GI Exam
A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a.Liquid stool b.Pale and bluish stoma c.Blood-smeared output d.Ostomy pouch intact
b.Pale and bluish stoma Response Feedback:The nurse should assess the stoma for color and contact the health care provider if the stoma is pale, bluish, or dark. The nurse should expect the client to have an intact ostomy pouch with dark green liquid stool that may contain some blood.
A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites? a.Increase oral fluid intake. b.Monitor intake and output. c.Weigh the client daily. d.Provide a low-sodium diet.
d.Provide a low-sodium diet. Response Feedback:A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.
A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect? a.Mid-sternal chest pain b.Frontal headache c.Vertigo and syncope d.Nausea and vomiting
a.Mid-sternal chest pain Response Feedback:Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. Nausea and vomiting, headache, and vertigo and syncope are not side effects of vasopressin.
A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this client's teaching? a."Increase your protein intake by drinking more milk." b."Drink plenty of fluids to prevent dehydration." c."Sips of cola or tea may help to relieve your nausea." d."You should only drink 1 liter of fluids daily."
b."Drink plenty of fluids to prevent dehydration." Response Feedback:The client should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.
A nurse assesses a client who is hospitalized with an exacerbation of Crohn's disease. Which clinical manifestation should the nurse expect to find? a.Dull, hypoactive bowel sounds in the lower abdominal quadrants b.High-pitched, rushing bowel sounds in the right lower quadrant c.Reports of abdominal cramping that is worse at night d.Positive Murphy's sign with rebound tenderness to palpitation
b.High-pitched, rushing bowel sounds in the right lower quadrant Response Feedback:The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn's disease. A positive Murphy's sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohn's disease. Nightly worsening of abdominal cramping is not consistent with Crohn's disease.
A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The client's respiratory rate is 8 breaths/min. What action by the nurse is best? a.Provide physical stimulation. b.Administer naloxone (Narcan). c.Ventilate with a bag-valve-mask. d.Call the Rapid Response Team.
a. Provide physical stimulation. Response Feedback: For an EGD, clients are given mild sedation but should still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurse's first action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for Versed. The Rapid Response Team is not needed at this point. The client does not need manual ventilation.
A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this condition? (Select all that apply.) a."How frequently do you drink alcohol?" b."Have you ever had sex with a man?" c."Do you have a family history of cancer?" d."Have you ever worked as a plumber?" e."Have you ever been incarcerated?"
a."How frequently do you drink alcohol?" b."Have you ever had sex with a man?" e."Have you ever been incarcerated?" Response Feedback:When assessing a client with suspected cirrhosis, the nurse should ask about alcohol consumption, including amount and frequency; sexual history and orientation (specifically men having sex with men); illicit drug use; history of tattoos; and history of military service, incarceration, or work as a firefighter, police officer, or health care provider. A family history of cancer and work as a plumber do not put the client at risk for cirrhosis.
After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a."I may have been exposed when we ate shrimp last weekend." b."I was infected with hepatitis A through a recent blood transfusion." c."Some medications have been known to cause hepatitis A." d."My infection with Epstein-Barr virus can co-infect me with hepatitis A."
a."I may have been exposed when we ate shrimp last weekend." Response Feedback:The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications, blood transfusions, or Epstein-Barr virus. Toxic and drug-induced hepatitis is caused from exposure to hepatotoxins, but this is not a form of hepatitis A. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection that is not associated with hepatitis A.
After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a."I will avoid large crowds and people who are sick." b."Nausea and vomiting are common side effects of this drug." c."I will take this medication with my breakfast each morning." d."I must wash my hands after I play with my dog."
a."I will avoid large crowds and people who are sick." Response Feedback:Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing.
A nurse cares for a client who has chronic cirrhosis from substance abuse. The client states, "All of my family hates me." How should the nurse respond? a."I will help you identify a support system." b."You must attend Alcoholics Anonymous." c."You should make peace with your family." d."This is not unusual. My family hates me too."
a."I will help you identify a support system." Response Feedback:Clients who have chronic cirrhosis may have alienated relatives over the years because of substance abuse. The nurse should assist the client to identify a friend, neighbor, or person in his or her recovery group for support. The nurse should not minimize the client's concerns by brushing off the client's comment. Attending AA may be appropriate, but this response doesn't address the client's concern. Making peace with the client's family may not be possible. This statement is not client-centered.
A nurse teaches a community group about food poisoning and gastroenteritis. Which statements should the nurse include in this group's teaching? (Select all that apply.) a."Parasitic diseases may not show up for 1 to 2 weeks after infection." b."Rotavirus is more common among infants and younger children." c."To prevent E. coli infection, don't drink water when swimming." d."Clients who have botulism should be quarantined within their home." e."Escherichia coli diarrhea is transmitted by contact with infected animals."
a."Parasitic diseases may not show up for 1 to 2 weeks after infection." b."Rotavirus is more common among infants and younger children." c."To prevent E. coli infection, don't drink water when swimming." Response Feedback:Rotavirus is more common among the youngest of clients. Not drinking water while swimming can help prevent E. coli infection. Parasitic diseases may take up to 2 weeks to become symptomatic. People with botulism need to be hospitalized to monitor for respiratory failure and paralysis. Escherichia coli is not transmitted by contact with infected animals.
After teaching a client who has a new colostomy, the nurse provides feedback based on the client's ability to complete self-care activities. Which statement should the nurse include in this feedback? a."You cleaned the stoma well. Now you need to practice putting on the appliance." b."I realize that you had a tough time today, but it will get easier with practice." c."You seem to understand what I taught you today. What else can I help you with?" d."You seem uncomfortable. Do you want your daughter to care for your ostomy?"
a."You cleaned the stoma well. Now you need to practice putting on the appliance." Response Feedback:The nurse should provide both approval and room for improvement in feedback after a teaching session. Feedback should be objective and constructive, and not evaluative. Reassuring the client that things will improve does not offer anything concrete for the client to work on, nor does it let him or her know what was done well. The nurse should not make the client convey learning needs because the client may not know what else he or she needs to understand. The client needs to become the expert in self-management of the ostomy, and the nurse should not offer to teach the daughter instead of the client.
A nurse assesses a client with Crohn's disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a.Distended abdomen b.Lower abdominal cramps c.Temperature of 100.0° F (37.8° C) d.Loose and bloody stool
a.Distended abdomen Response Feedback:The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the client's provider should be notified right away. Low-grade fever, bloody diarrhea, and abdominal cramps are common symptoms of Crohn's disease.
A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially causing complications of this disorder? (Select all that apply.) a.Elevated prothrombin time (PT) b.Decreased serum globulin levels c.Elevated international normalized ratio (INR) d.Elevated aspartate transaminase e.Elevated serum ammonia f.Decreased serum alkaline phosphatase
a.Elevated prothrombin time (PT)Response c.Elevated international normalized ratio (INR) e.Elevated serum ammonia Feedback:Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the client's confusion. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.
A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first? a.Heart rate and rhythm b.Inspection of oral mucosa c.Percussion of abdomen d.Recent dietary intake
a.Heart rate and rhythm Response Feedback:Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this client than heart rate and rhythm.
An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.) a.Policies related to consistent use of Standard Precautions b.Implementation of a needleless system for intravenous therapy c.Hepatitis vaccination mandate only for workers in high-risk areas d.Postexposure prophylaxis provided in a timely manner e.Number of sharps used in client care reduced where possible
a.Policies related to consistent use of Standard Precautions b.Implementation of a needleless system for intravenous therapy d.Postexposure prophylaxis provided in a timely manner e.Number of sharps used in client care reduced where possible Response Feedback:Nurses should always use Standard Precautions for client care, and policies should reflect this. Needleless systems and reduction of sharps can help prevent hepatitis. Postexposure prophylaxis should be provided immediately. All health care workers should receive the hepatitis vaccinations that are available.
After teaching a client with an anal fissure, a nurse assesses the client's understanding. Which client actions indicate that the client correctly understands the teaching? (Select all that apply.) a.Taking a warm sitz bath several times each day b.Utilizing a daily enema to prevent constipation c.Self-administering anti-inflammatory suppositories d.Taking a laxative each morning e.Using bulk-producing agents to aid elimination
a.Taking a warm sitz bath several times each day c.Self-administering anti-inflammatory suppositories e.Using bulk-producing agents to aid elimination Response Feedback:Taking warm sitz baths each day, using bulk-producing agents, and administering anti-inflammatory suppositories are all appropriate actions for the client with an anal fissure. The client should not use enemas or laxatives to promote elimination, but rather should rely on bulk-producing agents such as psyllium hydrophilic mucilloid (Metamucil).
A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, "I do not want to take this medication because it causes diarrhea." How should the nurse respond? a."We will need to send a stool specimen to the laboratory." b."Diarrhea is expected; that's how your body gets rid of ammonia." c."Do not take any more of the medication until your stools firm up." d."You may take Kaopectate liquid daily for loose stools."
b."Diarrhea is expected; that's how your body gets rid of ammonia." Response Feedback:The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The client must understand that this is an expected and therapeutic effect for him or her to remain compliant. The nurse should not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.
After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a."I must take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry." b."I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel." c."I'll rinse my rectal area with warm water after each stool and apply zinc oxide ointment." d."I shall clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment."
b."I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel." Response Feedback:Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not an effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry.
A nurse cares for a client with ulcerative colitis. The client states, "I feel like I am tied to the toilet. This disease is controlling my life." How should the nurse respond? a."To decrease distress, do not eat anything before you go out." b."Let's discuss potential factors that increase your symptoms." c."If you take the prescribed medications, you will no longer have diarrhea." d."You must retake control of your life. I will consult a therapist to help."
b."Let's discuss potential factors that increase your symptoms." Response Feedback:Clients with ulcerative colitis often express that the disorder is disruptive to their lives. Stress factors can increase symptoms. These factors should be identified so that the client will have more control over his or her condition. Prescription medications and anorexia will not eliminate exacerbations. Although a therapist may assist the client, this is not an appropriate response
A nurse cares for a teenage girl with a new ileostomy. The client states, "I cannot go to prom with an ostomy." How should the nurse respond? a."Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance." b."Let's talk to the enterostomal therapist about options for ostomy supplies and dress styles." c."You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable." d."The pouch won't be as noticeable if you avoid broccoli and carbonated drinks prior to the prom."
b."Let's talk to the enterostomal therapist about options for ostomy supplies and dress styles." Response Feedback:The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible.
A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus). Which statement should the nurse include in this client's discharge education? a."Take your radial pulse for 1 minute prior to taking this medication." b."Use a pill organizer to ensure you take this medication as prescribed." c."Follow up with your provider in 1 week to test your blood for toxicity." d."Transient muscle aching is a common side effect of this medication."
b."Use a pill organizer to ensure you take this medication as prescribed." Response Feedback:Treatment of hepatitis C with ribavirin takes up to 48 weeks, making compliance a serious issue. The nurse should work with the client on a strategy to remain compliant for this length of time. Muscle aching is not a common side effect. The client will be on this medication for many weeks and does not need a blood toxicity examination. There is no need for the client to assess his or her radial pulse prior to taking the medication.
A nurse cares for a client with hepatitis C. The client's brother states, "I do not want to contract this infection, so I will not go into his hospital room." How should the nurse respond? a."If you wear a gown and gloves, you will not get this virus." b."Viral hepatitis is not spread through casual contact." c."This virus is only transmitted through a fecal specimen." d."I can give you an update on your brother's status from here."
b."Viral hepatitis is not spread through casual contact." Response Feedback:Although family members may be afraid that they will contract hepatitis C, the nurse should educate the client's family about how the virus is spread. Viral hepatitis, or hepatitis C, is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing, blood and organ transplantation, accidental needle sticks, unsanitary tattoo equipment, and sharing of intranasal cocaine paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. The nurse would be violating privacy laws by sharing the client's status with the brother.
A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, "I am having trouble swallowing this pill." Which action should the nurse take? a.Empty the contents of the capsule into applesauce or pudding for administration. b.Ask the health care provider to prescribe the medication as an enema instead. c.Ask the provider to prescribe another medication.. d.Crush the pill carefully and administer it in applesauce or pudding.
b.Ask the health care provider to prescribe the medication as an enema instead. Response Feedback:Asacol is the oral formula for mesalamine and is produced as an enteric-coated pill that should not be crushed, chewed, or broken. Asacol is not available as a suspension or elixir. If the client is unable to swallow the Asacol pill, a mesalamine enema (Rowasa) may be administered instead, with a provider's order.
After teaching a client with diverticular disease, a nurse assesses the client's understanding. Which menu selection made by the client indicates the client correctly understood the teaching? a.Roasted chicken with rice pilaf and a cup of coffee with cream b.Baked fish with steamed carrots and a glass of apple juice c.Garden salad with a cup of bean soup and a glass of low-fat milk d.Spaghetti with meat sauce, a fresh fruit cup, and hot tea
b.Baked fish with steamed carrots and a glass of apple juice Response Feedback:Clients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup of bean soup) should be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet.
A nurse reviews the chart of a client who has Crohn's disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions? a.Client's weight decreased by 3 pounds b.Serum potassium of 2.6 mEq/L c.White blood cell count of 8200/mm3 d.Client ate 20% of breakfast meal
b.Serum potassium of 2.6 mEq/L Response Feedback:Fistulas place the client with Crohn's disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium level takes priority.
A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? a.Blood pressure increases from 110/58 to 120/62 mm Hg b.Urine output via indwelling urinary catheter is 20 mL/hr c.Respiratory rate decreases from 18 to 14 breaths/min d.A decrease in the client's weight by 6 kg
b.Urine output via indwelling urinary catheter is 20 mL/hr Response Feedback:Rapid removal of ascetic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the client's weight to drop as fluid is removed. Six kilograms is less than 3 pounds and is expected.
A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I am experiencing right flank pain and have a temperature of 101° F." How should the nurse respond? a."Take acetaminophen (Tylenol) every 4 hours until you feel better." b."Take an additional dose of cyclosporine today." c."Go to the hospital immediately to have your new liver evaluated." d."The anti-rejection drugs you are taking make you susceptible to infection."
c."Go to the hospital immediately to have your new liver evaluated." Response Feedback:Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention. Anti-rejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse should not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.
A nurse obtains a client's health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this client? a."I drink two glasses of red wine each week." b."I got a hepatitis vaccine before traveling." c."I take a lot of Tylenol for my arthritis pain." d."I have a cousin who died of liver cancer."
c."I take a lot of Tylenol for my arthritis pain." Response Feedback:Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about this limitation and should explore other drug options with the client to manage his or her arthritis pain. Two glasses of wine each week, a cousin with liver cancer, and the hepatitis vaccine do not place the client at risk for a liver disorder, and therefore do not require any health teaching.
After teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a."I must try to include at least 25 grams of fiber in my diet every day." b."I'll ride my bike or take a long walk at least three times a week." c."I will take a laxative nightly at bedtime to avoid becoming constipated." d."I should use my legs rather than my back muscles when I lift heavy objects."
c."I will take a laxative nightly at bedtime to avoid becoming constipated." Response Feedback:Laxatives are not recommended for clients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining.
A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic in appearance, and the family asks the nurse why the client is receiving little dietary protein. How should the nurse respond? a."Increasing dietary protein will help the client gain weight and muscle mass." b."Low dietary protein is needed to prevent fluid from leaking into the abdomen." c."Less protein in the diet will help prevent confusion associated with liver failure." d."A low-protein diet will help the liver rest and will restore liver function."
c."Less protein in the diet will help prevent confusion associated with liver failure." Response Feedback:A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the client's dietary protein will cause complications of liver failure and should not be suggested. Increased intravascular protein will help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein.
A nurse cares for a client with a new ileostomy. The client states, "I don't think my friends will accept me with this ostomy." How should the nurse respond? a."A therapist can help you resolve your concerns." b."With time you will accept your new body." c."Tell me more about your concerns." d."Your friends will be happy that you are alive."
c."Tell me more about your concerns." Response Feedback:Social anxiety and apprehension are common in clients with a new ileostomy. The nurse should encourage the client to discuss concerns. The nurse should not minimize the client's concerns or provide false reassurance.
A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first? a.Sedate the client to prevent tube dislodgement. b.Irrigate the gastric lumen with normal saline. c.Assess the client for airway patency. d.Maintain balloon pressure at 15 and 20 mm Hg.
c.Assess the client for airway patency. Response Feedback:Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration and occlusion of the airway. The client usually is intubated and mechanically ventilated during this treatment. The client should be sedated, balloon pressure should be maintained between 15 and 20 mm Hg, and the lumen can be irrigated with saline or tap water. However, these are not a higher priority than airway patency.
A nurse cares for a client who is scheduled for a paracentesis. Which intervention should the nurse delegate to an unlicensed assistive personnel (UAP)? a.Help the client lie flat in bed on the right side. b.Get the client into a chair after the procedure. c.Assist the client to void before the procedure. d.Have the client sign the informed consent form.
c.Assist the client to void before the procedure. Response Feedback:For safety, the client should void just before a paracentesis. The nurse or the provider should have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the side of the bed and leaning over the bedside table. The client will be on bedrest after the procedure.
A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important? a.Assess the client's stool for obvious food particles. b.Include the date and time on the specimen container. c.Put on gloves prior to collecting the sample. d.Ask the client about recent exposure to illness.
c.Put on gloves prior to collecting the sample. Response Feedback:To avoid possible exposure to infectious agents, the nurse dons gloves prior to handling any bodily secretions. Recent exposure to illness is not related to collecting a stool sample. The nurse can visually inspect the stool for food particles, but it still needs analysis in the laboratory. The container should be dated and timed, but safety for the staff and other clients comes first.
After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a."I cannot drink any alcohol at all anymore." b."I should eat small, frequent, balanced meals." c."I should not take over-the-counter medications." d."I need to eliminate protein in my diet."
d."I need to eliminate protein in my diet." Response Feedback:Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client.
After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the client's understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for additional teaching? a."I should drink bottled water during my travels." b."I will wash my hands frequently and thoroughly." c."I will not eat off another's plate or share utensils." d."I should eat plenty of fresh fruits and vegetables."
d."I should eat plenty of fresh fruits and vegetables." Response Feedback:The client should be advised to avoid fresh, raw fruits and vegetables because they can be contaminated by tap water. Drinking bottled water, and not sharing plates, glasses, or eating utensils are good ways to prevent illness, as is careful handwashing.
A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? a."My spouse will be here to drive me home." b."I will buy several bottles of clear sports drinks before the prep." c."I should refrigerate the GoLYTELY before use." d."It's a good thing I love orange and cherry gelatin."
d."It's a good thing I love orange and cherry gelatin." Response Feedback:The client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show a good understanding of the preparation for the procedure.
A client scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best? a.Ensure that the client has a ride home. b.Instruct the client on bowel preparation. c.Document this information on the chart. d.Ask the client about shellfish allergies.
d.Ask the client about shellfish allergies. Response Feedback: PTC uses iodinated dye, so the client should be asked about seafood allergies, specifically to shellfish. Documentation should occur, but this is not the priority. The client will need a ride home afterward if the procedure is done on an outpatient basis. There is no bowel preparation for PTC.
A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this client's plan of care? a.Antibiotic administration b.Low-fiber diet c.Intravenous glucocorticoids d.Skin protection
d.Skin protection Response Feedback:Protecting the client's skin is the priority action for a client who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohn's disease includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids.