GI Chapter 52, 54-60

A nurse is caring for a client following a laparoscopic hernia repair surgery. Which assessment finding will the nurse report to the surgeon immediately? A. Severe abdominal pain B. Blood pressure of 140/86 mm Hg C. Respiratory rate of 26 breaths per minute D. Mild abdominal distention

Answer: A Rationale: A slightly elevated blood pressure and respiration rate is common after a procedure in which the client experiences soreness and discomfort. Mild abdominal distention is common after a laparoscopic hernia repair surgery. However, severe, acute abdominal pain is not common and should be reported immediately.

A client with gastroesophageal reflux disease (GERD) is prescribed to start pantoprazole (Protonix) 40 mg every day. Which statement by the client requires further teaching by the nurse? A. "When I feel better, I can stop taking this drug." B. "I'll take this drug at 8 AM every morning." C. "This drug can cause headache and dizziness." D. "I should not crush the drug because it has a delayed release."

Answer: A Rationale: Treatment for GERD should be continued even if a client begins to feel better. Discontinuation of therapy can result in return of original GERD symptoms, which can further damage esophageal tissues. Side effects of pantoprazole (Protonix) can include headache and dizziness, which should immediately be reported to the client's health care provider. This medication should be taken on a regular, predictable schedule because proton pump inhibitors provide effective, long-acting inhibition of gastric acid secretion by affecting the proton pump of the gastric parietal cells. This medication should not be crushed because of its delayed release properties.

Over the past 3 months, a client with a history of gastroesophageal reflux disease and obesity has implemented lifestyle changes. What lifestyle changes does the nurse recognize as important for the client to decrease chances of development of cancer of the esophagus? Select all that apply. A. Lost 10 pounds B. Sleeps with two pillows C. Has quit eating processed foods D. Drinks a glass of wine every night E. Uses a nicotine patch instead of smoking

Answer: A, B, C, E Rationale: Losing weight can result in a decrease in intra-abdominal pressure, which can reduce the symptoms of reflux that are associated with an increased risk for development of esophageal cancer. Nocturnal reflux can be reduced by sleeping with the head of the bed elevated or with the use of two pillows. Chemicals used in processed foods, as well as smoking, can contribute to an increased risk for esophageal (and other types of) cancer. Excessive alcohol intake is associated with esophageal cancer.

When taking a history of a client diagnosed with a gastric ulcer, which assessment findings does the nurse expect? Select all that apply. A. Vomiting B. Weight loss C. Epigastric pain at night D. Relief of epigastric pain after eating E. Melena

Answer: A, C, E Rationale: Clients with ulcer disease may experience nausea and vomiting, most commonly with pyloric sphincter dysfunction. Weight loss is most commonly associated with gastric cancer, not gastric ulcer. Duodenal ulcer pain occurs 90 minutes to 3 hours after eating and often awakens the client at night. However, eating does not lessen the pain; it actually is exacerbated (worsened) by certain foods and drugs. Minimal bleeding from ulcers is manifested by occult blood (melena).

A client is provided with materials to obtain three fecal occult blood tests (Hemoccult). What health teaching does the nurse provide? Select all that apply. A. "Avoid red meat and raw vegetables for a week before getting the samples." B. "Drink a gallon of GoLYTELY before you collect the first sample." C. "Do not take food or fluids for 24 hours before the test." D. "Do not take ibuprofen for a week before obtaining the samples." E. "Avoid vitamin C tablets, foods, and juices a week before getting the samples."

Answer: A, D, E Rationale: To avoid obtaining false-positive results associated with fecal occult blood tests (Hemoccult), patients must avoid certain foods before the test, such as raw fruits and vegetables and red meat. Vitamin C-rich foods, juices, and tablets must also be avoided. Anticoagulants, such as warfarin (Coumadin), and nonsteroidal antiinflammatory drugs should be discontinued for 7 days before testing begins.

A nurse is assigned to care for a client who had an open partial colectomy and descending colostomy this morning. What assessment findings are expected for the client? Select all that apply. A. The colostomy stoma is purple and dry. B. The nasogastric tube is draining yellowish green fluid. C. The client has pain that is controlled by analgesics. D. The colostomy is not draining any stool. E. The perineal incision is covered with a surgical dressing.

Answer: B, C Rationale: A healthy stoma should be reddish pink and moist. A NG tube may be in place, draining yellowish green fluid. The client may experience pain postoperatively, which will be controlled with analgesics. The colostomy should start functioning in 2 to 3 days postoperatively; initially, gas will be passed, then liquid stool, followed by more solid stool. Perineal incisions are associated with an AP resection, not an open partial colectomy, which is an abdominal surgery.

The nurse auscultates a client's abdomen and hears a loud bruit near the umbilicus. What is the nurse's best action based on this assessment finding? A. Document the assessment finding in the medical record. B. Palpate the abdomen lightly in all four quadrants. C. Report the finding to the health care provider. D. Place the client in a semi-Fowler's position.

Answer: C Rationale: A bruit heard over the aorta usually indicates the presence of an aneurysm. The nurse should not percuss or palpate the abdomen and should immediately notify the health care provider of the findings.

A client with a family history of colorectal cancer (CRC) regularly sees a health care provider for early detection of any signs of cancer. Which laboratory result may be an indication of CRC in this client?

Elevated carcinoembryonic antigen

A 67-year-old male client reports pain in the inguinal area that occurs when he coughs. A bulge that can be pushed back into the abdomen is found in his inguinal area. What type of hernia does he have?

Reducible

Which nursing action is best for the charge nurse to delegate to an experienced LPN/LVN?

Reinforce the teaching about avoiding alcohol and caffeine for a client with chronic gastritis.

A client with colorectal cancer was started on 5-fluorouracil (5-FU) and is experiencing fatigue, diarrhea, and mouth ulcers. A relatively new chemotherapeutic agent, oxaliplatin (Eloxatin), has been added to the treatment regimen. What does the nurse tell the client about the diarrhea and mouth ulcers?

"5-FU cannot discriminate between your cancer and your healthy cells."

A client has been diagnosed with mild gastroesophageal reflux disease and asks the nurse about nonpharmacologic treatments to prevent symptoms. What does the nurse tell this client?

"Avoid caffeine-containing foods and beverages."

A client is scheduled for a colonoscopy. What does the nurse tell the client to do before the procedure is performed?

"Begin a clear liquid diet 12 to 24 hours before the test."

A client who has been diagnosed recently with esophageal cancer states, "I'm not comfortable going to my father's birthday lunch at our family-owned restaurant because I'm afraid I'll choke in public." What is the nurse's best response?

"Could you perhaps invite everyone over to cook at your home? That will allow you to be together and be more relaxed."

A 49-year-old woman comes to the emergency department with reports of black tarry stools that started 2 weeks ago. In taking a gastrointestinal (GI) history, which questions does the nurse ask that pertain to Gordon's Functional Health Patterns? (Select all that apply.)

"Do you have any difficulty chewing or swallowing?" "Do you have pain, diarrhea, gas, or any other problems? Do any specific foods cause these symptoms for you?" "What is your usual bowel elimination pattern? Frequency? Character?" "When was your last colonoscopy?" Correct

The nurse is caring for a client who is to be discharged after a bowel resection and the creation of a colostomy. Which client statement demonstrates that additional instruction from the nurse is needed?

"I can drive my car in about 2 weeks."

The nurse is teaching a client about dietary choices to prevent dumping syndrome after gastric bypass surgery. Which statement by the client indicates a need for further teaching?

"I can eat ice cream in moderation." Milk products such as ice cream must be eliminated from the diet of the client with dumping syndrome. The client with dumping syndrome can no longer consume sweetened drinks. Alcohol must be eliminated from the diet. The client can eat sugar-free pudding, custard, and gelatin with caution.

The home health nurse is teaching a client about the care of a new colostomy. Which client statement demonstrates a correct understanding of the instructions?

"I need to check for leakage underneath my colostomy."

A client with irritable bowel syndrome (IBS) is constipated. The nurse instructs the client about a management plan. Which client statement shows an accurate understanding of the nurse's teaching?

"I need to go for a walk every evening."

The nurse is teaching a client how to prevent recurrent chronic gastritis symptoms before discharge. Which statement by the client demonstrates a correct understanding of the nurse's instruction?

"I should avoid alcohol and tobacco."

The Certified Wound, Ostomy, and Continence Nurse is teaching a client with colorectal cancer how to care for a newly created colostomy. Which client statement reflects a correct understanding of the necessary self-management skills?

"I will make certain that I always have an extra bag available."

The nurse is teaching a client who has undergone a hemorrhoidectomy about a follow-up plan of care. Which client statement demonstrates a correct understanding of the nurse's instructions?

"I will need to eat a diet high in fiber."

The nurse is educating a group of older adults about screening for colorectal cancer. Which statement by a group member indicates the need for further clarification about these guidelines?

"I will need to have a routine colonoscopy every 5 years."

A 24-year-old male is scheduled for a minimally invasive inguinal hernia repair (MIIHR). Which client statement indicates a need for further teaching about this procedure?

"I will need to stay in the hospital overnight."

A client with peptic ulcer disease asks the nurse whether a maternal history of gastric cancer will cause the client to develop gastric cancer. What is the nurse's best response?

"If you are concerned that you are at high risk, I recommend speaking to your provider about the possibility of genetic testing."

A client suspected of having irritable bowel syndrome (IBS) is scheduled for a hydrogen breath test. What does the nurse tell the client about this test?

"If you have IBS, hydrogen levels may be increased in your breath samples."

The nurse is teaching a client with peptic ulcer disease about the prescribed drug regimen. Which statement made by the client indicates a need for further teaching before discharge?

"Nizatidine (Axid) needs to be taken three times a day to be effective."

A client with malabsorption syndrome asks the nurse, "What did I do to cause this disorder to develop?" How does the nurse respond?

"Nothing you did could have caused it; it is the result of flattening of the mucosa of your large intestine."

A client has been diagnosed with terminal gastric cancer and is interested in obtaining support from hospice, but expresses concern that pain management will not be adequate. What is the nurse's best response?

"Pain control is a major component of the care provided by hospice and its staff members."

A client with gastroesophageal reflux disease has undergone a laparoscopic Nissen fundoplication (LNF). What will the nurse include in postoperative home care instructions?

"Remain on a soft diet for about a week and avoid raw fruits and vegetables."

The nurse has placed a nasogastric (NG) tube in a client with upper gastrointestinal (GI) bleeding to administer gastric lavage. The client asks the nurse about the purpose of the NG tube for the procedure. What is the nurse's best response?

"Saline goes down the tube to help clean out your stomach." Gastric lavage involves the instillation of water or saline through an NG tube to clear out stomach contents and blood clots. It does not involve the instillation of medication. An NG tube is not typically placed in a client without a particular purpose in mind. Gastric lavage does not involve enteral feeding.

A client with colorectal cancer is scheduled for colostomy surgery. Which comment from the nurse is most therapeutic for this client?

"Tell me what worries you the most about this procedure."

A male client's sister was recently diagnosed with colorectal cancer (CRC), and his brother died of CRC 5 years ago. He asks the nurse whether he will inherit the disease too. How does the nurse respond?

"The only way to know whether you are predisposed to CRC is by genetic testing."

An older female client is diagnosed with gastric cancer. Which statement made by the client's family demonstrates a correct understanding of the disorder?

"This may be related to her recurring ulcer disease."

A client has a long-term history of Crohn's disease and has recently developed acute gastritis. The client asks the nurse whether Crohn's disease was a direct cause of the gastritis. What is the nurse's best response?

"We know that there can be an association between Crohn's disease and chronic gastritis, but Crohn's does not directly cause acute gastritis to develop."

The outpatient clinic nurse is caring for a recovering client who had a colonoscopy. The client asks for a drink. How does the nurse respond to this request?

"When you are able to pass flatus (gas), you can have a drink."

A client has been diagnosed with terminal esophageal cancer. The client is interested in obtaining support from hospice, but expresses concern that pain management will not be adequate. What is the nurse's best response?

"Would you like me to get a nurse from hospice to come talk with you?"

Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit?

A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis

The RN on the medical-surgical unit receives a shift report about four clients. Which client does the nurse assess first?

A 36-year-old admitted after a motor vehicle crash with areas of ecchymoses on the abdomen in a "lap-belt" pattern

Which client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) unit?

A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy

Which client does the medical-surgical unit charge nurse assign to an LPN/LVN?

A 47-year-old who needs to receive "whole gut" lavage before a colon resection

While working in the outpatient procedure unit, the RN is assigned to these clients. Which client does the nurse assess first?

A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP)

The nurse is reviewing the medication history for a client diagnosed with gastroesophageal reflux disease who has been prescribed esomeprazole (Nexium) once daily. The client reports that the drug doesn't completely control the symptoms. The nurse contacts the provider to discuss which intervention?

Changing to a twice-daily dosing regimen

Which of these assigned clients does the nurse assess first after receiving the change-of-shift report?

Middle-aged adult with an esophagogastrectomy done 2 days earlier who has bright-red drainage from the nasogastric (NG) tube

The nurse finds a client vomiting coffee-ground emesis. On assessment, the client has blood pressure of 100/74 mm Hg, is acutely confused, and has a weak and thready pulse. Which intervention is the nurse's first priority?

Administering intravenous (IV) fluids Administering IV fluids is necessary to treat the hypovolemia caused by acute gastrointestinal (GI) bleeding. Administration of an H2 antagonist will not treat the basic problem, which is upper GI bleeding. Enteral nutrition will not be part of the treatment plan for acute GI bleeding. Administration of antianxiety medication will not treat the basic problem causing the client's change in mental status, which is hypovolemia.

A client is admitted to the hospital with elevated serum amylase and lipase levels and a decreased calcium level. Which gastrointestinal health problem is indicated by these laboratory findings?

Acute pancreatitis

A client is admitted to the emergency department in severe pain with a gunshot wound to the right upper abdomen. Admitting vital signs are TPR 98-96-28; BP 118/70; oxygen saturation 94%. What is the nurse's priority when monitoring this client? A. Open the airway to improve breathing. B. Give oxygen via nasal cannula at 2 L/min. C. Monitor vital signs frequently. D. Determine how the client was shot and by whom.

Answer: C Rationale: Penetrating abdominal trauma is caused by GSWs, stabbing, or impalement with an object. The liver is the most commonly injured organ from penetrating abdominal trauma, and trauma is the leading cause of death in adults younger than 40 years in the United States. With what appears to be stable vital signs at this time, the nurse should monitor vital signs for any changes that may indicate complications from the penetrating abdominal trauma. It is not within the nurse's scope to determine who shot the client.

The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order does the nurse assess these clients? A. A client planned for an esophagogastroduodenoscopy (EGD) at 1 PM (1300) B. A client requesting pain medication 2 days after a partial gastrectomy C. A client with peptic ulcer disease experiencing a sudden onset of acute stomach pain D. A client who is NPO for tests to rule out gastric cancer

Answer: C, B, A, D Rationale: A client with peptic ulcer disease experiencing a sudden onset of acute stomach pain is at risk for local gastric mucosal injury. Peptic ulcer perforation is a surgical emergency and can be life threatening; therefore, this client should be seen first. The client who had a gastrectomy is not expected to have moderate to severe pain 2 days after surgery and may be experiencing a complication. Therefore, this client should be assessed next. Although the client scheduled for an EGD and the client who is NPO are both scheduled for testing and do not require immediate attention, the client having an EGD needs to receive pretest care in preparation for this invasive procedure for which moderate sedation will be required. The last client to be assessed is the one who is not yet scheduled for testing at a specific time.

A client has undergone a subtotal (partial) gastrectomy for gastric cancer and is scheduled to begin radiation therapy. What is the most important information for the nurse to include in the teaching plan for this client? A. Management of alopecia B. Medication management C. Nutritional intake D. Skin care

Answer: D Rationale: Although all of the choices should be part of the client's teaching plan, the priority is to ensure that the client has special skin care associated with external radiation. Radiation can cause problems with skin and tissue integrity.

A client in the outpatient clinic tells the nurse about experiencing heartburn and nighttime coughing episodes. Which action does the nurse take first?

Ask the client about medications and dietary intake.

A client with gastric cancer is scheduled to undergo surgery to remove the tumor once 5 pounds of body weight has been regained. The client is not drinking the vanilla-flavored enteral supplements that have been prescribed. Which is the highest priority nursing intervention for this client?

Ask the client if a change in flavor would make the supplement more palatable.

The nurse is assessing a client who had abdominal surgery yesterday. What method provides the most accurate data about resumption of peristalsis in the client?

Asking the client whether he or she has passed flatus (gas) The best and most reliable method for assessing the return of peristalsis following abdominal surgery is the client's report of passing flatus within the past 8 hours or stool within the past 12 hours. Although auscultation and counting the number of sounds was once a method of assessing for bowel activity, it is no longer considered the most effective method. Observing the abdomen is one method of examining a client's abdomen, but it is not a reliable way to assess for resumption of activity after surgery.

A male client in a long-term care facility is 2 days postoperative after an open repair of an indirect inguinal hernia. Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)?

Assisting the client to stand to void

The nurse prepares a teaching session regarding lifestyle changes needed to decrease the discomfort associated with a client's hiatal hernia. Which change does the nurse recommend to this client?

Avoid working while bent over the computer. The client should avoid working while bent over because this position presses on the diaphragm, causing discomfort. The client with a hiatal hernia should eat four to six meals a day. The head of the client's bed should be elevated approximately 6 inches. Both tea and coffee should be eliminated from this client's diet because of the caffeine content.

The nurse is monitoring a client with gastric cancer for signs and symptoms of upper gastrointestinal bleeding. Which change in vital signs is most indicative of bleeding related to cancer?

Blood pressure from 140/90 to 110/70 mm Hg

The nurse case manager is discussing community resources with a client who has colorectal cancer and is scheduled for a colostomy. Which referral is of greatest value to this client initially?

Certified Wound, Ostomy, and Continence Nurse (CWOCN)

The nurse is assessing a client with gastroesophageal reflux disease (GERD). Which findings does the nurse expect to observe? (Select all that apply.)

Dyspepsia Flatulence Regurgitation

The nurse is observing a co-worker who is caring for a client with a nasogastric tube following esophageal surgery. Which actions by the co-worker require the nurse to intervene? (Select all that apply.)

Checking tube placement every 12 hours Keeping the bed flat Providing mouth care every 8 hours

The nurse and the dietitian are planning sample diet menus for a client who is experiencing dumping syndrome. Which sample meal is best for this client?

Chicken and rice Chicken and rice is the only selection suitable for the client who is experiencing dumping syndrome because it contains high protein without the addition of milk or wheat products. The client with dumping syndrome should not be allowed to have mayonnaise, onions, or buttermilk ranch dressing; the dressing is made from milk products. The client can have whole wheat bread only in very limited amounts.

A client with a bowel obstruction is ordered a nasogastric (NG) tube. After the nurse inserts the tube, which nursing intervention is the highest priority for this client?

Connecting the tube to low intermittent suction

The nurse is caring for a client with esophageal cancer who has received photodynamic therapy using porfimer sodium (Photofrin). What instructions does the nurse include in teaching the client about porfimer sodium? (Select all that apply.)

Cover all exposed body areas. Follow a clear liquid diet for 3 to 5 days after the procedure. Tissue particles may be found in the sputum.

The nurse is working with the dietitian to plan a menu for a client who has persistent difficulty swallowing. What is a suitable breakfast selection for this client?

Cream of wheat and applesauce Both cream of wheat and applesauce are foods of semi-solid consistency and are appropriate for this client. The client who is having difficulty swallowing should be given semi-solid foods and thickened liquids.

What is a common gastrointestinal problem that older adults experience more frequently as they age?

Decreased hydrochloric acid

A client has undergone conventional esophageal surgery. The client's diet has been advanced to semi-solid, and feedings are well tolerated. The client reports experiencing diarrhea about 1 hour after each meal. What is the priority nursing intervention to help prevent further diarrhea?

Encourage the client to take fluids between meals rather than with meals.

A client with colorectal cancer had colostomy surgery performed yesterday. The client is very anxious about caring for the colostomy and states that the health care provider's instructions "seem overwhelming." What does the nurse do first for this client?

Encourages the client to look at and touch the colostomy stoma

A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client?

Examines the RUQ of the abdomen last

A client has a routine sigmoidoscopy with a tissue biopsy. What complication is the nurse looking for in a postprocedure assessment?

Heavy bleeding

The admission assessment for a client with acute gastric bleeding indicates blood pressure 82/40 mm Hg, pulse 124 beats/min, and respiratory rate 26 breaths/min. Which admission request does the nurse implement first?

Infuse lactated Ringer's solution at 200 mL/hr.

The nurse practitioner is performing an abdominal assessment on a newly admitted client. In which order should the nurse proceed with assessment technique?

Inspection, auscultation, percussion, palpation

The nurse is assessing a client who has come to the emergency department with acute abdominal pain. The client is very thin and the nurse observes visible peristaltic movements when inspecting the abdomen. What does the nurse suspect?

Intestinal obstruction

Which substance, produced in the stomach, facilitates the absorption of vitamin B12?

Intrinsic factor

What is the mechanism of action for the chemotherapeutic drug cetuximab (Erbitux)?

It blocks factors that promote cancer cell growth. Cetuximab, a monoclonal antibody, may be given for advanced disease. This drug works by binding to a protein (epidermal growth factor receptor) to slow cell growth. The medication does not destroy the cancer's cell walls and does not stimulate the body's immune system or stunt cancer growth in that manner. The treatment does not decrease blood flow to rapidly dividing cancer cells.

The nurse is reviewing orders for a client with possible esophageal trauma after a car crash. Which request does the nurse implement first?

Keep the client nothing by mouth (NPO) for possible surgery.

The nurse is caring for a client diagnosed with esophageal cancer who is experiencing diarrhea after conventional esophageal surgery. The nurse anticipates that the health care provider will request which medication to manage diarrhea?

Loperamide (Imodium)

The nurse reviews a medication history for a client newly diagnosed with peptic ulcer disease (PUD) who has a history of using ibuprofen (Advil) frequently for chronic knee pain. The nurse anticipates that the health care provider will request which medication for this client?

Misoprostol (Cytotec) Misoprostol is a prostaglandin analogue that protects against nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers. Bismuth subsalicylate is an antidiarrheal drug that contains salicylates, which can cause bleeding and should be avoided in clients who have PUD. Magnesium hydroxide is an antacid that may be used to neutralize stomach secretions, but is not used specifically to help prevent NSAID-induced ulcers. Metronidazole is an antimicrobial agent used to treat Helicobacter pylori infection.

The nurse is assessing a client who comes to the emergency department with acute abdominal pain. The nurse notes a bulging, pulsating mass when inspecting the abdomen. Which action by the nurse is correct?

Notify the provider about this finding immediately. A bulging, pulsating mass may indicate an abdominal aortic aneurysm, and the nurse should notify the provider immediately. Palpating the abdomen or even touching the abdomen with a stethoscope may cause this to rupture, which would be a life-threatening emergency. Because this is a potential life-threatening situation, questioning the client about stool habits is not appropriate.

The nurse is caring for an older adult male client who reports stomach pain and heartburn. Which symptom is most significant in determining whether the client's ulceration is gastric or duodenal in origin?

Pain occurs 1½ to 3 hours after a meal, usually at night.

The nurse is reviewing admitting requests for a client admitted to the intensive care unit with perforation of a duodenal ulcer. Which request does the nurse implement first?

Place a nasogastric (NG) tube, and connect to suction. To decrease spillage of duodenal contents into the peritoneum, NG suction should be rapidly initiated. This will minimize the risk for peritonitis. Antiembolism stockings will need to be applied, monitoring output is important, and famotidine (Pepcid) will need to be administered, but the nurse's first priority is to minimize the risk for peritonitis.

The nurse is reinforcing the instructions on swallowing provided by the speech-language pathologist to a client diagnosed with esophageal cancer. Which instruction to the client is the highest priority?

Place food at the back of the mouth as you eat. Placing food at the back of the mouth when eating will help the client avoid aspirating. Both tongue movements and sealing of the lips should be monitored in this client. The client's head should be tilted forward in the chin-tuck position. The client should be able to reach food particles on her or his lips and around the mouth with the tongue.

A client with an intestinal obstruction has pain that changes from a "colicky" intermittent type to constant discomfort. What does the nurse do first?

Prepares the client for emergency surgery

After a colonoscopy, a client reports severe abdominal pain. The nurse obtains these data: temperature 100.2° F (37.9° C), pulse 122 beats/min, blood pressure 100/45 mm Hg, respirations 44 breaths/min, and O2 saturation 89%. Which request from the health care provider does the nurse implement first?

Provide oxygen at 6 L/min per nasal cannula.

A client is scheduled to be discharged after a gastrectomy. The client's spouse expresses concern that the client will be unable to change the surgical dressing adequately. What is the nurse's highest priority intervention?

Providing both oral and written instructions on changing the dressing and on symptoms of infection that must be reported to the provider

After an abdominoperineal resection, a 75-year-old client is referred to a home health agency. Which staff member does the nurse manager assign to perform the initial assessment on this client?

RN who is new to the agency with 5 years experience in the emergency department

A client arrives at the emergency department with acute abdominal pain in the left lower quadrant. In which order does the nurse examine and assess the client's left lower quadrant (LLQ), left upper quadrant (LUQ), right lower quadrant (RLQ), and right upper quadrant (RUQ)?

RUQ, LUQ, RLQ, LLQ *RLQ is where most bowel sounds can be heard

A client with an inoperable esophageal tumor is receiving swallowing therapy. Which task does the home health nurse delegate to an experienced home health aide?

Reminding the client to use the chin-tuck technique each time the client attempts to swallow

A client is being discharged after a minimally invasive esophagectomy. Which teaching point does the nurse consider to be of the highest priority during the predischarge teaching session?

Report the presence of fever and a swollen, painful neck incision.

A client has been discharged home after surgery for gastric cancer, and a case manager will follow up with the client. To ensure a smooth transition from the hospital to the home setting, which information provided by the hospital nurse to the case manager is given the highest priority?

Schedule of the client's follow-up examinations and x-ray assessments Because recurrence of gastric cancer is common, it will be a priority for the client to have follow-up examinations and x-rays, so that a recurrence can be detected quickly.

Which factors place a client at risk for gastrointestinal (GI) problems? (Select all that apply.)

Smoking a half-pack of cigarettes per day Socioeconomic status Some herbal preparations Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

After an automobile crash, a client is admitted to the emergency department with possible abdominal trauma. Which health care provider request does the nurse implement first?

Start an IV line and infuse normal saline at 200 mL/hr.

A client is experiencing bleeding related to peptic ulcer disease (PUD). Which nursing intervention is the highest priority?

Starting a large-bore IV

A client asks the nurse, "Can you tell me some foods to include in my diet so that I can reduce my chances of getting colorectal cancer?" Which dietary selection does the nurse suggest?

Steamed broccoli with turkey

A 56-year-old woman returns from the postanesthesia care unit (PACU) after an open colon resection and colostomy for ascending colon cancer. She has IV fluids running at 100 mL/hr and is receiving morphine PCA. An NGT is in place connected to low suction, and she is NPO. Her abdominal dressing is dry and intact, and her oxygen saturation is 95% on 2 L/min of oxygen via nasal cannula. She is allowed out of bed to the bathroom or chair today. You are assigned to care for this patient for the rest of the day shift. 1. Upon the patient's admission to your unit at 11 AM, should you delegate taking the patient's vital signs to an experienced nursing technician? Why or why not? 2. At 5 PM, the patient states that she needs to go to the bathroom. Will you delegate this activity to the nursing technician? Why or why not? 3. While the patient was in the bathroom, her oxygen saturation level decreased to 88%. What is your best action at this time? 4. The patient's husband asks you about his wife's prognosis regarding her cancer survival. What is your best response at this time?

Suggested responses: 1. Upon the patient's admission to your unit at 1100 (11 AM), should you delegate taking the patient's vital signs to an experienced nursing technician? Why or why not? You should initially, and in the early hours after surgery, assess vital signs to establish a baseline and to monitor initial recovery. After you have deemed that the patient is stable and progressing normally, delegation of vital signs can be assigned to an experienced nursing technician, with the understanding that you must follow all Nurse Practice Acts related to appropriate delegation. You must communicate the task that is to be performed (vital signs checks), the frequency of the task (e.g., every 15 minutes, hourly, and so on), and the method by which the task should be accomplished (manual vs. automated monitoring for blood pressure, and so on). You should also clarify that you need the experienced nursing technician to report his or her findings back to you in a specific time frame (e.g., every 15 minutes, hourly, and so on). It is important that you follow up with the experienced nursing technician regularly to obtain a report of the vital signs that were taken, so that you can make appropriate nursing decisions based on that data. 2. At 5 PM, the patient states that she needs to go to the bathroom. Will you delegate this activity to the nursing technician? Why or why not? You should accompany the patient to the bathroom during this initial ambulation. This provides you, as the nurse, with assessment information about the patient's ability to transfer, her steadiness and gait, and her response to initial ambulation. This information will help you determine whether you should delegate future transfers or ambulation needs (e.g., going to the bathroom) to the nursing technician. 3. While the patient was in the bathroom, her oxygen saturation level decreased to 88%. What is your best action at this time? It is common for a patient's oxygen saturation to decrease upon initial physical activity after surgery. Maintain patient safety, allowing her time to sit on the toilet. If possible, escort her safely from the bathroom back to bed. Continually assess oxygenation. When it is feasible, take the patient's vital signs. Reassure her that you will remain with her to decrease concerns of anxiety which may affect oxygenation. If oxygen saturation does not improve or vital signs are unstable, contact the patient's surgeon. 4. The patient's husband asks you about his wife's prognosis regarding her cancer survival. What is your best response at this time? Colon cancer for many patients is highly curable. Survivability depends on many factors, including stage of the cancer at the time of discovery and treatment.

A 67-year-old man drove himself to the emergency department (ED) after vomiting bright red blood twice within 6 hours. He is alert and oriented and admits to having a few drinks last weekend. He takes some medicine for his stomach, but he cannot recall the name of the drug. He reports intermittent dizziness and fatigue over the past 2 days. His skin is dry and pale, and his abdomen is slightly distended. He reports pain (4/10) in the mid-epigastric area. His BP is 140/90, heart rate is 110/min, respirations are 24/min, and temperature is 98.9° F. 1. What actions are appropriate in the care of this patient in the ED? As the nurse in the ER, what additional questions will you ask his wife? 2. What data will you document? 3. Which task is most appropriate to assign to the nursing assistant working with you? 4. You are performing additional assessment and history on the patient. Which finding should you immediately report to the health care provider? 5. What medication is the physician most likely to prescribe for emergency treatment of acute and severe bleeding of the patient's ulcer?

Suggested responses: 1. What actions are appropriate in the care of this patient in the ED? As the nurse in the ED, what additional questions will you ask the patient? Collect a history of current or past medical conditions, with a focus on gastrointestinal (GI) problems, particularly any history of diagnosis or treatment for Helicobacter pylori infection. Ask about GI upset, pain, and its relationship to eating and sleep patterns and actions taken to relieve pain. Ask about alcohol intake and tobacco use, and whether foods precipitate or worsen symptoms. Determine whether the patient is taking corticosteroids, chemotherapy, or nonsteroidal antiinflammatory drugs and ask whether he has ever undergone radiation treatments or had GI surgeries. Inquire about any changes in the character of the pain because they may signal the development of complications. Assess the impact of ulcer disease on the patient's lifestyle, occupation, family, and social and leisure activities. Interventions include those targeted at pain management, elimination of H. pylori infection, the healing of ulcerations, and prevention of recurrence. 2. What data will you document? Document all objective assessment findings, the patient's subjective reports of pain, interventions, and responses to interventions. 3. Which task is most appropriate to assign to the nursing assistant working with you? Delegate routine collection of vital signs to the nursing assistant, with the understanding that you must follow all Nurse Practice Acts related to appropriate delegation. You must communicate the task that is to be performed (vital signs checks), the frequency of the task (e.g., every 15 minutes, every hour, and so on), and the method by which the task should be accomplished (manual versus automated monitoring for blood pressure, and so on). You should also clarify that you need the nursing assistant to report his or her findings back to you immediately after obtaining the vital signs. It is important that you follow up with the nursing assistant regularly to obtain a report of the vital signs that were taken, so that you can make appropriate nursing decisions based on that data. 4. You are performing additional assessment and history on the patient. Which finding should you immediately report to the health care provider? Report any bright red or coffee-ground vomitus because they can indicate massive bleeding. Report sudden, sharp pain that begins in the midepigastric region and spreads over the entire abdomen, as well as a tender, rigid, or boardlike abdomen. 5. What medication is the physician most likely to prescribe for emergency treatment of acute and severe bleeding of the patient's ulcer? A common drug regimen for H. pylori infection is proton pump inhibitor (PPI triple therapy, which includes a PPI such as lansoprazole (Prevacid) plus two antibiotics such as metronidazole (Flagyl, Novonidazol) and tetracycline (Ala-Tet, Panmycin, Nu-Tetra) or clarithromycin (Biaxin, Biaxin XL) and amoxicillin (Amoxil, Amoxi) for 10 to 14 days. Some health care providers may prefer to use quadruple therapy, which contains combination of a PPI and any two commonly used antibiotics as described above with the addition of bismuth (Pepto-Bismol). Bismuth therapy is often used in patients who are allergic to penicillin-based medications.

A 50-year-old man has his first screening colonoscopy today. You are assigned as his pre-procedure nurse. When you take the patient's vital signs before the procedure, his blood pressure is 148/86 mm Hg. The patient states that he has a history of hypertension that is being well controlled with medication and diet. He tells you that he took his amlodipine (Norvasc) this morning with a small amount of water. 1. Why do you suspect his blood pressure is increased? What other assessment data will you collect? 2. What actions might you consider to decrease his blood pressure? 3. After the procedure, the patient asks for something to drink. How will you respond to him and why? What evidence supports this decision? 4. What evidence-based position should the patient be in after the procedure and why? 5. The patient tells you that he had a polyp removed. What health teaching about colorectal cancer screening will you provide?

Suggested responses: 1. Why do you suspect his blood pressure in increased? What other assessment data will you collect? If the patient's hypertension has been documented as being well controlled with medication and diet, you can anticipate that he is feeling anxious about the procedure. 2. What actions might you consider to decrease his blood pressure? Offer therapeutic supportive presence, allow the patient to express his concerns and feelings about having the colonoscopy performed, provide information about the procedure and reassure them that pain will be controlled with medication as needed, and recommend deep breathing exercises or positive imagery to decrease anxiety. 3. After the procedure, the patient asks for something to drink. How will you respond to him and why? What evidence supports this decision? Following a colonoscopy, the patient should be maintained NPO (nothing by mouth) until he passes flatus to indicate that peristalsis has returned. Provide information that explains the rationale for not drinking after a colonoscopy and provide gentle reassurance that fluids will be provided after the patient passes flatus. An example of evidence that supports this practice is Tichansky, D.S., Mortan, J., & Jones, D.B. (eds.) (2012). The SAGES manual of quality, outcomes and patient safety, Springer Science + Business Media, LLC. 4. What evidence-based position should the patient be in after the procedure and why? The patient should lie on his left side to promote comfort and encourage passing flatus. 5. The patient tells you that he had a polyp removed. What health teaching about colorectal cancer screening will you provide? Explain to the patient that colorectal cancer can be treated when it is detected early. The American Cancer Society (2013) recommends that screening begin at 50 years of age and should be done every 5 years thereafter. Patients at high risk for cancer may require more frequent screening.

A 21-year-old with a stab wound to the abdomen has come to the emergency department. Once stabilized, the client is admitted to the medical-surgical unit. What does the admitting nurse do first for this client?

Take vital signs. Assessment of vital signs should be done first to determine the adequacy of the airway and circulation. Vital signs initially reveal the most about the client's condition.

A client with peptic ulcer disease (PUD) asks the nurse whether licorice and slippery elm might be useful in managing the disease. What is the nurse's best response?

These herbs could be helpful. However, you should talk with your provider before adding them to your treatment regimen."

Which client assessment information is correlated with a diagnosis of chronic gastritis?

Treatment with radiation therapy

A client is being evaluated in the emergency department for a possible small bowel obstruction. Which signs and/or symptoms does the nurse expect to assess?

Upper abdominal distention, metabolic alkalosis, and great amount of vomiting

The nurse is caring for a client with a hiatal hernia who had an open fundoplication yesterday. Which task does the nurse delegate to unlicensed assistive personnel (UAP)?

Using a pillow to support the incision when the client coughs Assisting a client to cough is a task within the education and skill level of UAP. NG tube maintenance, pain assessment, and assessment of bowel sounds require more knowledge of the potential complications associated with this surgical procedure, and are actions best performed by licensed nursing staff.

The nurse working during the day shift on the medical unit has just received report. Which client does the nurse plan to assess first?

Young adult with epigastric pain, hiccups, and abdominal distention after having a total gastrectomy. The client with epigastric pain is experiencing symptoms of acute gastric dilation, which can disrupt the suture line. The surgeon should be notified immediately because the nasogastric tube may need irrigation or re-positioning.