GI disorders med surg exam 2

c

A client has a nasogastric (NG) tube in place for gastric decompression and complains of increasing nausea. What action should the nurse take first? a) Advance the tube 2 cm b) Place client in a recumbent position c) Irrigate the tube with saline d) Obtain abdominal x-ray to assess tube placement

d

A client is admitted to the hospital for acute pancreatitis. The nurse obtains the client's vital signs, performs a physical assessment, and reviews the client's health history. What is the priority intervention by the nurse? a) Reduce environmental stimuli. b) Institute constant observation of the client. c) Continue to monitor the client's vital signs. d) Assess the client for alcohol withdrawal symptoms.

a, b, e

A client is admitted with the diagnosis of acute pancreatitis. For which clinical manifestations should a nurse assess the client? Select all that apply. a Jaundice b Acute pain c Hypertension d Hypoglycemia e Increased amylase

b

A client is at high risk for developing ascites because of cirrhosis of the liver. How should the nurse assess for the presence of ascites? a) Observe the client for signs of respiratory distress. b) Percuss the client's abdomen and listen for dull sounds. c) Palpate the lower extremities over the tibia and observe for edema. d) Listen for decreased or absent bowel sounds while auscultating the abdome

a

A client with cirrhosis is admitted to the hospital. Which assessment finding is consistent with development of portal hypertension? a) Hematemesis b) Asterixis c) Elevated blood pressure d) Confusion

c

A client with cirrhosis is scheduled for a liver biopsy. The client asks if there are any risks after the procedure. The nurse's best response is: a) "There are relatively no risks associated with this procedure." b) "The major risk is infection at the biopsy site." c) "The major risk is bleeding postprocedure." d) "The major risk is liver failure postprocedure."

c

A client with cirrhosis who is receiving lactulose (Cephulac) is currently having 6 diarrhea stools per day. Which of the following prescriptions does the nurse anticipate from the health care provider? a) Take Neomycin sulfate (Neo Tabs) orally 4 times per day b) Repeat serum ammonia level now c) Decrease frequency of lactulose dose d) Restrict fluids to 1500 mL/day

b

A nurse reviews the laboratory results of a client with acute pancreatitis. Which test is most significant in determining the client's response to treatment? a) Platelet count b) Amylase level c) Red blood cell count d) Erythrocyte sedimentation rate

d

Neomycin is prescribed for a client with cirrhosis. What should the nurse explain is the reason for taking this medication? a) Prevents an infection b) Minimizes intestinal edema c) Limits abdominal distention d) Reduces the blood ammonia level

b

The client is admitted to the hospital with acute pancreatitis. The nurse taking a history should question the client about which of these risks for developing pancreatitis? a) Inflammatory bowel disease b) Alcoholism c) Diabetes mellitus d) High-fiber diet

b

The client returns to the nursing unit postoperatively after a colostomy. Which of the following assessments would require immediate action by the nurse? a) Stoma is bright red b) Stoma is bluish c) Stoma is draining serous fluid d) Stoma is draining no fluid

c

The nurse is administering cephalic lactulose to a client with a history of cirrhosis of the liver. The client asks the nurse why this medication is needed because the client is not constipated. What is the best response the nurse could give? a) "This medication helps you to stop drinking so much alcohol." b) "This medication helps you to relax and not feel anxious." c) "This medication helps you to lower your high ammonia level caused by your liver disease." d) "This medication helps you to keep your abdomen from being so distended."

c

The nurse is doing discharge teaching for a client who has cirrhosis and ascites. Which of the following foods used by the client as snacks should the nurse instruct the client to avoid? a) Whole wheat bread b) Cookies c) Potato chips d) Hard candy

b, d, e

The nurse is preparing to insert a small-bore nasogastric feeding tube. Which actions are appropriate for the nurse to take? Select all that apply a) Measure the tube from the top of the nose to the scapula b) Insert the tube into the nares with the client's head hyperextended c) Use a 3 mL syringe to aspirate stomach contents d) Check the pH of the stomach contents e) Place the client in a Fowler's position during administration of the feeding

c

The nurse reviews the client's laboratory tests and notices that the total serum bilirubin is 2.5mg/dL. Which clinical manifestation would the nurse identify as most likely to be present? a) Ascites b) Diarrhea c) Scleral icterus d) Hypertension

d

The nurse should teach the client with liver disease to avoid which over the counter (OTC) medication after discharge? a) Ferrous sulfate (Feosol) b) Psyllium (Metamucil) c) Folic acid (Folate) d) Acetaminophen (Tylenol)

c

When an intestinal obstruction is suspected, a client has a nasogastric tube inserted and attached to suction. For what response should the nurse critically assess this client? a) Edema b) Belching c) Fluid deficit d) Excessive salivation

a

a client with cirrhosis of the liver and ascites is scheduled to have a paracentesis. What should the nurse do to prepare the client for the procedure? a) Instruct the client to void. b) Tell the client not to eat for four hours. c) Give the client the prescribed analgesic. d) Have the client turn to the lateral position.

d,e

a nurse is performing the physical assessment of a client admitted to the hospital with a diagnosis of cirrhosis. The nurse expects to observe what skin conditions? Select all that apply. a) Vitiligo b) Hirsutism c) Melanosis d) Ecchymoses e) Telangiectasis