emptied immediately before the procedure to decrease the chance of puncture with the trocar used in a paracentesis. A paracentesis usually is performed with the client in the Fowler position to assist the flow of fluid by gravity. Eating a diet low in fat for three days before the procedure is not necessary for a paracentesis. Staying on a liquid diet is not necessary for a paracentesis.
A client with cirrhosis of the liver has a prolonged prothrombin time and a low platelet count. A regular diet is prescribed. What should the nurse instruct the client to do considering the client's condition? 1 Avoid foods high in phytonadione. 2 Check the pulse several times a day. 3 Drink a glass of milk when taking aspirin. 4 Report signs of bleeding no matter how slight.
correct ans- 4 One of the many functions of the liver is the manufacture of clotting factors; there is interference in this process with cirrhosis of the liver, resulting in bleeding tendencies. The storage of fat-soluble vitamins (A, D, E, and K), water-soluble vitamins (B1, B2, folic acid, and cobalamin), and minerals (including iron) is compromised in cirrhosis; therefore, these nutrients, including phytonadione, should not be limited. Should the client bleed, the pulse rate may be increased, but it is not necessary for the client to check the pulse rate several times daily. A client whose prothrombin time is prolonged and platelet count is low should not be taking aspirin, even with milk.
A client is diagnosed with celiac disease. Which foods should the nurse teach the client to avoid? Select all that apply. 1 Corn 2 Cheese 3 Oatmeal 4 Rye bread 5 Fruit juice
i put 1, 3, 4 ans- 3, 4 Gluten is found in rye, oats, wheat, and barley, which should be avoided because gluten in these grains is irritating to the gastrointestinal mucosa in clients with celiac disease. Gluten is found in oatmeal and rye bread and should be avoided. Gluten is not found in corn. Gluten is not found in milk and dairy products. Gluten is not found in fruit.
Before a male client signs an operative consent for an abdominoperineal resection, the nurse verifies that the client understands that surgery likely will result in which outcome? 1 Permanent ileostomy in the jejunum 2 Permanent colostomy and impotence 3 Temporary ileostomy and diminished libido 4 Temporary colostomy in the descending colon
i put 4 ans- 2 Large portions of bowel and rectum are removed; during the perineal portion of the surgery, nerves involved in penile erection often are damaged. An ileostomy will not be performed because the lesion is in the descending colon. A colostomy after an abdominoperineal resection is permanent because the rectum is removed; sexual functioning, not libido, may be affected. The descending colon is removed; the colostomy will be permanent.
A nurse is caring for a client who is vomiting. When caring for this client, the nurse considers the fact that the vomiting reflex follows a set pattern. List the following steps in the order that they occur. 1. Contraction of abdominal muscles 2. Closure of the trachea to prevent aspiration 3. Initiation of reverse peristalsis in the stomach 4. Relaxation of the upper esophageal sphincter
Ans: 3, 1, 2, 4 Reverse peristalsis starts the sequence; with contraction of the abdominal muscles, gastric contents are propelled into the esophagus, and the upper esophageal sphincter relaxes so vomiting can occur. Finally, the trachea closes to prevent aspiration.
What should be the nurse's focus when caring for a client after abdominal surgery? 1 Identifying signs of bleeding 2 Preventing pressure on the suture site 3 Encouraging use of an incentive spirometer 4 Detecting clinical manifestations of inflammation
Correct Ans: 1 Bleeding and hemorrhage are the most serious concerns. Bleeding disorders are common when bile does not flow through the intestine. Phytonadione, a fat-soluble vitamin synthesized in the small intestine, requires bile salts for its absorption; phytonadione is used by the liver to synthesize prothrombin necessary for clotting. Preventing pressure on the suture site, encouraging use of an incentive spirometer, and detecting clinical manifestations of inflammation are not as serious concerns.
When inserting a catheter to irrigate a client's colostomy, the nurse meets some resistance. What should the nurse do? 1 Probe with the irrigating catheter to determine the contour of the bowel 2 Obtain a more rigid tip for the irrigating catheter to insert into the stoma 3 Apply pressure to the irrigating catheter to overcome the spasm of the bowel 4 Instill a small amount of solution from the irrigating container into the stoma
Correct Ans: 1 Instilling a small amount of solution from the irrigating container into the stoma helps distend the bowel ahead of the catheter and eases catheter insertion. Probing with the irrigating catheter can cause damage to the delicate mucous membrane of the intestinal tract and may perforate the bowel. Using a more rigid catheter tip can cause damage to the delicate mucous membrane of the intestinal tract and may perforate the bowel. Applying pressure to the irrigating catheter can cause damage to the delicate mucous membrane of the intestinal tract and may perforate the bowel.
Twelve hours after a subtotal gastrectomy, a nurse identifies large amounts of bloody drainage from the client's nasogastric (NG) tube. Which action should the nurse take? 1 Obtain vital signs 2 Clamp the NG tube 3 Instill 30 mL of iced normal saline into the NG tube 4 Record the observations and continue monitoring the client
Correct Ans: 1 Large amounts of blood or excessive bloody drainage 12 hours postoperatively indicate that the client is hemorrhaging. Vital signs should be taken. Clamping the tube is contraindicated; accumulation of secretions causes pressure on the suture line, preventing further observation of drainage. The primary healthcare provider must prescribe instilling 30 mL of iced normal saline into the nasogastric tube. Continuing to monitor the drainage and record the observations is an unsafe intervention at this time; action must be taken to address and stop the hemorrhaging.
A client is admitted to the hospital with severe back and abdominal pain, nausea and occasional vomiting, and an oral temperature of 101° F (38.3° C). The client reports drinking six to eight beers a day. A diagnosis of acute pancreatitis is made. Based on the data presented, what symptom is the primary nursing concern for this client? 1 Acute pain 2 Inadequate nutrition 3 Electrolyte imbalance 4 Disturbed self-concept
Correct Ans: 1 Pain with pancreatitis usually is severe and is the major symptom; it occurs because of the autodigestive process in the pancreas and peritoneal irritation. Although clients with this medical diagnosis often are malnourished, addressing the client's pain takes priority. There are not enough data for electrolyte imbalance; additional data, such as for skin turgor, serum electrolytes, and intake and output, are needed to identify whether the client has a fluid and electrolyte imbalance. There are no data to support the presence of a disturbed self-concept.
A nurse is caring for a client with cholelithiasis and obstructive jaundice. When assessing this client, the nurse should be alert for which findings that are consistent with these conditions? Select all that apply. 1 Ecchymosis 2 Yellow sclera 3 Dark brown stool 4 Straw-colored urine 5 Pain in right upper quadrant
Correct Ans: 1, 2, 5 Inadequate bile flow interferes with vitamin K absorption, contributing to ecchymosis, hematuria, and other bleeding. Yellow sclera results from failure of bile to enter the intestines, with subsequent backup into the biliary system and diffusion into the blood. The bilirubin is carried to all body regions, including the skin and mucous membranes. Pain in the right upper quadrant occurs especially after eating foods high in fat and is characteristic of acute cholecystitis and biliary colic. With obstructive jaundice the stool is clay colored, not dark brown; the presence of bile causes stool to be brown. When bile levels in the bloodstream are high, as in obstructive jaundice, there is bile in the urine, causing it to have a dark color.
A client who had abdominal surgery asks the nurse about when the client can return to work after discharge. Which is the most appropriate response by the nurse? 1 "Not for at least two weeks." 2 "What type of work did you have in mind?" 3 "You can return to work soon if you know what it means to take it easy." 4 "You cannot return to work soon because you must get plenty of rest when you get home."
Correct Ans: 2 The nurse must identify the client's work activities before an appropriate response can be made. The client probably can do light work that will not injure the surgical site. The response "You can return to work if you know what it means to take it easy" is vague and demeaning and gives little direction to the client. Recovery from abdominal surgery usually takes more than two weeks. While a client needs rest after abdominal surgery, this response is premature depending upon what the nurse discovers during further assessment.
A client with cancer of the pancreas has a pancreaticoduodenectomy (Whipple procedure). The nurse expects that the client will have which tube after surgery? 1 Chest 2 Intestinal 3 Nasogastric 4 Gastrostomy
Correct Ans: 3 Nasogastric surgery involves the stomach, duodenum, pancreas, and common bile duct; a nasogastric tube removes gastric secretions and prevents distention of the gastrointestinal tract. A chest tube is used to remove air or blood from the chest cavity; the chest is not entered in the Whipple procedure. Intestinal tubes are used for small bowel obstructions; except for the duodenum, the small bowel is not included in the Whipple procedure. A gastrostomy tube is used to deliver nutrients into the stomach of a client who cannot ingest food via the oral route.
A healthcare provider prescribes a gastrointestinal endoscopy with a capsule endoscopic device. What should the nurse instruct the client to do? 1 Check the recorder every hour. 2 Avoid eating food and fluid during the test. 3 Avoid stooping and bending during the test. 4 Swallow the capsule as soon as it is placed in the mouth.
Correct Ans: 3 Stooping and bending during the test should be avoided to prevent inaccurate test results. The recorder should be checked every 15 minutes. Avoiding food and fluid during the test is unnecessary. The capsule should be held under the tongue for one minute while the unit verifies that the light source is functioning.
A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the primary nursing concern? 1 Chronic pain 2 Risk for injury 3 Electrolyte imbalance 4 Inadequate gas exchange
Correct Ans: 3 The stomach produces about 3 L of secretions per day. Fluid lost through vomiting can produce inadequate fluid volume and electrolyte imbalance, which can lead to dysrhythmias and death. Although pain is associated with gastric ulcers and requires intervention, it is not life threatening as is an electrolyte imbalance. Although the risk for injury is a concern, it is not the priority. Although respirations may be shallow when the client is experiencing pain, this is not the priority.
A client is diagnosed as having malabsorption syndrome secondary to celiac sprue. The client asks the nurse if there is anything that can help improve symptoms. What should the nurse encourage the client to incorporate into the diet for symptom improvement? 1 Folic acid 2 Vitamin B12 3 Corticosteroids 4 Gluten-free diet
Correct Ans: 4 Gluten, a cereal protein, appears to be responsible for morphologic changes of the intestinal mucosa with nontropical sprue (adult celiac disease). Folic acid, along with antimicrobial agents, is used to treat tropical, not celiac, sprue; it causes dramatic improvement in tropical sprue. Vitamin B12 may be administered if macrocytic anemia or achlorhydria develops; however, it does not correct the major pathology. Corticosteroids may be used for refractory celiac disease.
A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential life-threatening complication should the nurse assess the client after this surgery? 1 Infection caused by the excretion of feces 2 Injury caused by exposed intestinal mucosa 3 Altered bowel elimination caused by the ostomy 4 Limited water reabsorption caused by removal of intestine
Correct Ans: 4 The continuous excretion of liquid feces may deplete the body of fluid and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance. Although the irritation of the skin by fecal material may result in an infection, this usually is not a life-threatening complication. Although the stoma should be protected from injury and altered bowel elimination is a concern, these are not life-threatening complications.
A high cleansing enema is prescribed for a client. What is the maximum height at which the container of fluid should be held by the nurse when administering this enema? 1 30 cm (12 inches) 2 37 cm (15 inches) 3 51 cm (20 inches) 4 66 cm (26 inches)
I put 1 Ans: 2 For a high colonic enema, the fluid must extend higher in the colon. If the height of the enema fluid container above the anus is increased, the force and rate of flow also increase. 30 cm (12 inches) is too low for a cleansing enema. The heights of 51 cm (20 inches) and 66 cm (26 inches) are too high and may cause mucosal injury.
A client is diagnosed with gastric cancer, and a subtotal gastrectomy is performed. After surgery the client begins to hemorrhage. What clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? Select all that apply. 1 Oliguria 2 Bradypnea 3 Diaphoresis 4 Tachycardia 5 Hypertension
I put 1 & 4 Ans: 1, 3, 4 Decreased blood volume leads to decreased glomerular filtration; compensatory antidiuretic hormone (ADH) and aldosterone secretion cause sodium and water retention, thereby decreasing urinary output. Diaphoresis and tachycardia occur because of the sympathetic nervous system-mediated response. Respirations become rapid and shallow, not slow, because of the sympathetic nervous system-mediated response. Hypotension, not hypertension, is the response to a decrease in circulating blood volume.
Two weeks after sustaining a spinal cord injury, a client begins vomiting thick coffee-ground material and appears restless and apprehensive. What is the most important initial nursing action? 1 Change the client's diet to bland. 2 Obtain a stool specimen for occult blood. 3 Prepare for insertion of a nasogastric tube. 4 Monitor recent laboratory reports for hemoglobin levels.
I put 2 Ans: 3 The client should have a nasogastric tube inserted to keep the stomach decompressed; the nurse should monitor the amount and characteristics of the drainage. Coffee-ground gastric fluid indicates blood that has been influenced by gastric juices. The healthcare provider should be notified. Changing the client's diet to bland is unsafe; the client needs immediate medical attention. Obtaining a stool specimen for occult blood is indicated at the next bowel movement, but it is not the priority. Monitoring recent laboratory reports for hemoglobin levels is unsafe; the client needs immediate medical attention.
A nurse is caring for a client who recently is diagnosed with a gastric ulcer. The nurse expects that the plan of care will include a prescription for which type of diet? 1 Soft diet 2 Low-fat, high-protein liquid diet 3 Hourly feedings of dairy products 4 Regular diet with foods that are tolerated
I put 2 Ans: 4 No specific diet is recommended; the client is encouraged to avoid meals that overdistend the stomach and foods that cause gastrointestinal (GI) distress. There is no need for a soft diet; a soft diet is appropriate for those who have difficulty with chewing and swallowing. The client does not require a liquid diet. High-fat dairy products increase GI secretions and may not be tolerated by some clients.
A client is admitted to the hospital for the implantation of radon seeds in the oral cavity. Which intervention is most important when the nurse is caring for this client after the procedure? 1 Providing a regular diet within two days 2 Administering nursing care in a short period 3 Giving frequent mouth care at least four times daily 4 Having a member of the family stay with the client continually
I put 3 Ans: 2 Nursing care should be organized and administered efficiently so that the nurse's exposure to radiation is kept to a minimum. A regular diet is contraindicated until the radon seeds are removed because chewing can dislodge the seeds. Frequent mouth care is contraindicated because it can dislodge the seeds; drying of the mucous membranes cannot be prevented. A family member should not be in attendance continually because this will expose the family member to excessive radiation.
After many years of coping with ulcerative colitis, a client makes the decision to have a colectomy as advised by the primary healthcare provider. Which is most likely the significant factor that impacted on the client's decision? 1 It is temporary until the colon heals. 2 Surgical treatment cures ulcerative colitis. 3 Ulcerative colitis can progress to Crohn disease. 4 Without surgery, eating table foods is contraindicated.
correct ans- 2 When the diseased bowel is removed, the client's symptoms cease. Surgical removal of a body part is not temporary, but permanent. Ulcerative colitis does not progress to Crohn disease; clients with ulcerative colitis have an increased risk for colorectal cancer. Without surgery, eating table foods is contraindicated is not a true statement; these clients can still eat table food.
What information from a client's history should the nurse identify as risk factors for the development of colon cancer? Select all that apply. 1 Hemorrhoids 2 Increased age 3 High-fiber diet 4 Ulcerative colitis 5 Low hemoglobin level
correct ans- 2, 4 A slower fecal transit time, which occurs with aging, may increase the risk for colon cancer. Chronic irritation of the intestinal mucosa, such as occurs in ulcerative colitis, increases the risk for colon cancer. Hemorrhoids are not a risk factor; they are associated with constipation. A high-fiber diet is linked to a decreased risk for colon cancer. Low hemoglobin level is not a risk factor for colon cancer; this may occur as a result of cancer and its therapies.
A client is diagnosed with chronic pancreatitis. Which dietary instruction is most important for the nurse to share with the client? 1 Eat a low-fat, low-protein diet 2 Avoid foods high in carbohydrates 3 Avoid ingesting alcoholic beverages 4 Eat a bland diet with no snacks in between
correct ans- 3 Alcohol will cause the most damage. Alcohol increases pancreatic secretions, which cause autodigestion of the pancreas, leading to severe pain. Although the diet should be low in fat, it should be high in protein; also, it should be moderate in carbohydrates. The client should be consuming a sufficient amount of complex carbohydrates each day to maintain weight and promote tissue repair. A bland diet can be consumed, but snacks high in calories are also recommended.
The nurse provides discharge teaching to a client related to management of the client's new colostomy. The client states, "I hope I can handle all of this at home; it's a lot to remember." What is the nurse's best response? 1 "I'm sure you will be able to do it." 2 "Maybe a family member can do it for you." 3 "You seem to be nervous about going home." 4 "Perhaps you can stay in the hospital another day."
correct ans- 3 Reflection of feelings conveys acceptance and encourages further communication. The response "I'm sure you will be able to do it" is false reassurance that does not help to reduce anxiety. The response "Maybe a family member can do it for you" provides false reassurance and promotes dependence. The response "Perhaps you can stay in the hospital another day" is unrealistic and does not address the client's concern in a way that supports the ventilation of feelings.
A client recovering from hepatitis A asks the nurse about returning to work. Which is the best response by the nurse? 1 "As soon as you're feeling less tired, you may go back to work." 2 "Unfortunately, few people fully recover from hepatitis in less than six months." 3 "Gradually increase your activities because relapses may occur in those who return to full activity too soon." 4 "You cannot return to work for six months because the virus will still be in your stools, and you still are communicable."
correct ans- 3 Relapses are common; they occur after too early ambulation and too much physical activity. Fatigue is a cardinal symptom; if the client tires at rest, a return to work must be delayed. The client does not stay contagious for six months.
The nurse is developing a list of appropriate foods for a client who has been prescribed a low-sodium diet. The nurse reviews the list with the client. The nurse evaluates that the teaching is understood for food to include in the diet. Which food item did the client choose? 1 Broiled scallops 2 Bologna on rye bread 3 Shredded wheat cereal 4 Beef and cheese enchilada
correct ans- 3 Shredded wheat cereal has low sodium content. Shellfish, processed meats (bologna), and beef and cheese enchiladas are high in sodium.
A client who is admitted to the hospital and requires a colon resection states, "I want to be a do not resuscitate (DNR)." The nurse questions the client's understanding of a DNR order. Which response by the client best indicates to the nurse an understanding of a DNR order? 1 "My doctor will know what to do." 2 "My family can make the decisions for me." 3 "If something happens to me, I do not want CPR." 4 "If I have a heart attack, I do not want any medication."
correct ans- 3 The statement, "If something happens to me, I do not want CPR," specifically states that if cardiac or respiratory arrest occurs, the client would rather die peacefully and does not want cardiorespiratory resuscitation. If a DNR order is signed by the client, cardiopulmonary resuscitation will not be instituted. The response, "My doctor will know what to do," reflects an advance directive (e.g., durable power of attorney for health care), wherein a client gives power to another person (agent, surrogate, or proxy) to make healthcare decisions on the client's behalf. The response, "My family can make the decisions for me," reflects an advance directive (e.g., durable power of attorney for health care), wherein a client gives power to another person (agent, surrogate, or proxy) to make healthcare decisions on the client's behalf. The response, "If I have a heart attack, I do not want any medication," reflects an advance directive (e.g., living will), wherein the client directs treatment in accordance with personal wishes.
After a subtotal gastrectomy (Billroth I), a client begins to eat more food in varied forms. After meals, the client experiences a cramping discomfort, a rapid pulse, and waves of weakness, which often are followed by nausea and vomiting. What does the nurse conclude is the cause of this response? 1 Slow movement of food in the small intestine 2 Rapid routing of dilute food mixture into the small intestine 3 Quick passage of hyperosmolar food solution into the small intestine 4 Entry of less concentrated food than the surrounding fluid in the small intestine
correct ans- 3 Without an adequate stomach reservoir, the hypertonic, concentrated food mass moves into the small intestine, drawing fluid from surrounding blood and tissue and causing hypovolemia and symptoms of shock (dumping syndrome). The food passes too quickly, not too slowly, into the small intestine. The food mass is more concentrated (hypertonic).
A client who is having presurgical testing before a colon resection and possible colostomy says to the nurse, "If I have to have this surgery, I know my partner will never come near me." What would be the nurse's best initial response? 1 "You seem concerned that your partner will reject you." 2 "You are wondering about the effect on your sexual relations." 3 "You are probably underestimating your partner's love for you." 4 "You seem worried that the surgery will change how your partner sees you."
correct ans- 4 "You seem worried that the surgery will change how your partner sees you" is an open-ended response that encourages further discussion. The response "You seem concerned that your partner will reject you" is too specific; the nurse does not have enough information to come to this conclusion. The response "You are wondering about the effect on your sexual relations" is too specific; the nurse does not have enough information to come to this conclusion. The response "You are probably underestimating your partner's love for you" denies the client's concern and may cause feelings of guilt for questioning the partner's love.
A client with a diagnosis of stomach cancer expresses a lack of interest in food and consumes only small amounts. What is the best intervention the nurse should offer this client? 1 Smaller portions more frequently 2 Nutritional supplements between meals 3 Supplementary vitamins to stimulate appetite 4 Only food the client likes in small portions at mealtimes
i put 1 ans- 2 Clients with stomach cancer develop nutritional problems, especially weight loss. Nutritional supplements provide more adequate calories and nutrients. Although smaller food portions given more frequently may be helpful, adding nutritional supplements between meals is important to ensure the client receives adequate daily nutritional requirements. Vitamins do not stimulate appetite. Offering only food the client likes in small portions at mealtimes does not ensure adequate nutrition; if the portion size is reduced, meal frequency must be increased.
The nurse is caring for a client with a 25-year history of excessive alcohol use. Which assessment finding is consistent with the client's history? 1 Signs of liver infection 2 A low blood ammonia level 3 A small liver with a rough surface 4 An elevated temperature and a generalized rash
i put 2 ans- 3 Scar tissue that forms as cirrhosis progresses causes the liver tissue to contract, making the liver small with a rough surface; little lumps are formed as scar tissue pulls the liver at certain points. The client has cirrhosis, not a liver infection. The liver converts ammonia to urea; therefore, the blood ammonia level increases, not decreases, when the liver fails. A high fever and a generalized rash are adaptations of an infection, not cirrhosis of the liver.
After a subtotal gastrectomy, a client begins to eat more food in varied forms. After meals the client experiences a cramping discomfort and a rapid pulse with waves of weakness, which often are followed by nausea and vomiting. The nurse concludes that the client is experiencing dumping syndrome, which is caused by what process? 1 Sluggish passage of food into the small intestine 2 Rapid passage of a dilute food mixture into the small intestine 3 Sudden passage of a hyperosmolar food solution into the small intestine 4 Passage of food that is less concentrated than surrounding extracellular fluid in the small intestine
i put 2 ans- 3 Without an adequate stomach reservoir, the hypertonic, concentrated food mass quickly empties ("dumps") into the small intestine, drawing fluid from surrounding blood and tissue, causing hypovolemia and typical signs and symptoms of shock. Dumping syndrome occurs when food passes too quickly, not too slowly, into the small intestine. The food mass is more concentrated (hypertonic), not dilute, in dumping syndrome.
The nurse is creating a discharge teaching plan for a client who had a subtotal gastrectomy. The nurse should include what instructions about minimizing dumping syndrome? Select all that apply. 1 Drink fluids with meals. 2 Eat small, frequent meals. 3 Lie down for one hour after eating. 4 Chew food five times before swallowing. 5 Select foods that are low in fiber.
i put 2, 3 ans- 2, 3, 5 Small, frequent meals keep the volume within the stomach to a minimum at any one time, limiting dumping syndrome. Lying down delays emptying of the stomach contents, which will limit dumping syndrome. Fluids should be taken between meals to decrease the volume within the stomach at one time. Dumping syndrome occurs after eating because of the rapid movement of food into the jejunum without the usual digestive mixing in the stomach and processing in the duodenum. Chewing a set number of times before swallowing is not pertinent to solving this problem. High fiber, complex carbohydrates, moderate fats, and high protein in small, frequent meals are recommended to prevent dumping syndrome.
After an acute episode of upper gastrointestinal (GI) bleeding, a client vomits undigested antacids and reports having severe epigastric pain. The nursing assessment reveals an absence of bowel sounds, a pulse rate of 134, and shallow respirations of 32 per minute. In addition to calling the healthcare provider, what is the priority nursing action? 1 Prepare the client for surgery. 2 Administer oxygen per nasal catheter. 3 Place in the supine position, with legs elevated. 4 Ask the client if there have been any black stools.
i put 4 ans- 1 These symptoms are classic indicators of a perforated ulcer, for which immediate surgery is indicated; this should be anticipated. Although oxygen may be helpful, it is not the priority. The symptoms are more indicative of perforation than of shock, so placing the client in the supine position with legs elevated is not appropriate at this time. Black, tarry stools indicate bleeding, not perforation.
